HANSARD

Printed and Published by Nova Scotia Hansard Reporting Services

Ms. Maureen MacDonald (Chair)

Mr.Chuck Porter (Vice-Chairman)

Mr. Patrick Dunn

Mr. Keith Bain

Mr. Graham Steele

Mr. David Wilson (Sackville-Cobequid)

Mr. Keith Colwell

Mr. Leo Glavine

Ms. Diana Whalen

[Mr. David Wilson (Glace Bay) replaced Mr. Leo Glavine]

WITNESSES

Department of Health

Ms. Cheryl Doiron

Deputy Minister

Ms. Brenda Payne

Executive Director, Acute and Tertiary Care

Mr. Keith Menzies

Executive Director, Continuing Care

Ms. Linda Smith

Executive Director, Mental Health, Addictions, and Children's Services

Ms. Sandra Cascadden

Chief Information Officer

In Attendance:

Ms. Charlene Rice

Legislative Committee Clerk

Mr. Jacques Lapointe

Auditor General

Ms. Evangeline Colman-Sadd

Assistant Auditor General

HALIFAX, WEDNESDAY, JANUARY 16, 2008

STANDING COMMITTEE ON PUBLIC ACCOUNTS

9:00 A.M.

CHAIR

Ms. Maureen MacDonald

VICE-CHAIRMAN

Mr. Chuck Porter

MADAM CHAIR: Good morning. I'd like to call the committee to order. Before we start with our hearing this morning, I wonder if we couldn't all rise and have a minute of silence out of respect for the young people and their teacher who so tragically lost their lives on the weekend.

[ One minute of silence was observed.]

MADAM CHAIR: Thank you. Please be seated. Today we are very pleased to have with us officials from the Nova Scotia Department of Health with respect to wait times, a very important topic and certainly a timely subject. We had a report yesterday, from the Canadian Medical Association, I believe, and I understand the department has come with a copy of this report which hadn't been provided in our package, due to its release yesterday. I'd ask the clerk if she will table a copy of that and it will be circulated at a later time to the members.

We will begin in our usual fashion of introductions of members of the committee, members of the Auditor General's staff and the witnesses from the department. Following that we will have a brief opening statement from the department and our usual round of questions.

[ The committee members and witnesses introduced themselves. ]

MADAM CHAIR: Thank you very much. Ms. Doiron, the floor is yours.

MS. CHERYL DOIRON: Thanks. You will notice that I brought more than my usual couple of people with me this morning. As we all know, wait times encompass such a broad range of programs and the interaction between them and also it depends so much on many of the enablers, including Human Resources and Information Systems and beyond, so I tried to bring some people that I thought would be able to directly address some of the questions that the members might have.

It is our pleasure to speak with you this morning about this subject in the health care system in Nova Scotia. Waiting can occur at various stages of the health system, from the time it takes to see your family doctor or a specialist to the time it takes to receive various diagnostic services or treatments, and there are many reasons why waits occur. An aging and increasingly unhealthy population means there is an increased demand for medical attention and for more complex care. The variety of tests and services available and their cost means that we must make choices about when and where these services can be offered. Finding and keeping the right mix of health professionals in the areas in the province where we want them can be a challenge at times.

Even with the best maintenance programs and ongoing funding, sometimes health care diagnostic equipment is unexpectedly unavailable, making it necessary to reschedule patient tests at a later date or at a different facility. This can cause a ripple in the system that affects time other people are waiting for the same diagnostic tests. The amount of time that Nova Scotians wait for health care appointments is directly impacted by people missing scheduled appointments without providing sufficient notice. There are many other factors.

Nova Scotia is committed to improving access and reducing the wait time for tests, treatments and services across the province. Since 2004, when the First Ministers met and Nova Scotia agreed to the 10-year plan to strengthen health care, we have worked on many fronts to better understand our wait times, including getting meaningful and reliable information and using the information to shorten wait lists and address backlogs, investing in the right equipment and sharing more information to increase accountability.

Nova Scotia's plan does not stop there. It also involves having the right mix of health care professionals as close to home as possible, the right services in place to meet the growing seniors population, the right measures in place to respond quickly to pressures across the health system, the right technology systems in place to create system efficiencies and help us provide safer, faster care and the right primary health care services available in communities. It also includes efforts to educate the public about how to manage chronic conditions and how to lead healthier lifestyles. We are working closely with our health partners in the district health authorities and the IWK to continue to make progress.

In the material you received from us in preparation for today, you will have seen examples of that progress. From the installation of new equipment to the expansion of services, we are improving wait times in the province. While wait times are important it is also important to note that wait times are not the only driver affecting decisions we make in the health system. Appropriateness,

quality of care and better outcomes are examples of some of the other equally important factors that we must consider in maintaining and improving our health system.

We are thinking differently about our health system these days and that means we're also acting differently. You will also have noted that the department is on the brink of releasing the first comprehensive review of the health care system, maybe a little sooner than we thought. While I will not be able to speak in any detail today of that report or its recommendations I can tell you that there will be some very positive impacts on wait times as these recommendations are addressed.

I thank you for this opportunity. My staff and I now look forward to answering your questions.

MADAM CHAIR: Thank you. The opening round of questions will be with the NDP caucus. Mr. Wilson, you have 20 minutes.

MR. DAVID WILSON (Sackville-Cobequid): Thank you, deputy, for coming before the committee again. I think it's important that this committee looks at areas that Nova Scotians feel are most important. I can tell you from my experience over the last couple of years as the NDP Health Critic that health care is probably the most important area for Nova Scotians, especially now in rural communities. I have found over the last several years that I've received hundreds of calls, as the Health Critic, from throughout this province, many of them from individuals living in rural communities.

I know that you mentioned the report that's going to be released tomorrow, I believe, the long-awaited report that the province funded to have Corpus Sanchez consultants look at our health care system here today. I understand your unwillingness to answer direct questions about that. What I'm going to try to do is go over some of the areas where we feel there is some concern around wait times, things from surgery wait times, long-term care wait times, ER wait times, and those individuals who are seeking specialists. We could probably talk for days on wait times, so I'll try to do my best to limit to the areas I'm going to cover to try to get some answers.

As you are aware, I think you're aware, we've taken wait times seriously as a Party over the last number of years, it has always been at the forefront of questioning in the Legislature. Last Spring and throughout the summer we, as a Party, decided that we needed to do something to try to engage Nova Scotians to tell us some of their issues in wait times and try to engage health care professionals to try to show us or tell us where we can improve on health care delivery here in the province.

In the Fall we released a paper called "Shorter Wait Times: Options for Action". We did that because we have been hearing from Nova Scotians throughout the years about their concerns. My first quick question because we do have limited time, have you seen a copy of that paper that we released in the Fall?

MS. DOIRON: Yes, indeed we have. I would like to say that we certainly appreciate the dialogue and the results of that dialogue because basically I think the suggestions in that report are very consistent with where we believe we need to be as well. We know that we have already started acting on a number of the initiatives that were identified in the report and I don't think there were really any inconsistencies with what we thought were the appropriate directions to try to deal with this rather overwhelming issue and to attempt to respond to people who live anywhere in the province.

[9:15 a.m.]

MR. DAVID WILSON (Sackville-Cobequid): Thank you. That definitely helps us to ensure that we, as a Party, are discussing the important aspects of health care and health care delivery in the province. One of the areas that I've been a strong advocate for over the years, even prior to becoming an MLA, is around the collaborative practices and the use of our nurse practitioners. Definitely I think today in the atmosphere we have in the province, in the past, it's very difficult in the environment of doctors who lead the drive on changes within the health care system, where nurse practitioners weren't as accepted as they should be when they first started to train here in the province. I think we've turned that corner where we see, especially rural physicians, realizing that they need these professionals to provide the services to their residents, especially in rural communities.

One of the things we talked about was utilizing more nurse practitioners and one of the questions - I believe I've asked you this before - is why aren't we exploiting nurse practitioners and ensuring that they have every opportunity in every part of this province to provide the service? They can provide great service to individuals and hopefully reduce the pressures on emergency rooms, the need to see a physician. Maybe a quick comment on why, I believe - but I don't know if it's your opinion - that we haven't utilized nurse practitioners to the utmost here in this province.

MS. DOIRON: Thank you for that question, it's a very significant question, I think, because first of all I agree that we need to keep building the resources we have with nurse practitioners. We have, I think, made some significant progress and you mentioned the change in thinking that many professionals, including physicians, have been transitioning through, if you like, to come to the point where we truly can start to look at collaborative practice.

As we had started to set up collaborative practice groups in the province, for a while it was some of the early thinkers, I guess, in the physician groups who were willing to kind of go down those roads. In a way, we were kind of setting up these collaborative practice groups and opportunities in the sense as add-ons to the system that is there.

I think we're all coming to the conclusion that it is now time for us to transition to a different place where we are collectively thinking differently about how we provide care and how we practice with groups. Certainly, nurse practitioners are an extremely important group that we need to continue to build on and to add to our system. I think, as importantly, we need to look at exactly how other

health care workers are being utilized as well and to truly start to deal with how teams of staff can work better and provide better service to the public and to communities. When I say that, I'm thinking of people who are already in the system be it RNs, LPNs, pharmacists, dieticians and others, but also other groups that we have not used quite as much and are currently exploring, such as physician assistants.

I believe the time is right and I think the thinking has actually taken a dramatic shift and we're basically hearing the similar kind of directions and intentions coming from physician groups, other professional groups, university groups where our people are prepared, et cetera. At this point, I think the job of the department is to facilitate that, to try to coordinate it across the province and to try to enable it, and that's where we want to go.

MR. DAVID WILSON (Sackville-Cobequid): I think one of the things we don't do enough is look within our province on where in certain areas they're doing good things. One example quickly is Long Island/Brier Island, where I think it was a couple of years ago now, a nurse practitioner was put in place, also with paramedics who had an extended scope of practice. From all reports that I've read about that initiative, the residents have really expressed their happiness, their willingness to work with that type of team. I know at first, there was some reluctance to accept it because we weren't focusing everything on a physician but from all reports, it's well received within the community, a high percentage of satisfaction rate and actually, a reduction in the number of residents who seek emergency room visits. With that example, I think we need to accelerate the use of that program, the use of that example.

Recently, I met with a nurse practitioner who was really sent to me from a physician who was frustrated because they wanted to open up a collaborative practice here in the province close to Windsor. What they found were just roadblocks, having to deal with 10 to 12 different individuals to try to come to an agreement, an arrangement that would allow a physician to work with a nurse practitioner. Finally, after several months, things started to move. Why are those roadblocks still there?

One of the statements that was made to these two individuals was that there was no template for an arrangement of a collaborative practice within the Capital Health region, which kind of blew my mind that there's not a template that if a doctor states to your department that they want to organize this type of clinic or collaborative practice that here you go, this is how you do it.

Why are there so many roadblocks and why isn't there one individual in this province overseeing collaborative practices to ensure nurse practitioners and physicians who want to work together can do it smoothly and quickly? We are in need of them yesterday, so maybe a comment on that.

MS. DOIRON: I'm not quite sure which particular situation you're referring to so it's hard to relate to that specifically. What I can say is we have, over the last several years, been seeking and actually receiving each year some additional dollars to set up additional collaborative practice

groups. Generally the way that has been approached is that we basically send out a request for proposals and any group that wishes to put forward a proposal can do so. We have been seeing quite an increase in the number that are coming in and also in the variation in the type of groups that people want to pursue, such as initially we were looking, I think, primarily at primary health care - GPs, nurse practitioners and perhaps some other professionals. We are now looking at and trialing, for example, a nurse practitioner in a nursing home. There's a trial going on at Northwood to look at that application.

We have discussed and are looking at the role and the protocols, for example, of having a nurse practitioner in an emergency department. So we keep going beyond where we are now.

We have not had adequate funding at this point to approve every single application that has come in because, as I said earlier, generally up until now this has been an add-on approach through the system, so it's always new dollars. I think we are at a point where we can collectively start looking at how do we simply re-organize what we have in the system in a way to make that feasible and a way to allow it to permeate a lot of different kinds of locations and different kinds of practice. That is what we are currently pursuing.

We had this past year a changeover in our lead in the department for primary health care and I don't know if that contributed to any confusion for a period of time. We do have a Director of Primary Health Care in the department currently, Maria Kuttner, who basically is responsible for organizing and coordinating the initiatives around this particular area.

I also want to note and agree with you in relation to the potential that is still there, I think, to capitalize on the competencies that paramedics can bring into collaborative practice. So I believe that we have yet a long road to travel but we want to pursue that and basically take that much further. As you're probably well aware, I think without exception, wherever we have put primary health collaborative practice groups or other collaborative practice into action, we get extremely positive feedback from the public. So this seems to be an approach that the public really likes to have - that is being able to access a group of practitioners, as opposed to just a single practitioner or a single physician.

MR. DAVID WILSON (Sackville-Cobequid): So you had stated there wasn't enough or adequate funding towards this. Have you been directed from government to limit the number of collaborative practices currently, because of that funding gap, and/or have you requested to ensure in the budget for this coming year that this is an area where we need to explore and add funding to?

MS. DOIRON: We have not been given any direction to limit whatsoever. What we have been doing more recently is yes, we appreciate getting the extra funding, it makes it very feasible to kind of rush forward, look at the approval proposals and kind of get something activated.

What is a little bit more time consuming and difficult is actually transitioning the system to be able to take the resources we have and reassign them in a way that allows collaborative practice

to occur. Again, we have no restriction on our opportunity or ability to do that. For example, we have done things already where if we, for example, in a small community, may have difficulty recruiting several doctors but maybe have one or two doctors but have the funding in the system to apply to a number of additional, we are exploring those opportunities to say well take the funding that is there and create a different kind of team and approach and allow that to occur. I think we have more of those opportunities to come in the future. So I don't really see any limits on that.

We've also approved some proposals that have come in from district health authorities where they themselves have reorganized some of the resources they have and have them proposed that they support a team in a different way. So right now I think one of the messages that we would like everybody to hear is that we are extremely open-minded about being creative around this and we are inviting health professionals and our managers and our public to help us to understand how we can do this effectively, both with new dollars but particularly with the dollars we already have.

MR. DAVID WILSON (Sackville-Cobequid): Definitely that's something that we've echoed because one of the criticisms any Opposition Party has when making suggestions and providing examples of what we should do is, where does the money come from? We've been saying consistently that there is money within the system to deal with some of these wait time issues and delivery issues; it's a matter of who is doing it, where they are doing it and how they are doing it. We've heard that recently from Dr. Jaap Bonjer, the head of Dal surgery who recently released Keeping the Promise document - I believe just before Christmas - and talking about reducing wait times, especially around surgery. That is an area where we've seen a consistent increase in wait times throughout the province.

The federal benchmark for knee and hip replacement is 26 weeks and we are consistently over that - I believe we're at 36 weeks. That agreement and that benchmark was agreed upon four years ago. So what have we done to improve that? What has government done to ensure that if we're going to make the promises to meet these benchmarks, why are we not seeing a reduction in those wait times?

MS. DOIRON: A very fair question. Basically as you know, there were five major areas that those benchmarks applied to and in the other four we're doing reasonably well. Like many provinces, we are having a real struggle with the knees and hips, particularly those areas of orthopaedic wait times. We have been taking a whole variety of approaches to that. I think basically so you don't have to constantly listen to me, I'm going to defer the question to my Executive Director of Acute and Tertiary Care and let Brenda Payne give you a little bit of perspective on that.

MADAM CHAIR: Ms. Payne.

[9:30 a.m.]

MS. BRENDA PAYNE: Thank you very much. In response to what we've done, specifically related to orthopaedics, there have been a number of initiatives that we've actually implemented over

the last couple of years because we've been aware, for a variety of reasons. One of the predispositions for requiring knee or hip replacements are really related to our incidence related to arthritis. We know in this province that in comparison to other jurisdictions across the country, arthritis is quite prevalent in our province for Nova Scotians.

We have several centres throughout the province that provide orthopaedics and although Dr. Jaap Bonjer specifically related to Capital Health, the department actually has added additional resources for orthopaedics in other parts of the province where orthopaedics are provided; specifically in District 3, we added another orthopod. We also moved the New Glasgow orthopaedic program from two to three, because our objective was clearly not to focus in on one particular district health authority, that being Capital, but in fact our residents throughout the province need to have access to orthopaedics in all of our centres.

Also, about three to four years ago, we met with Capital Health specifically to say, we have a significant issue in this district, how can we work together in order to help you with orthopaedics? As such, Capital presented to the Department of Health a proposal to actually increase orthopaedic in-patient beds by 25 and also to assign an OR theatre specifically to hip and knees.

That initiative did not - we were hoping that in fact we would produce an additional roughly 570 additional hip and knee procedures, in order to address the wait list. In fact, what happened is because of the issue of anaesthesiologists, they were not able - even with our additional significant dollar investment into Capital - were unable to meet that because of HR issues. We are very pleased - orthopaedics is one of our priorities for the upcoming years. There are a number of initiatives that we are currently engaged in with our objective because it has now become one of our priorities to reduce that wait time. But not unlike other jurisdictions, to solve the problem it involves a number of people, including the public in terms of lifestyle changes, et cetera. We intend to continue our focus and we are optimistic and anticipating a significant reduction in orthopaedics over the next number of years.

MADAM CHAIR: Order, please. The time has now expired for the NDP caucus.

Mr. Wilson for the Liberal caucus, you have 20 minutes.

MR. DAVID WILSON (Glace Bay): Thank you, Madam Chair. Good morning, deputy. I don't know why you needed all the backup; we always treat you well when you come to Public Accounts. We affectionately refer to you as the person with the worst job in Nova Scotia, as a matter of fact. It's good to see you again and not good to talk about the same old problem which we've talked about many, many times before - the issue of wait times.

An interesting report in the media today - I'm sure you read it briefly - from the Canadian Medical Association, which had a study done that showed the impact of wait times on the economy in this country is pretty staggering. As a matter of fact, they estimated about $14.8 billion annually that it costs the Canadian economy. There is some controversy surrounding that report because the

president of the Canadian Medical Association is the owner of a private health care clinic in Vancouver. I didn't mean to bring up the "P" word, but it does come up from time to time when you discuss wait times.

I have some specific questions on wait times, but I did want to get some mention in of the fact - and I know it's not that you're reluctant to talk about the contents of the Corpus Sanchez report, but I understand you can't do that until it's actually released. I did want to ask your opinion on one thing. Wait times in this province, and they are some of the highest wait times in the country, depending on the particular procedure that you're talking about, if I said to you that joint replacement surgery in Nova Scotia has one of the worst wait times in the country, I think you'd agree with me and you'd agree that something has to be done about that.

I'm wondering, in your opinion, have we been taking our time lately in Nova Scotia in regard to what we're doing about wait times, whether it be in surgery, long-term care, or ER wait times, have we been taking our time and holding back pending the release of the Corpus Sanchez report, waiting to see what the Corpus Sanchez report is going to tell us and perhaps knowing that that report is going to tell you and us that we have to start doing things differently and by differently, I'd like to have your opinion on what I consider to be different and what you consider to be different, maybe two different opinions? That is a wide-ranging question that I've thrown at you and I don't want you to take all of my 20 minutes, but I would like an answer. Thank you.

MS. DOIRON: It is quite a broad question. I'm going to try to be reasonably precise and then if you wish to pursue further, obviously, feel free. I first of all want to say thank you for your sympathy and I want to say that I have a wonderful team and because of that we are able to do some pretty tremendous work in the province with the Department of Health and in health issues.

I do want to say that we have not been holding back awaiting the report. While we'll talk about the contents of that report tomorrow, I think one thing I'd like to say about that today is that as we pursued this work, the work was pursued in partnership, as you know, with the district health authorities and the IWK. Through this entire work, the CEO, their senior teams and the board chairs have been extremely involved.

It was our objective as we pursued this work that basically we would come to the end of that report in a position where we all agreed with what is in the report - in other words, we would own the content of that report. What we did not want was to pursue this extreme amount of work - and it was extremely detailed work - and end up with a report that would be put on a shelf or that we would start debating whether we agreed or disagreed with. I think that part of the hope through this is that, as we pursued our way through the process of the work, that it was a process that we all engaged in and I think that gives us great hope as we start to look at what is flowing from that report because there is already a tremendous leadership commitment to take our health system to those next places.

We did not stop work in the interim. Anything that we felt was consistent with the directions that we thought the health system would probably want to pursue, we tried to continue that work. As one example, Brenda has given you some perspective on some of the activity around orthopaedics. Another orthopaedic initiative, because we can't mention them all in each answer, but we are now one of three or four provinces working with what's called, Bone and Joint Canada, which arose out of the Calgary approach to dealing with knees and hips which has been extremely successful and which dramatically cut the wait times there once there was implementation of a different approach that looked at the continuum of care from the very beginning right through the recovery from hip and knee surgery. It basically helped people during a waiting period - a hopefully reduced waiting period - to prepare better for the surgery, to be in better shape, to work with a collaborative team in a clinic kind of setting and rather than simply be referred from one doctor to another and be put on a wait list. That's the kind of continuum and continuity that we want to pursue as we go down the road.

We have been invited with that group who are now working with an area in Ontario and also with British Columbia - Nova Scotia is now a group that's working toward that kind of an objective. We honestly believe that through that and a whole variety of other initiatives that Brenda has indicated, we will be able to in a definable near future, be able to truly impact what is probably the most difficult and longest wait time that has the most impact perhaps on the quality of life of people waiting.

I give you that example to say it is but one example of many things that we've been trying to pursue as we also take a look across the entire system and say, how do we deal with that across multiple programs and services?

MR. DAVID WILSON (Glace Bay): I thank you for that answer, but we're going to disagree on a few points. One is that I guess you can tell people that there's a continuing of continuity and you can tell people that, as you mentioned in your previous remarks to my colleague from the NDP, there has been a rush to try to find a solution to some wait times. In my opinion, there has been no rush in Nova Scotia to try to find a solution for wait times. If there is, then you and I have a different opinion of what a rush is.

I first started talking about this when I got elected some eight or nine years ago and we're still talking about it here today. You've been through various deputy ministers in your department and various ministers in your department - quite a few as a matter of fact - over that time period. Wait times today, in a lot of cases, are worse than they were back eight or nine years ago. So if that rush is there and when you keep mentioning phrases as you've used here this morning as well about being open minded, about being creative and about how to do things differently, then those phrases seem to go right out to the now famous phrase that your current minister uttered not too long ago, that everything is on the table in this province. That again always raises the red flags about private health care in this province and eventually where that's going to take us. I'm interested in having your opinion for the record here today, do you feel that private health care in some form or shape is around the corner in this province?

MS. DOIRON: Basically, I think my personal opinion, professional opinion, is consistent with where the government is today and that is first of all to say . . .

MR. DAVID WILSON (Glace Bay): If you can tell me that, I'll be happy.

MS. DOIRON: My understanding - and I think I've heard this pretty recently from both the Premier and our current minister - is that what we are supporting is a public system for things that are in short service. Basically that does not necessarily exclude the inclusion of the private provider under certain conditions, but it means that the private provider, should they be engaged, would have to do so within a publicly defined, publicly funded system that does not end up with queue jumping. That is the approach that I would say I support.

There are times when I think it is appropriate to enter into partnerships with the private sector, but I think each case has to be extremely well examined on its own merit, on the intentions and the purpose, on the win-wins that may go with it, on the business case that would have to accompany it. I keep going back to the example, because I know historically many hospitals in previous days had contracted things like food services or support services of one type or another. The major clinical service that has been a contracted service from the private sector in this province for years has been our ambulance service, but that has been under well defined conditions, under standards, under deliverables and I think it has stood up quite well to scrutiny. We, in a sense, oversee that system and manage those standards, the deliverables and monitor what is occurring within it. I think it is continuing to serve Nova Scotians well.

I am not of the opinion that we should see private health care providers come into this province and simply set up business. You will see in the bill that was tabled not this session, but the last session of government, the parameters that are around that bill actually provide more restrictions on what private companies can do in this province than the current state of no legislation to address it.

[9:45 a.m.]

My hope would be that at some point we might have circumstances that will help us define under what circumstances and conditions we can partner with the private sector. We would only do so case by case. Each case, whether it was on a district's specific basis or a provincial basis, would be reviewed by the department and under the direction of the minister. Basically, under those circumstances I think I would be open to seeing if there are any opportunities we currently don't have available to us.

MR. DAVID WILSON (Glace Bay): What would you say to a person in this province - and there are many, as I mentioned we have some of the worst wait times in the country - to the person who has been waiting for months for joint replacement surgery, for the person who waited nine hours last night in an ER room in parts of this province just to get a doctor to even see them? What would you say to a person who hasn't had cardiac surgery but is requiring it and walking around on pins

and needles waiting for an appointment in Halifax? What would you say to a person who cannot get into a long-term care bed because the system is jammed for whatever reason? How would you tell those people that Nova Scotia has a plan to deal with wait times? What would your answer be to them if they had an opportunity to get to meet the Deputy Minister of Health and say hey, I can't get my hip replaced and I haven't been able to for months, what are you going to do about it?

MS. DOIRON: Basically I think in that situation, what you have just done is identify the breadth and scope of the areas and the issues that are impacted or do impact wait times. For example, in terms of people waiting for beds in a long-term care facility, I think you are aware of our continuing care strategy, it is moving ahead as quickly as we could keep moving it. We are in the process of putting more community-based programming out there. We are in the process of building, by next year and the year after we will have completed in excess of 1,000 beds - the ones that were RFP'd and others that were okayed prior to that.

Basically we are doing all kinds of mitigation strategies in the interim. For example, we recently called for proposals from the district health authorities to increase day programming spots in the province. We know that this Spring, Capital Health, for example, will be I think opening up something in the order of about 400 spots for daycare. We could go through lists and lists of what is happening.

In the Project Management Office that is managing the program initiatives under continuing care - not the bed side, the programming side - we have 108 discreet projects that are in implementation - some have already been achieved, others will be within the next year or two - over and above day-to-day work. Then, of course, we have the beds on a pretty fast schedule as well.

That basically, as you know, has a relationship to the freeing up of beds in the acute care system. I'm not going into detail with all the other ways we're working on different fronts to address some of those bed issues but we are, through what I've mentioned and some other initiatives, basically intending to impact some significant changes in numbers in how the in-hospital beds will work. We have validated, with the district health authorities, that as long as they have those beds available and we have adequate beds in the system but they must be free for acute care patients. If those beds are free and we can flow patients appropriately through the system, then we will not have the wait time that you mentioned for that person probably in the emergency department.

We will, I think, through some of the other initiatives that we're talking about with primary health care and attempting to work differently at the various community levels, we will also be impacting that wait in emergency departments. We will hopefully be doing things that will keep the 75 to 80 per cent of the patients who don't need to be in emergency departments, away from there. It's no good to simply say that and not follow through with alternative approaches to how people can get care. That is the intention in the very immediate future, to keep working on those kinds of approaches and to collaborate and work with people at the community level, in order to deliver the kind of basket of services that they believe is going to best serve their community.

So those are just a couple of comments, Madam Chair. I don't want to go on too long and take up the minister's - sorry - the MLA's time.

MR. DAVID WILSON (Glace Bay): I never want to be Minister of Health, let's make that perfectly clear.

I don't have much time left but I will comment on the long-term care. There are, in terms of what's being done with the continuing care strategy that you have and the single point of entry system in this province for assessment for nursing home placement, for instance, your department has quoted that as reducing wait times. I think in reality that it's having the opposite effect, that there's a backlog of assessments and beds that are being left empty, especially respite care beds. If assessments are taking too long, then respite care is no longer needed and probably, in my humble opinion, home managers should be allowed to assess for respite cases on their own.

I would be interested in knowing the vacancy rate for nursing home beds and for respite care beds. Let me give you an example; we know that in Windsor, for instance, there was a nursing home manager there who said that his respite care bed was empty for almost 100 days last year, so do you have a comment on that?

MS. DOIRON: Yes, I do, but I think I would like to defer, Madam Chair, to Keith Menzies.

MADAM CHAIR: Mr. Menzies.

MR. KEITH MENZIES: Thank you for that. With respite care we have been looking very closely at the utilization of the respite beds. We carried out a complete review of them in the past few months. You are right, in some areas of the province there have been fairly high vacancies in those respite beds. That has led us to make two changes with the respite beds; first of all, we've taken some of them out of the respite grouping and are making them regular beds so that we're making better use of them but at the same time ensuring that we keep some respite beds in areas in every district across the province, so we are recognizing the utilization issue there.

The second part is that the district health authorities have said we need a different kind of bed as well; we'll set some of those beds aside for adult protection beds. One of the difficulties we have is that if somebody needs adult protection and they need a safe place to be, if there isn't a regular nursing home bed available we wind up having them in emergency so we will take several respite beds and convert them to adult protection beds, so that there is that immediate safe place out of the hospital.

The district health authorities have acknowledged that there are times when people present in emergency who need some kind of service that doesn't require them to be in hospital but, because there's no other place for them to go, they will wind up staying in hospital. So we are working with a pilot in two districts to try and identify the care need that would allow us to place that person in a different bed. We will partner between a district health authority and a nursing home in that area

to identify the care need first and then what additional resources we need to be able to move that person.

So we are attempting, certainly on an interim basis and into the future, to use those beds more effectively.

MADAM CHAIR: Thank you very much. Order, the time has now expired for the Liberal caucus.

Mr. Porter for the PC caucus, you have 20 minutes.

MR. CHUCK PORTER: Thank you, Madam Chair and welcome this morning. I'm glad to see you. I guess wait times is something near and dear to my heart. I've been involved in the health care system, as you probably know, for a few years. I've seen a lot of examples of wait times in the health care systems and what it means to people are certainly different things. To some it means waiting in the emergencies, as we've heard a few moments ago, to some it means getting into long-term care, surgeries, et cetera. It has never really been defined because today someone will come into my office and talk about waiting for a knee surgery and I know that is one that takes a while, as an example, they're not thinking about the wait time at the emergency to get in. So to me it is just really something that is very broad and seems to be all over the board when we talk about wait times. Wait times for surgeries, wait times - I'd like to see that certainly better defined when we talk about if there are improvements to specific wait times in certain areas, then people should know about that instead of just saying oh, wait times are you wait, you wait, you wait. I think there's some room there.

I want to go back to a couple of things that have already been mentioned. One, I'll pick right up, Mr. Menzies, where you just left off. It is interesting, a couple of issues have come up about my area and I'm going to speak to both of them because it seems that the wait time for the respite care bed - I remember a day when if a respite bed was needed, you made a phone call to Dykeland Lodge or the Windsor Elms and within a couple of hours that person moved and it worked very well.

Today, with the centralized, or whatever the proper terminology is for this system, it's not working as well, in my opinion. I speak from experience, it's not working well at all. Both of my nursing homes in Windsor, Dykeland Lodge and the Windsor Elms, have experienced numerous vacancies, and I know that you're working on that. I hear about that from councillors, from folks who work at the home and I visit the homes on a regular basis so I know, and it's not just the respite beds, it's long-term care beds; there seems to be an awfully long wait to get in there. I can assure you there is no shortage of people waiting over in Unit 500 at Hants Community, to be moved into either of those beds.

It is a very strange thing to me as to how that whole system operates and how those placements are done. Just personally speaking, I don't think it works very well, in my own opinion. So I'm interested in the respite care bed, we'll start with first, Mr. Menzies. I know it takes, speeded

up, a week to get in there is what I've been told, from dealing with a case - it would take a week to get that person into a respite care bed that was available. Is that accurate or am I being misled?

MR. MENZIES: I can't speak to a specific situation without going back to that client and understanding what happened with that client. One of the changes we've made in our practice as well, that I didn't speak to you about a minute ago, at one point when we went into the cost of care three years ago, the changes in the way care is paid for, we did require at that point that anybody looking for respite would go through and have a care assessment done and have the decision made around placement at the placement office.

We have since gone back in this past year and changed that, so it's not a care coordinator who sees you and makes the determination that you can access a respite bed. So it should be easier for people in communities to access those beds.

MR. PORTER: Easier to access those beds - can you give me a time frame, then? You know, we've got a coordinator, that's great, what are we looking at in time? A couple of days? A couple of hours?

MR. MENZIES: I think it's a matter if a client has not had any contact with continuing care that there is a care assessment to be done, so there is a period of time to have that done. My understanding is that once somebody is approved for respite, you come forward and yes, you're approved for respite. From there on there shouldn't be any time lag at all in that. So if there's a specific case that you're referring to, I'd like you to give me the name afterwards and I'll go back and look at it.

MR. PORTER: That's fine and I'm not really digging at specifics to an individual or one or two, just in general, because it's not one case, it appears to be more than one case. But you talked about being approved, maybe you could speak to and clarify for me then, how long does it take to get approved?

MR. MENZIES: It's the care coordinator who assesses the clients and decides that the person is eligible for respite and needs that kind of service and that's the approval, when the care coordinator has done her job.

MR. PORTER: Any idea, on average, what's . . .

MR. MENZIES: It's a matter of - it's very short, it should be very short. There's no referral to anyone else for approval and review.

MR. PORTER: I see, okay, then it's just bed availability mostly after that.

MR. MENZIES: Yes.

MR. PORTER: All right. And on the same vein, I guess, let's talk about long-term care beds in general. I know both of the homes that I spoke of this morning have had vacancies. What's the average time frame to get into a bed?

MR. MENZIES: The average wait time in terms of getting into a bed, I believe, is in the area of about 60 days from the time a person has been assessed and is determined to need long-term care. I think you're talking about two different issues. One is . . .

MR. PORTER: I'm going to go back to the other one just to be clear and I'll clarify that for you right now. That's good, 60 days on average, after the assessment.

MR. MENZIES: Yes.

MR. PORTER: Let's talk about the bed becoming available at the Windsor Elms now being filled. Sorry if I wasn't clear on that.

MR. MENZIES: In terms of filling beds, the timelines we have are that the home advises us that they have a vacancy and what kind of bed it is, whether it's for a male or a female, if it's shared space, whether it's an Alzheimer's unit or whatever particular need or capacity that bed provides or is able to provide in that bed. The placement office then matches up the client on the wait list who has that same need. This should all happen, on average, we say no more than five days.

[10:00 a.m.]

I know specifically there have been particular issues in Windsor around some of the placements and when we've gone back recently looking at this, one of the things we have happening also is that we are receiving more and more requests for urgent admissions, where families are reaching the point where they're no longer able to provide support. So we're looking at how do we support families better, through better adult day.

On average, the nursing homes on average - occupancy in the nursing homes runs on average across this province at a rate of about 99.4 per cent per year, so it's a fairly high level of occupancy. We place over 2,000 people each year and there is obviously some time in there in terms of allowing families the opportunity to say yes or no to a bed and then when they said yes, also giving them time to make the transition.

So our experience has been, and this is consistent going back at least 12 years, that on average the nursing home beds in this province run with a 99.4 per cent occupancy level and many of our homes are exceeding that. There are some homes where there are specific issues that we all need to resolve with them.

MR. PORTER: So I certainly understand there's a time frame when a room becomes available, it takes time for families to come in, remove items and so on, and to go through that

process, you know, choosing another client to come in and fill that bed. No question, I know that process is there. Not to be critical of any staff either, certainly I understand that there are numerous cases probably on any given day where there are new people coming into the long-term care system, waiting somewhere, whether it be in a hospital bed or with family or wherever.

It certainly appears that the centralized, or again, whatever that right word is that you're using - would you agree that it's better, or not as good? Or would you think that it works better than it did in days gone by, when a doctor could pick up the phone or a nurse could pick up the phone at the emergency and speak with the administrator at the home and say, listen, I have Jane here and she's in desperate need of respite for a week to give family relief, do you have a long-term care bed?

MR. MENZIES: I think I've already spoken to the respite issue and I think we are trying to make that as accessible as possible and we can go back and look at specific cases.

In terms of a centralized wait list for nursing home care, I worked in the system when every home had its own wait list and if you had tried to do any planning around needs for clients and for Nova Scotians by simply adding up the wait lists of all the homes, you would never have been able to do it, because people would place their names on three and four wait lists to take the first bed they could get.

My personal view is that we are much better off with a centralized process on wait lists. We do process people's applications as quickly as we can. We have an issue here right now that we're dealing with in terms of lack of capacity, and I think many of the things and concerns we have relate to building that capacity over the next year or two.

MR. PORTER: I think that the understanding for lack of capacity is well received, but the other understanding is when we hear about beds being available for days and weeks and even a month maybe at a time when there's a bed that has just not been utilized in long-term care, that's an issue for me, because I've got people knocking on my door saying, Chuck, there are 11 beds full on unit 500, I don't understand.

So we're just kind of curious and maybe the centralized system works very well, maybe it's very well organized. The general appearance to the public, though, at least from the people I deal with - and of course the people I deal with want to be there tomorrow, or today even. Their family members, if they've been there, they know how it has worked in the past and again, just because it may have worked easier in the past doesn't mean that it was necessarily all that it was cracked up to be.

Just the same, when we're talking about wait times, and I want to go back to it being broad and the general understanding of Nova Scotians, because that's what they really see. They may not know all the details, Mr. Menzies, that you've just gone into, they just see oh, there's a bed available and Mom is waiting, it should happen relatively quickly but it doesn't. So I think your detail is important.

MR. MENZIES: Certainly there's always room for improvement. This central wait list, single-entry-access process came in a few years ago and we do need to go back and look at what works well and where the difficulties are that we need to alter as well.

MR. PORTER: And that was basically a follow-up question, how often do you reassess that central system and make changes? Or do you make changes, or are you of the opinion - you seem to be fairly favourable towards it, but is tweaking required?

MR. MENZIES: There have been tweakings at different times, but we do need to go back and take a good look at the overall system and what parts of it are working well and how we can improve on the areas that aren't and some of the areas that you've identified.

MR. PORTER: Thank you for that. Something that was also mentioned was about nurse practitioners this morning and people say, well, what have nurse practitioners got to do with wait times? They have a lot to do with them when they're working in the doctors' offices. They can see numerous patients, do treatments, et cetera. There are a lot of things well within their scope of practice.

You mentioned templates this morning. There's not a template, if I got that right, designed or now underway to be designed. But templates have existed for a long time and I could refer to a few, one being the doctor's office having a nurse or an LPN in there working. I mean again it's a collaborative approach, it's not new. The other would be a doctor with a student or an intern - not new, there's a collaborative approach there. Why are nurse practitioners or PAs all of a sudden a new phenomenon? There's a scope of practice. To me, again very simplistic because I'm a health care provider and I would say, this is not a big deal, why wouldn't it be something as simple as putting policies, scope of practice in place, and open the doors for doctors to invite folks in.

We talk about people who can't get doctors or they've got to wait six weeks or four weeks or two weeks, whatever it is to see their family physician. There seems to be a way to offset that and how close, is my question, are we to moving to that, because one comment that was made - and I wrote this down - a long road to travel. Well, the issue is, how long is that road, because time is of the essence, there's no question. That road needs to be - I'm interested to know how long that road is.

MADAM CHAIR: Ms. Doiron.

MS. DOIRON: Thank you, Madam Chair. I don't want to give the impression that we're not moving quickly with these things because I think there has been a lot of movement. I talked about the long road and basically said that I think we have arrived at a point where the perspective, the philosophy and the acceptance of collaborative practice has changed.

There's no question that we've had teams of people out there in many settings before. I think the main difference with what we've talked about with nurse practitioners is setting up a practice

where the nurse practitioner is working side by side as a partner with a physician, as opposed to an employee or a direct report, or having that master-servant relationship. So collaborative practice generally refers to a different approach to working together. It has taken some time, I think, for various professions to get to the point of understanding what that means.

There have been, if you like, templates from the perspective that as we walk down the road, as we have in the past with the College of Nurses, the College of Physicians and Surgeons, Doctors Nova Scotia and various other groups, pharmacists and so on, to say what does this all mean, basically there has been a lot of discussion around what are the criteria, what are the circumstances under which this practice takes place? There are things that are in place such as, for example, contracts between some of the parties, the understanding of the relationship between, for example, the district health authorities and a collaborative practice group in their area. Generally speaking, nurse practitioners become the employees of the district health authority, not employees of the physician. Understanding how that works differently than simply a doctor hiring a nurse to be available in his office has actually changed thinking.

Thinking does take time to change, it's about the physician working on an AFP as opposed to everything being driven by volume on a fee-for-service basis and inviting those physicians who want to work on that basis and look at the practice differently, looking differently at how the various partners interact with the patient, or the patient and their family and so on. I think through that, there has been a road travelled which we have somewhat arrived at, if you like, with a much larger group and each of the professions understanding it better, being willing to go into these different kinds of models and basically treating each other differently in the process. There are people who don't see it that way still.

I have been at meetings where I sat at a table with quite a strong physician leader - not in this province - whose entire focus was on how the physician was going to be served by a nurse practitioner, by a physician assistant or by any other professionals who might be working in a group. I think generally speaking that there has been a much larger understanding gained over the last five years, perhaps. If you look back a little bit more in history, the idea for nurse practitioners and the concept under which I think we're currently understanding, was being pushed forward 20-plus years ago by the nursing associations, so it has been a road to travel.

I think we are at a point now where we have tremendous opportunity to change the model, the way people are relating, first of all, the way they're educated. We have come to that point I know in this province when I speak with the deans of the health professions, the deans of the medical school and so on, that there is an entirely different perspective and dialogue that now is taking place that I think will lead to different kinds of behaviours, and that's where we really needed to go. We obviously will have further roads to travel, but we've come a long way.

MR. PORTER: I agree, I think that the health care system certainly has come a long way in certain areas. You touched on it very briefly with regard to the funding, the nurse practitioner would be funded by public funds, not from the doctor, so I understand there are some things to work out

there. That aside, does the department, or yourself more specifically, favour such nurse practitioners in their scope and their ability to work in this province?

MS. DOIRON: Yes.

MR. PORTER: That's a simple answer.

MS. DOIRON: I don't want to take a long time, I know the time is short, but we have been encouraging it. As we went through over the past years and I would say over the past six to 10 years, there was a lot of activity and facilitation by the province bringing people to the table together, allowing different groups and professions to work through what these partnerships meant and to accept them. I think getting some of these collaborative practice groups out there on the ground has done the most to influence people's thinking, because those who have been engaged with them are generally very, very positive. As I said earlier, they tend to get extremely positive feedback and response from the public. So I think we kind of did that a little bit slowly to make sure that the practitioners, and so on, were willing participants and that we were able to basically change the system and people's way of thinking without forcing the issue and getting a lot of reaction.

MR. PORTER: Thank you. I know we're running short on time, but just on that, I know I'm going to have an opportunity to come back, so I don't want to get into a long answer, but we'll go to wait times in general. You also talked about primary care earlier this morning. Do you think that Nova Scotians, in general, understand the differences in the level of care? What is primary care? What does a Nova Scotian take primary care to mean? What does that encompass?

MS. DOIRON: I think that we probably do have a lot of work to do to help the public understand exactly what we do mean by primary care. Primary care, again, crosses a lot of boundaries. Certainly the simple answer and the most immediate one is that primary care is about having good care with a family physician and so on, but primary care is a lot more than that now and it actually does involve some of the practice groups. Primary care has a place in mental health, primary care has a place in continuing care, and what we mean by that is basically having people understand where the first source of response and entry into the system should be on a basis that, as well, people within that primary care spectrum take responsibility for a lot of their own health and wellness, and their understanding of how they can do that.

I think there's a lot of work going on in that regard, but I don't think that we really do have a full and clear understanding on a public level, and that's part of where we need to go in our system. The next emphasis, while we have to sustain our high-level services, the real emphasis should be about how we actually engage people and basically rebuild the whole area of primary health care.

[10:15 a.m.]

MADAM CHAIR: Thank you. The time has now expired for the PC caucus. The next round of questions will be 12 minutes per caucus.

Mr. Wilson for the NDP caucus. You have until 10:27 a.m.

MR. DAVID WILSON (Sackville-Cobequid): I know our time is limited, so I want to first start with where I ended my last round of questioning. I believe it was Ms. Payne who gave the answer around orthopaedic surgery and the benchmarks set four years ago or more. You had stated that ortho surgery is going to be a priority for the upcoming year and that hopefully, we'll see a reduction in wait times in that area. The government has said that in the past. Four years ago they said it. They said it at the start of their agreement with the federal government on the benchmarks. It begs to leave, why should we believe the government now? That's a comment, I don't want an answer on it, that's my comment. It's difficult for me in my position to continually hear this from a government that they're going to tackle this problem and we continue to see it pushed off into the future.

So around the surgical wait times, an easy, hopefully quick answer from the deputy minister, why don't we have a centralized, one-list surgery wait list in this province for surgeries?

MS. DOIRON: Good question. That is the direction we're pursuing. As you know, we've been going down the road to implement a number of information systems over the past years, getting some of the fundamental pieces in place. One of those next initiatives on our radar is definitely to go to a computerized wait list system in the province. It's also a bit of a transition and I do believe that people are understanding it better.

It used to be that a physician kept his own wait time. He would inform the hospital when he wished to put somebody on the list. He would decide what his priorities are on his wait list, and we still need the clinician to have that kind of discretion around where the priorities are, but we also need to take more responsibility at the administrative level to have a collective wait time that is basically on a provincial basis. I guess that's a short answer to say that that hopefully is coming.

MR. DAVID WILSON (Sackville-Cobequid): I think it's important to recognize, to have all these lists out there - no wonder some people are left out. It may be because their physician is from a small community or a rural part of this province that might not have the pull within the Capital District or within the surgery rooms here in Halifax.

I would like to turn quickly to the wait time reduction fund which was part of the agreement between the federal government and the provinces. I believe that there was about $122 million allocated toward our province. How much of that fund has been spent? I guess we'll know how much is left with that question.

MS. DOIRON: I think at this point, just so you can hear from somebody else, I'll defer the question to Brenda Payne.

MADAM CHAIR: Ms. Payne.

MS. PAYNE: In terms of those actual dollars, we've spent the bulk. We still have some equipment purchases related to mammography, but that has been spent very specifically in a variety of areas that have covered oncology, equipment purchases, orthopaedics, et cetera, as I have referred to over the last number of years.

MR. DAVID WILSON (Sackville-Cobequid): So maybe a ballpark figure of how much is left, is it $10 million, $20 million that's left or less than that?

MS. PAYNE: There is roughly around $2.3 million.

MR. DAVID WILSON (Sackville-Cobequid): Thank you. Now I want to turn quickly to long-term care. It has definitely been an issue throughout the province over the last several years. I know that recently the government, after many years of what I feel not doing anything with it, has come forward with a continuing care strategy. One of the real big questions is always, how many seniors are waiting, and these numbers bounce back and forth. In a recent news article, someone within the department had stated there were about 1,500 individuals waiting for a nursing home placement.

We did a freedom of information request back in November and the information we received as of November 28^th was that there was 2,132 seniors waiting here in this province for a nursing home. Would you agree with that number? Does that seem like a number that is reflective of the wait list for long-term care placements? Mr. Menzies.

MR. MENZIES: I think if you look at the information that was provided to you, there are people who are awaiting placement in a nursing home and that's the number of 1,500. When you saw that total of 2,100, I'm thinking what that is - we also have a list of about 600 people who are looking to move from one nursing home to another and they're on a transfer list. When they were placed in a home, they were required to take a second or third choice, or placed in a home that wasn't of their choosing and they are waiting to move, so that's the distinction. When you are looking at the capacity of how many people are really waiting to get into a nursing home, it's the 1,500. That's the distinction.

MR. DAVID WILSON (Sackville-Cobequid): I agree, thank you. With the continuing care strategy, originally government was looking at 1,500 beds and those numbers were reduced to, I think the number they were consistently using was 832 new beds to be built by 2010. Even with the 1,500 number - which we can debate on the actual number - with that number, 832 new beds are not going to service the number that we have today and we all know the growing population, increase in age and increased demand on long-term care. Are you not worried that the continuing care strategy that we have today will not meet the needs in five years, in two years, maybe? Maybe a comment on that, Mr. Menzies.

MR. MENZIES: Perhaps I could start. One of the critical components of the continuing care strategy is that we need to look to solutions other than nursing home beds alone. In that strategy, we

talk about supporting people, not only seniors, but people in their homes and in their communities with better access to services that will enable them to remain in their community at home. Those are not necessarily all services that we would traditionally call health services. It's about appropriate transportation, house maintenance - all of those kinds of services that I think we've seen Veterans Affairs use to enable their clients to stay at home and in the community for much longer periods of time and therefore rely on the beds much less than we do currently. That is the part of the strategy that really has to succeed or we, in this province, will be placed in a position where we will have to build another 8,000 beds and that's really very unsustainable.

MR. DAVID WILSON (Sackville-Cobequid): I would agree and it kind of leads right into my next line of questioning and that is around the home care aspect and the self-managed home care component to where I think it is an important area we need to look at. Currently in Nova Scotia, Nova Scotians can have self-managed care if they have dementia or cannot manage their own affairs. I believe that giving seniors the option of paying a family member, a neighbour, or a friend would help alleviate some of the pressures that you just mentioned, especially in the coming years. So simply, why not allow seniors or their legal designate, power of attorney, to access self-managed care, to give them more control and to keep them home and really, I believe, reduce the burden of the need for long-term care facilities?

MADAM CHAIR: Ms. Doiron.

MS. DOIRON: Before I defer that question to Keith, I just want to correct or add something to the last question, so we don't leave it with any misinterpretation. The number of beds that were approved was not reduced. Basically, the 1,500 beds that were identified were part of the 10-year strategy and what we did was say, we will take 832 of those beds and put them in place by early 2010; some of them will be available in 2009, in fact. In addition, over and above that, we had already had previous approvals for something in the order of about 250 beds approximately. So the new beds that are coming on stream within the next year or two years is actually a total of about 1,100 - not just the 800-some that were RFP'd - and then we anticipate continuing to add so many beds a year until we get up to that number that was announced. So now I'll defer the other question to Keith.

MADAM CHAIR: Mr. Menzies.

MR. MENZIES: With regard to self-managed care and extending that to families, we are working now on that to determine how quickly we can do that and how the policy to support it can be in place. We recognize that's an area that many families are seeking, particularly in situations where a spouse or family member has dementia and it will certainly create a much better service for people.

The one area you mentioned I think is something that will bear considerable consideration because to our knowledge it's not available anywhere in Canada, is where you pay family members directly. Our understanding, from talking to Veterans Affairs where they do allow that, they have had

some issues. So while we will certainly look to extend self-managed care to a family-managed care kind of service as quickly as we can, the idea or concept of paying family is one that has some concerns attached to it and we would want to understand that more fully from Veterans Affairs before we move in that direction.

MR. DAVID WILSON (Sackville-Cobequid): I know I don't have much time so my last question to the deputy minister is, we all have been hearing tidbits of this report that's going to be released tomorrow, the Corpus Sanchez report. Part of the buzz is around, they're not specifically saying closures of emergency rooms, but a transformation of their roles. In your opinion, should emergency rooms or any emergency rooms in the province close throughout this province?

MS. DOIRON: The Premier, I believe, and certainly our minister has been saying that emergency departments will not close so I think that is our position. I also believe that consultation with the public is a good thing - I think you would support that based on the work you have been doing during the past while. I have also in my own experience in the past, not just in this province but others, have found the public to be very astute when you give them an opportunity to discuss things that are of real importance to them and to their communities. I think that we also need to remain open, that potential dialogue with the communities in this province may lead all of us to some other ways of approaching things and we are certainly open to that.

MADAM CHAIR: Order, please. The time has now expired for the NDP caucus.

Ms. Whalen for the Liberal caucus. You have 12 minutes.

MS. DIANA WHALEN: I'll be sharing the 12 minutes with our Health Critic, Dave Wilson. I just have a couple of quick questions that I hope we can get on record and get an answer to. I wanted to talk to you about the bone density machines that are needed across the province - I think I speak for all the MLAs that we've heard from the Osteoporosis Association. They've made a strong case for prevention, for the need to identify when people need to have treatment because it can, in fact, be reversed if we know about it and yet there are waits, particularly in HRM, of over a year to have that test done. Can you address that? I'll just expand a bit further, the IWK had a machine offered where private fundraising was done by an individual who knew that there was no machine for children, raised the funds and it was refused for over a year, I believe you have solved that in the meantime. It's not the only case where the community has responded and the Department of Health has not. Can you tell me what's being done that we can do better on the bone density measurements?

MS. DOIRON: Thank you, an excellent question. Because I know this is a passion of Brenda Payne's, I'm going to pass the question to her.

MADAM CHAIR: Ms. Payne.

MS. PAYNE: Thank you very much for the opportunity to speak to this issue. We have worked very closely with the Osteoporosis Society, the Nova Scotia Chapter and recognized, and

have recognized over the last number of years, because we have been monitoring not only the demand, but where the need exists.

[10:30 a.m.]

In early 2000, we formed a committee made up of health care providers as well as our partners at the Osteoporosis Society and at that time we doubled the capacity within the province by adding additional bone density units in Yarmouth . . .

MS. WHALEN: Can you come closer to the current situation because I was visited by them last year and I can tell you they're impatient and they're stressing to MLAs to be impatient and I feel that as well.

MS. PAYNE: Let me get to the point . . .

MS. WHALEN: I'm sorry, I just want to take you from 2000. I only have six minutes and about six questions.

MS. PAYNE: We have actually added three additional bone density units, one at the IWK that will be up and running very shortly, we've added an additional one in Valley which opened in December and we are actually adding an additional one in Capital that will be at the Dartmouth General that should be operating in March.

MS. WHALEN: Ms. Payne, what's the wait list today to get a bone density scan done here in HRM?

MS. PAYNE: In HRM, it is roughly around 476 to 496 days.

MS. WHALEN: And you've been looking at it since 2000. I think it's fair to say that there is no rush, that we're not moving forward fast enough. In six minutes, I guess that's the one point I could definitely make on this is, people should have access to this and we need to reverse the effects of osteoporosis and the way to do it is to scan. If it is still over 400 days - and it was more than a year ago that an article appeared which Marilla Stephenson had written about concerning the private money that was raised for a machine at the IWK. I thought it was solved and you're telling me it is soon going to open. I believe the crux of the matter is the human resource plan and maybe I could ask the deputy, where is the human resource planning in the Department of Health? Have you got a plan for addressing so many of these critical needs of technical people that we need to get in those places so these services can be offered?

MADAM CHAIR: Ms. Doiron.

MS. DOIRON: Basically, we have been working on a number of fronts. I know our nursing strategy which has been successful has just been renewed. We have a number of physician initiatives

that have been undergone. We have reviewed the situation with lab techs and we now have the lab program operating in this province at our community college. We have just recently done a review of all the medical radiological technologists in the province and have a report that we're now putting together an action plan on. I could speak to some other initiatives, but the next step that we're taking is to basically bring together everything we're doing and bring an umbrella around that and looking at a total health human resource strategy, so that we can take the pieces we currently have and then go beyond that and determine where our gaps are and how that now fits in a plan to move forward.

I know you would all be aware that given the number of beds that are going to be opening in long-term care, we also have been working on a plan to make sure that we're educating adequate people in this province or attracting them to be able to provide care for those beds as well. So lots of work, but we now need to put that comprehensive plan around it and we are going to do that.

MS. WHALEN: Is there any timeline that you could give us for the release of a human resource plan?

MS. DOIRON: Yes, we are looking at the comprehensive plan having a state of readiness by this Spring.

MS. WHALEN: So we could look forward to it in a couple of months, two to three months?

MS. DOIRON: I would say probably March, April.

MS. WHALEN: Okay, we'll make a note of that, thank you. One quick question on long-term care for Mr. Menzies. We had heard from some of the smaller long-term care facilities in this province that they can't afford the work that it requires to go into makeup an application for these new beds. They need to provide architectural plans and a lot of detail that will cost them in the range of $75,000, simply to apply for the granting of additional beds through the department. Can you comment on that because we know that the last round you announced of new beds were going to rather large organizations such as Shannex, who are doing a wonderful job, and one of the Stevens companies as well. Why is it so expensive so that some community-based facilities can't participate?

MR. MENZIES: With regard to the RFP process that we went through this past year around new beds, that was an issue that was raised by a number of the homes - they were reluctant to put any money into developing those plans. I don't know the exact number, $75,000 sounds like a lot of money to develop a proposal because it doesn't require detailed architectural drawings or anything like that, so I'm sure of the numbers.

MS. WHALEN: That was the figure that I heard from Bridgewater, from a place there.

MR. MENZIES: I'm surprised at that number because that seems quite high to me. Aside from that, one of the things in going to an RFP for those new beds is something that we have said in this sector - and my colleagues as well as myself when I was in the field had always said - if we're

going to add capacity in this province, everybody should have an opportunity to bid on it. If those individual community boards were reluctant to put any money into that I'm not sure what we can do to support them or to have them do so, but we weren't able to find a way to provide resources without really taking away some of the basic fairness.

MS. WHALEN: It's clear though that a larger organization or a big corporation would have the resources to compete in a more sophisticated way than a community-based board. What would you think was the appropriate cost for a community-based board to step in? Is $10,000 or $20,000 more acceptable because in their budgets, that's still really too much?

MR. MENZIES: I think part of this, and we did have a number of bids from other organizations who are non-profit and who did participate in the process, so many of those providers, some of the smaller providers did find ways to do that. One of the things that we will do after we've completed this round is to try and understand better what the drawbacks were or what did prevent people from participating, so that next round we can fix that.

MS. WHALEN: Thank you.

MADAM CHAIR: Mr. Wilson, you have four minutes.

MR. DAVID WILSON (Glace Bay): Thank you, Madam Chair. I will take all of those four minutes and I may let the deputy minister reply, I'm not sure. The situation as it stands right now, and we can talk about this as much as we want, wait times have been around for a very long time.

Back in 2004, we, as a Liberal caucus, had a round table on wait times that toured the province. At that time, there were such things identified in the community as access to acute care beds, lack of home care services, delay in primary-care health care services, long waits at ERs and a lack of resources for mental health services. All of that, I'm sure, sounds very familiar to each and every one of you. In the meantime, unless we do something to change it - and I caution people that the release of a report tomorrow does not necessarily represent a cure for everything that's happening in health care in this province. There are many, many studies that have been done on health care in Nova Scotia that are now sitting on a shelf collecting dust. I hope that's not the case with the Corpus Sanchez Report - depending of course on its recommendations - but I hope that we start to finally take action.

You've outlined some and I agree with you and I congratulate you, that in some aspects you have taken some action. In other areas, let me give you a brief example since I think I have the time. A colleague of mine from Digby-Annapolis who always said that we have to start doing things differently but didn't think that in that case, and they have a problem keeping a doctor in Digby. He went to the local hotel there and asked the manager if they would be willing to put a doctor up - basically to offer free room and board to a doctor. The manager said, absolutely, of course we'd be willing to do that if that's what would bring a doctor to this area.

It is that kind of thing, when you talk about being creative, it is probably a good example of what we have to do in this province, just in terms of recruitment for doctors or whatever the case may be. The human resource shortage that we were talking about for many years is now here, and if it's not, then tomorrow it will be.

I don't think that we're prepared for it, I don't think we're ready for it, and I don't think we've seen the worst of wait times in this province because I think the worst is yet to come, unfortunately. Having said that, I will give this final thought and then let the deputy minister reply. I know you have a hard-working staff and I know that you're doing as much as you possibly can to try and cure this problem.

I think on the political side of it - which is where you're not deputy, I know - but on the political side of it, the will has not been there to do this in an expeditious manner. That will has not been there to try to get this done sooner rather than later, and because of that and because of the lack of that will and because of the lack of that commitment, we're in the current situation that we are right now. I find that unfortunate. With that, and whatever time is remaining, I turn it over to the deputy minister, Madam Chair.

MADAM CHAIR: Thirty seconds.

MS. DOIRON: In very short terms, basically I would like to just concentrate for the seconds I have on the portion of your statement that reflected upon mental health and simply say that we, too, are extremely concerned about the wait times in mental health. We need to make this a focus in the department.

We have been working on it, there's no question we've added significant millions of dollars to mental health over the last five years but even with the adding of those millions and millions of dollars, the proportion of dollars going to mental health in this province has diminished, not increased, because of the major increases that have been going to acute care and long-term care and so on. So one of the focuses that we want to start picking up on in the Department of Health is to say, we need to provide the right focus on mental health and take some significant action over the next few years to address that.

MADAM CHAIR: Mr. Bain. You have 12 minutes.

MR. KEITH BAIN: Thank you, Madam Chair. I just have one question before I turn it over to my colleague. It is concerning nurse practitioners as well. The smaller rural communities, and I serve many of those in my riding and I guess I'll make reference to the North of Smoky area where there are four or five different communities, there is a nursing home and a small hospital with one doctor. I guess a nurse practitioner on the scene at a nursing home would provide better care to the residents of the home.

We mentioned before about the Northwood pilot. I believe that pilot began possibly a year and a half ago, almost two years ago. I guess what I want to know is, how long is the pilot and when can we expect a report on the pilot and the possible implementation or placing of nurse practitioners in some of these more remote nursing homes?

MS. DOIRON: Madam Chair, basically I think the pilot is due to come to a conclusion, in terms of the time frame, within the next few months, at which point we have also built into that pilot an evaluation process. But, at the same time, we don't want to slow down the advance of additional attention from doctors and nurse practitioners in the nursing home sector. We have been moving in that area as well and maybe I'll ask Keith to just quickly outline the approach that has being taken to involve people from a medical health point of view more so on the nursing home side.

MADAM CHAIR: Thank you. Mr. Menzies.

MR. MENZIES: One of the areas with nurse practitioners, a point I would like to make is that in smaller communities those nurse practitioners should include the nursing home in their practice base. I don't think in the rural communities we will have nurse practitioners working there outside of a primary care kind of approach for the whole community. That really is a much more appropriate way for them to be part of that nursing home anyway, rather than setting up parallel systems or services in a nursing home versus community, but we would really like to see that move forward.

One of the areas we've put considerable planning in this past year is working with the district health authorities and developing a role for a primary health care leader, or leadership role, and that is specifically to have a physician in each of the districts whose role will be to work very closely with the nursing homes and the district health authority to ensure that we're moving towards providing the best care in the best location. That means taking every opportunity to ensure that services are provided in the home, rather than transitioning people to hospital and building on various opportunities like nurse practitioners.

MR. BAIN: Thank you, Madam Chair. I'll turn it over to my colleague.

MADAM CHAIR: Mr. Porter, you have until 10:52 a.m.

MR. PORTER: Thank you, Madam Chair. My question will be around wait times, about actual wait times in certain areas. How do people get in the queue for treatment? I'm assuming, very simply, it's that you go to your family physician, who refers you. Is there anything special outside of that?

MADAM CHAIR: Ms. Payne.

MS. PAYNE: Again, and this is a very quick, general response, you will have been seen by your family practitioner and then referred to a specialist who, based on your clinical symptoms, will then prioritize where you should fit, whether it's an emergency, whether it's urgent or whether it's

an elective. That places you within a queue, again at a particular district health authority. So it really is based on the clinical judgment, again, of the physician or the specialist who determines the priority case of that particular individual.

[10:45 a.m.]

MR. PORTER: I know we spoke a bit about it earlier on, but that's specifically within the region, unless there's a higher level of care. Just as an example - and I'll use the Valley versus the Capital region - if there's a need to come out of one region to come to the other, obviously that happens. Generally speaking, if it can be done within that region's surgical procedures it's done, that's the list you're on.

MS. PAYNE: Right now, until we complete the project of having one wait list, it would be within individual - even individual surgeons or a specialist's list.

MR. PORTER: Just on the list itself, could you tell us what the longest wait time is out there right now? If I said there was a gentleman who's looking to get a knee replaced, what's the longest period of waiting time that gentleman may go through right now?

MS. PAYNE: On a generality, we're looking at 18 months to two years, and again that's particularly within Capital. We know that there are variations between and amongst orthopaedic centres and the districts in terms of wait times.

MADAM CHAIR: Ms. Doiron.

MS. DOIRON: Thank you, Madam Chair. I just wanted to add to that comment, particularly noting the issue of people crossing the district boundaries. We now have, as I think you know, a Web site on which we post a large number of wait times for either procedures or diagnostic procedures and we keep adding, in fact, to that Web site. We encourage the public to look at that Web site, because the wait times in each district are given for any particular procedure.

We are seeing more of this where, by reviewing that, the individual may then speak to their family practitioner or their physician and basically request that they be referred to another district where maybe the wait time is shorter. Certainly that's something we very much encourage with both diagnostic and surgical procedures and referring back to the issue on bone densitometry, that can certainly have a major impact, because where the wait list is the longest in Halifax, we have both Lunenburg and Truro that have much better wait times and people are free to go there.

MR. PORTER: Thank you, I was going to speak to that, so thank you for answering that in advance for me. A question relevant to that is I understand there are people living in the Eastern Shore area and hospitals to come to Hants Community, as an example, to have

procedures done, so can you speak to that a little bit? That's something relatively new, from what I understand.

MS. DOIRON: It is, I think, a little bit new. On the other hand I think we are trying to look in Nova Scotia at our health system as a total system. Certainly, when we look at the areas where we have our longest wait times with the orthopaedic procedures, it's really gratifying to know at this point that we have the doctors, who are the orthopaedic surgeons, coming together across the four sites that provide surgery, now taking a look at how they can jointly approach the wait list situation as well as doing things within their own districts. We need to assist the areas that have the longest wait times to provide relief to them from other districts.

Having that mentality of willingness to do that is a big issue, and I think we're seeing that now when you see Capital Health, which has some of the biggest issues here, standing up and saying we're going to co-operate with Stadacona, we're going to work as partners with Amherst, we're going to be looking differently at the facilities in our own district - be it Dartmouth or wherever it might be - and basically we're going to take a look at how we can distribute our work differently.

I think the phrase that really struck me when I heard Jaap Bonjer give his presentation on this was the approach that he took - think like a system, act like a team. I think we can expand that beyond Capital Health and say now it is crossing boundaries and more and more not only administrative people, but clinicians are willing to look at things that way.

MR. PORTER: This leads me to an interesting question, why do we have boundaries? The question has been asked, we have these districts, or what we'll refer to as boundaries - albeit unseen - but there are boundaries. When you go in - and I know from experience from years gone past - to these different district health authorities there are a lot of differences, everything from equipment to policy and procedure, to the mentality of workers, albeit good, but there just seems to be a different philosophy on how things get done. I wondered, people have asked, why do we have these and I said, we'll find out, we'll ask, so I ask for your thoughts on that.

MS. DOIRON: That's a big question, because you're asking me to comment on the issues and merits of structures and boundaries and we know they have changed over time in this province, as well as many others. Let me put it this way, when I first came to this province my first job was to transition the province from four regions to nine districts plus the IWK. I looked at that and thought, we're under one million people and we're going to have 10 health boards and 37 community health boards, do you think maybe we could be a tad over-governed here?

I wondered about that, but I went ahead with that responsibility and task and I became a total convert, because what I've discovered is in this province it works for people to have leaders within their own communities and in the smaller communities people they know who are working on their behalf and they can relate to them and within that system it works. It will only work for the province if we can, at those senior levels, both administratively and clinically, work across those boundaries where it makes sense to do that.

That's why we did this work for the review that's coming out tomorrow, because we were initially trying to respond to a government direction to us to look at value for money in relation to

district health authorities. We looked at a couple of them individually several years ago and at that point, in the work that I do and others here do sitting with the CEO group and the senior teams, we jointly said the only way that we can make sense of this and do what's best for the province is to look at this as a province. So that's what has occurred. I think while we have the boundaries that serve their purposes as a closer-to-home relationship, we now are also thinking like a province, thinking like a system, working like a team across those boundaries.

MADAM CHAIR: Order. The time has now expired for the questioning portion of today's meeting. I would invite the deputy to make some final remarks and closing comments if you wish.

MS. DOIRON: Thank you, Madam Chair. I want to say thank you to the committee for asking us to come forward on this topic. As we all know, there are many challenges within this topic area, it's very broad and we can't come here and say everything is wonderful and well. We can say that we've made a tremendous amount of progress, that we have some very specific directions that we're now seeking that we think are going to provide significant relief factors to wait times in fairly immediate ways. We have the pain clinics which have opened and are starting to do a job in that area. We have the work going on in continuing care that will start to free beds up and allow flow to occur differently through our facilities. We have our focus on primary health care, and basically we also are focusing on our enablers.

We did not get today to share much with you about the information system support side of what we're doing and we could have simply taken this entire session to talk just about that. I can assure you that in the area of information system support, there is a huge amount of work that has been accomplished. There will be a huge amount of work accomplished over the next couple of years that is going to significantly serve that purpose of enabling things to happen and to work differently.

While I know that we have much left to do and we acknowledge that, I'm extremely encouraged that we seem to be given the support at this point to say, go ahead and keep moving in these multiple directions that will start to have a true impact and make the system work better not just for a little while, but in the long term, so we are encouraged. Again, I thank you for bringing us here today.

MADAM CHAIR: On behalf of the committee, I'd like to thank you and perhaps we will have you back since there is so much more to discuss. I'm sure we will at a future date.

At this time I would like to ask members of the committee, I believe you have a report from the subcommittee with respect to future topics that are being proposed. I would like to move this report and ask for approval of this report. Is there any discussion on the report? Mr. Steele.

MR. GRAHAM STEELE: Madam Chair, I did have three comments on it. The first one is the recommendation that we hear from the Department of Environment and Labour. The topic is actually six different topics that are all unrelated to each other and it concerns me a little bit that we would be proposing to call in one department for two hours on six different topics. I wonder if in the

subcommittee meeting that's going to follow this meeting, we might ask our subcommittee to refine that a little bit so that it's more focused. An unfocused meeting isn't good for the witnesses or the members.

My second comment is on the recommendation that we bring in the NSAHO and the Department of Health on essential services legislation. I, myself, don't see it the role of this committee to discuss legislation that hasn't been passed yet. Our job is supposed to look backward at the past operations of government. Although, obviously, it's an extremely important topic, I'm not quite sure that I see how the Public Accounts Committee could tackle that.

My third comment is that I want to make sure that there's space to have representatives of the Office of Immigration back one more time. I don't think we have anything on our agenda for January 30^th, for example, or perhaps members of the committee might want to wait until after the forum with nominees and mentors, but in any event I don't want to lose sight of the fact that we need to bring them back one more time.

MADAM CHAIR: We are having a subcommittee right after this meeting, so we will take up those issues that you've raised. Is there any further discussion? Would all those in favour of adopting this report with the provision that we have that discussion - Mr. Steele.

MR. STEELE: Given that it's hard for me to approve the report when I've just given three reasons why I'd like to amend it, could we . . .

MADAM CHAIR: Perhaps we can defer the report until we have the discussion in the subcommittee, which is going to happen shortly. Is that agreeable? It is agreed. Thank you.

There is one final matter I want to bring some information around. The last time this committee met there was a point of order raised by Mr. Porter regarding whether or not the subcommittee had the authority to release documents, and this is with respect to the Nominee Program. I have been in consultation with Legislative Counsel and will continue to have that discussion. It's in its initial stages with Mr. Hebb. In the meantime the subcommittee is still discussing the management of the large number of documents that we're receiving on the Nominee Program. A subcommittee meeting follows this one.

No documents have been or will be released while we're having this discussion. We will report back to the full committee on the outcome of our discussions. So that will continue and you will get a ruling on the point of order shortly.

Thank you, that concludes the business. We now stand adjourned. We will meet next week and we have officials from the Department of Economic Development with respect to the Nominee Program. Thank you.

[The committee adjourned at 10:59 a.m.]