HANSARD

Health Human Resources

Printed and Published by Nova Scotia Hansard Reporting Services

Ms. Maureen MacDonald (Chair)

Mr.Chuck Porter (Vice-Chairman)

Mr. Pat Dunn

Mr. Keith Bain

Mr. Graham Steele

Mr. David Wilson (Sackville-Cobequid)

Mr. Keith Colwell

Mr. Leo Glavine

Ms. Diana Whalen

[ Ms. Diana Whalen replaced by Mr. Harold Theriault. ]

In Attendance:

Ms. Charlene Rice

Legislative Committee Clerk

Ms. Evangeline Colman-Sadd

Assistant Auditor General

WITNESSES

Department of Health

Ms. Cheryl Doiron

Deputy Minister

Ms. Cheryl Burgess

Executive Director - Health Human Resources

Mr. Ian Bower

Director - Physician Services

Donna Denney

Nursing Policy Advisor

Donna Dill

Director - Continuing Care Monitoring and Evaluation

HALIFAX, WEDNESDAY, MARCH 5, 2008

STANDING COMMITTEE ON PUBLIC ACCOUNTS

9:00 A.M.

CHAIR

Ms. Maureen MacDonald

VICE-CHAIRMAN

Mr. Chuck Porter

MADAM CHAIR: Order, I'd like to call this meeting to order, please. We're running a bit late and we have only a limited amount of time.

Good morning everyone. I'd like to welcome our officials from the Department of Health. Welcome back to the deputy minister - it wasn't that long ago since we had you here with us - and welcome to the new witnesses you've brought with you.

Before we begin, I'd just like to mention for the information of the new witnesses who are here that, for the purposes of Legislative Television, we try to identify who will be answering a specific question so that your microphone will light up before you speak. So if you can kind of be mindful of watching for the light before you start to respond. As much as I can, I will direct questions or members of the committee will indicate if they're going to switch from one member to another, that they're going to ask a different person.

So without any further ado, we'll start in the usual manner. We'll have introductions by the members and the staff and yourselves, the floor will then be yielded to the deputy for an opening statement and then we'll start with questions. So, Mr. Wilson.

[The committee members and witnesses introduced themselves.]

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

1

MS. CHERYL DOIRON: Thank you very much, Madam Chair. I want to thank the committee for the opportunity to share with you today some of our recent efforts in the area of health human resources. Ensuring that this province has the right number mix and distribution of qualified and hopefully fulfilled health care providers to successfully meet the needs of Nova Scotia is a very important task. It's one that my staff and I take very seriously. Together we will do our best to answer all of your questions. Nova Scotia relies on the knowledge, experience and expertise of over 50,000 health care providers, often during some of the most stressful periods in the lives of those who are ill.

Today over three-fourths of Nova Scotia's entire health care budget is invested in the highly-valued providers who form the heart and soul of our health system. As we look ahead, we know that the area of health human resources holds challenges but also opportunities and we know that these challenges are not unique to Nova Scotia. Across North America and around the globe most other jurisdictions are, or will very soon be, in a similar position.

An aging population afflicted with chronic disease requires more care and often longer appointments. Rural populations everywhere are shrinking as urban populations swell. The baby boomers are retiring and birth rates are not keeping pace. Labour shortages across the board are beginning to appear and health is no exception.

At the same time the next generation steps forward, bringing with them a different set of values and expectations. Rightly, they want more balance in their lives. As a province, we are fortunate to have natural advantages attractive to many health care providers. Health care professionals have identified lifestyle as one of the major factors they take into consideration when deciding where to practice. In this area, life in Nova Scotia offers incentives not found everywhere else but in such a competitive environment, we recognize that our natural beauty and unmatched lifestyle is not enough.

We must create compelling reasons for health care providers to come to and stay in Nova Scotia. I believe that we have already done some very good work in this area. For instance, we know from national statistics that Nova Scotia is doing well in physician recruitment and retention. We have more doctors than any province in the country. More Nova Scotians also have a family physician than people in other provinces. In fact, 95.1 per cent of us have a regular family doctor, whereas nationally only 86.4 per cent of Canadians can say the same.

There are a number of tools that the province uses to support the districts and our partners in their efforts. Thanks in part to these initiatives, we are able to say that last year we added more doctors to our province than we lost. We increased the number of physicians practicing in our rural areas and we increased the number of doctors graduating from our medical program. We've also experienced success in retaining and recruiting nurses. Overall there are more nurses practicing in our province and more nurses choosing to relocate here. Importantly, we are doing well in keeping the nurses we have. A full 86 per cent of nurses

who graduate from our programs are staying here; 83 per cent of them have full-time jobs. When compared to the national average for the same employment or same time employment, only 43 per cent is the figure we look at on a national basis. So compared to that, we're doing quite well.

We know from talking to nurses that compensation must be competitive but that many other things are equally or more important. In response, we are creating quality practice environments, enhancing professional development opportunities and taking steps to ensure that we offer work-life balance that nurses need and want. As a result of our efforts under the Nova Scotia strategy to make improvements in these areas, over the last few years we have had more than 500 nurses relocate to our province.

We're having success in other areas as well. We are among the top three provinces in provider numbers for a variety of professions, including medical laboratory technologists, medical radiological technologists, physiotherapists, psychologists, nurse practitioners and audiologists and others.

Finding innovative and sustainable ways to deliver care in safe and supportive environments is important, providing the workplace tools and education providers need to excel. We are also creating conditions that enable health care providers to use their knowledge, their skills and their judgment effectively. These things have made our achievements possible.

While we have had successes, some unmatched by other provinces, there is more to do. There are challenges and they are more pronounced in certain areas and in certain disciplines and in certain specialties. In the past, we have focussed primarily on recruitment strategies for specific professions. As we move forward, we need to approach our challenge in a more comprehensive way.

Recently we developed a new Internet portal to support a provincial approach to recruitment efforts. It's a significant departure from past efforts and a good example of a new kind of thinking. The new Web site highlights the Nova Scotia lifestyle experience. It presents a comprehensive and team-based overview of health care in the province and it gathers under one banner all the information a health care provider would need to make the decision to come to and to stay in Nova Scotia. It is accompanied by memorable new recruitment materials that present Nova Scotia as a prescription for a better life, stunning images of our province and clever prescription side effects showcase the unmatched lifestyle that we have that we can offer.

This Spring, we will launch a national advertising campaign based on this concept. It will encourage more health care providers to relocate to our province. This project shows that as we move forward, we are thinking differently, we are taking the whole picture into account and we are trying new ways of doing things.

Our next step is to develop an integrated health human resource strategy. It will be collaborative, needs-based, inclusive and informed by best practice and evidence. It will take into account the whole of the health care system and address inter-related needs across the health system. The plan will identify our HHR requirements for the next 10 years, priority actions for the first two years will be determined as well as results and targets for the five and ten year marks. Strategies to meet these targets will be included. This will not be a static plan. As more becomes known about the most effective and efficient models of care for our province, adjustments will be made accordingly.

[9:15 a.m.]

Initiatives to staff more than 1,000 new long-term care beds being made ready will be part of the larger integrated plan. In fact, efforts are underway right now. Already we have identified how many and what kind of providers are needed and work to recruit and train those providers has begun.

In 2007, we ran a $900,000 advertising and bursary campaign to encourage Nova Scotians to become continuing care assistants. This program was successful in filling more training and certification programs than ever before. Moving forward, we will expand our advertising efforts to encourage continuing care providers to relocate to Nova Scotia. We will look at ways to help providers trained in other provinces more easily transition into our workplaces and will continue to expand training opportunities and offer significant bursaries to those interested in becoming CCAs.

To ensure we sustain an increase in available health human resources in continuing care and across the board, we'll also do more. We will continue to build incentives into new contracts designed to keep more late career nurses in the health care system. Right now we lead the country in alternative payment plans for physicians, and will continue to consider recruitment and retention key issues as we negotiate the physician master agreement which is currently underway.

We will increase the use of our health care teams in collaborative and alternative care models across the province. We will incorporate time-saving technology, like PACS and the electronic health record system, to help improve provider efficiency and patient care. New infrastructure and equipment will make our province more attractive to practitioners. To date, $90 million from the federal medical equipment budget has been spent on new equipment. We've added six new MRIs, a PET scanner, CT scanners and 12 lead defibrillators in our ambulances and we're replacing, improving and expanding the Colchester Regional Hospital, the Lillian Fraser and the QE II Emergency. Time's up, okay.

I think that there are a few other things I could mention but because we have a time factor, I will close there and address other things through questions. Thank you, Madam Chair.

MADAM CHAIR: Thank you very much. The opening round of questions will be 20 minutes for each caucus.

The honourable member for Sackville-Cobequid, from the NDP caucus.

MR. DAVID WILSON (Sackville-Cobequid): Thank you, Madam Chair. Six thousand, two hundred and ninety-nine hours, or 262 days, were approximately the number of hours or days that emergency rooms were closed last year here in the province. The figures that the deputy minister gave us about the percentage of Nova Scotians with family doctors is quite high but when you flip that and look at the actual number, we're looking at close to 50,000 Nova Scotians without family physicians. The problem with that is that they seem to be concentrated in certain areas of the province. For example in Digby, I believe almost a third of the residents in that area of the province have no family doctor. Their emergency room is one of the ones that is identified that closes quite often throughout the province. So with those staggering figures would you agree, deputy minister, or disagree that the health of Nova Scotians is at risk when we have such figures like that here in the province?

MADAM CHAIR: Ms. Doiron.

MS. DOIRON: Clearly there are challenges in the province and I don't think anybody means to diminish that. Certainly, we want to have every citizen in the province have access to primary health care and beyond. I guess when we compare how we are doing relative to the rest of the country, we are in a comparably good position but there are situations and there are locales where we have particular challenges and obviously we do work and have to keep working on those.

I think maybe what I'm going to do is ask Ian Bower to basically bring us up to date with exactly what is happening in Digby because I know that's one of the areas that has been challenging over a period of time.

MADAM CHAIR: Mr. Bower.

MR. IAN BOWER: Thank you for the opportunity to be here and to speak to that question. It is a very challenging situation in Digby that we've been aware of and working with for a period of time with the local partners. We've had some successes. I think one of the challenges that the deputy spoke about is the fact that not only is our population aging but so is our workforce. We had a number of people in that community that, due to the experience of their work life, decided that practicing in the ER was not something that was sustainable for them any more. So we did have our challenges in (a) meeting the primary health care needs of the community and (b) keeping the emergency room open. These are challenges that are replicated in a few other towns as well.

Back to the successes on what we've done with Digby recently - we have looked to adopt a new model in primary health care, that is the implementation of nurse practitioners to work with and further leverage the family physicians that are there in the community. That's not dissimilar from down in the Digby Neck where we have a nurse practitioner that is servicing out of Freeport for the Long and Brier communities. We looked at a similar type of model in Digby.

As well, we know the district has been successful in attracting an additional physician to the area which has allowed us to keep the ER open more often than it was before the person came. It's not perfect, we understand that - when you're closed one day a week in the month of March, that poses a challenge. We have also offered up to working with the district health authority, the community and the municipality working on providing alternative payment plans for physicians in that area as well which weren't there before.

The town had traditionally been a fee-for-service town which is still the most predominant way that family practice is provided in the province, but we have over years created situations with alternative payment plans which essentially become more attractive to prospective physicians, income guarantees, that sort of thing.

MR. DAVID WILSON (Sackville-Cobequid): I know the member next to me will appreciate it if I spend some time on Digby but it seems to be at the forefront. Just recently, I think a couple of days ago, in the paper, the municipality is looking at paying up to $185,000 to attract two physicians to that area. Deputy, do you feel that is what the municipalities have to do in the province and what support are you giving the municipality when they come up with a figure like that? Are you helping out with that $185,000?

MADAM CHAIR: Ms. Doiron.

MS. DOIRON: Basically, we do not provide funds to municipalities for those purposes. I guess what we do is try to assist local communities, municipalities, and local groups that are working on behalf of their citizens to come together and to discuss and find alternate ways and multiple ways to access primary health care. So it has not been our practice to essentially provide funding to municipalities but we have, on a couple of occasions, seen groups such as that decide that they want to participate and offer something that might help with recruitment. We have not objected to that, if that's what they wish to do. We will continue to assist by providing planning resources from the department, to offer staff from the department, to help to bring people together and to provide information and background for people who want to look into those kinds of issues. Generally, we have not offered cash to groups such as that.

MR. DAVID WILSON (Sackville-Cobequid): My concern and my fear is that we're going to have some municipalities that just can't meet the expectation that Digby has brought forward with this $185,000 - they just won't be able to do that. I think that's a very important

concern that the government needs to recognize, that what we're doing and what I've seen over the last little while is, we're having municipalities compete amongst each other in our province. We're having DHAs compete for health care professionals from one DHA to the other. What role and what vision and what direction are you trying to emphasize that what we need here in the province is the province as a whole going together forward, making sure that we have the professionals here in our province and then try to provide and fill the holes where it's most needed, not who has the most money or which municipality can come up with the better incentive package?

MS. DOIRON: Thank you for that question, it's an excellent question. I think sometimes in the absence of having an overall plan and strategy, the danger is that people will get into competitive bidding for people, if you like, and from time to time I think we see something like that occur. Generally what we have attempted to do from the department's perspective - and sometimes that is also working with the unions or Doctors Nova Scotia or other groups - is basically try to level that by providing other kinds of incentives. For example, we have programs where we will target localities where maybe it's difficult to attract physicians and offer resources to the physician, as opposed to providing dollars to the municipality, for example, to get into some kind of a bidding competition.

Our programs tend to be aimed at saying, what are the most critical areas and what is the combination of strategies that we can put in place that will attract the professional to go to that area. For example, I think the physician debt repayment plan is one of those areas where generally we will associate that with the locales that are harder to fill relative to physician coverage and try to promote things of that type that will entice people to go to areas that are difficult to recruit to.

I also would like to add that the strategies we have been developing are developed in a very close partnership with the district health authorities. I think by doing that then we are also able to manage, if you like, and have the co-operation of the leads in those areas in terms of stabilizing things across the province and not getting to the issue of the kind of bidding and competitions that I think we used to see in some years past. So I think that has been minimized compared to where it was some years ago but when we continue to get into situations where there may be increasing shortages, we need to make sure that the strategies - which we are in the process now of developing - are addressing those issues very clearly and that we have commitment to work with those strategies.

MR. DAVID WILSON (Sackville-Cobequid): I think it is important and it is something we've called upon for years - this strategy. It's unfortunate that it has taken this long in the current government's mandate to wake up and realize that we have an issue here in the next few years around health care and human resources.

In 2000, four communities were designated as demonstration projects for collaborative practices under what was the Strengthening Primary Care Initiative. They were

designed to alleviate the pressure of the hospital and the emergency department. In your opinion, how successful were those collaborative care models?

MS. DOIRON: We found that all of those demonstration projects went excessively well. We had an issue in one that was basically more of a human resource performance issue which was basically dealt with and corrected but the model itself was extremely successful. Because of the success with those models and the very good work and evaluation that was done around that, we basically then made a decision to move forward and try to increase the number and the type of collaborative practice groups that are through the province.

We have been adding several additional opportunities each year and I can tell you that as these keep growing, we keep getting more and more positive results with it. I know that in a couple of communities up through the Cumberland area that were having difficulty recruiting physicians, they went to a model with collaborative practice and were able to interest the physicians in the area in supporting that. Initially I think some of the members of those communities, as reported to me by the staff of the DHA - initially the communities would say, what's wrong with us that we can't have a doctor? It didn't take very long - in fact, it was less than a year - before they had other communities within their jurisdiction saying, what's wrong with us that we can't have a nurse practitioner?

It basically speaks, I think, to the comfort level that communities tend to have, once they have an opportunity to experience collaborative practice groups, so that their care is being managed by a team as opposed to simply a single physician or practitioner. So the challenge we're currently having is keeping up with the requests and the demands that are there to keep adding to this.

One of the intentions, of course, that you would have seen through the PHSOR report, basically emphasizes the need to do a much more overall transition to enhance primary health care in the province, and that would be part of the transformation piece that we'll be working on very much over the next few years as we continue to add more collaborative practice groups.

[9:30 a.m.]

MR. DAVID WILSON (Sackville-Cobequid): I would agree with you, I mean everything that I've read and the people I've talked to have all supported the collaborative practice model. It seems to be the term of this decade, I guess, "collaborative practice" but the problem is that I believe, and I think it is true here in the province, that it takes too long right now for an interested physician and a nurse practitioner to get the approval, get the contract in place so that they can start practising.

I've been contacted over the last little while by one nurse practitioner and a physician who initially were told there was no template in Capital Health for collaborative practice. I

mean it baffles me when we have a physician ready to step up to the plate, a nurse practitioner ready to do work - even though they're still in Capital District they're on the outskirts, more rural - and have been given finally a 100-page application to fill out. From what they've told us, they've talked to no less than 12 different individuals. So there are challenges there that I think we're going to lose the opportunity for interested physicians and nurse practitioners to create these collaborative practices.

As Mr. Bower mentioned, the Long and Brier Islands - I've read the report, I know and I've talked to individuals who have worked there and have increasingly supported that type of model. The satisfaction rate with the residents in that area is high, the reduction of ER visits has occurred, so why are we not taking that and running with it and using it, and using it especially throughout the rural communities? Why is it taking so long and why isn't there someone who I could call today who could walk me through the whole process, if I was a physician who wanted a nurse practitioner to work with me?

MS. DOIRON: I'm going to make a short comment, Madam Chair, if I may, and then ask Donna Denney to speak a little bit more specifically to the process for going through this. A more general comment that I want to make is that one of the challenges we've had in the department is that so far, as collaborative practice teams come along or people express an interest in funding for that purpose, it has tended to be looked upon, if you like, as an add-on to the current system.

What we're saying now is, we have to go through a transformation so that we literally change the way people think and the way people work. That has to start very early, I think, in the careers of people. I must say that all of the schools that are educating our health professionals today have also come to that conclusion. All of the health programs - the Medical School at Dalhousie included and other locations - are actually committed at this point to saying that we need to kind of redesign and have an integrated curriculum and a work experience, a learning experience for students going through their preparation phase and coming out into the system and working differently.

So while we're continuing to try to keep adding to the system we have, we are now also just starting down that road of saying, we do have to figure out how to truly transform the system into a different way of working because if we were working differently and doing that in a more systematic and across-the-system way, then we probably could use the resources we have differently, as opposed to keep adding more resources for every specific team that may want to come forward.

I just want Donna to speak briefly to the process.

MR. DAVID WILSON (Sackville-Cobequid): Briefly, if you could.

MS. DONNA DENNEY: In terms of the primary health care nurse practitioner, the process would be to apply to the primary health care and the funding arrangement is through the primary health care services within the Department of Health. Communities do submit their requests for a collaborative team and it would go in and be evaluated against certain criteria and then, based on funding, would be considered in the mix of those that would be funded in subsequent years.

MR. DAVID WILSON (Sackville-Cobequid): So the deputy minister - thank you for that - mentioned the schools that educate our health care professionals. One of the things we're going to need to do is make sure that we can attract new students to the CCA or nursing or medicine over the next number of years.

I use the example of where I was trained as a paramedic, it was the School of Allied Health. It was a great setting, within the hospital, was supported by government through some funding, had a paramedic program, had cytology, X-ray technician, ultrasound, and it originally had the nursing diploma program there. I use my example because I was a mature student when I decided to go back to school. I had two choices: go to the School of Allied Health, where tuition was under $1,000 - $1,300 with books and everything; or decide to go to Holland College in P.E.I., where tuition was $5,000, plus living expenses. It made my decision easier to go to school here in Halifax, where I grew up, where I live, because of financial reasons.

Now, with that school gone, a lot of it transitioned to universities and community colleges. The paramedic program, which was cancelled - and we didn't have one here in the province for a few years - is now delivered by St. John Ambulance, which is a great program. But the cost of it now is $10,000 for the paramedic program, and the continuing care assistant one has increased and the nursing has, of course, increased because it's a degree program.

What do you say to how we're going to attract these new health care providers in our province when we have a situation where, within 13 years, a program went from under $1,000 to $10,000 and if you want to upgrade in the paramedic program, it could cost you up to $20,000 for another year? Where have we gone in the last 13 years, and I'm concerned with that because of the cost of schooling, and how are we ever going to entice mature students, not only the ones coming out of school but mature students returning to school, who are underemployed, to be part of this health care system that we're going to need the increase in human resources in the future?

MS. DOIRON: Madam Chair, a very good question. Certainly costs have gone up in education, as they have everywhere. We have tended to basically look at professional groups that we need to target and to help motivate people through assistance with bursaries in a number of areas. Often when we're doing this we're associating the bursaries with return for

service. That has tended to be very successful. We've done that in a number of areas and the strategy that we're developing may end up targeting more.

I'll give you a couple of examples. One is the laboratory technologists - running into real severe shortages in this province, the program had been cancelled in this province. So we basically purchased seats from the Province of New Brunswick for several years and we gave students bursaries - I think they were in the order of about $4,000 - to attend that program but with a return for service for each bursary year. That has worked extremely well. Then, in the interim, that gave us an opportunity to develop and re-establish our own laboratory technology program here at community college.

We know that we are going to have to attract and/or prepare hundreds of additional people for the long-term care beds that are going to be coming about. We are in the process of starting to do that. We had already been in the process of offering bursaries to continuing care assistants to take the nine-month program that community college offers. We are essentially escalating those kinds of opportunities through the strategy that we're working out to make sure that we're going to be in a position to staff those beds.

In addition, we're working with the employers in the sector and they are basically offering supports as well. There's options for the way the program can be taken. For example, you go nine months to community college and complete the program or basically get the fundamental components of the program and work part time while you complete the rest.

So I think that those are just two examples but I think in some cases we do have to provide support for the fees that students have to pay and we target those kinds of supports to where we have the greatest needs.

MADAM CHAIR: Thank you. the time has expired for the NDP caucus. The member for Digby-Annapolis, you have 20 minutes.

MR. HAROLD THERIAULT: Thank you, Madam Chair, and thank you, panel. You probably have one of the greatest challenges that this province faces and I assure you, when we get through this challenge or when you get through this challenge and we correct all this, hopefully you'll receive the greatest reward. But we will get through it.

I just want to thank Mr. Wilson for bringing up Digby because in the western area, that's probably one of the our greatest challenges down there. I just want to elaborate a little bit more on the nurse practitioner who works in that area. I've talked to those people down there for many years, long before I got into this job, and they think it's the greatest thing since sliced bread, and it has cut the ER times down 50 per cent, or maybe more, from off that island and they're very comfortable with it. I don't think they would trade that nurse practitioner for two doctors. She does house calls but she works hand in hand with the

paramedics down there; one little phone call and they'll be at your door in two or three minutes. It's great and it works great, even probably a lot less expensive than doctors. I'm not knocking doctors here, we need doctors.

A documentary that was on the CBC, I don't know if you saw it here a few weeks back - Doc Zone it was called. There was a young doctor on there who said he would never practice again without a nurse practitioner in the community. So that said something for him, too. I believe that's the way we need to go in a rural area.

Last August or September this was brought up and it was said that we would have two or three more in the Digby area for the Digby hospital, of nurse practitioners and that's never really happened yet. Is it because we can't find these nurse practitioners or get them prepared, is that the reason?

MADAM CHAIR: Ms. Doiron.

MS. DOIRON: I'll defer, if I may, to Donna Denney.

MADAM CHAIR: Ms. Denney.

MS. DENNEY: We do know currently that we have more nurses trained as nurse practitioners and licensed than are actually working. I think it's a situation of recruiting to rural Nova Scotia, so that's our greatest challenge. So we do have those nurses prepared, pending funding, to work in the areas but again, it goes to the challenges of recruiting to rural.

So I think in terms of the communities trying to support development of nurses, within their communities to take some of these programs as well as probably a good initiative, but I do know there are more trained and ready to license and to practice there but it's a recruitment to that area, to rural, which I think is a continuing challenge in other disciplines as well.

MR. THERIAULT: It'll happen, I believe that will happen.

I'd just like to ask a question about the Digby hospital. We have a beautiful little hospital there, it used to be a 90-bed hospital and that's gone downhill continuously, continuously. We have a regional hospital each side of it, an hour and a half away, to Kentville, an hour and a half to Yarmouth which seems to be in code purple quite often. The people just say to me, all the time I hear it, what a wonderful little hospital we have here. Why can't we utilize this hospital more to take the strain off the Kentville and Yarmouth Regional Hospitals? It seems like a good common sense thing to happen but it just doesn't seem to be happening, it just seems to be more talk of it closing more and more all the time.

Has the department ever thought of using that hospital, where it is in between, as a sub-regional hospital of some sort?

MADAM CHAIR: Ms. Doiron.

[9:45 a.m.]

MS. DOIRON: Thank you, Madam Chair. I think Digby is a particularly challenging area because as you pointed out, the distance to travel to get to a more major centre is significant enough that you wonder if we should not have something more in Digby.

One of the challenges that has occurred over the last years for all of us, including the department, is the change in expectation and the willingness of professionals, including physicians, to work on the basis that used to be the case. We used to have a number of locations where you would find physicians who would be willing to cover 24/7, even with only two or three in a group.

Physicians have, over the last 20 years, positioned themselves very differently and now in terms of looking at the appropriateness and lifestyle, not critical of them at all, because I think it is difficult if you are going to be on call every second night and maybe called out in the middle of the night, to carry out appropriately the things you need to do during the day but generally they have pulled away from those areas.

It would have been the beginning of the 1990s, when I was doing work in Saint John, New Brunswick - there was a huge challenge between the Saint John Regional Hospital and St. Joseph's across town. Both of them had full-service emergency departments but it became pretty clear that population in that area was not going to grow extremely high and basically we were not going to be able to continue two 24/7 emergency departments, with specialists and sub-specialists on call to both sites, because it does not work well to put one doctor on call to go to more than one site. We ended up having to dramatically shift the role of St. Joseph's Hospital in order to make sure we had adequate professionals to provide the 24/7 requirements of the major facility. I think that is partly the same kind of thing we are experiencing in some small towns but it has gone to a more rather extreme area.

We also know, and you can pretty well track - and I know you are probably well aware of the migration that we've had from smaller communities where we have some hospitals in this province, to larger centres. The areas that are growing in this province include mainly Halifax, maybe Kentville and Truro, are the main growth areas. There are a lot of little hospitals that are having difficulties.

When you go to any number of professionals - for example, without giving a location, there is one diagnostic imaging technologist in this province who was working at a very small facility as the only X-ray tech. She has had a heart attack and a stroke, her community

pressures her because their fear is that if she leaves they won't be able to attract another X-ray technologist. Their fear is if she leaves, then other things collapse around her as well relative to emergency and so on. It is all of these reasons and more that we said we need to really, seriously, take a look at developing a rural health strategy and as part of our transformation plan, we need to engage citizens in different parts of the province and in those small communities themselves in thinking through what is the best way to approach health service in their area, what's the best basket of services that we can provide considering all the factors that are there.

I think we're probably similar to what has been happening in a lot of other locales in this country in terms of having to redefine the system somewhat to deal with the realities that we are currently facing.

I think that's a pretty broad answer but I think it is also a pertinent answer because we are not likely to get all of the doctors and all of the other professionals we need to continue with 24/7 service of the type we've had in the past. We need to figure out what is the kind of service we need for the future.

MR. THERIAULT: If we, today, in western Nova Scotia could recruit 10 or 12 doctors that are needed down there, would there be sufficient funds in the budget to pay for these doctors?

MS. DOIRON: If you're talking about 12 doctors over and above any doctors that are currently in the system, probably we would need to take a look at how we would deal with that. The likelihood of getting 12 doctors to come to the Digby area, I think, is remote but on the other hand, I think any ideas people want to bring up as we continue the dialogue around where we're going to go here, any idea is a valid idea and any question needs to be answered with a serious attempt to look at the issues and the variables around it and to provide the best kind of information and so on that we can, not only to the people in the department but more so to the people at the community level to work with, so that we can jointly then say what looks like a feasible kind of future potential.

I know we speak to this quite often but we are thankful that we have such a superb ambulance service in this province because at least the critical care that people can get to at a very short turnaround basis is certainly accessible because of our extremely good ambulance service and our paramedics. In that sense, nobody has to fear that they are going to have a life-threatening situation arise that they can't get reasonably quick access to competent help. What we have at a facility basis, we need to kind of regroup and think that through, but we do need to do it together.

MR. THERIAULT: Here's one idea and then I'm going to pass this on to Mr. Colwell and this has to do with our senior citizens in senior homes. I have people in Digby that could go into an assisted living home down there, a private home and it would cost $1,200 per

month. They haven't got enough income to pay for this, the $1,200 they would need to stay there, which would take care of them in an assisted living environment. So they are going to Tideview Terrace, the seniors home, and applying there to go into that seniors home which the government will pay up to $2,400 per month. Why isn't the department looking at helping these seniors with a few hundred dollars per month to go into an assisted living home? Can you answer that one, please?

MS. DOIRON: I think so, I'll try. We basically agree that we don't have adequate placement for the residential care facilities with assisted living, or the Level 2 nursing home long-term-care beds, so we don't have an adequate number of those. With the work currently going on we are, as you know, building not only the 800-some beds that were RFP'd through the process that has been going on recently, but some other commitments that were previously made, so we're in the process of building something like 1,100 new beds. A portion of those are assisted living beds and the other portion are long-term care.

Where we have residential care facility beds, we're building those to Level 2 standards, so if, in fact, we got in a situation where we need to have more the Level 2 and less of the other type, we can turn them over very quickly. So I think the reality that we are all facing is the long term that went on in this province where there were no new additional beds being provided and we think we're in the process of fixing that.

Some of the beds will start coming on stream in probably the last half of 2009, and we're anticipating they should all be out there by early in 2010. So once we get in that position we should be able to place people in the appropriate level of service, whereas now I think people are scrambling to get any assistance that they can.

MR. THERIAULT: Thank you.

MADAM CHAIR: Mr. Colwell.

MR. KEITH COLWELL: I have a couple of direct questions, I want direct answers. Number one, you indicated that the nurse practitioners are available in the province to go to work. Is the funding available today to put two new nurse practitioners in Digby, yes or no?

MS. DOIRON: Yes.

MR. COLWELL: Is the funding in place to put two or three new doctors in Digby?

MS. DOIRON: Yes.

MR. COLWELL: That's great. That's the answer you should have told us first - a lot easier instead of dancing around the question so much. That's good to know. I'm sure my

colleague is pleased with that - now we can proceed with the community to make sure that will happen.

There has been a story in the paper about the VG Hospital and the emergency operating rooms and if you'd give me direct answers on this, I would prefer it rather than the stuff you normally have to say. Is there a move or is there availability in the budget, or another site that they can move these operating rooms immediately, to resolve this problem?

MS. DOIRON: There are not three to six ORs at another site but we certainly can enhance some of the work on some of the other sites. The ORs, for example, in Dartmouth or the ORs in Windsor, or even some of the work that's going on where they had some capacity up in Amherst, they're doing some procedures for Capital Health. We probably can expand more of that but we don't have additional ORs ready to walk into over and above the ones that are currently operating.

MR. COLWELL: Long term, it has been estimated, what, $500 million to replace the old VG site, the Centennial Building? What short term are you going to do and what long term? Again, I want direct answers.

MS. DOIRON: There are probably a number of things going on that are going to deal with more effective processing of people through ORs. One of the areas has to do with orthopaedics where the longest wait list actually exists, as you know. We are in the process of working with other people right now to try to understand and implement some of the best practices that were implemented in Calgary, for example.

Several years ago they went through a process and basically it involved putting in not just a referral to a doctor, but a referral on the front end to a whole clinic that would work with a patient. That basically better prepared the patient for surgery, and in some cases the work that was done with the patient - and I think it was a pretty high number - ended up not even having to go to surgery. There were also clinics on the other side where there was a much more effective way of dealing with the individual and a much more successful transition of people through the operating room space that they had. We're in the process of trying to develop and implement that model, and that's just one of several examples of how we're trying to get at different ways of doing things.

Capital Health, through their chief of surgery, Dr. Jaap Bonjer, is trying a number of initiatives. I think their longer term plans also include using more of the time at the Digby site, using the other smaller sites for some of the more minor day surgery procedures and looking at their ability to process people differently in their organizations.

MR. COLWELL: Another item I want to bring up that hasn't been discussed here, it has come to my attention that the people who provide the prosthetics in the province - is that under your responsibility?

MS. DOIRON: We do have programming to offer support to people who have to get prosthetics but there are some private companies that actually provide the prosthetics as well.

MR. COLWELL: There's one organization that, I believe, the province funds directly. I can't remember the name of it, but it's right across from the VG site, the Nova Scotia Rehab Centre is it?

MS. DOIRON: Yes, that's correct.

MR. COLWELL: It has come to my attention an individual in my riding who had to go outside Nova Scotia to get some prosthetics because number one, the staff didn't have the proper training and it wasn't provided, and are understaffed. I have all of the documentation on that particular case. The individual went - and fortunately, he could afford to pay for this very special prosthetic which should have been supplied here in Nova Scotia, free of charge, under his circumstances and wasn't - but fortunately he had the funds to go outside the province to get this done immediately and go forward.

From what I understand, if my information is correct - and I have no reason to believe it isn't because this individual wasn't there to grind an axe or complain about anything. He just wanted to make sure that no one else had to go through this same process. There's evidently only one person in the province, or at this site where the province operates and pays for it, who is reasonably well trained - great staff, indicated the staff there was terrific to work with. But if they don't have the resources to work with, if they don't have the training to work with and all the other things that go with that, that means we have people who aren't getting service they should get, number one, and if they've got to go outside the province and pay for it, that's not acceptable.

[10:00 a.m.]

MS. DOIRON: I've not heard of this situation so I think that we can certainly look into that and see what the current situation is. To my knowledge, it hasn't been represented to the department as an issue by the rehab facility or by Capital Health under whom they operate.

On the other hand, if a person requires prosthetics and they can't get it in this province, then basically as long as the physician is recommending that they have to go outside the province, usually it can be arranged that their need would be fulfilled and paid for. So I'm not sure what happened with this case, we can certainly review an individual case, but I think I'd also want to follow up on the comments you're making about our ability to provide the service, period.

MADAM CHAIR: Order, order. The time has expired now for the Liberal caucus and I recognize the member for Victoria-The Lakes. You have 20 minutes.

MR. KEITH BAIN: Thank you, Madam Chair, and good morning and thank you for being here this morning. I want to talk a little bit about ERs. I'm going to start off by talking about ER closures and I know in my area, in the Cape Breton District Health Authority, we often hear of closures within the Northside General and New Waterford Consolidated more than any other within the authority.

I guess my question is, why are we experiencing these closures and what's being done to rectify the problem?

MADAM CHAIR: Ms. Doiron.

MS. DOIRON: Thank you, Madam Chair. Well, one of the reasons why we experience that is having adequate doctors for 24/7 for the number of emergency departments we have in the province. I think we're operating 37 emergency departments and in a province of this size, most provinces aren't doing that, to be quite frank, because they found that they've had difficulties with the same thing, staffing 24/7.

I think that as part of the rural health strategy, we need to be looking at how do we best serve the population we have? The other thing about emergency departments, which I think is a critical issue, is the fact that we know we have 75 to 80 per cent of people going into the emergency department who are classified, or triaged as they call it, at a level 4 or 5 - 1 being the most acute. Usually, maybe not 100 per cent, but usually a level of 4 or 5 does not need to be seen in an emergency department.

Now that's not the fault of the public for going there, I don't think we have systematically provided the real alternatives for them to go somewhere else. So again, as part of the transformation of the health system, we need to look at issues like that and say, how do we provide alternative ways for the public to get the kind of care they need, without forcing them to go to emergency departments that should be dealing with the more acute people, and then see what impact that has and then how we organize the system.

One of the things that we want to do, and I think we will be able to do this next year, at least I hope so when the budget is approved, we've been talking I think for some time about wanting to put into this province, as many other provinces have, a telephone triage kind of line that would give people access to a nurse on the other end who can provide advice. That kind of service has been available in a number of areas in this country for long enough that there's pretty solid evidence to demonstrate that when people have that kind of opportunity, then there will be a drop in the number of people presenting at the emergency department.

So in some cases what happens in some of our emergencies, due to the volumes that are coming in, we sometimes even have to have more than one physician on a shift. If we can have physicians responding just to emergencies and be able to provide through a multiple

grouping of practitioners, other alternatives, then basically it's that kind of rethinking that I think is going to take us into a future that can better respond to people and deal more effectively with how we operate emergency rooms.

MR. BAIN: So would the department be looking at closing ERs and opening more walk-in clinics?

MS. DOIRON: The minister and the Premier have said that we will not close ERs. I think that as we go through and talk with communities, if we come up with ideas that talk about different ways of utilizing ERs, then we will bring that information back. But at this point in time our instruction is that we will not be closing ERs.

MR. BAIN: And I guess one of the things, and again referencing the Cape Breton District Health Authority, is that both the Northside General and the New Waterford Consolidated are in fairly close proximity to the regional hospital. I'm sure that, at times, is taken into consideration.

MS. DOIRON: Absolutely.

MR. BAIN: I guess another question is, do the other Atlantic Provinces face the same challenges in ERs as we are facing?

MS. DOIRON: Madam Chair, they do. I know that the other Atlantic Provinces have already taken some steps that we have not taken and we may not take, particularly with emergency rooms. I think you would probably be aware, but it's easy to access information about the number and location of emergency rooms in New Brunswick which have either been closed or changed status.

P.E.I. has, over the last couple of years, dramatically shifted some of how they're operating their system and, in fact, they have basically closed some emergency rooms. They also now have a model where they're operating the whole system directly out of the Department of Health.

Newfoundland and Labrador has some special challenges, of course, because of the geography and the distances, but I'm not quite as familiar with exactly where they are in that. I do know that in the Maritimes there have been ER closures and other approaches taken.

MR BAIN: So the challenges are certainly out there right across the country.

MS. DOIRON: In fact, it's out there across the country. I sometimes actually get astounded myself when I'm with colleagues from other jurisdictions. Recently, I was talking with the deputy out in Alberta and she was basically very concerned because one of her

challenges of that day or week was a shortage of nurses, to be able to staff emergency rooms and intensive care units.

So when you go across the country, even provinces where they at least are purported to have a lot more resources than we do, are not able necessarily to successfully fill all the positions that they're willing to pay for. They're having challenges both with physicians and nurses, and other professionals.

So we have challenges and I don't think we can sit on our laurels, for sure, but it is a little bit comforting to know that people like to work in this province and that we do have the highest per capita numbers of GPs, specialists, nurses, LPNs and so on. So we have real challenges and we have to figure out some better approaches for the future. We will do that openly and honestly with the communities that need to be involved in that.

MR. BAIN: Thank you for that. Some people, if they go to an ER and it's quite crowded, they don't want to - are we ensuring that those individuals, that everybody who goes to the ER sees a doctor? That they don't leave without seeing someone, what steps are being taken to ensure that happens?

MS. DOIRON: Within the health system in this province, there are a number of emergency rooms, particularly those that have high volumes of patients, where they will have an initial triage of people. Usually somebody is assessed as soon as they go in, or very shortly after. Basically the people who tend to wait the longest are usually the people who are not as severe.

We keep hearing reports like, I had a heart attack, I went to the emergency room, I got tremendous service, I was taken care of right away, et cetera. I think usually that's the kind of case we have when we have serious situations going on.

With the way the system works right now, people then do have to wait, even though they may have seen a nurse, they still have to wait to see the physician before there's a completion of the visit.

MR. BAIN: And that's where they're categorized as Level 1, up to Level 4.

MS. DOIRON: That's right.

MR. BAIN: I guess when we talk about doctor shortages and ERs, why can't we just pay doctors more to cover ERs - an incentive?

MS. DOIRON: Well, if I may, I want to defer that to kind of give some of my staff a chance to speak here because I know they know a lot more about this kind of thing, so I'm going to defer this to Ian Bower.

MADAM CHAIR: Mr. Bower.

MR. BOWER: Thank you for the question. Paying them more is what's happening across the country in emergency rooms, as incentives. It's not dealing with some of the fundamental challenges that the deputy has already raised about the critical mass of physicians that may be in an area where an emergency room is. If you have two physicians who can serve the patient population adequately, however they have an emergency room that they also need to staff, that becomes the challenge. So it's not the financial side, it's the lifestyle side that becomes the challenge.

So the other part of this is that in family practice, who are typically the people staffing these smaller ERs, they have over time - because of the volume of acutely true emergent cases coming in, as the deputy has referred to - they've lost some of the comfort with seeing emergencies so they are feeling less interested in fulfilling that role of 24/7 coverage. So there are a number of issues that work beyond the finances, but that is one strategy that other provinces are definitely adopting.

MR. BAIN: Could more nurse practitioners and paramedics staff ERs to keep them open?

MADAM CHAIR: Ms. Doiron.

MS. DOIRON: I think that there's real opportunity to utilize nurse practitioners and other professionals in order to serve the public but we cannot ask nurse practitioners, for example, to be doctors. So we need to understand, when we put people out in a system to work, what the scope of practice is that we should be asking them to carry out.

I think Ian said it the last time he answered a question - that if we do have other professionals, though, we can leverage the time of the doctor differently. If the only person the individual is seeing is a doctor, then whatever the need is or whatever the interaction is, basically is with the doctor when, in fact, other professionals can very effectively handle much of that. So it's unlikely that we would say that we would have an emergency department without a doctor but we might have some other kinds of services we do, where a doctor is not necessarily there all the time.

MR. BAIN: In the rural areas, of course, it's the difficulty of having doctors look after the ERs that's certainly a challenge. I know that in the past there have been doctors from metro here who would spend a weekend in Cape Breton to look after the ERs. Is that an incentive? Is there an incentive there to have some of these urban doctors go to the rural areas to fill the gaps in the ERs?

MS. DOIRON: I'll defer to Ian again.

MADAM CHAIR: Mr. Bower.

MR. BOWER: Sure, there are incentives available, both through the district health authority and through the province, our central funding agency for physician services, to support those physicians who may want to relocate from their community of practice, to another locale to assist with a service. We call it "locuming" in the business, which is really temporary relief of a physician or a vacancy or something along those lines, but we do provide funding ever year and we do in a number of places - Digby, as one example, is kept open on the weekends by locuming physicians for the most part, and there are other places where it is working as well. So we provide added incentives to the basic payment associated with working in ERs, to support those physicians to go to those places where they are needed.

MR. BAIN: So it sounds like it's successful but, are there areas where it just can't happen within the province - or it won't happen, I should say. The doctors say, no, I'd love to but I'm not going there.

MR. BOWER: I think there are geographic challenges and distance and proximity and disruption of your lifestyle where you are to do these things, I think there's no doubt about that. I think the incentives are there for those who are interested and willing. We also have to keep in mind, again, back to the point that the supply of family physicians who are able to provide that service, even though our numbers are strong in family medicine, albeit there are sensitive areas where we have some gaps and things of that nature that we've already discussed. I think that the supply of those family physicians who are willing and able to continue on providing emergency services does pose a particular challenge for us and we do have a host of strategies that we're looking to proceed with that will help them in their continuing professional development, that sort of thing, that will allow them to continue to function in that capacity.

MR. BAIN: Mr. Wilson said there are approximately 50,000 people in this province without a family doctor. My question is, how many family doctors does Nova Scotia need?

[10:15 a.m.]

MR. BOWER: That's a very good question. I think, as the deputy has alluded to, there are a number of scenarios we could use looking forward. If we look at the current gap today and you look at the number of vacancies that are in the province, the number of vacancies roughly add up to the number of people who require a family physician, if you take the average family physician as having 1,200 patients, if you want to look in that vicinity.

I think what the deputy has mentioned and I think we've all talked about, and questions have come from the committee about the opportunities in collaborative practice and how that impacts on the number of physicians that we may need in the future, it may

change the number of what we need depending on the amount we leverage those providers with, multidisciplinary, interdisciplinary teams in communities.

MR. BAIN: That's fine, Madam Chair, I'd like to turn it over to my colleague.

MADAM CHAIR: Mr. Dunn.

MR. PATRICK DUNN: In your opening comments, you were talking about Nova Scotia providing incentives perhaps not matched anywhere else. Could you give me some examples of the incentives you were referring to?

MADAM CHAIR: Ms. Doiron.

MS. DOIRON: Madam Chair, I think I would like Donna Denney, in this case, to at least begin with the nursing strategy and some of the incentives in that.

MADAM CHAIR: Ms. Denney.

MS. DENNEY: Thank you for the question. In terms of what we do in incentives for nursing, we offer a number of bursaries for students in their fourth year of their program and with a return-to-service agreement. We provide support for a re-entry program and we have a number of nurses who are not practising that we want to attract back into the profession, so we do provide that support through scholarships or bursaries for the re-entry program. Relocation, again, there's a $5,000 award for somebody wanting to relocate to Nova Scotia, up to a maximum. Our best combination is if we have a husband-wife, a couple or pair coming back, then they can both get the $5,000.

The relocation, the co-operative program, we have gone from 60 up to 120 up to 180, to the point where we're wanting to fund all of the third-year nursing students in the co-operative program and that's a significant incentive because we can correlate that to their places of employment following graduation, so we're really encouraging the co-operative program in the third year of the nursing programs.

We do offer LPN bursaries and that helps LPNs around increasing their scope of practice with administration of medications and assessment skills, things that may not have been in their original core program, so that really increases the scope of practice of LPNs. So those are just a number of some of the incentives that we do provide to attract nurses into the workforce and to relocate to Nova Scotia.

MR. DUNN: You mentioned a fourth-year bursary, the return-to-service agreement. Could you expand on that just a bit?

MS. DENNEY: The return-to-service agreement is that they would replace for years of service for the $4,000 bursary that we do offer them upon employment.

MR. DUNN: Trying to entice and attract doctors to any part of the province, what are the major requests from these professionals themselves? After talking to many, many of them there must be some common ground where they have certain requests.

MADAM CHAIR: Ms. Doiron.

MS. DOIRON: I'll defer that to Ian Bower.

MADAM CHAIR: Mr. Bower.

MR. BOWER: Thank you, again, for the question. I think the physicians themselves have identified that the attractiveness - the incentive, if you will - to go to an area is really four components: it is financial, it is professional, it's personal, and there is an intangible aspect as well. We do pretty well in this province with respect to the professional and financial aspects, we do quite well.

The make-or-break decision for most of these physicians is about the personal attributes that a community will have for them and their family and some of the intangible aspects, whether it be a family connection or something along those lines, is what actually makes the decision. Employment for a spouse, school for their children, those kinds of things are often the most important factors for the physicians.

MR. DUNN: We all realize it is a very fierce competition for professionals in this particular field. A physician in my constituency last year was recruiting, to recruit new doctors to the area in another province and ended up being recruited himself to the province that he went to. It ended up that it just worked the opposite way - he ended up going to another province which was very unfortunate.

I guess I would just like to have some more comments with regard to - you did mention in your earlier statements we added more doctors than we lost, we know we don't have enough doctors and so on. Just dealing with the graduating medical students and so on, the number of seats versus the number of students from outside the province that are here and anything to do with any tangibles with regard to keeping them here in the province and so on, or are we looking at increasing more seats, or can we increase seats, and if we can't, why can we not? Any comments along those lines?

MADAM CHAIR: Ms. Doiron, the time is actually expired but I will give you time to answer the question.

MS. DOIRON: Thank you Madam Chair. Several years ago we were running at 82 seats per year in our medical school. We increased the number by eight, so we now have 90 seats in our medical school. You may be aware that New Brunswick is intending to begin an English-speaking medical program in Saint John within the next year or two years. One of the limitations we've had in just adding numbers to the medical school has been some of the limitations they have with infrastructure. We know that the university needs to deal with some of that - I don't think the medical school has had any real infrastructure improvement since the 1960s so we are aware of that. However, once New Brunswick opens their medical school, I think the number of students that we've generally had from New Brunswick is somewhere in the order of approximately 20, so that will free up 20 places.

We will have to pay additional dollars if we want to add 20 seats to the medical school but given that we were really heavily subsidizing the New Brunswick students - basically, the Province of New Brunswick had a rate that they paid to Nova Scotia that amounted to approximately half of the cost of the cost of a student at Dal in medical - in other words, we should be able to add 10 seats without even having to be too concerned about the dollar factor.

We are in negotiations with that with Dal and I believe they see it that way as well. We have had good conversation to say that when we make that move, when we have that opportunity, they should be for Nova Scotia students who are willing to stay in the Province of Nova Scotia. So there is some planning going on and we will have to then discuss, do we add the 10 more seats or not. There is lots of potential being considered.

Dal, I believe, is also looking at the possibility of dealing with some of their infrastructure issues, obviously, that will take a little time even if there is a decision to proceed, which there isn't at this point. I think that there is great potential to add physician seats to the province.

We are also looking at this point at potential other incentives that would work on the basis of saying, we need to bring back to Nova Scotia students who are going to other countries to get their medical degrees. So there is discussion about how to offer incentives for that as well.

MADAM CHAIR: Order, the time has indeed expired. The next round will be 10 minutes per caucus. Mr. Wilson, the floor is yours.

MR. DAVID WILSON (Sackville-Cobequid): I believe there are 19 different documents and hundreds of pages of studies that were provided to the Public Accounts Committee on human health resource planning, to prepare for this meeting. Does it say anywhere in these documents provided that essential services legislation, or taking away the right to strike from health care workers, is an effective recruitment tool?

MADAM CHAIR: Ms. Doiron.

MS. DOIRON: We have not addressed that through the documentation we have in the department, no.

MR. DAVID WILSON (Sackville-Cobequid): Of course, that was a hot issue in the last session and government has stated that that is the case, which I would disagree with. In fact I know, and hopefully you would agree, that employee satisfaction is probably an important tool in retention of health care workers. Have you taken any job satisfaction surveys for health care workers in the last couple of years maybe?

MS. DOIRON: I don't think that we have done a comprehensive across-the-entire-system approach to that, but there have groups and pockets of workers where that has occurred. It is also a fairly regular occurrence in most of the district health authorities to do satisfaction surveys with their own employees, so it has not been an organized, orchestrated, government approach to doing that.

MR. DAVID WILSON (Sackville-Cobequid): I think it should be an extremely important part of a human resource plan. What concerns me the most in our environment today, here in the province, is that we have a Minister of Health, a Premier and a government willing and ready to open the doors for private health care delivery here in Nova Scotia. They have publicly stated, everything is on the table, to that effect.

Reading through this big binder here with all of this information, I didn't come across once any indication of what effect that will have on our human resources in the public system. Are you concerned or have you talked about the effects of allowing private health care delivery in Nova Scotia and the effects on our human resources - the most important part of our public health care system - and what effects that will have on it?

MS. DOIRON: I would preface my comments with saying that it is not my job to debate the political side of these issues. I would, however, add that any advice that we have provided from within the department basically is based on the fact that any approach taken to how we provide health care should be done within the constraints of the Canada Health Act. Consequently, that means whatever approach is taken that we should be having the public system define health care, define the way service will be delivered, fund the service that is delivered and avoid any potential for queue jumping. So those are principles, I think, that are consistent with the Canada Health Act that we, as staff, provide advice about. I would say that the proposed Act reflects that point of view that staff have offered to that.

I know that we have experience in the health system in contracting private services and usually that experience has been based on non-clinical support. Over many years, in many places in this country there have been examples of contracting housekeeping services, maintenance services and others. We actually have a very good example in this province of

contracting a clinical service that has been working well for us, as the member, of course, knows, given that we do contract the ambulance service to a private provider.

I think where the program is defined, where standards are maintained, where evaluation against those standards is carried out, where deliverables are clear and where deliverables are also monitored, it's possible for things to take place successfully on that basis.

Based on my own personal experience in a number of different jurisdictions, my view is that every single case and situation has to be looked at individually to see if there's a win-win and basically, no one approaches a panacea for the situation in the health care system.

MR. DAVID WILSON (Sackville-Cobequid): That's why I think it's so important that government and your department has knowledge of the satisfaction rate of the health care workers. I know personally that they're overworked, they're stressed, the demand on their job now is extremely high, especially in some of the rural settings.

[10:30 a.m.]

My fear is that if the government - and I know it's not your position, you implement government policies, I understand that - but if the government goes ahead with this without looking at the full picture, and you're trying to reassure us that's what your job is going to be, but I don't trust the current government on making sure all of those problems are looked at appropriately before taking that jump into private delivery here in Nova Scotia.

I'll give you an example of my own case when my son was born. He was in the NICU, I believe it was called, and we had a nurse who watched him for the whole week and she was so excited about having the weekend off. The next day, I think it was a Saturday, we came in and the same nurse was there and she said she made the error of answering her phone and with the mandatory overtime, she had to come in.

Right there, if you were to ask that nurse if there was the possibility for her to go work in a private clinic, work eight to five, nine to five, nine to four for the same money if not maybe more, I think the likelihood is that she may jump ship and go to that private clinic. So that's why I have a fear that if government is going to take these initiatives and go down this road, that job satisfaction - you need to make sure you know where our health care workers are.

I would now like to turn quickly to a couple of little different issues - hopefully you can give me some short answers. It's my understanding that Northwood is now looking at offshore workers to complement their continuing care workers and the number they have. Are you aware of this and where are they with that? Is that something that has been approved

by your department and by government? Is this an initiative that they're going to be able to gain access to?

MS. DOIRON: Yes, we're basically encouraging people to look at not only recruiting continuing care workers and others from within our own province, but to look beyond the province and, if it would be helpful, beyond the country. I think the number is - and Donna Dill can correct me - that as we open these new beds we will need something in the order of 1,600 continuing care assistants and we need to produce or find those people over the next year and a half. We have some very good figures going forward for the next programming arena, and the second phase of that needs to be staffed as well. Part of our recruitment campaign is there will be a huge ad campaign going out fairly soon and part of that is aimed at that very perspective. Yes, we're interested in looking abroad, but particularly looking within - this is a wonderful opportunity for some people in our own province.

MR. DAVID WILSON (Sackville-Cobequid): We'll look forward to hearing some more on that. I know I only have about a minute left, so quickly, back to the Medical School and the seats. Quickly if you could, how much is each medical seat? What does that cost the province? Do you fear that there may be an impact on the resources for Dalhousie Medical School when New Brunswick gets their 10 seats up and running in Saint John?

MS. DOIRON: A couple of years back - and it may be a bit more now- we estimated that it was about $56,000 to $57,000 per student, per year. New Brunswick will be funding their own program. We're not concerned that's going to draw resources from our program at all. There's also preparation of faculty from New Brunswick who will go on to work in concert with faculty here. We're quite comfortable that program can operate without doing anything to minimize the program here.

MADAM CHAIR: Order, the time has expired. I recognize Mr. Colwell for 10 minutes.

MR. COLWELL: Just back to our problem with prosthetics - I just want to make it clear that the gentleman I'm talking about had a prescription and everything was done the way it should be done. His out of pocket costs were still $5,000 over and above that which shouldn't be the case because we could have had it done here, it would have been a lot easier. Unfortunately, a lot of people don't have the ability to pay the extra $5,000 or whatever it may be - it could be more than that, depending on where they have to go.

The point I'm making is we need to make sure that our staff - and I stress the staff who are here now are doing an excellent job with what tools they have to work with and the training they have, so that's not an issue. The issue is, they need more training and they need not actual facilities but actual equipment to work with. I don't believe, from what I understand and again, without knowing all the facts I'm just guessing here and guesses aren't good in this type of business, that if indeed they had the facility upgrade - and I don't mean

buildings, I mean just equipment - and some additional training, and probably a couple more staff because I understand there is only one person in that facility that can do some particular type of work which is not suitable, that indeed we could do a lot more of this in Nova Scotia and save Nova Scotians money and also make their lives a lot more comfortable, especially if they've lost a limb or some other incident when they have to have this kind of treatment. The faster this can happen, the faster they recover and the faster they can get back to work or on with their lives. I would ask you to investigate that.

If you're interested - and I know you are because you take this job that you do very seriously and that's never in question from me - I would be very pleased to bring the gentleman in and let you talk to him directly with your staff and just see what the situation is. This gentleman has no axe to grind, he's not interested in going to the media, none of that stuff. He just wants to make sure that what happened to him doesn't happen to anyone else and he can't say enough good about the staff who are there now. So this is not a vendetta against anybody or anything, it's just to make sure the service is there for the people who really desperately need it.

MS. DOIRON: I will follow up with Mr. Colwell, personally, to kind of set up a meeting for that purpose but what I will also endeavour to do is to investigate the situation that is existing at the Rehab Centre with regard to the service. Once we have some information together and if we need to be looking at some development there, we can put that into a brief document and submit it to the committee so there will be an answer to the group.

MR. COLWELL: I would appreciate that very much. I will give the remainder of my time to Mr. Glavine.

MADAM CHAIR: Mr. Glavine.

MR. LEO GLAVINE: Thank you, Ms. Doiron and staff for coming in today. Even though I'm pressed for time, I have a lot of questions to ask, I will echo my comments of my colleague, David Wilson (Sackville-Cobequid), who always says you have one of the toughest jobs in the province but we found out yesterday maybe the Minister of Community Services has the most dangerous job in the province.

One of the areas that I will dispute with you and I think it is misleading to Nova Scotians, for the minister - and you echoed it this morning as well - that the doctor and health professional shortage is a crisis across the country but here in Nova Scotia we have the highest doctor to patient ratio in the country. Meeting with Doctors Nova Scotia recently they said, perhaps yes on a per capita basis but if we do the doctor equivalency, we do not have as bright a picture as is often painted by the Department of Health.

I was wondering if you are prepared to give Nova Scotians, in conjunction with Doctors Nova Scotia, a real picture of our family physician issue? I know in my area it is

very severe to the point where 14 Wing Greenwood is looking at establishing their own clinic for their families because they don't have enough physicians in our area. We lost a husband and wife team and moved in a collaborative practice but that only picked up a fraction of the patients they dropped. Which leads me to really getting full clarification on that aspect but also, have you done a study with physicians across Nova Scotia with a simple question of what are your hours of practice a week, how long will you continue to practice? We do need a lot of lead time there and I'm not so sure that we have the best statistical profile in our recruitment picture.

MS. DOIRON: Clearly, there are issues in terms of the distribution of physicians in this province. While the overall figure might be accurate the issues that exist in various places in the province are very real, so I don't mean to negate that at all.

We actually do a fair bit of review of the kind of information and data we have. Part of that, of course, is based on both the statistics we have through MSI and also the deliverables and the reporting processes that are now occurring under the AFP process. So there is a fair opportunity to assess the extent to which a physician is working. We do have measures, for example, that will say that so many hours or so much activity might correlate with full time or part-time FTE practice, so there is some work of that nature that has been done. I think we can enhance that work and as part of the process that Cheryl Burgess is developing with an overall strategy we need to go more deeply into that work. I'm just going to check to see if Ian Bower has anything to add to that.

MADAM CHAIR: Mr. Bower.

MR. BOWER: I think the only thing that I would add is that I think the provincial numbers are - I think you've identified a complexity in it, in terms of measure full-time equivalency. I should mention that the National Physician Survey does take place on a cyclical basis where we have pretty good data about the satisfaction, the plans of Nova Scotian physicians and what their work life is like from that survey. So we do draw that out and try to incorporate that in our planning. Again, your point is well taken that the provincial numbers are good, sometimes that does not speak to some of the distribution challenges that exist.

MR. GLAVINE: One of the areas - with limited time - that I do want to address today and ask where perhaps some help is coming. Recently, we know we've had a number of newspaper articles and I'm sure Janet Knox, CEO, who does a great job in our area, has raised alarm about Valley Regional and the crisis that is there and, in my view, will become much more severe. I was disappointed in the sidebar article to hear the minister say, relax, smile, be happy, in 2010 we're going to have some help for you.

I did not like that comment and I do have great respect for the minister but I thought it was a little flippant in light of the fact that we have one-third of the beds occupied by long-

term care. We have patients coming in with congestive heart failure who spend two or three days in emergency wards and a quality of care currently - despite the tremendous staff that is there, they are not able to deliver to the Valley the kind of quality care that they need. We need a comprehensive look. If we had palliative care and 10 people in a facility that could take 10 of the 35 people out of the beds, I think that would go a long way. We have a home care system that now, again, despite the tremendous work that John Dow is doing, we know that it is just on a thread form day to day, six months of wait time, we can't get people back in homes.

I have had three presentations - and I would like for you, the deputy, to really look into this with the view of devolution down to the DHA - from home care workers who are afraid to perhaps go to the authorities and tell the real issue. We have them being paid for hours they do not work; we have them with insufficient time to get to patients, on occasions; we also have cases whereby due to very haphazard scheduling are just so handcuffed in an efficient, smooth way of charting their day, so therefore they end up with periods of time when they could be seeing more patients but don't do so, but still get paid for. We have about a six-month waiting list here, so that's an area that has to be tackled. We obviously don't have enough long-term care beds and I think we need to look at short-term solutions with, again, three persons in a home or more that can be subsidized and given certification by the department.

The biggest thing that is coming - and I'm sure you didn't hear it here first - but when surgeries get cancelled, doctors get paid per surgery in most cases and we're going to see surgeons leaving the region because of the tremendous backload that we have and the inability for them to perform in a regional hospital as they should.

[10:45 a.m.]

Today - I don't know when you've been down lately - our hospital for the last five or six weeks has operated in a state of crisis and I think the situation will only get worse. We have, in the Valley, according to the strategy on aging, we have three communities whose population is 25 per cent or over, we have five more communities with 20 per cent or over. We are seeing the tip really of what is going to happen probably across the province and in other jurisdictions because it is a wonderful retirement area. The stresses on the health care are enormous. Is there a comprehensive plan?

MADAM CHAIR: Order. I actually allowed the member to go over by two minutes in terms of what he was putting out. We'll move to the PC caucus and the deputy, perhaps, in her closing comments could address your concerns there. Mr. Dunn, 10 minutes.

MR. DUNN: Just one question dealing with wages. I'm thinking of different professionals and an acquaintance mentioned to me recently that a lawyer starting their articling here in this province is around $39,000 but in a similar position in New York it is

$150,000. However, leaving it to one side and returning back to this country, my question is, are wages for our physicians in Nova Scotia competitive with any other area of Canada?

MADAM CHAIR: Ms. Doiron.

MS. DOIRON: We have generally taken the approach in this province and been supported by the government to take an approach where we usually have the most competitive wages in Atlantic Canada. As the collective bargaining goes on with various groups, of course, there are always comparisons about what's happening nationally and it can, because of timing, maybe sometimes have a small window where we are catching up because negotiations have gone ahead in another jurisdiction. It is generally well known that Nova Scotia does fund its health care professionals at a rate that is very competitive in the Atlantic area. We don't try to compete with Alberta, for example, but I think we are pretty well in the ballpark for competition with some other major areas in Canada, as well as making sure that we stay ahead in the Atlantic area.

MR. DUNN: DHAs competing for professionals and the province versus districts and so on and various districts on individual campaigns trying to entice people to their area. My question is, could this possibly be fostering an unhealthy environment with this type of activity going on between the districts?

MS. DOIRON: Obviously there is competition across the province to some extent but I think there is even more integration of efforts across the province. As I sit, as I do on a monthly basis with CEOs and my staff sit with the other folks in the districts, there is a high level of joint planning in terms of how to approach some of these issues.

We are tending, I think, to get into more of an issue with district health authorities feeling competitive in order to attract management staff. Management staff become more the challenge in this province because as we continually up the negotiations with the unions, then we also need to take a look at how is that positioning people at that first level of management and supervision. Those kinds of issues, again, are on the table in our discussions and we've recently been having discussions about what recent negotiations have done relative to the compression of the management group. I think that when we do things together like that it helps to decrease some of the unhealthy competition that can occur between jurisdictions.

With the physician side we did - several years back, basically in regulation - come to a decision together that the various district health authorities, in their competition for physicians, would not have unlimited latitude in terms of anything extra that they could offer. There's a window where if they want to provide something extra to attract a physician and particularly where that makes it impossible to get a physician from maybe out of province to come in province, but we do not have the extremes, the differentiation between the districts as had previously existed with the competition in that area. So it's there but it's somewhat managed and a little bit minimized to where it had been.

MR. DUNN: Because of this shortage - and I think you alluded to this in your opening comments that 24-7 service may not be possible in all the areas of the province, in particular the smaller communities - what do you envision with regard to the next 10 to 15 years with regard to 24-7 service, in particular in these smaller areas?

MS. DOIRON: I believe that we need to be providing through the health care system alternative ways for people to stay healthier and people to get access to primary health care in a way that is helpful and convenient for them, if you like, and also to best utilize an array of health professionals in the process of doing that. There are a lot of models that we can look at in the process of doing that.

We are going to have that kind of dialogue throughout the province where district health authorities will probably be the face of it to their own communities but we need to make sure going into it that we provide appropriate information for health professionals but also for the public, community health boards and so on, to be able to say what is actually happening in our community. So what is our experience with various services, with supply of people, with utilization factors, various hours of the day and night and all of the things that go into saying, if you had the resources that are currently being spent in your area, how would you like to spend them?

What I'm not doing is saying that the Department of Health, or me, or anybody else will not be predetermining what that means. I think it has to be a true consultation and see where the minds of the public are at this point, as well as in terms of what we're ready for. Let's create that vision as well to say that our primary health care system is not as robust as we think it needs to be so let's talk about how to get it there, and that's part of the work that will go on over the next two or three years.

MR. DUNN: Perhaps as just a closing comment, I certainly commend and applaud your department for all your fine work and the focus and vision I see coming from your department with regard to looking at anything, all options on the table because you certainly had to change from the past and look to the future, as far as being innovative, being creative and so on, and coming up with some viable solutions. Anyway, I commend your work. Thank you.

MADAM CHAIR: The questioning portion of our meeting has now concluded and I would invite the deputy to make some concluding comments.

MS. DOIRON: Thank you, Madam Chair, I will be very brief. I think there are pockets of things happening in a number of areas of health where we have been very responsive to many of the human resource needs that we have in the province. When we do the comprehensive strategy, which is basically going to be starting up very soon - we hope to have some outcome from that by the end of May - I think what we're going to find is that there has been a great deal going on but we will identify the pockets where there may be

gaps, and then with an umbrella strategy be able to say then what are the next best steps in the strategy to kind of move the whole system forward from a health human resource perspective.

I would like to quickly respond to Mr. Glavine, if I may. I think that the area he represents, I believe, is just about the most challenged area in this province because they tend to get hit with concerns from all fronts. We may have, in one area of the province, a long-term care system that is not as responsive as it needs to be and will be, but maybe the home care system is working well.

In the Valley, we have issues where we have wait lists both for residential care, for long-term care, for home care, and it just compounds all of the problems that are there. We are working with Janet Knox - who, as you say, is an exceptional leader - and her staff to say, what else can we do from a temporary bed perspective, and there's one idea that actually I'm going to be talking about later today. But we are looking to say, what can we do from a bed placement point of view?

I know that we've had, and Janet has had, a fair bit of dialogue with VON. While we're not completely to where we need to be, they have actually in the last few months decreased the waiting list by 30 per cent, they've had success with hiring people.

A third issue I want to mention because it's germane to being able to get home care services there and making sure they're quite responsive - in addition to all the people that we need to seek in order to staff the beds that are coming up - we also have been working with a shortage in this province, across the province, in the order of about 400 home care workers - many of them are, of course, mostly CCAs, continuing care assistants.

So part of the plan in the HR side of what we're doing right now, in terms of augmenting the numbers we're educating, includes that gap number that if we can drive that out there over the next months, that should also help the Valley to recruit enough people to go in behind and provide that care.

Part of the challenge we've been having - and you mentioned the issue of home care workers being paid for time that's not used - all of the home care services need to be looking at how to best manage that situation. In the last round of collective agreements, there was some attention to providing some guaranteed hours to these workers. For example, if they ended up with a slate of what they were supposed to do in a day and then somebody calls in from their home and cancels out because they also have choices, then basically that's unused time. We were finding that if the home care agencies adjusted against that and only paid for the hours worked, then you had home care workers who were not wanting to work in that workforce because they were not sure of what their pattern of work or income was going to be.

We are in the process across a number of home care agencies of trying to manage, what is the balance between guaranteed pay and the opportunity to make sure we're making the best use of their time? That's currently ongoing work, but we're well aware that there's an issue there.

I want to thank Mr. Glavine for the support he provides to the health authority down there because they have some very big challenges, but I think that we can keep doing interim work that will keep relieving the situation until we get stabilized.

MADAM CHAIR: Thank you very much. On behalf of members of the committee, I want to thank the officials from the department for being here today. It's always very informative and a pleasure to have you here with us. With that, the committee stands adjourned until March 26^th, when we have the Auditor General.

The subcommittee will meet at 11:00 a.m., we'll give people an opportunity to leave.

We stand adjourned.

[The committee adjourned at 10:58 a.m.]