HEALTH

Mr. Chairperson (Marcel Laurendeau): Would the Committee of Supply come to order. This section of the Committee of Supply has been dealing with the Estimates of the Department of Health. Would the minister's staff enter the Chamber at this time, please.

We are on Resolution 21.4 Health Services Insurance Fund (c) Hospital and Community Services, Hospitals.

Hon. James McCrae (Minister of Health): We have with us today Dr. John Wade, Deputy Minister of Health, and Mr. Tim Duprey, Assistant Deputy Minister for Finance and Administration, and the regulars that have been here all along who have provided us with so much valuable assistance.

Mr. Dave Chomiak (Kildonan): Mr. Chairperson, I thank the minister for accommodating our requests in terms of dealing with matters under this particular item. The budget has identified approximately $53-million reduction for hospitals. Can the minister provide us with any kind of a breakdown as to where those allocations come from, and in terms of breakdown, urban\rural, tertiary care versus community hospital or any kind of breakdown in that regard?

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Mr. McCrae: As I said earlier, those numbers have not been finalized, but they will be as we proceed through the fiscal year. It is a time of change and so you are going to see that $53 million come out. You will see $38 million or so go in to help bring about the achievement of that $53-million saving, but obviously the design teamwork and rural issues have not yet been resolved, so it is impossible for me to say at this point.

Mr. Chomiak: But surely that figure did not come out of the sky, Mr. Chairperson. Is there not an analysis or a breakdown in terms of how that, I mean, irrespective of what the design team recommendations are, and I understand they have done or are doing their financial analysis. Surely that figure did not just come down, surely it was based on some kind of analysis. Can the minister give us that?

Mr. McCrae: The deputy minister and all of the people with whom he consults, i.e., hospital CEOs and medical leaders have identified those figures and targets in a preliminary way.

Mr. Chomiak: I am developing a new style as we are moving on this. I am not going to flog a particular horse more than twice, so I am just forewarning the minister. In terms of the transition support, the $38 million, can the minister give us an outline or a breakdown as to how that money can and will be allocated?

Mr. McCrae: As I told the honourable member the last time we discussed this, we cannot achieve all those millions in savings beginning April 1 because we have not even made the decisions yet, so it is expected that a lot of changes will happen later in the year. So in order to keep the present system going until then, we need that $38 million to make that happen. In addition, alternatives in the community need to be financed. It is too bad that we have this strike on right now because it confounds the issue a little bit. Anything we can do in the community, in block care or in long-term care, to bring about a reduction in acute care are the kinds of things that will happen. Announcements will be made and implementation will happen, but certainly I expect to see it later in the year.

Mr. Chomiak: Let me try a specific example. Community Health Centres have seen a budget reduction this year. The government has announced a $38-million one-time, I assume, hospital transition support. What if a community health centre were to come forward with a proposal of several million dollars of a massively expanded community-based program? Would that be considered under the $38-million transition?

Mr. McCrae: Community health centres are included and are part of this process. Proposals coming forward from them that would assist us in achieving the goals we have agreed upon as part of the consultative process are obviously going to get looked at seriously by decision makers.

Mr. Chomiak: But I am correct in assuming this $38 million is one-time transition support?

Mr. McCrae: Yes, sir.

Mr. Chomiak: Just to take the example further, Mr. Chairperson, if, for example, community health centre X said, we want to offer a $1.5-million program of community outreach to provide X, Y and Z services to our clientele, and you say, yes, it fits in with our plan, you have $1.5 million this year, how can that community outreach, should that service be assured that it is going to have long-term or continuing funding for that program, how is that going to work?

Mr. McCrae: Obviously, the question is a bit hypothetical, as the honourable member would acknowledge, but a program that finds favour with the group that is looking at these issues would no doubt have to be funded, certainly, for this year on a this-year basis. If the program is to be sustained in future years, then it would have to be financed on an ongoing, yearly basis in the future. Funds would have to be identified for the purpose in the way that we always identify funds.

In a system where you do not keep adding new funds, which we do not do anymore, we have to reallocate. We know that there are areas of the health system where we are spending money, but we are getting limited health care outcomes that we can measure or use to justify the expenditure. It is in those areas where I could see reductions happening in favour of dollars being spent in areas where it is expected that the outcomes we want to achieve could be achievable.

Mr. Chomiak: That is what I am basically trying to get at in terms of what the $38 million actually represents.

Mr. McCrae: In the same way that $53 million was a preliminary number identified by the decision makers, in the same way the $38 million was identified as what would be needed--and that was identified in a preliminary way too. So the planning must carry on in earnest to make sure that we can--there seems to be some comfort around the fact that that $38 million is sufficient to get the job done.

Mr. Chomiak: What I am getting at is, the $53 million is gone. The programs have been removed. The downsizing will take place. I mean, that is accepted. The $38 million is a one-year, one-time transition. If it is to be used totally as a transition in order to move the system, I understand that, but I do not have a clear understanding in terms of what we are going to be left with in the end, because there is always a danger when government does one-time funding to programs as to what the future of those programs is.

Mr. McCrae: I am not sure if we are at cross-purposes. I hope not. The goal here is to remove expenditures of $53 million in the hospital system on an annual basis. We have to do that. The honourable member for Inkster (Mr. Lamoureux) knows why we have to do that. [interjection] In part, we have to do that. He is right in saying, in part, because there is more than one reason for adjusting our health system. It is not simply because the dollars are being removed. It is the right thing to do, Mr. Chairman. There are some outcomes that we are expecting but not getting, and we need to get them or else how can I justify in this House or anywhere else all this expenditure when I am not getting the outcomes that I need as the Minister of Health in the province? So we have to take that $53 million out.

The acute care sector has been identified as the place to do it. We are told that we have all these beds per thousand population, more than we need. How many more? That is what the discussions are all about. How many more have we got than what we need? I was teasing the honourable member for Inkster who, you know, suggesting--he was saying that we can take all these hundreds out. Nobody knows today, I suggest, exactly how many beds too many we have in our acute sector. We know in rural Manitoba, generally speaking, and in Winnipeg, Manitoba, generally speaking, but we need to get some precision around this, because you have to be precise in these sorts of things. It is hard to do that, especially when you are working with professional A, B and C, and you get four opinions. I mean, out of three professionals, getting four opinions is a difficult thing to deal with, but that is the kind of thing that happens. So we have to make some choices and decisions that have to do with quality care.

We know, everybody here admits that we have excess capacity. When we start to trim it, that is when we start to get into the difficulties, but that has to happen this year, and thank goodness we are not doing it all just by ourselves. We have all of these professionals and caregivers and client organizations involved in the decision making.

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Mr. Chomiak: Perhaps I will give an example that I gave to the Red River students in the hallway. Patient X goes into a hospital. We say that there may no longer be a need for patient X to enter that facility in that institution. Patient X still has a symptom, an illness, and his symptom and illness has to be dealt with somewhere, so patient X may not go to an acute care facility. The question is, where does patient X receive health services and how does patient X receive the health services that are required? That is the issue.

Now let me go to a specific then. The minister has already stated that there will be a reduction in emergency wards in the city of Winnipeg. I am not going to quibble about the numbers, but that has been stated. The government has announced a fairly extensive rejigging of the emergency system in the city of Winnipeg. Are monies allocated from this $38 million for that purpose, and what is going to be the structure in the future?

Mr. McCrae: I think I understand the honourable member's question, unless it is a specific answer which has not been arrived at. We know we have an overcapacity of emergency services. Everybody agrees. I think even the honourable member for Kildonan (Mr. Chomiak) agrees. So it comes down to a question of location of emergency services, location of quasi--if that is the right word in this context--emergency services.

Should there be seven, eight--yes, eight including Children's--emergency rooms operating in the city? The answer is no. There should not be. We do not need eight emergency rooms in a little city like Winnipeg. So how many do we need? Well, we have been told we need five. I think that is what we were told--six, counting Children's.

The honourable member knows this issue very well. He is an expert, I suggest, because he knows that we need six, counting Children's. I do not know if he agrees or disagrees with that, but that is what we are told by the experts.

So then the question is, where? If we have got eight and we need six, then two are not needed. It is pretty easy to figure out what this discussion is resolving itself to, and that is that two need to look at some kind of change. The issue is, should it be Misericordia Hospital and Seven Oaks Hospital, which have been identified by some as the two? Well, those who support those two hospitals, you can expect to hear from them very quickly, or maybe we should leave them open and just work with the Victoria General Hospital. You will hear from those people too.

An Honourable Member: I would suspect so.

Mr. McCrae: And you would be right. So I think we understand that, and all I want to do, and all everybody else involved in the process wants to do, is make sure that the system is working when people have emergency requirements.

Now I used the expression quasi-emergency, and I wonder if we are doing, or have in the past done, enough work in that area. You know, when all the walk-in clinics in the city are closed in the middle of the night, it seems reasonable to expect that people are going to want to go to their hospital emergency room, and that is not the best practice. Everybody knows that is not the best practice. So, rather than run a full-service emergency room in more places than we need them, should we not look to make sure that we have the capacity for the right kind of service for the right kinds of situations?

There will always be those situations where it is not clear what your emergency problem is, and you may be best to show up at Health Sciences Centre, for example, where they have every kind of medical emergency equipment that you can expect to have in a modern and well-equipped emergency facility. That makes sense. We are not asking people not to access emergency service when they need it. No one has ever said that, and no one is going to say that, but if you have a hangnail--you know, that is the only example I can use. That is not the best example, but if you have got--

An Honourable Member: A broken foot.

Mr. McCrae: --a very minor problem. I was not going to say a broken foot because I know there are a couple of members in this place who would get--

An Honourable Member: I waited until Monday. I did not use the emergency room.

Mr. McCrae: Anyway, if you have a very minor situation and yet a worrisome one, maybe the full-scale emergency room is not the right place.

I like to encourage physicians and patients to have the kind of relationship, where they can consult at the appropriate time, and if it is in the middle of the night--as a person who was the father of young children, I know what it feels like at three o'clock in the morning to feel your child virtually burning up with fever and you wonder what to do. Should I go to the emergency room? Should I call my doctor? What should I do?

Well, I was not shy about that sort of thing. Maybe others should not be either. I would phone the doctor and find out what advice the doctor would give. Very often that kind of advice prevented me from taking the child to the emergency room. Sometimes it would be, do this, do that, and the other, and check with my office in the morning, and by that time, when morning arrived, the need even to check with the doctor further had passed. But that is good medicine, good health, I suggest, to have access to your primary care person.

I do not know, maybe my answer is not specific enough for the honourable member, but I think that all of the people working on the design teams, including emergencies, are attempting to look at what we need and then trying to make sure that we have the budget there to deal with what we need. It is clear to everyone that we have the budget to deal with what we need. It is just not properly allocated. Getting it reallocated is a painful, painful experience and transition. It gives rise to people saying, well, you do not know what you are doing, simply because you are doing something with which they do not agree.

They do not always agree for good population health reasons, but they agree for other reasons, or disagree or whatever. That is why we need to spend some tax dollars to inform the public of what the issues are and the various proposals to resolve them.

We will come under some fire, I suggest, Mr. Chairman, for spending taxpayers' dollars to hire communications companies like Biggar Ideas, for example, who win when requests for proposals come forward and their proposals win out of a field of others, but anybody who is critical of a government that wants to include the public in the consultation process perhaps wants to focus the public's attention on their particular point of view to the exclusion of everybody else's. That is something that we are going to address head-on, and we are doing it now.

I see ads and I hear ads setting out the government's position vis-à-vis the position of other interested parties. I think that is appropriate in this day and age, at this time of change and transition, and I fully expect to hear criticisms from my colleagues opposite, but the point is they did it, other governments are doing it, and it has to be done. In order to bring about necessary change, you have to have a population that understands the need for that change. It is for that reason that you will see more of this sort of thing, Mr. Chairman.

Mr. Chomiak: I note that answers to questions ought not to provoke debate, and I can indicate that the minister's response could keep me standing in this place debating for well into next week, just to the minister's response, but I want to utilize the opportunity of staff who are available, and I want to ask some other specific questions, although I may return to this area.

Can the minister give us a specific outline? The minister has provided us with the bulletins. Where is the financial analysis with respect to the Urban Planning Partnership at specifically, and will we have access to that information before the final decisions are made?

Mr. McCrae: The analysis of the cost is underway at this time. It is not completed.

Mr. Chomiak: Will we have opportunity and access to that information prior to the government making final decisions?

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Mr. McCrae: Virtually everything we do is public, and I have every expectation that all aspects of this process will continue to be very public.

This is a very open process we are in. There are so many people involved in it. It is no wonder that documents are made available publicly before I make them available because we have so many partners, and they simply want to make sure that their point of view is properly aired, so documents become available. That is a price a government has to pay for being so very open like ours is.

Mr. Chomiak: I would still like to get some understanding from the minister as to who is making the decisions with respect to the allocation of this $38 million. Is it the deputy minister and senior staff, or is it the urban planning teams? Who will be making the decisions with respect to the allocations of these funds, of this $38 million?

Mr. McCrae: I believe in ministerial responsibility, Mr. Chairman. No matter what committees and representatives in the department, or whoever, are involved in proposals, I will never escape accountability for decisions that get made. So, therefore, I might as well say I am the one who makes all of the decisions.

Mr. Chomiak: Mr. Chairperson, as a percentage increase probably Blood Transfusion Services has received one of the largest, if not the largest, increase in the Department of Health. Can the minister outline for us what that money is to be allocated to?

Mr. McCrae: We have a new funding method which is no longer subsidized by other provinces. Funding for blood cross-matching service is no longer subsidized by other provinces. New funding for the switch in blood products to--oh, here is a word--Factor VIIA. That is what this is about. It is the way that Blood Transfusion Services funding has changed. The subsidization from other provinces is not there, so it would reflect a greater expenditure on the part of our government.

Mr. Chomiak: Mr. Chairperson, I asked this before, and the minister gave me a brief answer. Where are we going with respect to the Canadian Blood Agency and the Red Cross in terms of the government's plans?

Mr. McCrae: I do not know if the honourable member received the communique that was--he did. Okay. Well, that communique really forms the substance of my answer, and it is the same answer I gave before, but the minister has agreed that solutions must be governed by four very important principles. Safety of the blood supply is paramount. A fully integrated approach is essential. Accountabilities must be clear. The system must be transparent.

Our working group will be consulting the Canadian Blood Agency, the Canadian Red Cross, interested consumer groups to ensure that we come to some fruition respecting at all times these four principles.

Mr. Chomiak: The member for Inkster (Mr. Lamoureux) and I were anticipating allocating some time this afternoon, and we were very pleased that the deputy minister is here. I understand that he may not be here for the balance of the afternoon, and I just wanted to confirm that because I am taking the questioning now, I just wanted to confirm that the member for Inkster at 4:30 will have an opportunity to question with the deputy minister present. I understand he has an appointment that is rather important. So, is the minister confirming that?

Mr. McCrae: Yes, Mr. Chairman.

Mr. Chomiak: Can the minister give me any idea of what the rolling budgetary expenses are for the hospitals for the upcoming fiscal year, the three-year rolling budgets that are given out regularly to the hospitals?

Mr. McCrae: We are not working on a three-year path at this time, Mr. Chairman. Transitions are going to be part of the culture of health delivery for the next number of years, but certainly for this next year. In the next three years it is impossible for us to have a three-year rolling report to make because we expect to see change in the next year or so. At that time, once the major changes are over, it may be that the rural health authorities or whoever might be doing that in the future, but we do not have it that way at this point.

Mr. Chomiak: I wonder if we could get an update from the minister with respect to the consolidation of the cardiac program and the neurosurgery programs at Health Sciences Centre and St. Boniface.

Mr. McCrae: Mr. Chairman, significant progress has been made in these areas. More progress, I think, is possible. We have leadership at the two programs. The programs are the subject of agreement pursuant to the so-called Wade-Bell report. I believe subject to perhaps subsequent information being made available to the honourable member, we have been able to address our physician resource issues much more effectively. I am just not certain if we have solved all of the problems there yet, but through the advent of the academic health consortium we have made and will continue to make very good progress in cardiac sciences and in neurosciences.

Mr. Chomiak: I am aware of some of the statistics the minister has released with respect to cardiac surgeries. Would it be possible for the minister to give us some statistics in terms of waiting lists for the various major surgeries at the major surgical centres?

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Mr. McCrae: We have some very, very significant improvements here with respect to surgeries. We are going to be able to do about 1,000 cardiac surgeries compared with the traditional 600 to 700, which is very, very significant. In March 1995, interim funds were approved for the period of March 15 to June 15, 1995, as a short-term strategy for reducing waiting lists. These dollars were redirected institutional funds and were shared with seven hospitals to reduce the waiting lists for joint replacement surgery, open-heart surgery, MRI scans and radiation oncology.

Dr. William Lindsay, head of the cardiac sciences program, is addressing issues related to cardiac surgery. This new system is expected to identify the priority of each patient based on standard clinical indicators. The final statistics for 1995-96 will not be available until later this year, but we do know that 58 additional joint replacement surgeries were funded in 1995-96. We have also been advised that St. Boniface General Hospital and Health Sciences Centre expect to have performed approximately 1,000 open-heart surgical cases in 1995-96, compared with 749 in 1994-95. We also provided funding for an additional 450 MRI procedures and have continued to work with the Manitoba Cancer Treatment and Research Foundation to address waiting lists for radiation therapy.

Manitoba Health will continue to work with the physicians and hospitals in 1996-97 to improve the system, to ensure that Manitobans receive surgery within appropriate time frames. Specific issues will be addressed in this consultative process.

All in all, a very, very positive report, Mr. Chairman.

Mr. Chomiak: Could the minister give us any idea when we anticipate we will see the secondary services report I have always called it Wade-Bell II. When we will be seeing that report?

Mr. McCrae: We hope, Mr. Chairman, if we are fortunate, to have this in our hands by the end of this month.

Mr. Chomiak: Will it be made public at that time?

Mr. McCrae: We will ascertain that when we receive it.

Mr. Deputy Speaker: Order, please. I know the honourable members want to carry on their conversation. They are doing it in the right place, if they could just tone it down a little bit. The honourable minister, to continue.

Mr. McCrae: I am sure that at some point that will indeed be public. Just exactly when, I do not know, but we will look at it with interest when we get it. So many people are involved in inputting it, I cannot imagine it not being a public document at some point in the future.

Mr. Chomiak: I believe I have previously asked and, if I have not, I am asking now, if the government will give us a list of all of the major consulting contracts that have been undertaken this year and last year with respect to the Department of Health?

Mr. McCrae: Mr. Speaker, anybody that is paid by the government is listed in the Public Accounts.

Mr. Chomiak: The government has contracted with a significant number of companies and individuals who do major work, and it is only in the spirit of openness and in the best interests of the public that they know who those people are and what those contracts are and what they are being paid. I would ask the minister again whether or not he will release that information.

Mr. McCrae: I agree with the honourable member, Mr. Chairman, and that is why this government is so extremely open.

Mr. Chomiak: Now that the minister has stated the fact, will he also translate it into action, and will he release that information?

Mr. McCrae: The action the member is referring to is very apparent. It is already part of our system.

Mr. Chomiak: Will the minister release information concerning the KPMG contracts?

Mr. McCrae: We will take the honourable member's question as a representation or under advisement.

Mr. Chomiak: Mr. Chairperson, is the process towards an integrated service delivery system anticipating another public forum as was conducted in the past?

Mr. McCrae: Mr. Chairman, we see KPMG has already facilitated public forums. I know the honourable member knows that. At some point, you have all this input unprecedented anywhere right here in Manitoba, and then you have to make some decisions. It is not easy to do that, especially when you know somebody is going to be there to say, you did not consult enough because, obviously, I do not agree with your decision.

So only when we have consulted enough and agreed with the point of view of the dissenter will the dissenter be happy, and then you are going to make everybody else unhappy. Let us get our minds around the idea of the quality of service and listen to the advice we get. Go to the forums, and I commend the honourable member for the role he has played in that regard, but the forums have been had, and now it is time for us to look at the information gleaned and make some quality decisions.

Mr. Chomiak: Mr. Chairperson, I am not going to pursue the issues of bed numbers and the like because that has already been pursued by my colleague in this forum.

What I would like the minister to outline for us therefore is what the time frame is for the decision-making process. Surely, the Department of Health which anticipates cutting $53 million out of the acute care sector this year and which anticipates putting in $38 million by way of transition funds has a time frame and an outline of the decision-making process.

I wonder if the minister can outline for us what that will be because people at the various institutions are clearly--and I do not think we always appreciate what effect these decisions have on the people who are caregivers in the system.

Mr. McCrae: I am reminded every day.

Mr. Chomiak: Well, the minister says he is reminded every day. I think it would help the process immensely in terms of dealing with caregivers if they were to have some idea of what the time frame is in this regard.

Mr. McCrae: The time frame for these discussions is April 1, 1996, to March 31, 1997. We know a lot of significant things have to be done. We know a lot of significant things have already been done, announced, implemented. It is in the course of that time.

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With respect to the hospitals, the honourable member wants to know when is this going to happen and what is going to happen. Well, I do not know, Mr. Chairman. If I knew that, I would have announced it and done it already. Let us be reasonable here. We have said that the KPMG report should be available at the end of this month. I expect that the work of the Urban Planning Partnership, they are finalizing their work now, so, there again, maybe at the end of this month we will reach that stage, but there is a lot more to do in preparation for what goes from that then.

I am trying to be as responsive as I can, but I do not know how to tell the honourable member that on, I do not know, September 4 we are going to make a decision about the Seven Oaks General Hospital, or on August 12 we will make one about the Misericordia. I do not know how to answer that question at this point, and it is not for lack of trying, Mr. Chairman.

Mr. Chomiak: Mr. Chairperson, the minister has been helpful with regard to that response because the two major pieces of the puzzle, if I can put it in those terms, the Urban Health Planning Partnership and KPMG, if those two enterprises come together at the end of the month, which is what the minister stated or very close to that, then presumably in the next several months there will be two things happening; well, possibly two things happening. Either there will be ministerial decisions and announcements, or what I was under the impression there was going to be, there will be some kind of a public discussion followed by ministerial decisions or final decisions.

I will tell the minister why I say that, because, for example, we who have been working on behalf of Seven Oaks Hospital have been advised from the very highest levels that there is going to be some kind of public process prior to the final decision taking place. So perhaps the minister can outline which of those scenarios is going to be followed.

Mr. McCrae: We have been and are in a consultation process. I do not know what the honourable member perceives unless it is that he rents a room in the Legislative Building and has public hearings at which everybody comes and says, we disagree with the government. That may be his idea of a good way of making public policy.

We have had the process we have had thus far with the design teams and the Urban Planning Partnership. We have been receiving feedback from interested parties ever since, and that feedback is being brought to the attention of the Urban Planning Partnership and the KPMG. They will make their views known at the end of this month, and then it will be decision time very shortly thereafter.

Mr. Chomiak: The minister again has been helpful. He has outlined what the process is. I was under the impression--well, I laid out the two scenarios, and the minister has made clear KPMG comes in, the Urban Health Planning Partnership comes in and shortly thereafter the minister is making decisions, and he is not anticipating any kind of a public forum or a public input in this regard.

So the minister has been helpful and has laid out the scenario, and it is different than what was communicated to me. It was communicated to me, as to the scenario, specifically that relating to Seven Oaks Hospital, because the impression that the chair of the board, Olga Fuga, gave to us on the Seven Oaks grassroots committee was that there would be some kind of a public--what the chair of the board, Olga Fuga, gave to the committee was that she was under the impression there would be some kind of a public input prior to the final decisions taking place. The minister is saying the public input has already taken place. He is affirming that from his seat--

Mr. McCrae: Thousands of petitions, thousands of people in this building and--

Mr. Chomiak: The minister says thousands of petitions and thousands of people in this building. That is true, and the grassroots of the city have generated a fair amount of public attention and drawn public attention to their viewpoints. One hopes that the government will be persuaded by the efforts of those citizens. Indeed, one hopes that the government will be persuaded by the efforts of the citizens that are now appearing in front of the independent committee to review home care, and we will see from that process perhaps that the government will respond and deal with the issue as has been obviously directed by the citizens of Winnipeg who have shown their opposition almost unanimously to the government's plans to privatize home care. But I digress, Mr. Chairperson, from the line item in the Estimates.

The minister made reference, in an earlier comment, to walk-in clinics, and the minister has constantly identified walk-in clinics as a difficulty in the system. Can the minister outline what plans are in place for walk-in clinics in the province of Manitoba?

(Mr. Frank Pitura, Acting Chairperson, in the Chair)

Mr. McCrae: Mr. Chairman, it is getting harder and harder to identify what a walk-in clinic is, so the question the minister puts is difficult to answer. [interjection] That is the next question? Well, it is hard to identify what a walk-in clinic is because, I guess, at some point, some people thought that that was a no-appointment place. Well, you can make appointments there. Emergency rooms are walk-in clinics if you want to stretch the definition far enough. An emergency room, you walk in, you get service. Sometimes you wait, but you get service. So I am having a little bit of a loss.

We are trying to work through the MMA, too, through the billing number system and the Physician Resource Committee. I know this is not a very specific answer, but it is hard because it is so very hard to identify what we mean when we talk about a walk-in clinic.

Mr. Chomiak: Mr. Chairperson, that is in fact one of the issues, is identifying what constitutes a walk-in clinic and how one deals with funding arrangements attached thereto. Can the minister give us any more insight as to where the department is going in conjunction with the MMA and the MMA agreement to define the parameters of what constitutes a walk-in clinic?

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Mr. McCrae: Mr. Chairman, they are just lining up for my job. I cannot figure this out, why everybody wants my job so much.

The work of the Patient Utilization Review Committee is ongoing. The work of the Medical Review Committee is ongoing. The work of the Manitoba Medical Services Council in partnership with the government is also ongoing. Through all of those vehicles, we will continue to work toward better practice patterns for physician services; and combined with some help from public education programs, we expect to get a better type of utilization of our health services.

I know that when we get into a debate about eye care, for example, or we get into a big debate about how often you should have a full physical exam, those are really good things. Even though usually the government is the target of all of these discussions, somebody has to lead and so leading means being there and being part of the discussion. I think that is an appropriate thing for governments and I am first to tell you it is not always easy, but those discussions are going on.

Manitobans, I think they are getting much more informed about the services that there are out there, what they cost, how best to use them, and you are always going to find somebody who is just an outright loser when it comes to the use of our health system. There is going to be somebody breaking every rule in the book and that is going to happen. That is why you need these structures that we have in place like the utilization or medical review. But generally, even today, I think there is a sense that people want to use their health system right, and they are asking the government to build the kind of health system that lends itself to being used right and then it will be better. We will get better outcomes. We will get better value for our money and all the rest of it.

The government is not the be-all and the end-all of the health system. We are a funder basically, but it is time for governments to be vigilant about just what it is they are funding and lending their support to. Let us get the value for the money being spent.

On May 7, the member for Kildonan (Mr. Chomiak) requested information respecting Manitoba Health's contract with the Victorian Order of Nurses. Manitoba Health is continuing to purchase nursing home help services under the new contract terms with the VON until September 30, 1996. The rates currently being billed are--I do not know if that is something I should be making available at this point.

Mr. Chomiak: Mr. Chairperson, this is not meant as criticism, but dealing with questions in this area is a lot like dealing with jello at this point, because virtually every issue affecting hospital and health care is under the auspices of one or other Urban Health Planning team. Because the Urban Health Planning teams have not made their final recommendations, and because KPMG has not made its final recommendations, it is very, very difficult to ask questions because, frankly, we are not going to get answers. But there are several areas where it is fairly clear.

In fact, I personally think that the government is going to proceed--and one should not give personal opinions, but I am on this track anyway--I think most of their recommendations under the Urban Health Planning Partnership are probably going to be going forward. That is my personal view. Certainly, it appears to me from the way the government is moving--at least in this area, the area of labs--given the recommendations of the previous lab committee and given the fact that most of those recommendations dovetailed with those of the Urban Health Planning Partnership that there is going to be major and significant changes in the lab sector in Winnipeg and the province of Manitoba.

Can the minister tell us how negotiations are going, for example, with MDS?

Mr. McCrae: It would be inappropriate and incorrect to describe any contacts that have been made by or to or from MDS as negotiations.

On May 3, the honourable member for Radisson (Ms. Cerilli) asked if permission is required by the parents of youths in order to be tested for HIV and AIDS and, further, if confidentiality can be assured.

A physician is obliged to follow the wishes of a patient respecting confidentiality. This includes testing for other STDs and/or pregnancy.

With respect to a youth, if the youth's physician is convinced that the youth is a mature minor and able to make appropriate decisions for him or herself, it is quite appropriate for the youth to request testing and specifically to request that the parent not be involved. If a parent suspected something and sought information directly from the physician, the physician would then no doubt encourage the youth to release the information and/or the physician might hold a family conference, including the youth, to discuss the issues, particularly if the youth still lived at home and to ensure the best interests of the youth are observed.

Mr. Chomiak: Mr. Chairperson, can the minister describe for me what a rapid-response laboratory is?

Mr. McCrae: I think the expression carries the connotation that you are going to get quick service.

Mr. Chomiak: Mr. Chairperson, yes, I recognize it is that but, because it is a specific recommendation and in fact it is fundamental to the recommendations of the laboratory committee and because people in the lab sector are asking this over and over again, I wonder if the minister could just outline what is envisioned by a rapid-response lab? Is it a way station where samples are dropped off? I mean, is it a place where some analysis and some menu takes place but a limited menu? Can the minister define it? Since it is strongly recommended in the urban design team report, because it appears to be something that is probably going to be introduced and because people in the lab industry who have come to me say they do not know what that means, what is meant by it?

Mr. McCrae: Maybe we will just turn it around a little. The honourable member has done a fair amount of work in this area, and maybe he can tell us what his understanding of that term is as it is used. That way we can have an appropriate exchange of information, Mr. Chairman.

Mr. Chomiak: Mr. Chairperson, my understanding, from reading into it, is that it is a scaled-down version of a lab that has a limited menu that provides for--and the limited menu or the kind of services that are the standard and the most frequent services utilized and that it provides those and it is a drop-off depot where other, longer term testing is done, can be transferred to a central repository. That is how I read into it, but I really do not know, and the people in the industry are really uncertain as to what is meant by this term of art.

Mr. McCrae: When we return tomorrow, Mr. Chairman, I will have a little, I think, something more to say so that the honourable member will get a sense of where the department is as we look at these recommendations that come to us. We will consult the design team for a further understanding that we can share tomorrow with the honourable member.

Mr. Chomiak: Mr. Chairperson, I thank the minister for that response. Just clarification again, the minister indicated, of the $38 million, none of that is to be allocated to capital. Is that correct, $38-million transition?

Mr. McCrae: None of that $38 million contains allocations for capital improvements.

Mr. Chomiak: So, returning to a line of questioning I had started earlier in the afternoon, if for example the government accepts the recommendations of the emergency design team, and if it is necessary to augment the resources at one or two of the hospitals, the tertiary care facilities presumably in the city of Winnipeg, and if it is necessary to deal with capital equipment, for example, putting more ambulances on the road, presumably that could be dealt with through transition since it is the City of Winnipeg that handles the ambulances, would that money then come out of the transition fund for both the changes required at one of the tertiary care facilities and, if needed, the extra funding for transport and other related items?

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Mr. McCrae: We are not going to be accepting any recommendations that are going to end up costing us more. We have to redesign a system that will no doubt require some expenditures to redesign, but we are not out to spend more on an annual basis for any particular program simply because somebody suggested we ought to change it. We want to see changes that will improve service, but by that we also want service delivery to be made more efficient. We know we have thousands of people who have told us that our system is less than efficient.

That being the case then let us move to do something about that, but we know there are not more dollars available. The member for Inkster (Mr. Lamoureux) can attest to the fact that next year we are going to be working without $220 million that we have had up until now, and we will not have that. That is a reality that some people tend to want to deny exists or to--I do not know, I do not know where they are coming from. The fact is we have to do a job here and we have less money to do it with. Obviously, when we look at the overall plan here, we cannot accept the in totality recommendations that have us spending more money when we have less money to spend.

So we will come out with the old Rubik's cube again, I guess, because it is the best way to describe some of these complicated issues. The idea with the Rubik's cube is to get all the red cubes to line up on the one side of the cube and all the blue ones and the different colour. You do not have your puzzle solved until you have all the cubes in the right places. So here with our design teams we have got all these design teams, at first working separately, coming together, and now we are trying to put all this puzzle together. It is quite a job as the member would no doubt understand, but we are not able to spend more money, and in the area of capital we have certain limitations there, too.

Mr. Chomiak: Well, this takes me right back to where I commenced questioning when we started the Estimates this afternoon, and that is, what is the $38 million going to be utilized on? Perhaps the minister can give me an example or two, so that I can have some grasp of what the $38 million is going to be utilized for.

Mr. McCrae: This is May 9. We are a month and nine days into a new fiscal year, and we have not closed any beds or achieved any savings. We have had to pay money to keep the services that we have got open. That is an example.

Mr. Chomiak: So I misunderstood the utilization of the $38 million. I was under the impression that the $38 million was a transition fund that would permit changes to take place and ease the transition from one to the other.

What the minister is saying, and I want to understand this completely. The example the minister has given is somewhat different from that. Is the minister saying that is only one example of what the $38 million will be utilized for, and my initial assumption is still correct that other monies will be utilized for structural changes, not structural meaning capital but structural changes in order to make this difference? Is that correct?

(Mr. Chairperson in the Chair)

Mr. McCrae: If I give the honourable member another example, it might make it clearer. I think he has got it.

The first example was that the passage of time calls for us to spend money that we expect not to spend next year. Second example, the idea of alternative housing project where nursing services might be part of the program. It gets people out of the hospital. That alternative housing comes with a price tag, too, so we need money to finance that alternative.

We will also need to have funds in place next fiscal year, so that we can carry on with this alternative, but there will be savings in the hospital in the meantime, and it is from those savings that we will be able to fund programming in the future and remove funding from the health system, as well.

Mr. Chomiak: Well, the minister answered a question I had posed earlier and gave me some satisfaction that some consideration will be made, because there is a real problem in one-year funding on a transition basis in terms of a long-term program. It is a trap that all governments fall into and it creates difficulty.

But the second point, the $53 million has already been taken out of the system or allocated within the system, so where are the savings going to come next year that will allow that continuing program to continue?

Mr. McCrae: I do not think we are speaking at cross purposes. I think the honourable member maybe is having trouble with the reality that we have to have a net reduction of $53 million out of the health system for subsequent fiscal years. He is having trouble grappling with that. [interjection] No, he is saying okay. He is understanding that, but he is saying you cannot do it without further problems that go with it. No one is saying this is an easy process that we are in; I am not.

An Honourable Member: Because you are projecting decreases, as well, next year.

Mr. McCrae: You are going to have to ultimately have enough savings, if that is the right word here, to finance the level you need to arrive at in budget terms, but also to finance alternative services that you have to put into the community. We fully recognize that. It is not an easy process. I am not sure where the honourable member is taking me with this, but maybe he is trying to come up that somehow it was worse than $53 million. Well, in real terms, that argument could be made. We have significant problems that have been brought about for the various reasons.

I wish the federal Liberals had handled it a little differently. I do not object to the goal they are trying to achieve--in fact, I support that goal--but it is a little hard to swallow this pill when they are not taking the pill themselves. Funding transfers to provinces are being reduced at rates way above reductions in the federal government programs themselves. That is the part we take issue with. That political fight, we are not going to just drop it, but there is no point setting up fair share offices and going and bleating and wailing and moaning and whining and screaming and all of that.

It has happened and it is going to happen. I cannot change it. So there is no point in absence of our ability actually to respond appropriately, just to fight the good fight for political purposes. This is too important to engage in that sort of thing. I do not mention it every time I stand up, but, every so often, so that the members will understand that it is not like I want to do all these changes as quickly as they need to be done. Yet, when you look at Manitoba and compare with other jurisdictions, we are taking a much more staged approach to things that we see elsewhere.

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It is for that that we have been judged a year ago at the polls and, you know, five, six, seven, whatever years, I guess it is not that many, four years from now, we will potentially be judged again based on our ability to deal with the resources that we have and to make adjustments accordingly. It is not easy, as I have told the honourable member, and we would invite the honourable member's support for the types of changes that we are engaged in.

It will call for significant change this year, and when you look at the bigger picture, it is a little bit hard. That is why when I appeared in the main foyer of the Legislature here and spoke to about 1,000 people who wanted to make their views known about the Seven Oaks Hospital, it is my responsibility as a minister to look at the health system province-wide.

The member for Inkster (Mr. Lamoureux) in opposition can afford the luxury simply of looking at the Seven Oaks Hospital and nothing else. The member for Kildonan (Mr. Chomiak) enjoys the same luxury. He can be critical on all fronts, and I, for my part, have to justify positions taken in various parts of the system for the sake of the whole of the system. That is the difference between my responsibility and theirs, and I accept that responsibility.

Mr. Chomiak: Mr. Chairperson, in fact, I now have a much better understanding of the funding under the transition and what that money is to be utilized for. In fact, there has been a cumulative reduction in hospital funding for the past several years. We have gone down considerably in the last several years, and it has been an absolute decline. It has been a net decline in the hospital sector for the past three years. So we are simply proceeding down this front. The minister is saying the net decline will continue, and the real test, the real test of the process will be where resources are going to be utilized outside of the acute care sector in order to deal with what I referred to earlier as that patient symptoms. The patient still remains and the question will be where those resources will be placed and where those resources will be utilized, because the patient will still exist, though the bed may not exist or the institution or the means by which that patient will be dealt with will not exist.

The thing that surprises me is that with a net decline, an absolute decline, I would anticipate some substantial increases in certain areas, such as community health centres, and the minister has indicated there is an increase in home care this year. Heaven knows, there has to be, given the demands that are going to be placed on the home care system in the next several years if these changes go through.

I think I now understand what the $38 million is going to, and it does differ somewhat from my earlier observations. If one looks at the writings and the comments of the design teams during the process, if there is one point they are insistent on throughout, it is that resources have to be put in place before the changes take place. I do not know if those resources are going to be in place if the minister anticipates proceeding with all of these changes this fiscal year. That has always been our criticism of the government health reform policy since 1992. I wonder if perhaps the minister might want to comment on that.

Mr. McCrae: It is true that the honourable member has been critical at times of our performance. We are getting better across the country, I suggest, at measuring program efficiency and performance. There was a time when we did not do that. I sometimes think the honourable member and his colleagues are living in that time before measurement became a part of the system. Measurement simply was based on how many hospital beds you got, how many nurses you hired, and as long as you could throw more money into it this year, things were looking pretty good. Whether you were getting any health outcomes was quite another matter. So even though it requires change, we are now looking at outcomes far more seriously than we ever have and, for that, I finally thank those who have been involved in the system that brought that about.

What we are doing is pretty consistent. What we are doing this year is quite consistent with what you see in the 1992 document, Quality Health for Manitobans: The Action Plan, which enjoys unanimous support. Yes, people will quibble about whether we are really doing that or not doing that, and that is what politics is all about. It has nothing to do with health care, it has to do with politics, how well you can convince the people that the other person is wrong and you are right. That is what it is all about. It is in that environment we work. I often feel like thanking people, especially senior people in the Health department or in the Education department for that matter or any social service department for their forbearance. They did not really get into the job to be politicians or to know all about the politics of these things but they soon find out that is what they need to learn about because it is the environment they are working in, and I think it is unfortunate.

Be that as it may, it is like that because people right across the province value their education system, their health system, social services system. They expect their politicians to speak out on issues. So whether you are on the opposition side or the government side, people want to know what you stand for. They want to know what is wrong with the system and they want to know what is being done to fix the system, but if there is any major improvement in health services that is very important for the longer-term future, it is the fact that we have finally learned to measure results rather than input. We are measuring output now and that is a far better measurement in terms of making decisions about the system, making decisions about changes. Doing this, we need to be as sensitive as we can in times of change. I say as we can, I do not have any choice about change. Change is necessary.

So while we are going about that change, let us at least try to be sensitive to the people in the system. I refer to the employees and the caregivers and the stakeholders. Obviously, the reason the changes are happening is for the purposes of the consumer that is the No. 1 priority person in the system. After that everybody else is important, too; but the No. 1 consideration has to be the patient, the customer, the client, whatever the consumer is.

I think I am hearing the honourable member. I know that sometimes he can be critical. Sometimes it is deserved. Most of the time it is not. Sometimes it is, and when it is, it is our duty to be responsive and be prepared to acknowledge that that particular change was not necessarily the right change, or it was not done right and to say so.

I know the other day when Premier Klein was in the gallery, the honourable member for Kildonan made the point that, well, you know, Alberta, they had the courage to admit they were wrong and to change course. What the honourable member for Kildonan forgot to mention was that Alberta had already taken some $600 million out of their health system by the time Mr. Klein had said, we better take a detour--as I recall in response to the laundry workers at one of the hospitals or somewhere like that. The honourable member has interpreted all that as to be a major withdrawal from positions taken. I do not see it that way. After $600 million has come out of the health system in Alberta, for the Premier of the province to say, well, you know, maybe we should take a little detour, if we came anywhere close to taking that kind of money out of our health system on a per capita ratio basis, we would certainly be able to say, hey, we probably do not need to make any more changes.

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Even then it would be the wrong thing to say because I think change is necessary. Maybe Mr. Klein made his detour for the right reasons. I am not so familiar enough with Alberta politics and the health system there to know. But to characterize what he did as a complete withdrawal from the direction he was going is totally, totally misleading because they have got behind them significant change that it remains in front of us. This is not Halifax, but there are things about the system in Halifax that ought to be looked at in relation to what we are doing here. That is where they are making one hospital out of five.

I am going to get someone to write me a speech, Mr. Chairman, that sets out what is happening across our country, because we do not live simply in Manitoba and we are separate from everywhere else. I remember being in opposition saying to people like Eugene Kostyra and what is his name, Victor Schroeder, Finance ministers, and being critical of all their tax grabs and everything like that. He would say, well, you know, we are third best, Saskatchewan does this and B.C. does that. I would say the same thing these colleagues opposite are saying to me, but let us talk about Manitoba. So the more things do not change, the more things seem not to change. On the other hand, we are proud of our place in Canada as a health jurisdiction and we ought to be, and it is a credit to our politicians, it is a credit to our caregivers, it is a credit to our policy makers at all levels, that we have achieved what we have achieved in Manitoba.

So I accept some of the criticisms the honourable member might make. Generally, I reject but sometimes I accept because sometimes he is right, and when he is, I should listen.

Mr. Chomiak: Can the minister indicate who is doing the population-based analysis that the government is using to help determine these final decisions?

Mr. McCrae: The Epidemiology branch of my department and the Manitoba Centre for Health Policy and Evaluation are involved in providing analysis of population health trends and issues.

Mr. Chomiak: I am familiar with most of the population-based analyses done by the Centre for Health Policy and Evaluation. I am not familiar with that done by the Epidemiology branch of the department. Can the minister table that data so that we, on this side of the House, can have an understanding of where the government is proceeding in various areas concerning its decisions concerning population-based decision making?

Mr. McCrae: Everything the centre puts out, the centre puts out. I do not control that. With respect to the Epidemiology section, the one report I recall is the burden of illness on diabetes, and I am sure the honourable member has that, but if he does not, he can get it. If there are others, we will have a look and see if there are others we can share with the honourable member.

Mr. Chomiak: I thank the minister for that response. I just want to understand this correctly. The minister has indicated that the decisions that are going to be made are based on the population and needs-based assessments that have been taking place. Is it correct to assume that those decisions that are being made, and those analyses are the ones done by the Centre for Health Policy and Evaluation and no other external agencies or bodies?

(Mr. Mike Radcliffe, Acting Chairperson, in the Chair.)

Mr. McCrae: The rural health authorities, of course, will be involved in developing their needs assessments in the regions of Manitoba. They will be assisted by the same reports that the honourable member and I have been discussing the last few minutes.

Mr. Chomiak: So it is correct for me to assume that the data that I have from the Centre for Health Policy and Evaluation, the public reports and the reports that have been referenced by the minister or will be forwarded to me from the Epidemiology Branch, are the basis upon which the minister and the department will be making its decisions?

Mr. McCrae: Well, that is a hard one, because they are definitely part of the decision-making process, but here we are listening to what people have to say from the northwest corner of the city. We are looking at their petitions. So there are a whole variety of things. The things the honourable member tells me I have taken into account, the member for Inkster (Mr. Lamoureux).

These are two very important sources of interpreted data. You know the epidemiology section or the Manitoba Centre for Health Policy and Evaluation or individual hospital records of performance in their hospital, how many surgeries and what kinds and all of that. That is data which you look at when you are analyzing things.

There is quite a large combination of things but, ultimately, we want to put more emphasis on outcomes and less on politics, if possible. I mean, that is very important, to leave the politics out as much as you can and make health the No. 1 priority.

But how do you leave the politics out if you are looking at changing a hospital, let us say in one corner of the city of Winnipeg, and the people in that corner say, what are we, chopped liver? You are dealing with questions like that in an environment where you are trying to look at population health outcomes and stuff like that. It is hard to jump from one argument to the other, with some people it is. I think we have to be sensitive to the political views out there but, through public education and that vehicle, try very hard to make sure that we are trying to build a health system for everyone and that will be there for a long time.

It is no good for me to say today--let us use Saskatchewan for an example. Somebody said, we need this hospital in 52 locations. Then along comes another government and says, well, no, you do not, and they shut them down. Was that a political thing or was that a health-related thing? You be the judge. I am sure those people who said, we need this hospital, thought they were thinking about their health. Well, the NDP, what were they thinking about when they shut down and padlocked 52 hospitals? I do not know if they put condemned on them or what they did, but they shut them down.

Converted is the new politically correct language for the closure of a hospital. I use that as an example so the honourable member will understand that obviously, ultimately, as I said at the beginning this afternoon, the government of the day is going to be the one that will be credited with or blamed for whatever decisions get made. I am trying very hard to focus the attention of all participants in the process, including members of the public, on the population health issues because that seems to be the most justifiable, over the long term, approach to take.

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There were people very upset about eye care when it was time to take eye care out of Seven Oaks Hospital and Health Sciences Centre and locate it at Misericordia Hospital. I do not know what those people are saying today, but we have proved that what we said was going to happen would happen. We are doing more procedures, we are doing it cheaper, and we are probably doing it better as well. So that all said, where are the people who felt that Seven Oaks was the right place to do eye care? Where are they today, and what are they saying today? Well, they are faced with the facts, and the facts are that we are doing a better job with eye care today than we used to do, even though some people wanted to stop us from making the changes.

Those are some general comments. I know the honourable member's foot needs a rest, so maybe we should take a break.

Mr. Kevin Lamoureux (Inkster): Mr. Chairperson, maybe it might be appropriate at this time because I do have a number of questions that I would like to pose with the deputy minister being here. He had indicated that he was hoping to be here for 4:30 p.m. So maybe what we could do is just take a few minutes recess and allow staff to use facilities, and we will get right back underway.

The Acting Chairperson (Mr. Radcliffe): The suggestion has been made that the committee recess for five minutes. Is it the will of the committee to be recessed? [agreed] The committee stands recessed.

The committee recessed at 4:31 p.m.

________

After Recess

The committee resumed at 4:42 p.m.

The Acting Chairperson (Mr. Radcliffe): The committee will come back to order, and I would now recognize the honourable member for Inkster.

Mr. Lamoureux: Mr. Chairperson, I am going to attempt to be as brief and as concise as possible in terms of my questions, given the deputy minister's availability. I welcome the opportunity, and, hopefully, the deputy minister will be my preference, even to have the deputy minister respond directly to the questions, quite frankly; but of course, that is not the tradition and he has to go through the Minister of Health (Mr. McCrae).

The question that I have to start off with is, the government's Action Plan back in 1992, the former deputy minister played a very significant role in terms of putting the document together. In the letter from the then deputy minister, I want to recite one particular quote, and it is in the opening letter where he says: “Recognition that services must be provided closer to communities where people live and work. By bringing together those two solitudes of community oriented and institution oriented services, we will bring about a better balance between the two systems. Throughout the change, we must ensure that the interests of the recipients of service is always our top priority.”

The document in other places makes reference to community hospitals and the benefits of the community hospitals. It also indicates that tertiary hospitals quite often will do things which community hospitals could, in fact, do. I am curious as to where or what the deputy minister believes on this because I know it does have an impact. The deputy minister is the individual who sat and chaired this particular committee. I am very much interested in a personal opinion, and I know that is very abnormal to make a request of that nature. I am wanting to know if anything has changed in essence in terms of the department's view of community hospitals.

Mr. McCrae: What the honourable member read out is not inconsistent with the views of the administration today from what it was when it was written.

Mr. Lamoureux: There were a couple of things that were provided to me regarding the Urban Health Planning committee in how the decision in essence was going to be made, and I am just going to list some of those things, and I am wondering if the deputy minister might be able to indicate if I have missed out on some of the things.

To take into consideration in coming up with the recommendations, you were to take a look at the size of medical program, including acute geriatrics, the size of surgical program, number of operating rooms, ICU beds, primary clinic space, diagnostic service capabilities, age and quality of physical plant, and day surgery capacity. In essence would you say that, was there any other significant thing that was taken into consideration prior to or in putting together the decision for recommendations?

Mr. McCrae: In addition to what the honourable member read out, we need to have as underlying principles the appropriate number of acute care beds being available. The member has to keep in mind they also work from an understanding that there is no new money for capital improvements. The issue of patient and physician mobility is also part of this. The other one that I do not think the honourable member mentioned was the consistency with the Memorandum of Understanding with the faith-based organizations which has to do with missions and ethics and roles of faith-based facilities.

Mr. Lamoureux: I had three other points which I was hoping would have been taken into some consideration; minimal capital expenditures, and it sounds as if that is something that was taken in consideration in terms of making the decision. Another one in which I would ask for a comment on is--actually two--the future needs of Winnipeg, how that was taken into account and the principle of community hospitals if, in fact, that was taken into account.

Mr. McCrae: Indeed, the honourable member is right to point out those considerations because they, too, were part of the underlying assumptions that needed to be taken into account. Future population health requirements, aging population, growing population, number of births expected in the years ahead. In addition to that, the emphasis on hospital beds is not the main emphasis here although it is not excluded. The requirements are very, very important. We know that surgery, for example, it used to be when someone had an operation, friends would be told, well, this is what room number John or Mary is in, that is where you can send your get-well cards. Well, we now know that in most cases you just send your get-well card to the person's home, because that is where they are. They have either had their surgery based on a not-for-admission basis or they have had a very short stay.

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I think that the member has to remember this is not a hospital-based health care system anymore. I think that is the mistake the honourable member makes and a few others around do as well. There is so much more that can be done in the community which was a major part of the assumption.

The community is more important today. There was a time when probably 60 percent of hospital admissions not that long ago were on an inpatient basis. That is reversed. Sixty percent is outpatient now, and one of the things we would like to do within three years is move that to 85 percent. Now the honourable member knows what that means. That means less requirement for acute hospital beds, more requirement for surgical facilities and more requirement for supports in the community. That is the kind of assumptions that those people working on this project have had in mind.

These are not unrealistic assumptions. These are based on our ability in this technological age to do a better and more efficient job. Those changes are real; they are happening. In fact, we are following those changes. In terms of hospital acute capacity, we are following, we are not leading, because even with today's surgical patterns, we have way more hospital acute bed capacity than we need. The honourable member, I think, recognizes that. Obviously, we can quibble whether we need three beds for every thousand people or 3.2 or 2.8 or something like that, and that is fine. It is reasonable that that should happen, but we cannot run away and hide from the fact that we have excess capacity in our acute beds.

One of the other assumptions, requirements, adopted right at the design team level is that before reductions take place in acute care, there be the appropriate supports in the community. Why do you think we have added the personal care capacity that we have added in recent years? Why do you think that we have spent so much more to develop our Home Care program, 111 percent as of now in terms of spending, yet the numbers do not come out. It is because the units of service are filled with an intensity of care that was not there 10, 15 years ago. People are getting high-level nursing services provided in their homes today that people were only getting in the hospitals years ago.

Those are the types of things that we have taken into account, the very things that members opposite talk about all the time, and that is exactly what is happening.

Mr. Lamoureux: One of the questions I was thinking of asking and obviously am going to ask, but I will then continue to a different line after I pose this one, and that is I am not entirely convinced that there was an adequate amount of time for the Urban Health Planning committee in being able to gather the information.

For example, minimal capital expenditures was a part of that decision-making process, and I think it was very difficult to gauge what type of costs, and that is why there has been some pressure on the Minister of Health in terms of what sorts of cost analysis studies have been done. I do believe that there are going to be some fairly significant capital costs under the current recommendations.

I wanted to pick up on what the minister was talking about in terms of acute care beds. I think there is a valid argument that in Winnipeg we could see a number of acute care beds being cut back, and I think if it is done properly and it is monitored, any potential negative impact would, in fact, be minimized if there would even be a negative impact, as long as it is done in a proper fashion and monitored.

Under the current recommendations that have been put forward, what number of acute care beds would Winnipeg have? Can we get an approximate number under the current proposal or under the current recommendation?

Mr. McCrae: We have not arrived at that kind of number to this point. Many numbers have been bandied about, but until we factor in some of the things that need to be factored in, we are not going to talk about numbers until it is time. The factors we have to look at have to do with the average age of our population, the average age of our male population, the average age of our female population, the number of children there are to be served.

Those children and adult women and men are not all from the city of Winnipeg. They are from all over the province of Manitoba, they are from northern Manitoba, they are from Northwest Territories, they are from Saskatchewan, they are from Ontario, sometimes they are from elsewhere as well. What are the population health indicators in the various regions? How many people in Marquette region, for example, will be expected to require cardiac services that can only be accessed in the city of Winnipeg? How many people will require services on an inpatient basis or even on an outpatient basis but at one of our Winnipeg hospitals? Where are they all going to come from? Are they going to be male persons, female persons? What age are they going to be?

We have to have a lot of profiles to build into this model before we can be as clear with the number of hospital beds that it is expected would be the requirement. That is coming; the work is underway. In a sense, we are having a parallel examination of those issues in this Chamber as laypersons. Here we are, maybe some of us, trying to substitute our noninformed judgment for the judgment of those people whom we have asked to take part in this; people like doctors, nurses and other health professionals in the system.

I think that process is underway. I have told the member for Kildonan (Mr. Chomiak) that by the end of May we expect to be far enough along to have arrived at some recommendations. Conclusions should be arrived at before too much time after that. Do not forget we have budget requirements we have to keep in mind as we go through this year. The work of the primary and secondary study is coinciding with the work of the design teams and the Urban Partnership and Urban Strategy committees. Those are all things that we are indeed taking into account.

Where are all the doctors? Where are all the patients? What are the requirements going to be? You have to use the population health data that we have. Luckily in Manitoba we have a database that is unmatched anywhere, so we are expecting that we are going to make some pretty solid and justifiable decisions. No doubt the honourable member is going to be there to ask us questions about what inputs we had into the decision making that happened, and no doubt we will have answers for him when those questions come forward. There is no point asking them prematurely,

Mr. Lamoureux: The minister himself has encouraged and I think, in some part, I have been able to give some sort of insight in terms of where it is that we are coming from as a party in terms of the acute care beds. There have been other studies. I make reference to The Action Plan, but also from the Manitoba Centre for Health and Policy Evaluation, and one of the conclusions, and this is from a report from December '94, and in it it says that as part of the conclusion, less expected perhaps was the finding that the teaching hospitals also treat considerable portion of low acuity, low resource intensive cases, suggesting we function not only as a tertiary care institution, but also a large community hospital, particularly for pediatric and obstetric admissions.

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I say that because I believe that the Health Sciences Centre, in essence, is known throughout the world as a first class facility. I do not want to do anything to undermine the importance of this particular facility, but I am curious as to knowing the number, from what I understand and this is again information that was provided to me back in November of '95, there were some 854 acute care beds at the Health Sciences Centre. In the mind of the department or from within the Department of Health, do they have an idea of what it would take in order to retain that credible presence in terms of, there is a push to say, look, some of these community hospitals could be doing some of the things that the Health Sciences Centre is doing? To what degree could you actually, if you had to cut acute care beds, cut from the Health Sciences Centre before calling into question the integrity of that particular facility?

Mr. McCrae: I do not think anybody is disagreeing with what the honourable member is putting forward. In fact, I heard Dr. Wade say on more than one occasion that it is appropriate that treatment or surgery that is appropriately carried out in a community setting, like a community hospital, it is outright appropriate, that that is where it happened. Something that confounds this simple proposition is that you might be in Health Sciences Centre simply to get a gall bladder removed, which is something I am sure can be done at any community hospital in Winnipeg.

But suppose you are a stroke victim or suppose you have a cardiac condition, or suppose you have liver dysfunction, or who knows what all you might have, there are so many things that could happen to make what you might, at first blush, consider a routine procedure into something very different from a routine procedure. If, somehow, some other condition you might have or conditions you might have become an important factor in your very simple gall bladder surgery, maybe the appropriate place for you to be is at the Health Sciences Centre. That is the point. We have to keep that in mind and it might confound people who crunch numbers, including me, but I am reminded again by Dr. Wade this afternoon that we want very much, just like the honourable member does, to use our community hospitals for the types of purposes the honourable member is talking about.

I think we got further along in a debate on that point than we needed to because there never was a sense that we should just move everything to the Health Sciences Centre, even amongst the design teams which I think have the medical leaders in all the different disciplines involved in there. So some people immediately said, oh, well, you have got an academic surgeon on this design team. Well, what do you think they are going to do? They are going to want to move everything to the Health Sciences Centre.

How very naive for anybody who would say that. It is contrary, obviously, to the plan that the honourable member referred to a while ago, The Action Plan for Manitobans set out in 1992. Do you think we are deliberately, four years later, going to go out and do something that is totally inconsistent with what we set out to do in the first place, which was based on good evidence and good data, good research that caused us to put that plan in place in the first place?

The former Health spokesperson for the Liberal party was totally onside, as I recall.

An Honourable Member: A good man.

Mr. McCrae: A good person, a medical person and, yes, he was critical when it was necessary to be critical, we certainly remember that. But on a couple of very important things, he was very supportive and maybe he took a few lumps for doing that, too, for being supportive, but he did the right thing and that was to support the kind of shift that the honourable member is talking about in his question.

For anybody now to suggest that, oh, you are veering off that is totally naive, because they think that because some physician involved on a design team has some political allegiance with some particular way of thinking, well, we have got to build on the member for Inkster (Mr. Lamoureux) some confidence that the people that are working and working very hard on these projects are not simply out anymore to protect their turf. The days of turf protection should be over. The days of putting the health needs of Manitobans as the priority in all of our considerations ought to be here now.

Turf protection ought to be a thing of the past. Health ought to be the question for today. I encourage the honourable member to be mindful of that and not to be out there trying to stir up trouble where it does not exist for whatever reasons. I mean, I am aware of the makeup of the design teams. I guess some people thought the design teams were hand-picked people who would dictate the future of health care without any cost-benefit analysis, without any analysis to make sure that doctors and patients can be mobile in the system, without any analysis that takes into account that there is no money, or very little money for capital improvement, without any analysis to take into account the other things that we talked about.

That is totally naive for anybody to think that way because when they do that, they impugn the real motives of the people who are involved in this process. It is not just the people who are members of these design teams because I have met with many, many practitioners, who, listening to the messages of the member for Inkster, reacted in a sort of negative kind of a way--all for what? To stir up in people a false sense of fear about the future? How is that a constructive approach? We have a job to do here. We have the right people on the job. We are listening to the people who are not closely involved in the committees themselves. You cannot have a committee of 10,000; it does not work. So you have to have these so-called, they called them troikas at one point because I think there were only three people on each team.

Everything is sinister when you are in the opposition. I remember, I was there once, so was the honourable Minister of Highways and Transportation (Mr. Findlay). I do not think the Minister of Culture, Heritage and Citizenship (Mr. Gilleshammer) had the pleasure to be part of that opposition movement which sometimes saw some sinister aspects and things where they might not really have existed. That is what we do in opposition sometimes. I know it happens quite a lot more in a time of major transition of a whole health system across the country. I guess it is human nature to want to be critical for the sake of being critical, but there is more to this. I invite the honourable member to harken back to the days of Dr. Gulzar Cheema and the contribution he made. He was critical when it was appropriate to be critical. He was not critical just for the love of being critical.

Mr. Lamoureux: There are several components of what the minister has just finished putting on the record and which I could address and probably should. The beginning of his answer, if you follow through the logic, one then might argue, because complications could occur even in community hospitals that ultimately you should have one giant facility and all people going to that one giant facility, if you want to carry the argument to the nth degree. I trust and hope that that is not what the Minister of Health would in fact be advocating.

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I wanted to give a specific example in terms of what it is that we are talking about. You have reports that are there saying that tertiary hospitals quite often will do things that could be done in community hospitals.

There was another report, again from the Manitoba Centre for Health Policy and Evaluation, this one January of '96. It made reference to tonsillectomy procedures. I looked at one of the graphs and in the graph it says, in 1989-1990 in our teaching hospitals, 897--I will just give the percentages--45.4 percent of these procedures were done in teaching hospitals. In 1993-94, 52.3 percent, which is an increase. If we look at our urban community hospitals, 29.2 percent in 1989-90, and that went down to 20.4 percent in '93-94.

Now, there might be all sorts of rationale in terms of being able to explain why that has occurred. The Children's Hospital facility, for example, might be one of the arguments used in order to justify it. No doubt, Mr. Chairperson, I believe, and it is not just me personally, because we do have other documents that are out there that are saying that there are operational procedures, types of care that are being provided in teaching hospitals that could quite easily be done in community hospitals.

Now, if we are talking in essence about the way in which we deliver our services and as a result of that we are looking at whether it is 2.5 percent beds per thousand or 3.2 percent beds per thousand, which works out to somewhere between a range of 386 to 858 beds--and those are the numbers that are most frequently being talked about--why it is so important and why it is so relevant is that if, in fact, you can allow for community hospital facilities to continue on and not put into jeopardy the quality of service being delivered at teaching hospitals and follow some of the suggestions that are coming from not only The Action Plan but the Health Policy Institute, it would seem to make sense. This is, in essence, the push that we are suggesting now and hoping that the Minister of Health, whenever there is, whether we are in session or we are not in session, will address that particular issue if, in fact, it is not taken into consideration once the ultimate recommendation or the decision that government has made becomes known to the public.

The last part of his comment he made reference to this protecting the backyard or individual's turf protection, those were the words that the minister used. I, like him, have talked to members of the committees, CEOs, individuals that sat on the Urban Health Planning Committee and I have heard firsthand that, yes, there was a certain element of turf protection that took place, so it is not me being paranoid, Mr. Chairperson, that in fact there was, to a certain degree, turf protection. That is something which I have heard from the board.

There was a lot of concern expressed from the medical profession regarding the composition and the percentage of tertiary representatives or individuals that had background with tertiary facilities that made up the particular committees. There are ultimately many different arguments that could be brought forward on either side as I have indicated to the minister previously. Our concern was that there were not options that were provided. I believe that if the Minister of Health said to the Ministry of Health, I want to have a model that sees community-based hospitals highlighted and does not put into jeopardy the quality of service being delivered at the Health Science Centre that, in fact, that model could and would be presented, but you have to provide the proper amount of time for that to be adopted.

I would ultimately argue that any costs that might be incurred because of that additional time, it would be money well spent, because we believe in the community hospitals. Ultimately, the Ministry of Health can say, well, look, we have hospitals across the country that are closing down. In some areas it might be justified; in other areas maybe it is not justified.

Because other jurisdictions might be doing something or taking action that is similar to what these current recommendations are does not necessarily mean that that is the direction that has to be followed. You also have to take into consideration public perception and what is the will of the public. What does the public want? The public wants to be able to have a community hospital facility.

Now I will be in my own backyard with the Seven Oaks Hospital, a lot of people look at it and they say, here is a modern facility. It is the most modern facility that we have in the province. The capital dollars that are going to be required will be phenomenal in terms of renovations. In terms of future needs of acute care beds, this is a hospital that is in, in all likelihood, a better position than any other urban hospital in the city of Winnipeg in terms of minimal capital dollars required into the future.

Does that mean that no change should be given to the Seven Oaks Hospital? No, we are not saying that at all. You can incorporate long-term care. You can incorporate geriatric services. To take away what people feel so closely to, Mr. Chairperson, your medicine, surgery, emergency, critical care, these are services in which people look at, in particular in my area of the city, and they say look, in the south end you have the Victoria, in the west end you have the Grace, in the east end you have the Concordia. What about the inner city? What about the north end?

That is the reason why, when we look at the proposal and we see that on the surface it appears as if the options have not been fully explored and we look in terms of resources, the minister has the responsibility to make a good decision. That good decision is going to be based on information that is provided to him. It is the Ministry of Health, in particular the deputy minister that is providing that information. The question then becomes, was the deputy minister provided the opportunity to be able to present options that would take into consideration more than what is currently before the minister? What we want to be able to prevent ultimately is a bad decision.

We believe that there are other options, and we do not necessarily understand why those options have not been fully explored, or at least espoused upon. Hopefully when the decision is made, that if we do see the closure of the Misericordia and the Seven Oaks Hospital, we will see answers to the many different questions that people are going to have that could call into the question the integrity of the government and the integrity of the Department of Health. The questions that I am posing are not questions that I have just thought of on my own. These are questions that have come from CEOs in some of the administrations, and more than the ones than just the--some might assume that it is from the Seven Oaks. That is not the case. Three, four CEOs that have talked to me first-hand about the process, first-hand about the options. That is the reason why it is so important to us, and I will let the minister respond.

Mr. McCrae: I am intrigued by the comments of the honourable member. I would like to give him some comfort that these options that he refers to, the ones that he has heard about in his discussions with certain CEOs are, indeed, not news to us. We talk to CEOs too, and we get their input, and we are reviewing their options and those put forward by board chairs as well, reviewing those things and analyzing and agonizing over all of this.

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I am intrigued by the honourable member's argument with respect to capital improvements vis-à-vis the Seven Oaks General Hospital. Now, I was here, I think, Mr. Chairman, you will recall that we marched down the hall to Room 254 to attend a large gathering respecting the Misericordia General Hospital where it was the triple A approach: acute, active and alive, or something along that line, for Misericordia Hospital, was the hue and cry. We had, I thought, an extremely civilized--civilized is the right word--evening. The honourable member of course was espousing the cause being put forward that day, which was to preserve Misericordia Hospital basically in its present state with acute care and all of that.

Now, the honourable member for Inkster (Mr. Lamoureux) has talked about the Seven Oaks Hospital and how minimal capital improvements are required to keep it as an acute care hospital. The honourable member for Inkster was very supportive of the people here that day and the position they were putting forward. I wonder if he would enlarge on the whole capital issue vis-à-vis Misericordia Hospital for us.

Mr. Lamoureux: What I alluded to was that the Seven Oaks Hospital is a very, relatively speaking, modern facility compared to other urban hospitals. There are going to be significant capital requirements, for example, if you expand acute care beds over at the Concordia Hospital. There are going to be very significant capital requirements if you have to start changing halls in the whole setup of the Seven Oaks Hospital in order to convert it into a geriatric centre. There are going to be very significant costs for emergency services, O.R. rooms at the Health Sciences Centre, and no doubt other areas as a result of the current recommendations.

It is estimated, at least I understand, that they might even have to have an entirely new emergency services built on with the Health Sciences Centre as a direct result of the recommendations. The Misericordia Hospital, currently and into the future, is going to require capital dollars in order to maintain in whatever capacity it is going to be delivering services.

We are at a bit of a handicap. Back in October, November, I had thought that, if we had to cut a number of acute care beds, the biggest loser out of this would be the Misericordia Hospital. The more that I got involved in talking to individuals, experts in the health care field, you get a better understanding of how in which acute care services are being delivered, I do believe that the Misericordia Hospital can have a future role in the deliverance of acute care, along with emergency services, and, yes, it is going to require capital dollars. There is no doubt about that into the future; all of our urban hospitals are going to require some capital dollars. If you were to look at the recommendations that are being proposed and you accept them wholeheartedly, the amount of capital dollars is something that really has not been addressed. How many capital dollars are going to be required to convert Seven Oaks Hospital into a geriatric service centre?

I could ask that question, but the minister does not have the answer. I asked back in December: How many capital dollars were going to be required in order to bring the Health Sciences Centre emergency room up to par? We currently know that even today we understand that overflow from the Health Sciences Centre emergency goes over to Misericordia. If you had closed down both Misericordia and Seven Oaks, what sort of a situation does that put the Health Sciences Centre, the type of capital dollars.

Ultimately, I do not believe that it will be the capital dollars that will have to prevail. It is the ongoing operational cost that government has to be concerned with, and where are you going to get the savings of those operational dollars? Well, look at the costs of maintaining older facilities compared to new facilities. Look at the cost of providing that service from a community hospital perspective to a tertiary hospital perspective.

I believe that there you will find many different ways in which dollars can, in fact, be saved. Ultimately, as I have indicated, it is the way in which you want to deliver that service, and I believe that service is best delivered in our community facilities. If, in fact, you have to cut back on acute care beds in order to acquire the savings, then there are acute care beds that can go, and I have acknowledged that in the past. The actual number, I am not prepared to give the minister a number, because he has much better resources that I do, but my concern is that he uses those resources, and at the end of the day, he is prepared to be able to answer the many different questions.

I guess, Mr. Chairperson, my final question is, because we are running out of time, the minister in a letter sent to me did indicate that, again, he was going to provide some sort of a public forum outside of the petitions and cards that have been sent in. I am wondering if he might be able to give us some sort of indication on whether or not that is going to happen in the near future, in particular, given that he indicated that there will likely be some decisions being made at the end of the month.

Mr. McCrae: The honourable member has failed the test of logic, Mr. Chairman. He did not address the question respecting the Misericordia Hospital that I put to him. He has not come forward with anything helpful in terms of how you address that capital issue at Misericordia Hospital, where it is clear that significant capital requirements would be part of a plan that would lead to the system that he supports.

He lent his support here at this Legislative Building in front of hundreds of people, let them know that he supports them. Well, the problem with that is that it defies logic. He has not given us any evidence at all to justify or to lay a foundation for that support that he has put forward.

I am a supporter of Misericordia Hospital, Mr. Chairman. I am always working with the people there. The fact is, though, in a time when dollars for capital expenditure are not there, the honourable member has failed to show that his support is well placed. Be that as it may, we are involved in that process that I referred to with the honourable member. I have answered this question. We are addressing his issues as he raises them. We are addressing other issues being brought to us through public consultations that are being conducted on a regular basis as we speak.

The Acting Chairperson (Mr. Radcliffe): The honourable member for Inkster, for 15 seconds.

Mr. Lamoureux: My question to the minister then is to reverse it. How many capital dollars then would be required in order to sustain Misericordia as a hospital with acute care services?

The Acting Chairperson (Mr. Radcliffe): The hour being 5:30 p.m., this committee is recessed and stands recessed until 9 a.m. tomorrow (Friday).