HANSARD

Printed and Published by Nova Scotia Hansard Reporting Services

PUBLIC ACCOUNTS COMMITTEE

Ms. Diana Whalen (Chairman)

Mr. Leonard Preyra (Vice-Chairman)

Mr. Clarrie MacKinnon

Ms. Becky Kent

Mr. Mat Whynott

Ms. Lenore Zann

Hon. Keith Colwell

Hon. Cecil Clarke

Mr. Chuck Porter

[Hon. Christopher d'Entremont replaced Hon. Cecil Clarke for a portion of the meeting.]

WITNESSES

Department of Health

Mr. Kevin McNamara, Deputy Minister

Mr. Abram Almeda, Acting Executive Director, Acute Care

Ms. Linda Penny, Chief Financial Officer

Cobequid Community Health Centre

Ms. Barbara Hall, Vice-President, Person-Centred Health

In Attendance:

Mrs. Darlene Henry

Legislative Committee Clerk

Ms. Sherri Mitchell

Legislative Committees Office

Ms. Evangeline Colman-Sadd

Assistant Auditor General

HALIFAX, WEDNESDAY, NOVEMBER 4, 2009

STANDING COMMITTEE ON PUBLIC ACCOUNTS

9:00 A.M.

CHAIRMAN

Ms. Diana Whalen

VICE-CHAIRMAN

Mr. Leonard Preyra

MADAM CHAIRMAN: It's just after 9:00 a.m., and I'd like to welcome the members of the Public Accounts Committee here today. We have witnesses with us from the Department of Health, and our subject today is emergency rooms and the provision of that service.

Just to begin, we like for the record to have all the members of the committee introduce themselves, then we'll go right around the room and introduce the other staff who are here today in the front row, and also our witnesses. So with that in mind, I'd like to begin with Ms. Zann.

[The committee members and witnesses introduced themselves.]

MADAM CHAIRMAN: Thank you very much. The committee meeting will go as we normally do today, with an opening statement from our guests and then rounds of questions. We'll begin as usual with 20 minutes of questions for each of the three caucuses, and then we'll let you know how many minutes are in the second round of questioning.

Today I will be sharing the chair with Mr. Preyra, our vice-chair, as this is a health issue and I am the Health Critic, so we'll be in and out of the chair through the meeting, if that's fine as well. Good. Thank you very much, Mr. Preyra.

To begin, I would like to ask Mr. McNamara if he'd like to begin his statement.

MR. KEVIN MCNAMARA: Thank you very much, Madam Chairman, and thank you for the opportunity to share with you today information on the continuing efforts to address emergency room closures in our province. I would like to begin by introducing our staff who are with me. On my far right is Linda Penny, Chief Financial Officer, and next to me, on my immediate right, is Abram Almeda, Executive Director of Acute and Tertiary Care. Together we will do our best to answer your questions.

Keeping emergency rooms open is one of the province's top priorities - ERs are out front in the health care system and Nova Scotians count on them in communities big and small. The issue of emergency room closures is not new in this province. This has been going on for many years and often, as has been said before, there's no quick fix to the problem, nor should we settle for band-aid solutions - instead, we need to thoroughly investigate the root cause of ongoing closures and put plans in place to address them for the long-term health of Nova Scotians.

The recent appointment of Dr. John Ross as the province's ER adviser on September 22^nd was a first and most important step taken to address emergency room closures. Dr. Ross will take a comprehensive view to leading emergency care improvement. He has already begun his work with district health authorities, physicians, and other health care providers, and will be offering advice and recommendations. Dr. Ross is working in emergency rooms across the province; he is gaining experience in all aspects of emergency room care in each of the districts in order to gain a system-wide understanding to the problems which are plaguing the ERs in our province. This invaluable experience will help him provide a more coordinated delivery of ER services in the province, which will improve access to emergency care for all Nova Scotians. We are confident that we will not have to wait a full year before seeing some tangible results from his appointment, and I look forward to sharing Dr. Ross' progress with you along the way.

Another step in the right direction came last week in the House of Assembly when the Minister of Health introduced a bill that will provide public accountability to communities experiencing emergency room closures - the Emergency Department Accountability Act enables government, district health authorities, and communities to work through practical solutions together. The introduction of this legislation will fulfill our commitment to provide ministerial accountability for emergency departments. This bill is focused on one aspect of the problem which is information, consultation, and reporting.

District health authorities are already required under existing legislation to hold public forums; the new legislation requires consultation in these forums on emergency department closures and consideration of proposed community solutions. District health authorities must report to the minister about the results of these consultations, as well as any potential closures, and these will obviously occur during the business planning process. This legislation puts the right information in the right hands and ensures that district health

authorities and communities are involved in the process. Accountability is another important step that we've taken to keep emergency rooms open in our province.

The Department of Health continues to support a number of initiatives to ensure patients have continued access to health services in our communities, and to deal with the shortages of doctors and nurses in rural Nova Scotia: First, to help stabilize physician coverage in rural areas and better meet the emergency department needs of communities, district health authorities have been given more freedom to tailor service and doctor compensation to their unique situation; and, secondly, we have increased funding for locum programs and are paying our emergency physicians more to help keep emergency departments open - for 2009-10 we will pay $41.5 million, a 7.5 per cent increase over the 2007-08 fiscal year.

The department also recognizes the importance of education - educating Nova Scotians on when they need to go to an emergency room and when they can receive health care in a more appropriate setting. Helping Nova Scotians choose the right health care solution at the right time can reduce traffic to emergency departments, which will reduce overcrowding. This Fall we launched HealthLink 811 - this province-wide service provides access to registered nurses and health information 24 hours a day, seven days a week.

The Department of Health is working closely with the operator to ensure that this new service achieves and maintains a high level of quality; however it doesn't replace a physician, it complements them. Last week, during the first week of H1N1 vaccinations, we averaged 3,000 calls per day from patients, some of whom may otherwise have gone to an emergency room.

Flu assessment clinics opened their doors to thousands of patients across the province last week, providing the right support to communities in the right setting and offering patients with an alternative to emergency rooms.

Another way to reduce the number of patients going to the emergency department is by offering incentives to doctors to open their family practices in the evenings and on the weekends. We know that some people go to an emergency room simply because they can't get in to see their family doctor during regular hours. It can be something as simple as getting a prescription filled, offering longer hours of service on evenings and weekends, that will meet the needs of these patients.

It is important to note that in those instances when an emergency department does close, it does not mean that residents are without emergency services or medical care. Anyone experiencing a medical emergency should always call 911. Nova Scotia, as you know, has a world-class air and ground ambulance service which is available 24 hours a day, 7 days a week, to provide immediate medical assistance.

Nova Scotia has a strong health care system and we are committed to maintaining it and improving it. We have more doctors per capita than any other province in the country, and subsequently, more Nova Scotians have a family physician than people in other provinces. But we recognize the distribution of doctors geographically is still a concern for many reasons and when an emergency department closes in a rural community, it is almost always the result of staffing shortages. That's why the Department of Health's recruitment and retention efforts are focused on improving this distribution.

Each district health authority has its own program and hiring incentives to recruit physicians and the province supports them by offering additional incentives based on need. We know that in the last year we increased overall the number of physicians practising in Nova Scotia by 53. We know, based on CIHI data, that since 2001 there has been a consistent increase in the number of doctors coming into this province.

We also increased our medical school seats at Dalhousie by 10, in 2008. A number of physician recruitment strategies are aimed specifically at getting more doctors in rural Nova Scotia. The return to service program supports residencies for eight international medical graduates each year in exchange for a commitment of service in an underserviced area for family doctors and for specialists. We offer a relocation allowance for up to $5,000 for physicians who will be practising full time in underserviced areas.

The Clinical Assessment for Practice Program, or CAPP, has brought more than 25 new physicians to rural Nova Scotia. We are in the process of finalizing five new contracts with physicians, under CAPP, to begin practising in underserviced rural communities in the next year.

We are also experiencing success in retaining and recruitment of our much needed nurses in our province. Today, even though Nova Scotia has more nurses per capita than the rest of the country, we still recognize the urgency and continue to invest in programs designed to recruit and retain nurses in Nova Scotia. Since 2001 more than $80 million has been invested in initiations that help recruit and retain nurses. Our continued effort to recruit and maintain qualified physicians and nurses to rural areas are more positive steps in addressing emergency room closures.

Opening the Cobequid Community Health Centre 24 hours a day, 7 days a week, and increasing the assessment bed capacity by three, is a commitment of the government for the next fiscal year. At this point it is really too early to discuss the details around that commitment.

The Cobequid Community Health Centre operates in tandem with other health centres and hospitals across the Capital District Health Authority. Our focus is on providing patients with the best possible care in their community. Our challenge is to do it in a fiscally responsible manner while minimizing negative impacts in other areas of our system.

Our population health challenges and economic realities are putting tremendous strain on the capacity of our health care system. The H1N1 pandemic has added even more pressure on our health care facilities and staff, but I'm proud to say that they're stepping up to the plate and doing a tremendous job.

These pressures cannot be addressed by simply adding more resources to the existing system, but rather by rethinking the way we deliver care and by making the right investment that will deliver results. Thank you, I would like to turn it over to Barb Hall.

MADAM CHAIRMAN: Thank you very much, I will ask Ms. Hall to read her opening statement as well.

[9:13 a.m. Mr. Leonard Preyra took the Chair.]

MS. BARBARA HALL: Good morning, and thank you for the invitation and opportunity to answer questions regarding emergency health services in Capital Health, and specifically to provide an update on the Cobequid Community Health Centre.

My responsibilities at Capital Health, as vice-president for Person-Centred Health Care, include district emergency services, continuing care, mental health services, addiction prevention and treatment service, primary health care, public health services, and the services provided at our smaller facilities, including Hants Community Hospital, the tri facilities, and Cobequid.

As the province's largest health district, Capital Health provides health care to more than 400,000 citizens in the district and specialized care to the entire province, as well as to the other Maritime Provinces. In terms of hospital-based services, each year we see over 33,000 patients admitted to our hospitals and over 871,000 outpatient visits, including in excess of 141,000 emergency visits. We do almost 700,000 diagnostic procedures, and over 35,000 surgical cases are performed every year.

I'm hoping these basic figures will provide some context to the challenges and successes we face in providing timely, safe, high quality, and fiscally responsible health care to the citizens of our province.

As a district we are often in the news regarding our challenges. That certainly comes with being the biggest district. Being the biggest, we employ the most health care workers, we serve the most patients, we provide the broadest range of services, and we administer the biggest budget. We welcome the opportunities to be accountable to our citizens. We hope that by being responsive to the high level of media and public interest, we are able to improve the public's understanding of the health care system by making explicit our actions, decisions, and operations.

[9:15 a.m.]

Like many other districts in this province, we have specific challenges with the delivery of emergency health services. For a number of years now we've experienced regular closures at one of our rural emergency departments, the Musquodoboit Valley Memorial Hospital. On the other end of the spectrum we continue to experience periodic crowding and longer waits at our urban emergency department, located at the QE II Health Sciences Centre. Recently, as you will know, we have begun to experience similar pressures at one of our suburban emergency departments, the Dartmouth General Hospital.

I think you need to understand that the challenges at each of these sites are different, so I don't want to paint them all the same. As Deputy Minister McNamara noted in his opening remarks, for our rural emergency departments it's primarily a matter of physician resources: too few physicians to provide 24-hour care every day of the week, year round. For the Dartmouth General, it's more a matter of patient demand exceeding our available in-patient beds. This limited capacity has been the primary cause of the emergency room pressures.

At the QE II, as you would expect, the challenges are more complex. For the largest emergency and trauma centre in the province, the challenges have more to do with the entire continuum of care and how patients flow through it. When problems are experienced with patient flow of any kind, they are first experienced in our emergency department. This really isn't an emergency department problem - it is a health system problem.

You're no doubt familiar with the challenges related to patients awaiting placement in the community. We call them alternate level of care patients. When we have alternate level of care patients waiting in our medicine or surgical beds, these beds cannot be used for patients who are admitted through the emergency department or transferred in from other facilities or who need to be admitted for scheduled surgery.

I don't want to lead you astray. ALC is not the only contributor to flow delays. I know it gets a lot of attention, but it's not the only factor. We also know that we must ensure that we are as efficient and effective as possible with discharging patients in a reasonable and predictable amount of time.

Another factor contributing to flow is the shortage of specialized health care providers, particularly nurses trained and experienced in critical care, emergency, and surgical care. When we have insufficient nursing resources, we must routinely close beds; sometimes it might only be for a shift, but we need to do that to make sure we can continue to provide safe care. Even those short-term closures can back up a system if they coincide with a day, or successive days, when demand from the public is in excess of the available resources.

Now I've just got a recent update - it's not in your notes - on our vacancies in the emergency department at the HI. Currently we are running a full complement of nurses. We do have some vacancies, but we're able to fill them with casuals, and we are expecting to hire five of the post RN diploma nurses who are graduating on the first of December. We have five graduates lined up and that will bring our complement up. We're also posting for seven LPNs. We're looking at our model of care in the emergency department and there is a role for LPNs there, so you will see a posting in the next two weeks for seven LPNs for the HI site to help us with flow.

As a tertiary referral centre for Nova Scotia and the Maritimes, we often have no control over the numbers of patients who need specialized, intensive care or intermediate care beds, or how long some patients need to recover in our post-anaesthesia care units. We call that PACU. So flow through those specific types of in-patient beds can be an issue. If the flow is blocked up in one of those beds, you can imagine that it has a ripple through the whole system.

These few examples demonstrate the complexity and inter-connectivity of the system where even small issues can show up in big ways. That's why we have to work on multiple fronts to improve the system. For more long-term care and community care capacity in our communities, to improve discharge planning, better prediction of the demand for services, recruitment and training of specialized health care, those are just a few of the things we're working on.

What I'd like to assure the honourable members of this committee is that we're working every day on these matters, seeking not only immediate solutions, but longer term transformation to ensure the sustainability of the system.

I also appreciate the opportunity to speak with you this morning regarding Cobequid Community Health Centre. That's a facility which is very near and dear to my heart. I have worked at Cobequid since the creation of the district health authorities nine years ago. I've also worked at the new Cobequid Community Health Centre since it opened a little more than three years ago.

Now before the facility opened its doors, we looked closely at the health care needs of the population living in the catchment area. One of the things that we looked at was how often people from that large catchment of about 100,000, including Sackville, Bedford, Waverley, Fall River, all the feeder areas, we looked at where they're going for services and where they were accessing services at the hospitals on the Halifax Peninsula and in Dartmouth.

We identified a number of specialty services and we worked with our various departments to open services at Cobequid that would look after the high traffic volume that was going into the city. Some of those services include GI - gastroenterology, urology,

increased diagnostic imaging capacity, cardiology. As well, we partnered with the IWK on delivering services such as a Well Women's Clinic and Child and Adolescent Mental Health. We have other partnerships with the IWK going on right now, including some physiotherapy and some orthotics.

The capacity of the emergency department at Cobequid was also increased when the new building was opened. Another thing we did was we instituted a Medical Surgical Day Clinic. What this means is that somebody who comes to the emergency department and is told that within the next 24 hours you need to have these tests or you need to be followed up, you need to come back; instead of making them come back through the emergency department, they come back through a Medical Surgical Day Clinic. That has been very successful.

The approach we took before the new centre opened is one we have continued every day since we continue to monitor evolving health care needs, including the usage of our various services, regular communication with the community health board in the area, and we remain open and responsive. We recognize that over time new services would be introduced and others expanded.

That is certainly the case with emergency services at Cobequid. We watch the patient trends and the number of ambulance visits after hours that go into the city and we've seen an increase in patient traffic between 8:00 p.m. and 10:00 p.m. So we do believe that the time is right to begin planning to expand the hours of service at Cobequid. That is something we'll be doing in consultation with our colleagues at the Department of Health, as part of our annual business planning process.

This, of course, needs to be done in the context of emergency services across the whole district, and focused on making wise investments to deliver maximum benefit and improved health outcomes for the citizens.

So, once again, I thank you for the opportunity to speak with you this morning and I look forward to answering your questions.

MR. CHAIRMAN: Thank you very much Ms. Hall and Mr. McNamara for a very wide-ranging and informative presentation.

We're going to start with the Liberal caucus. We will call the time 9:24 a.m. - you have 20 minutes.

MS. DIANA WHALEN: Thank you for your extensive comments which were touching on all of the important issues that we want to delve into a little bit more here today. Our concern is around the rural emergency rooms primarily, the closures that we've seen on a rotating schedule, and sometimes on an ad hoc basis. We are concerned about that.

I think I'd like to begin my questioning with Mr. McNamara around the hiring of Dr. Ross. Every time we speak about Dr. Ross in the House, we are always careful to say that he is very well regarded - we know he's an expert, that he has been very forthright and outspoken even in his evaluation and his work, and we know that he will give us good value as he goes forward in his efforts. But the contract we have for Dr. Ross, as I understand it, is $100,000, and he'll be looking at all the emergency rooms right across the province.

What I got from a lot of your opening comments was that the shortage of physicians and nurses really is at the root of the closures, primarily, and I wanted to get a sense from you today about whether or not Dr. Ross will have the ability to identify any solutions that he sees - is he being directed to any particular avenue or is it wide open in terms of this responses?

MR. MCNAMARA: In dealing with Dr. Ross, it is wide open. We have talked to him to do a review of the various districts. He has applied for privileges, by the way, in every district so that he can actually go and practise a shift or so in some of the rural communities, and he has already started in a few of them. This will give him an opportunity to talk at staff level while he's carrying out his duties and get a full understanding of some of the issues that are going on. He felt it was better to do it as part of working in the emergency room rather than just going and visiting and talking for an hour or so. At the same time, he will be meeting with the various vice-presidents of medicine to see what information he can glean to assist him as well.

MS. WHALEN: Okay, I appreciate that. Certainly we're all aware that the current government has been elected along with their promise to keep emergency rooms open across the province. That is certainly something that's near and dear to the hearts of all of those rural communities that depend on their emergency rooms, but my concern is that Dr. Ross may have recommendations that don't support that, or maybe he'll say that there are impediments to that - are there any instructions to him that his solutions must be geared to the 24/7 opening of all emergency rooms?

MR. MCNAMARA: No, there are no instructions to him to guarantee it being open, but at the same time what we have mandated him is to look at how we can keep emergency rooms open around the province. Again, if we're talking about a shortage of physicians and nurses, he's going to have to give us ideas that may work in the best for each of the local communities. That is the instruction - but, again, he's not directed in any way to come back with any type of report, it will be fully up to him to give us the recommendations he feels will best suit Nova Scotians.

MS. WHALEN: I appreciate that because I think we do need to have people who will give an honest assessment of a situation and come back with that. I think there could be some difficulty if it doesn't align with the political will, but I do think it's proper that we hear what the true assessment is of the province.

In terms of the contract that Dr. Ross has, would it be possible for us to see a copy of the contract - minus any personal information, of course, that might be in that - for committee members?

MR. MCNAMARA: I don't see any reason why the committee can't have the contract. I thought it was already released but, if not, that's possible.

MS. WHALEN: I think it would help us. Sometimes we have so much paper that we may not know where that is but, if we could see it, that would be helpful to us as we go forward. We'll certainly be hearing more from Dr. Ross over the year, certainly when he reports at the end of the year, so we would like to have a sense of the job description and the commitment that he has made as well to the province in taking on this position.

Again, going back to the fact that we know it is largely a human resource issue, I'm wondering about even the decision to hire an ER adviser, because that's $100,000 that we could have perhaps spent directly on addressing the human resource side of this equation. Can you give me a brief answer as to why the decision was made to go with an ER adviser?

MR. MCNAMARA: I can't give you what was behind the government's commitment totally, but what I can tell you in working with Dr. Ross and the minister is that we believe very strongly that if we can get an overall assessment, it would give us a better opportunity to be able to come up with a solution for the future. ERs have been looked at as part of Royal Commissions, but it's the first time that there has been an overall review of every single ER in the province, so I think it will give us a good database of information that can help us make some right decisions in moving forward.

MS. WHALEN: I know that the Corpus Sanchez Report did look at emergency rooms as well, so from our perspective in the Opposition, and just as members of the Legislature, it seems that it has been studied and there have been good recommendations brought forward already. The Corpus Sanchez Report, of course, was a million dollar report. That's why our question as to why it's necessary to take another year and get more recommendations. I guess it wouldn't be fair to ask you if you think they'll dovetail that? I think perhaps they will.

MR. MCNAMARA: We'll have to wait and see.

MS. WHALEN: Okay, fair enough. I know it's not fair to ask that question. I'd like to know if there's any provision to extend Dr. Ross's contract after this year is complete.

MR. MCNAMARA: The contract is open. It is renewable.

MS. WHALEN: There's no length of time at all specified in the contract?

MR. MCNAMARA: The initial contract is for one year, and in dealing with Dr. Ross, he felt that one year would be a good start and would be able to give him an idea if it works for him as well as for us in moving forward. We will decide as we get closer to an evaluation, which we set up a month or so before the conclusion to see if it's worthwhile extending or bringing it to a conclusion.

[9:30 a.m.]

MS. WHALEN: So there is no period of time in mind for an extension.

MR. MCNAMARA: No.

MS. WHALEN: Could this conceivably become a permanent position within the department?

MR. MCNAMARA: I don't see it becoming a permanent position. I think we have to evaluate all of our advisors that we use in the department, whether it's nursing, physicians, whatever, and looking at a more global health care human resource go forward, but that solution won't happen today either. It's going to take a little bit of planning.

MS. WHALEN: I understand. Is there any timeline right now for Dr. Ross' report, his recommendations to yourself and the minister?

MR. MCNAMARA: No, but what he has committed to is giving us regular reports. I did meet with him briefly yesterday. He's been a little bit slower getting off the mark than he would have liked because of the additional requirements of staffing assessment clinics for flu, so it is taking him a little bit. But he is going to try and give us a schedule of when he can try and give us some reports.

MS. WHALEN: I appreciate that. In terms of accepting the recommendations from Dr. Ross, has there been any direction to you at all about how those will be made public? Would the original recommendations be made public?

MR. MCNAMARA: I believe they will be, and again, there has been no discussion on keeping them secret.

MS. WHALEN: I think it's important that we see his recommendations in order to get the value for money for his work, although I know that they may not all be accepted at the end of the day.

MR. MCNAMARA: I think knowing Dr. Ross, we know they won't be secret anyway.

MS. WHALEN: That's a very good point. In terms of the lack of human resources at the emergency room, physicians seems to be the key element that's missing. Would that be true to say, that it's more often the physicians rather than nursing shortages?

MR. MCNAMARA: That is correct in rural areas - except for one, which is in Fishermen's Memorial Hospital in Lunenburg, where nurses are the issue.

MS. WHALEN: I'd like to explore the idea of the locums a little bit. You did actually touch on it in your opening statement, and you know that's something that the Liberal Party has been interested in, particularly because we have been proponents that we set up a proper locum system. That would allow the doctors to be on that list and to be sent, in the time they say they're available, to fill the shortages that arise. I've made the point in the past that we have doctors like Dr. John Gillis who - and I'm sure there are others - have travelled out of the province and go and fill emergency room shifts in Ontario and in other places. That seems to me to be a waste when we know that we could assign them here in Nova Scotia if there was a system.

Can you tell me where we're at with setting up a locum system? I should mention as well that the Premier had asked the Liberals for some information on our plan after he was elected in the past election, so we're hoping there's a political will to do some of that as well.

MR. MCNAMARA: I think on the locums, there are a number of individuals who have been identified who do locums. We do know that there are a number of physicians, even from Capital Health, who go outside the province because of the fiscal advantage of doing so. One of our challenges, as we're working through the locum program, is what is the appropriate fee to put in place so that you don't rob from Peter to pay Paul. We've had examples that when you do an increase in one area, the counter effect is that physicians move from next door to pick it up. It does then create a challenge. So it's something we have to look at province-wide. We also have to have some discussions, and we have identified this as an area to talk to our neighbouring provinces, how we can make things more equal so that we aren't robbing from one another as we're trying to look at the health care of even Maritimers.

It is not an easy solution and I think that the locums - like we've had suggestions, everything from having flying doctors type of idea, that you can fly in very quickly, I guess some of the fuss, remember the old Australian TV show, to the more recent ones of physicians just moving community to community. We also have physicians who now practice in the ER departments, even in some of our rural communities, who do travel to other rural communities to fill in, if their schedule so allows. I think we have spent, on our locum program in the last year, just over $1 million.

MS. WHALEN: Is that a new program now, I don't think it existed before, did it?

MR. MCNAMARA: No, it's new funding, correct.

MS. WHALEN: So $1 million over the last year?

MR. MCNAMARA: In the 2009-10 budget it's about $1.2 million, I think is the budget now.

MS. WHALEN: We're pleased to see it underway. It sounds like it's still very much a work in progress though, that it's not a program that's now actually being implemented?

MR. MCNAMARA: No, a lot of it is work in progress. We are working from week to week in trying to come up with the best solution, but we're going to also count on Dr. Ross' recommendation on how best to implement programs, including locums.

MS. WHALEN: Well, I would certainly encourage that there be more done in that. I was happy to hear you mention it, as I say, in your opening comments, but we think there's more to be done in that regard. You touched on so many other issues that I know the other members will get to, I wanted to try to keep my comments on a couple of areas. So I'm going to turn my questioning over, it's still to Mr. McNamara, but I would like to talk a little bit about the ER in metro, in terms of our Capital Health District, and looking specifically at the Cobequid Community Health Centre remaining open 24/7 which again was a commitment made in the election.

We understand that the community might see that as a positive, and I do understand why, I live in an area of mainland north which has 100,000 people in the catchment area and we don't have a facility. We are envious of the Cobequid Community Health Centre and thinking how wonderful that is to serve people. I, myself, go there for services from the Clayton Park area. So we think it's good, you know, as is, in a way. My concern is that the Cobequid Community Health Centre has no in-patient beds. It's not a hospital. So I guess I would like to explore with you how we could turn that into a 24/7 facility when you haven't got the ability to admit people.

MR. MCNAMARA: Again, you're asking me to speculate where the government may go and I'm not sure. When we've reviewed all the information, including from Capital Health and working with them, looking at what Dr. Ross may advise us, and looking at the needs of the community, how best do we serve it. The present facility is really not one that is built to have beds in it, so it's going to be working more as an ambulatory emergency centre.

I think if we look at the growth of the Cobequid Community Health Centre from when it was initially opened, it's too many years ago to remember, I happened to be the initial CEO when the original emergency department was developed in Lower Sackville. So I have a fair amount of affinity for the organization and what it has achieved, and at that time

I think, Barb, we were looking at about an 80,000 population. It has now grown to 100,000 as I've just heard. I think the Cobequid Community Health Centre does offer an opportunity to help take some of the strain off metro. I think it does offer us an opportunity to do some things in a unique way, but we have to do our homework to make sure we spend our money fiscally, to ensure that we can meet the needs of the patients in that area.

MS. WHALEN: I have a specific question to just ask you. Has there been any report done, within the Department of Health, which provides recommendations for government around the Cobequid Community Health Centre?

MR. MCNAMARA: My understanding is a report has been done but I, personally, have not seen it.

MS. WHALEN: You haven't seen it. Was that a report that the committee could see?

MR. MCNAMARA: I am not sure. So I will check, because I'm not sure how it was brought in. I don't know if it was a Cabinet document, I'm not being evasive, I just don't know.

MS. WHALEN: Perhaps Ms. Hall knows, whether she could give us some idea what that report states around the Cobequid Community Health Centre emergency room, any suggestions or recommendations?

MS. HALL: The report was done, I believe, in the Spring, and the previous government had asked Cobequid to participate with their staff on providing information that went into a report. I think the report was consistent with the approach that we need to continue to monitor the activities at Cobequid and expand it as the situation arose. It didn't specifically come out and recommend opening 24/7, if that's what you're asking - there was no specific recommendation.

MS. WHALEN: So it left it more open-ended. I would like to ask, through the chairman, for a copy of the report, if the department would consider that request, please. Further to that, I'd just like to know - perhaps Ms. Hall again, since you represent Capital Health - if you have a figure of the cost that is involved in opening the emergency room 24 hours a day at Cobequid.

MS. HALL: At the time that we participated in providing information and costs at that point in time, we were looking at between $2.5 million and $3 million was the estimate, depending on what services would be there and if you wanted to have full diagnostics and support.

MS. WHALEN: It would be difficult to open the emergency room without having certainly your X-ray department and imaging department open and those kinds of backups, your lab - blood work would have to be taken, right? Would that be correct?

MS. HALL: Well this was a model that was proposed, I believe, and the staffing was worked up by the folks who were doing the report and based on the numbers that we looked at for physician coverage, nursing coverage, support staff, and at the going rates of the union contracts of the time.

MS. WHALEN: Again, if we look at opening it 24/7, you'll run into the same human resource stresses or shortages that we've already seen. My concern is that we might find it just being one more of the overcrowded facilities or ones that might have to be closed because you don't have the physicians to keep it going - is that one of the things you'll be looking at?

MS. HALL: Certainly there will be challenges and that's what we would have to work out through the Department of Health - how we address those challenges. There are challenges in everything that you do in health care. So everything is doable.

MS. WHALEN: Since the whole system is integrated - and I might ask the chairman how much time I have left?

MR. CHAIRMAN: You have less than three minutes.

MS. WHALEN: Oh, very quick. I just wanted to say because of the integration between the health services, would it not make more sense to go to Dartmouth General and look at the fifth floor, which is not finished at the moment? We don't have beds on the fifth floor, but we have an overcrowded emergency room there that could be - you know if we had more in-patient beds, you'd be able to use it more efficiently.

MS. HALL: I think there are solutions for Dartmouth that could be done. It's hard when you look at all the interplay of all the emergency departments. There are solutions that would be specific to individuals and then there would be solutions that would work for the entire system. So the planning would have to be done taking all those points into consideration.

MS. WHALEN: I wonder, Ms. Hall, if you could assure me or let us know at the committee level here, whether or not we're looking seriously at a solution around the fifth floor for the Dartmouth General Hospital.

MS. HALL: There has been a proposal that was put in to the Department of Health around the redevelopment of the fifth floor of the Dartmouth General Hospital - it has been part of our business planning capital expenditure. There is a fairly significant price tag

attached to it and I don't remember what it is, but it's in the hopper with a variety of different things that we would like to do on a capital front.

MS. WHALEN: Have you any ballpark figure?

MS. HALL: I can't remember, and I didn't look at that before I came.

MS. WHALEN: Maybe you could perhaps provide it to us? That would be another little piece of information - we often have information come back to the committee.

I'd just like to know, with $3 million being a possible cost to open that annually at the Cobequid Centre, if that would be seen as the best use of resources within the whole gamut of things you have to look at? I guess maybe to Ms. Hall.

MS. HALL: In our business planning process we have a significant list of things that we'd like to accomplish in the health care system. They all have a price tag attached to them and we know the fiscal position of the province, so whether at this point in time that's the best use of resources, I'm not really prepared to say.

MS. WHALEN: Would the decision ultimately be one of the Department of Health?

MS. HALL: Absolutely, it would be done in partnership with the Department of Health. They have to look at not just the Capital Health District, but they have to look at the whole province and what's the best use of resources for the province - sometimes we like to think that we're the only player, but we know that we're not.

MS. WHALEN: I appreciate that. I think I have only a really short question time left.

MR. CHAIRMAN: About 10 seconds.

MS. WHALEN: I would like to ask Mr. McNamara about the 476,000 people that the minister referred to as Nova Scotians with underlying health problems, which is a staggering number - can you explain that number, is there double counting in that?

MR. CHAIRMAN: Thank you, Ms. Whalen, your time has expired. (Laughter)

It is now at 9.44 a.m. and we will start with Mr. Clarke for the Progressive Conservative caucus.

[9:44 a.m. Ms. Diana Whalen resumed the Chair.]

HON. CECIL CLARKE: Yes, thank you, Mr. Chairman, and I do want to welcome our guests to Public Accounts today.

Just to continue on with the questioning - first and foremost, if I could just go back to post-election and, really, to the deputy, what plan has been submitted by either Cabinet or the minister to the Department of Health pursuant to their platform document indicating that they had a plan with regard to ER closures?

MR. MCNAMARA: I missed your question, what plan was submitted by . . .

MR. CLARKE: Well, during the past election the NDP said they had a plan to fix ER closures - my question is what documentation has been submitted, by either Cabinet or the minister, to the department outlining that plan?

[9:45 a.m.]

MR. MCNAMARA: There is no documentation that was given to us that would outline their plan. What we have had in working with the minister was working around the ER adviser and working through the Emergency Department Accountability Act that was put in the House. But to date that is the information that we have access to - it doesn't mean they don't have it, just that we don't have anything further.

MR. CLARKE: Right. But absolutely no documentation has been submitted to the Department of Health, to your knowledge, with regard to the New Democratic Party's commitment that they had a plan to deal with and fix ER closures, other than their platform document we all know - and I don't expect you to speak to their platform or Party position, but just verifying that, indeed, where they said they had a plan, you have no paperwork to back up what their plan is or how they articulate implementing that plan to the department?

MR. MCNAMARA: To date, no.

MR. CLARKE: Thank you very much. If I can just turn then - however, I'm assuming and as has been indicated there is some paperwork associated with the work of Dr. Ross that would flow out of that, I know you indicated that there is a contract that was put in place, and the request was made to have the content of that and the document provided. In the contract, deputy, is the scope of work or the terms of reference part of that contract, or is it monetary and more specific?

MR. MCNAMARA: It is more specific to monetary, hours of work and how the thing versus - and it doesn't include the specific terms, no.

MR. CLARKE: If I understood correctly, it is an open-ended contract?

MR. MCNAMARA: It is a one-year contract with the ability to renew.

MR. CLARKE: Okay, and with the renewal, subject to another year the terms would be another $100,000, or any of those parameters put in terms of fees, the amount of time - if he went from two days a week for $100,000 to four days, there is no limitation on that?

MR. MCNAMARA: No, there is not.

MR. CLARKE: So, if the government looks at this and wanted potentially to go further, they have the flexibility of opening this as wide as they want or narrowing it or not renewing it?

MR. MCNAMARA: That is correct.

MR. CLARKE: Okay. Now, while it is not in the contract document, can you tell me, is there a written scope of work or terms of reference associated with the work of Dr. Ross?

MR. MCNAMARA: Yes, Dr. Ross and I have worked through the terms of what he will do. It is not totally prescriptive, but we tried, in the initial stages, to put in place the things that he would do to try to come up with some of the scope of work, the expectation.

MR. CLARKE: The terms of reference - was that after you signed a contract, then to work on the specifics of what he would undertake?

MR. MCNAMARA: No, most of it was done in advance. There are still a couple of things that we're fine tuning.

MR. CLARKE: So, I guess, Madam Chairman, what I would ask, through you to the deputy, is if we can receive a copy of the terms of reference and the scope of work, because the findings that would come forward, I would assume, should associate or be consistent with what those terms of reference and/or any modifications would be.

MR. MCNAMARA: I don't think there'll be a problem with that but I would just like to make sure that we finalize it before I provide the documentation, if that's okay with the committee members.

MADAM CHAIRMAN: Okay, thank you very much, Mr. McNamara. You can let our clerk know at the end of the day.

MR. CLARKE: Thank you, Madam Chairman, and I do respect the situation the deputy is in with regard to this. So Dr. Ross is now moving forward on his work, it's my understanding that he is to come forward with advice and recommendations but has no decision-making authority, is that correct?

MR. MCNAMARA: That is correct.

MR. CLARKE: And you had indicated that he has applied for privileges to work in various ERs and the like. I'm just wondering, when you mentioned that he's going to be working in these ERs, is he going to be working and actually working to observe, or working as a physician?

MR. MCNAMARA: He's working as a physician and part of the terms of reference, which you will see when we finalize them, it does say that he will also take advantage of spending a little extra time to do some other observations while he's there.

MR. CLARKE: So would Dr. Ross, his time that he's serving in working those ERs and providing services, is that time being paid for out of the contract, or would he actually be paid for the service time?

MR. MCNAMARA: He will be paid locum fees when he's actually serving as a physician.

MR. CLARKE: Okay. So not only is he getting his consulting fees, he's going to be getting his locum fees as well.

MR. MCNAMARA: That's correct.

MR. CLARKE: Okay, I just want to be clear. So has he indicated . . .

MR. MCNAMARA: If I can just clarify, the contract does specify, it's like an hourly rate so if we save money on doing one job, they'll save money on the other side. So it's not to be $100,000-plus, if that's what you're trying to . . .

MR. CLARKE: Well, that's what I'm wondering, is there a double fee there because one could assume if he's going to do that, if you're getting your contract for your advice or you're getting paid while doing those services, I'm just not clear. So it's stipulated in the contract that you have within that that's not the case?

MR. MCNAMARA: That's correct. We've also tried to minimize costs as well. For example, in order to provide support to him, my own secretary will provide secretarial support to him. We've reduced office - so we've tried to minimize any extra costs around this.

MR. CLARKE: And his travel costs, I would assume, like anyone else that would go, would be separate from the contract and just submit it on an as-cost or . . .

MR. MCNAMARA: It would include expenses.

MR. CLARKE: Right, and that would be as prescribed by the normal contractual obligations that we'd have to meet.

I just want to next go - and, Madam Chairman, I'll be sharing my time with my honourable colleague, the member for Argyle, who has much more involvement in his former capacity within Health. The Emergency Department Accountability Act that was referenced in your opening comments, can you tell me with that Act, what financial or budgetary authority has Cabinet given to the department to support the DHAs in implementing this Act?

MR. MCNAMARA: There's no budgetary tie-in to the Act. What it really asks of each of the DHAs is to provide first, when you're doing the normal public meetings, which are required under the existing Act and if there have been closures of ERs in their district, to include that as part of the agenda items for that meeting, number one.

Number two is that they are to provide the minister with a report on the number of closures and the hours that have taken place in their district, which most of them already do. So really it's information sharing, it's to make sure there's involvement of the community in anything that comes forward in the business plan, but there's not a fiscal responsibility beyond that.

MR. CLARKE: So as a result of this Act, what new information will be provided, deputy, from the DHAs to the government?

MR. MCNAMARA: I would say it would be more consistent in the district by district, so it would be the same information coming from all districts. It is information, as I understand in the Act, that will be made public, which is more than it has been in the past. So it's a summarization of what has occurred during the year.

I guess the main issue that comes out of it is that each of the DHAs will have some discussions with their local communities in the event of how they would work on the ER closures, which hasn't been a requirement in the past.

MR. CLARKE: So ideally we're asking for information, by and large, that's already available, which really is subject to not having the Act, that's just a policy directive that could have been provided without the framework of legislation. One of the concerns that has been raised in this House is that there are actually other components that have true financial and other impacts as a result of ER closures other than the closures themselves. If it's really going to get to the root cause of trying to deal with some of the findings and work on, I suppose, some of the scope of work and terms of reference that Dr. Ross would have, that indeed the Emergency Department Accountability Act is not really adding anything new.

I don't expect the deputy to speak to the politics of the legislation, other than maybe to clarify that there's nothing new as a result of this legislation that we, as a Legislature or government, will receive. What we potentially have is, I guess, we know it's basically political window dressing as opposed to actually effectively doing something for accountability in the ERs. Again, I don't expect the deputy to speak to that unless there has been any policy advice.

I guess the one question I would ask, with the Emergency Department Accountability Act, has there been specific policy advice from the department to the government in the formulation of this legislation?

MR. MCNAMARA: Yes there was and basically in working with the government in putting the Act together, one of the things we tried to talk about at the public meetings is how do we tie it into what's in the existing legislation, which relates to public meetings that are already required and so there has to be specific discussion on ERs, which was not in anything in the past. So there is, from my belief, more accountability on DHAs to talk about ERs, both to the communities and to the department.

MR. CLARKE: So in the formulation of this, was this legislation - I guess I would ask another question, Madam Chairman, just to the deputy for clarity purposes. Was this legislation being proposed by the department or brought forward specifically by the government?

MR. MCNAMARA: Brought forward by the government.

MR. CLARKE: I thank the deputy for that. I would like to just move next to the broader issue of ER closures. We all have the effect and I know what it's like to be part of the second largest district in the province and some of the challenges managing within that district and the impact of ER closures - the Northside General Hospital with over a 50-year tenure serving the region, and we know that the CBRM literally can have a horseshoe effect in terms of the Sydney Harbour and where facilities lie - when the Northside General Hospital closes, and it has been on an increasing basis, the only next site would be the Cape Breton Regional Hospital and, of course, New Waterford Consolidated and the Glace Bay General, which would at that point be 40-plus minutes away from the Northside catchment area and depending where you would be, even longer.

One of the challenges - and I guess my question to the minister is - I know from a community point of view and where the fear factor comes in from individuals, and regrettably also having the highest ratio per capita of community services, is people are afraid to go to the hospital because they don't have the cost and so a return trip to the hospital can be over $50 in a cab because they don't have the financial means even to have a car. Are there any provisions you have with the Department of Community Services to assist those individuals if they especially have to go to an ER visit?

MR. MCNAMARA: First I assume your question is to me, the deputy, and not to the minister.

MR. CLARKE: Yes.

MR. MCNAMARA: I'm not sure on that so I can't answer that at this point in time, but I would assume that some individuals can receive some subsidies through the Department of Community Services but it would be unfair to - we can ask the department on your behalf.

MR. CLARKE: Thank you, I would so request that. The other aspect with this - and I guess this is where I'm going - aside from the pressures within the ER rooms themselves, are the pressures on the public about utilizing an ER and so there's a portion of the public that is afraid to even go with regard to their ability to afford to be able to go. The second fear, of course, is when they call and are instructed, if you can't go call 911, then the 911 call comes with another fear of the costs associated with whether it has been deemed appropriate or not for the need for that service.

Again, probably not so much a question as a point on the ER closures and the effect they're having on areas that having been the core central units such as the regional hospital, as many would know, the Cape Breton Regional Hospital has achieved a lot of the objectives of what it was intended to do and that was to stop the number of trips required to the HRM for core services in many areas, especially - you know, undoubtedly, when we look at the Cancer Care Unit, the success rates we've had there, but on the acute care aspect of things, that's where things have fallen short. Now the default is to the regional hospital.

However, what I have noted, and I guess we have had the utilization of EHS and I've seen that directly at the Northside General Hospital, EHS has provided support to the nursing staff and subsequently to the doctors, especially in triage activity. Can you tell me, deputy, how common is that around the province and is it something you're looking at trying to utilize further with EHS?

MR. MCNAMARA: We've been working with our partners in EHS to try to come up with solutions in different areas. What is interesting that has happened in the province, each district does have different solutions that appear to work differently than in other districts, depending on the resources that are available, depending on the inventiveness of the people in the existing districts, whether it's physicians, paramedics, nurse practitioners or others.

One of the things that is interesting in trying to come up with solutions, a cookie-cutter approach doesn't always work even though sometimes we like to think it does, and that's one of the hardest things of trying to come up with a common solution that will work in all DHAs or all ERs. It depends on the problem that we're trying to face and it depends on the closeness, as well, of the EHS building to the ER, and also the co-operation between

the individuals. It is usually exceedingly good and is very supportive of one another, but I think we have to continue to use all the resources available to us to make sure we can provide safe health care to Nova Scotians.

[10:00 a.m.]

MR. CLARKE: Thank you very much. Madam Chairman, one of the things that has been a bit of a pressure, especially in an ER that's getting closed all the time and had access to EHS, quite frankly, the EHS personnel, when they're off duty, are paid less when they go in on call than they are when they're on the truck, as they say. So it's a disincentive for them to do additional service time. Is there a reason that you can explain, deputy, why we wouldn't be offering them the same rate of pay when they're in service on an ambulance versus in an ER?

MR. MCNAMARA: I was just checking. I have no knowledge of that, so we're going to have to go find out the information as well.

MR. CLARKE: The only reason I raise that, Madam Chairman, is it was brought to my attention by EHS workers providing relief and looking at the disincentive to actually go into an ER where they could be helping out. I do recognize, as well, there has been some reference as to the wider roles of LPNs and, of course, the nurse practitioners. With the nurse practitioner, and I guess it comes back to, if I can go to Dr. Ross bringing forward recommendations and advice to government where they can take unilateral action to provide direction to DHAs, I'm assuming if Dr. Ross comes through with recommendations and they want to close or consolidate - because Dr. Ross has not eliminated that in his own media comments as outcomes of his exercise - if government chooses to do that, that will affect personnel choices potentially across the province, is that correct, or directives?

MR. MCNAMARA: I'm sorry, would you repeat your question?

MR. CLARKE: So if Dr. Ross came in with advice to close or consolidate ERs and Cabinet takes that advice, they could implement that across the board?

MR. MCNAMARA: They could.

MR. CLARKE: They could. Yet we have an issue with a nurse practitioner in this province in an area where the community is being well served, in the Digby, Long and Brier Islands area, where the minister has stated that she cannot interfere or take an action that actually helps the outcome of health and ER services, or patient care services, in a region. Can the deputy tell me, not on the politics but on the policy side of it, what is different from a government acting to implement something that they deem to be in the interest of care versus the government intervening to provide direction that does the same outcome for care?

MR. MCNAMARA: I think the minister's direction for care is the same in both cases. What we are dealing with here, to separate the issue with Long and Brier Islands, is there is an employment relationship between an individual and the district health authority. In that case the district health authority is the employer and is accountable and responsible for that action, which would be different than making a direction that we shall consolidate some, for example, ERs, and then the district health authority would still have to deal with the employment relationship or any fallout that came out of it.

MR. CLARKE: Thank you. My point being is that in that time - and I guess my colleague will have to pick it up in the next round, my apologies, however, time flies when you're thinking about home - the reality is, the government can take actions that will be impacted by DHAs, provide directions on staffing and if you look at it, it's really more of a point, it is a two-way street when it comes to this and the minister, if she so chose to deal with an area, and the nurse practitioner issue, in an area where the community wants that, she could be providing direction with regard to that, that is not there.

What I've heard from the deputy is, it is top down on one aspect which affects the employment relations, how the DHAs have to respond to that, but the DHAs cannot receive direction on a matter that is very pertinent to a pressing community concern. Thank you.

MADAM CHAIRMAN: Your time has elapsed. We will now go for 20 minutes to the NDP caucus. Ms. Kent.

MS. BECKY KENT: I will be offering a few remarks and some questions. I'll be sharing, as well, with my colleague. I want to begin by thanking you on behalf of our caucus, thanking each and every one of you for being here and being so open to allowing us to ask for clarity. I know that sometimes it sounds like you're probably repeating yourselves over and over, but we do appreciate it. We know that there are great efforts underway, and the strategies that are ongoing now, we look forward to the continued results of those. I wanted to make sure that you know how much we appreciate that.

The few questions that I have are around clarity and I would say they are mostly addressed to the minister, through you Madam Chairman. It's on people's minds, you see it in the papers, and as MLAs in our communities, it's not uncommon for us to get lots of suggestions from everyone who is a user. And that's fair. They're taking themselves, or loved ones, and going through these health care services.

Often, people have suggestions. Frankly, I often hear, just hire more doctors, it's as simple as that. Clearly we know it's more complicated than that. Then we hear, or understand, that money doesn't solve everything. Sometimes it's not always about the dollar, at the end of the day. In this case, it could be the same, on the other hand, again, we all know money sometimes can talk and create results that we're looking for.

What I want to know from you today, what is the most effective way for our government to be utilizing the money that we have on this strategy, to ensure that we are getting the best ER service possible for all Nova Scotians? How are we using that money to make it the best tool it can be?

MR. MCNAMARA: I would think the first thing that we have to do is systemically deal with the flow through of patients. As Ms. Hall had indicated in her opening remarks, one of the frustrations for both staff and physicians, and probably work life of individuals who work in emergencies, is the feeling of frustration at times, that they have patients who are in their rooms that they can't move into beds because there are no vacant beds.

I think we have to think of how we can strategically use dollars to open up - some of it through the long-term care system as new beds are added. But also, are there ways to be able to do better utilization, to move people out quicker when they could be discharged? So, if we can reduce the frustration of individuals who are waiting, of staff who want to do a better job, but can't always. Sometimes it's also dealing with the frustration I know that staff have, and the points that we see from patients, that staff may appear to be sitting around doing nothing, when in fact they're trying to get a room vacant so they can take a patient in and provide care for them. It's perceived by the person sitting outside that the staff is sitting and having a party while the poor patient suffers.

We know that creates tensions between both. I think the best way that I can think of is systemically trying to figure out ways we can move them. The other thing is, how do we work in our policies in a common way? One good example is if a patient is being transferred from, say, Cobequid or a regional hospital, that they could go directly to a floor rather than going through the ER department. It reduces by one the number of individuals that show up there, it reduces the workload of the ER physicians - one less person they have to see - and the nurses. So these are things we have to work through. Other problems have been around for years, and there may be good reasons why those policies exist, but I think we have to do a lot better job of making it more streamlined.

MS. KENT: Thank you very much. Through the chairman, we recognize, and I think that Nova Scotians recognize, that the distribution of doctors geographically is still a concern in our regions. Emergency department closures in rural communities; we hear and certainly we heard from your presentation today, staffing shortages. Again we hear and are pleased to hear about the extensive recruitment and retention efforts that are being focused on right now.

I wonder if you can expand on that, the effectiveness of those recruitment measures and strategies that we have on what our government is doing around that. Just give us a little better sense of - I would like an understanding of that.

MR. MCNAMARA: Well, there are some things that I think we're doing very well in improving as we're trying to recruit physicians, and one is some incentives to try and develop more electronic medical records, which is something that newer physicians are really looking for; collaborative practices, which are something that newer physicians are looking for.

From my recent role as a CEO of a DHA and going to recruitment fairs, both for physicians from Dalhousie, from New Brunswick, from Newfoundland, what young physicians are looking for is - they have a number of questions. (1) Are there electronic medical records, (2) is it a collaborative practice, (3) what are you going to do to help me in my debt assistance, which is one of the issues, so you're in a competitive bidding, and it's sometimes hard to compete against the Albertas of the world, quite honestly, in terms of the dollars, or even some of the northern Ontario issues, in terms of the dollars that are available. Even in Nova Scotia there are different districts or different incentives. Sometimes incentives won't buy if you don't have the other things.

The other thing that I find physicians are looking for is, what supports are in the community to help me? For example, what specialists, if I do need them? Probably the other key thing is, how welcoming is the community to new physicians moving in? Some communities are much more open and welcoming and supportive than others. It is also a particular challenge if somebody comes from another culture - how do I fit into a new community that my culture may not be there and whether the avenues are available for me and my family. Also, we deal with young people coming in - what are the other activities that are available for young people? As the governments have approved, for example, new leisure centres and these types of things - say, swimming pools - are important things to physicians because they see that as part of a good family life.

MS. KENT: Thank you very much. And again, I guess around retention, recruitment, making sure that we have those doctors available, we've very fortunate here to have the asset of Dalhousie Medical School right here in Nova Scotia. We're proud to have it, and certainly the support that our government is offering is so vitally important to the success of the school and, of course, to the success of Nova Scotia, of Nova Scotians becoming doctors and staying here and practising.

Frankly, for me that's quite relevant. I'm a mother of a teenage boy in Grade 12 who has aspirations to be an anesthesiologist, and we know that that has the potential for upward of 11 more years of school for that specialized field - very proud of him, and God willing, that will happen. The reality is that these things take time; medical school takes a long commitment, it doesn't happen overnight. I know we have, I think, was it 10 new doctors? If I've got that wrong please correct me.

What is the reality of these new doctors - who would be coming through medical school that we've noted here in the information that we've received - what's the reality of actually seeing them in our health care, in our ERs here in Nova Scotia, time-wise, I guess?

MR. MCNAMARA: The 10 new seats started, so it does take a number of years, as you've indicated, before we see the results of it. At the same time, how do we maintain or keep the physicians that go through Dalhousie? One of the fortunate parts is having that.

The interesting part is that many of them like to stay in metro because after you've been going to school for so many years in metro, you end up marrying somebody from metro, having children and family, by the time they graduate, particularly now as they're getting older. This does create challenges for us. Those of us who work in rural communities, how do we get that individual to come out?

One of the things in some discussions with Dalhousie - and there is interest from Dalhousie - is there some way, for example, of being able to expose residents more to rural communities, as they're going through their training programs, to be able to do longer periods of their training out in rural hospitals? One of the issues for many of the districts is where is the appropriate lodging for people to stay? So you're dealing with those issues that have to be addressed. It isn't as easy as it sounds, because it does cost money to find appropriate housing. We don't have the old nurses' residence that we used to have at one time in every hospital that we could utilize for those things.

MS. KENT: I know my colleague is anxious to ask a question. I'm going to fit one more in. We've talked about, and recognize, that our government - we want to educate the public about their health care choices. We all have families, we want to make sure that at the time we need that emergency care, we wonder - I've done it myself - should I be heading over to the IWK, should I run into the Dartmouth General? We need to get that message out there. Our government launched the HealthLink 811, which is a nurse model, and I understand that's going well, with the increased pressures of H1N1 on that system.

Is there a way to make that program better though, to connect opportunities for that program to be accessed to doctors, pharmacists and such?

[10:15 a.m.]

MR. MCNAMARA: That is one of the areas that we're looking at, to explore how we can expand it into other information services and talking to pharmacists and others, so that is an area for the future, yes.

MADAM CHAIRMAN: Thank you very much. Mr. Preyra.

MR. LEONARD PREYRA: Thank you, Madam Chairman and welcome again to this committee. As you know, this is the Public Accounts Committee and we're very concerned about the spending of the taxpayers' money and to make sure that it's spent in the most effective and efficient way. We very much admire the work that the department is doing under really stressful conditions, especially this week, and we're happy to have you here.

I just want to pick up on your comment about thoroughly investigating the root causes of the ongoing closures and to put plans in place to address them for the long-term health care of all Nova Scotians, particularly the goal of looking at timely, safe, high-quality and fiscally responsible health care, which is a goal that we all share.

I want to come back to some questions about the antecedents and the root causes of some of the issues we're dealing with. Particularly, I want to talk a little bit about the Corpus Sanchez report. A quote from the 1990s says that ambulatory care services have not evolved as a result of careful planning, but in response to immediate pressures and needs, and this has le d to fragmented services, crowded facilities, inadequate access for patients, long waiting times and operational inefficiency.

This is from 1990, so the problem we're looking at goes back for quite a long way and it hasn't really been addressed in a systematic and structured way. In particular, during the mid-1990s, in fact, there was an attempt to restructure health care by reducing the number of health care professionals that were working in the field and now we're talking about shortages, so if we are going to talk about root causes, we really do need to look at it in a systematic and structured way, and take a long view.

I wanted to talk, especially, about the antecedents to Dr. Ross' appointment, a question for the Liberal caucus about whether or not it was inspired by the current government.

Corpus Sanchez report Recommendation 41 says that there's a real lack of a systematic view of health care, particularly emergency care, and that we do need an emergency health task force, a group of people to look at these closures in a systematic way. Subsequent to that, in the dying days of the last government, Mr. Almeda did a snapshot study of emergency room closures and that was one of the recommendations coming out of that, as well, that there was no systematic data.

The Ross appointment follows very much in line with what the governments were saying in the 1990s in terms of Corpus Sanchez and in terms of what Mr. Almeda was saying, that we really needed to look at emergency room closures in a more systematic way and so we have to look at the Ross appointment not as something that's done on the spur of the moment, or on the hustings, but this was something that a number of governments, a number of reports have said was needed, and it's being acted on.

I also want to make sure to give you another chance to clarify a question that has come up twice now about the mandate of Dr. Ross, that essentially, there are no limits on what Dr. Ross is looking at, there are no preconceived propositions, there are no instructions and there is no political agenda. Can you confirm that?

MR. MCNAMARA: That is correct. In working with Dr. Ross he does report to me, as deputy, and so that was one of the terms, is that his reports would come through and then we will deal with the outcome of the report.

MR. PREYRA: Right and your understanding of his appointment is that he is a skilled practitioner who is outspoken and independent minded and there is very little capacity, even if there wasn't a system, to impose any limits on what he might say?

MR. MCNAMARA: That is right and I'm hoping that he's not too outspoken. (Laughter)

MR. PREYRA: But you're not concerned about him being a puppet for any particular government or anything like that?

MR. MCNAMARA: Definitely not.

MR. PREYRA: I also want to talk about the second part of the question about the need for information, consultation and reporting and particularly the question coming out of the Conservative caucus that this is political window dressing. I want to go back to Corpus Sanchez again and in particular to the Almeda report, which was done in February and March of 2009.

If you go back to that report, and I don't want to because I have very little time, but this is a two-week snapshot of what was happening in emergency departments and essentially, that report says that the District Health Authorities have very little capacity to gather data, to report back except perhaps for Capital Health, there was no systematic look at why the closures were happening or where their roots lay. So, essentially, both Corpus Sanchez and the Almeda report and to her credit the Minister of Health just before the election came to the conclusion that we needed a more systematic way of gathering data, of consulting the public and of reporting back. Is that a fair statement of where this Accountability Act originates and where it can, in fact, provide benefits to our system?

MR. MCNAMARA: I believe that the Act will provide benefits and give us a more systematic look at the overall picture. Also, I think the second biggest benefit is that the district health authorities will consult with their communities on solutions of trying to solve the emergency room issues in their own area.

MR. PREYRA: So, it would be fair to say then that the origins of this proposal for reporting and data really lie in the pre-election period where the minister herself saw this gap in information and needed to find out more about why it was happening, to look at solutions, Is that correct?

MR. MCNAMARA: The direction to bring this Act forward came from the minister.

MR. PREYRA: Yes, it didn't come as a political direction from the minister, it really came from the department understanding that things were happening that we had little information about and hopefully and presumably this Emergency Department Accountability Act will give us a data set that we can rely on for reporting and addressing those problems and perhaps even help Dr. Ross in his work as he goes forward in making recommendations.

MR. MCNAMARA: Regardless of where it came back from, I think the Act will be very helpful to us in being able to provide a future direction.

MR. PREYRA: If I could move on to a third set of questions then about the root causes of emergency room closures and wait times. It seems to me that those are the two, and I know you have outlined a whole series of issues that relate to closures but a lot of it relates to shortages of doctors and inappropriate use, if I can use that phrase, of emergency rooms.

Again, this same issue percolates through from the 1990s through to 2009 that successive reports have said that emergency rooms are being used for primary care; 80 per cent, in fact, was the average that has been used for Level 4 and Level 5. There weren't formally recommendations but the findings were that we need to find some way of diverting people away from emergency rooms who were seeking primary care, of broadening the scope of practice for health care professionals and providers, of increasing physician recruitment.

So could you tell us something about strategies that you have in place or that you're planning on to, in fact, deal with those 80 per cent of the people who are coming to emergency rooms who really would get better and timely and more effective care in other places or by other health care providers?

MR. MCNAMARA: I think we have to work with all our health care partners on how we try to improve the system. For example, we know that a number of individuals do show up in emergency rooms because when you call for an appointment, it may take two weeks to get in to see the doctor. By the time you get there, the reason for your call no longer exists. That also leads to individuals not showing up, so there are times when a physician thinks he has patients coming in when no one is there. That's one of the things.

Second, we have individuals who have no physician and so they are looking to walk-in clinics or coming to emergency rooms. Then we also get individuals who, because of the restriction on office hours as people are trying to - physicians as well as everybody else -

trying to get to a more lifestyle balance with their families, are not working the hours of physicians many years ago who used to work 80 hours a week and keep the community going, are now trying to work more of a 40-hour work week. To be fair to those physicians, they still have other duties, they still have to go to the hospital and look after their patients, or go to the nursing home. They have other duties that we sometimes forget about, that they're trying to do as fulfilling their commitment to their community. So individuals end up, as a fallback, coming to ERs.

We have to think of how we can provide support to those physicians for after-hours, whether we get into more collaborative practice, we're trying to use incentives to encourage doctors to have evening hours instead of doing certain things during the day, if that may help some of the physicians, so it is a. . .

MADAM CHAIRMAN: Your time has elapsed on that question, but thank you. Perhaps we can carry that on. I'd like to change the chair with Mr. Preyra.

[10:25 a.m. Mr. Leonard Preyra took the Chair.]

MR. CHAIRMAN: Call it 10:25:30 a.m. You've got 10 minutes for the Liberal caucus.

MS. WHALEN: Thank you very much and there's an awful lot to still cover in this time. I'd like to carry on actually with the question you were answering. You mentioned in your opening statements about incentives to family doctors to extend their hours. So just to be very specific, have you got those incentives in place?

MR. MCNAMARA: The incentives are in place. One of the things is that the take-up isn't as high as we would have liked, so we will be working through Doctors Nova Scotia, and others, as we're trying to encourage physicians to take advantage of it. I guess all of us individuals would prefer not to work evenings.

MS. WHALEN: Are there any practices that you could point to that have been successful in extending their hours and have taken up your incentives?

MR. MCNAMARA: Not off the top of my head, no.

MS. WHALEN: No, I'm just wondering, what are the incentives? Is it additional remuneration for seeing patients? Would it be basically a premium to see somebody in evening hours?

MR. MCNAMARA: That is correct, it is premium dollars for the evening.

MS. WHALEN: Has it been well communicated to doctors that this is available?

MR. MCNAMARA: I would say it has been communicated to doctors. Has it been well communicated? I think what frequently happens to physicians, the same as us, we get so many different pieces of information, we may not read to its conclusions. I think we have to do a better job of making sure they understand exactly what is available to them.

MS. WHALEN: Okay, I think there might be better up-take, maybe, if there was a more personal approach or they were spoken to. There are some very large practices in metro, I think, that would be interested and would have the doctors to do that.

Moving quickly to the work that has been done in Cumberland, I noticed three different press releases, one from July 24^th, where the department said that there would be a temporary arrangement to help emergency room coverage in North Cumberland Memorial and South Cumberland Community Health, and that was put in place. I'm not sure what the costs were to that but there was an arrangement put in place. Then on September 30^th that was extended. There was another press release saying that. Could you tell me how this arrangement is working, when it comes to minimizing the closures in those two facilities?

MR. MCNAMARA: There is still the occasional closure, but overall, it has worked to the benefit of the community. One of the issues, or reasons for extending it, was to give Dr. Ross time to give us some advice on what we could do beyond the extension. At the time it came about because of a solution in another district and when we do a solution, as I mentioned earlier, you get a cause and effect, so if you do something in one district, another district is looking for similar results.

The cost was done within the total dollars that were available for those facilities, so it is making use of it in a more collaborative way. It wasn't increased overall dollars for the allotment, but it was using the dollars in a little different way.

MS. WHALEN: Okay, so there was no additional budget having to be allocated there.

MR. MCNAMARA: That's correct.

MS. WHALEN: And did it include paying the doctors more for being on service there?

MR. MCNAMARA: My understanding is that they would get more consistent dollars on certain hours, yes. So there is a financial advantage to the doctors.

MS. WHALEN: Would you consider it a pilot project?

MR. MCNAMARA: I guess we do a lot of pilot projects, yes.

MS. WHALEN: Well, when you test to see if something is working, and if it is working you could expand it elsewhere. I wanted to know, when we looked at your hours of closure that were also provided in our package, it indicated that those facilities that had 1,225 hours of closure in 2008-09, but Digby Hospital, for example, was closed 1,834 hours. I wondered why we were implementing a solution or trying something out in Cumberland rather than in an area that had more closures.

MR. MCNAMARA: The reason is the availability of the existing individuals to work in that district, and Digby is a particular issue because of the number of physicians that are available. We also had the same issue in Annapolis, and it's the number of physicians, and they're trying to carry out their collaborative practice, look after their normal patients, and at the same time, how do I provide service in the local emergency department? So it is a situation of not having them leave our province because we're overworking them.

MS. WHALEN: I appreciate that. I wanted to ask again, you actually referenced just now in your answer about Digby-Annapolis and one of the parts of the Corpus Sanchez report referred to that as an example. Just trying to find my exact question of it, but there was an additional - On Page 320 of the Corpus Sanchez report, it was like an addendum, almost, or an additional piece at the back. It was called a supplementary report, I think, on small and rural emergency departments. It said that there was a recommendation that government "Initiate an immediate detailed review of ED services in all facilities outside of Regional Hospitals with the intent to identify operational efficiencies."

[10:30 a.m.]

They're looking there at evidence-based changes, so I'm just wondering if you could indicate whether that review that was recommended in Corpus Sanchez would be the same thing that Dr. Ross is doing, or whether it has been initiated at all separately.

MR. MCNAMARA: It would be separate from Dr. Ross, but the information he'll be gathering will be part of it. One of the things in the Corpus Sanchez was to look at a rural health strategy, which includes looking at emergency services around the province. So that's a more detailed, much larger job.

MS. WHALEN: Has it been begun as a separate one?

MR. MCNAMARA: No.

MS. WHALEN: This report, Corpus Sanchez, was 2007, so we've had that recommendation available.

MR. MCNAMARA: There were certain priorities identified by the government of the day to move forward on, and those were moved on first, and we're trying to bring some of those to conclusion, i.e. models of care, and then we'll move on to the others.

MS. WHALEN: But you do see them as two separate tracks with Dr. Ross being involved, but the department will attend to this review.

MR. MCNAMARA: Definitely.

MS. WHALEN: Just again, in that same Page 320, it states that there should be the development of "cross-District responses to the delivery of Emergency Department Services where geographic realities support a shared service model," including Digby-Annapolis and Pugwash-Tatamagouche. I guess what I'm wondering is exactly what that means, when they talk about cross-district responses with a shared service model. We've seen a lot of closures in those two examples that are given, so I'm just wondering if there are any plans within the department to close either of those facilities within those two areas in that sense of getting the shared service model. Sometimes we don't understand the language.

MR. MCNAMARA: There has been some work done between South West and Annapolis on the Digby-Annapolis, and it hasn't come to a final plan that would solve the problem as yet, but they have done a lot of work in looking at how they might be able to share resources, be able to support one another to keep at least one of the emergencies open on a full-time basis. They're still working their way through with the available resources until we get a much larger solution to the bigger problem.

MS. WHALEN: If we're going to try and keep one open on a full-time basis, though, would that be the demise of the other one?

MR. MCNAMARA: Again, the two are working together. It may mean that, but hopefully not.

MS. WHALEN: So it could possibly mean that. There's no real way, then, to ensure that all of the facilities remain open 24/7.

MR. MCNAMARA: Without the resources. Until we get to a situation that we have enough physicians, enough nurses, and enough dollars, it will take time, but over time we will keep working to do our best to keep emergencies open. I think what we have to look at is, we may look at keeping emergencies open in different ways than we've done in the past. We have to look at what the resources are that we can add to it. It was mentioned earlier using paramedics in some areas, it might be using nurse practitioners. Is there a different way to be able to ensure that there is safe and effective first-line medical care available to people in our community?

MS. WHALEN: I appreciate that. I think what you're saying is you're going to be looking at all the options. It may not be doable to keep all of them open?

MR. MCNAMARA: It's impossible to say at this point in time.

MS. WHALEN: Well, we'll go back to the fact that you have an open mind about Dr. Ross' recommendations and the other studies that are going to be done.

MR. MCNAMARA: Definitely.

MS. WHALEN: We hope that will win out at the end of the day. I was glad to hear the mention about the less-urgent people attending emergency rooms. That has been an issue since my children were young, and they're now in their early twenties. So, you know, we have been trying to educate people about not overusing the services and going to the appropriate one, but you raise a good issue around the availability of the family doctors and the extended hours that are needed. I think that's very important for all of us. I would like to know more as we go forward - there might be another day that we have to explore some of those issues, because we don't really have time today.

You had indicated $1 million has been spent already on the locum service, and that is in planning? Could you be specific about what that has exactly accomplished, if there isn't sort of a running list now that doctors could plug into and be assigned and have their available extra hours, you know, put to good use within our own province?

MR. MCNAMARA: The department pays the funds. Most of the districts go searching for their own locums and most districts know who is available to do locums. I mean, it's a small province. The number of physicians are known to one another and they do search each other out to try to provide coverage. So it's a system, but it's run by the districts. What we do is we're the paymaster.

MS. WHALEN: I would suggest that's an ad hoc system that has been operating anyway, so what about the $1 million that we've put in place? Are we not trying to get a formal system?

MR. MCNAMARA: We haven't put our mind to putting a formal system in place. I'm saying it's done through the districts. It is ad hoc, and that's never going to change until we get a position . . .

MS. WHALEN: Can I interrupt and just ask, what's the $1 million being used for, then?

MR. MCNAMARA: It pays for locums.

MS. WHALEN: So it's for incentives for doctors?

MR. MCNAMARA: It's doctors. They get paid when they do a locum in an emergency department around the province.

MS. WHALEN: I think my time is up. Thank you very much.

MR. CHAIRMAN: We'll move to Mr. d'Entremont with the Progressive Conservative caucus for 10 minutes.

HON. CHRISTOPHER D'ENTREMONT: Thank you very much, Mr. Chairman, and of course I welcome the folks from the department and from Capital Health for being here today and talking about this issue. Of course, this issue is one that I had the opportunity to pull my hair out over a three-year period as well.

[10:35 a.m. Ms. Diana Whalen resumed the Chair.]

Mr. Chairman - or Madam Chairman, as we get the change happening here - you know, emergency room closures, and I'm going to try to touch on two sides of the story here, are really a symptom of a larger problem. When an emergency room is closed, well, it's either because we don't have the people in place or it's full, which is what was starting to happen here in Capital District for the last bit. I just want maybe some thoughts, you know, this is a symptom, what are the further problems? We've gone and we've looked at the staffing shortages - physicians, nurses, and others. What else is there that closes an ER on a regular basis - not necessarily if it's closed for an hour or two here and there, but these chronic closures that are happening in some of our districts?

MR. MCNAMARA: Closures come down to availability of staff. If you're talking about diversion of patients, which is different than a closure - the ER is still open, but they may say for patient safety reasons that we're at a situation that we don't want to have another individual come in that we can't care for - then you would divert to another ER, and that is something that is in place for the safety of patients.

MR. D'ENTREMONT: Let me go down those two roads, then. We'll talk about overcrowding, because that has been one that we have been talking a lot about. Here in the House we've asked a lot of questions. I know the member for Dartmouth East has asked a lot on behalf of his constituency in Dartmouth, and really it's the issue of over-Census, or Code Census, in that district. This can be either the deputy or Ms. Hall to answer this question as well. What's the update on census at the Dartmouth General, as well as HI, because I know they both sort of work together, and then I'll work my way toward Cobequid Community Health Centre.

MS. HALL: Well, in Dartmouth what we've done over the last couple of weeks is we've tried to put a little more capacity into the building, so by putting a few extra beds, and that seems to have helped a bit. I don't believe we've had a Code Census in Dartmouth for - I'm keeping my fingers crossed here.

The other thing that has compounded us over the last couple of weeks is, of course, the flu, so we've set up the primary assessment centres which are actually diverting a lot of traffic. Right now if those people had been going to either of our emergency departments, they'd be completely shut down and we'd be on divert, so that is working really well.

We continue to work with our colleagues at the Department of Health around capacity at Dartmouth General, is there some option in the future for extra capacity? We're also looking at our staffing ratios and our model of care in emergency to make sure that they flow. But for Dartmouth it really is the number of beds that are there, until we can increase that capacity, so we've done it on a temporary basis, we've increased by about five beds and that seems to make the difference. The only wiggle room we really have is around the surgery beds and we're trying desperately not to cancel surgeries. So that would be the other option that a district has, is to maybe close surgeries or shut them down and you could put medicine beds in surgery beds. Given wait lists and that, we're trying absolutely our best not to do that, so that's why we've got into a little bit of a bed crunch over the last little bit.

MR. D'ENTREMONT: The added issue, I think, that floats over this one, especially for the residents of Dartmouth, is the undeveloped floor. I know we've talked about this one before - and I'm looking over at Mr. Almeda as well because he and I have had conversations about this as well - on the whole Capital District infrastructure plan . . .

MS. HALL: Our master plan.

MR. D'ENTREMONT: The master plan, what was the cost associated with, let's say the development of that floor? Then I'm going to move to Cobequid because there are two very important infrastructure issues when it comes to the overcrowding at the Dartmouth General or a 24/7 ER at Cobequid, so when we talk about competing priorities and competing dollars.

MS. HALL: The top floor renovation of Dartmouth General, which has been looked at for several years, I don't want to say the amount because - do you know what it is? - I honestly can't remember, $15 million, thank you.

MR. D'ENTREMONT: And that was part of my point. Basically, depending on what kind of unit we wanted to put in there, I think the numbers would range anywhere between, I think eight was one number and would have been maybe a long-term care type set up, so you'd have an alternate level of care, or going into a full surgical floor which I think was the $15 million item.

MS. HALL: So that's just the capital costs, that's not the operational costs.

MR. D'ENTREMONT: That's correct, that's just actual fit up of an existing floor. All right, let me move to the issue of - and I'll hook them up together here in a second - if we go to Cobequid and we're talking about a 24/7 emergency room, the issue always that I understood for not having a 24/7 emergency room at Cobequid was that it did not have an in-patient unit. So in order to have an in-patient unit to keep that place open 24/7, we would actually have to build an in-patient unit which would probably cost us $15 million or more because, of course, that's construction. So I'm just wondering what your comment around that is, because that was my understanding, that we needed the in-patient floor.

MS. HALL: I've never seen any plans that contemplated putting in an in-patient tower, an in-patient unit attached to Cobequid, I've not seen that. I've heard about a three-bed assessment unit or something, but I've never seen anything that suggested that an in-patient tower be attached to Cobequid.

MR. D'ENTREMONT: But isn't that sort of the reason why it was never contemplated to be a 24/7 emergency room? Maybe I'll ask the deputy on that one because that was my understanding, that we could not put a 24/7 emergency room in there simply because there was no in-patient facilities.

MADAM CHAIRMAN: Mr. McNamara.

MR. MCNAMARA: My understanding is there are some issues around cafeteria-type services and those types of things, if you went into a 24-hour in-patient service. It wouldn't be a reason to stop having a 24 hour because there's no in-patient beds, it's no different than having 18-hours and transferring.

MR. D'ENTREMONT: Good, I wanted some clarity on that one. Since my time is running quickly short here, let me go to the Emergency Department Accountability Act that was placed in this House and approved. Even though I find it's an Act that's kind of short on what should be done here and I know in my discussions with the previous minister and even some of my frustration when I was there, there is some communication on closures that are flowed through the communications department and then brought up to the minister, so you sort of know what's going on. You don't know the whole picture, but you sort of know what's going on. I was wondering, why, in this bill, did we not put a reporting responsibility that had to be either weekly uploaded to a Web site, or something like, that so you can have real-time view of emergency closures in the province?

MR. MCNAMARA: I don't have any reason why it wasn't included, it probably wasn't thought of. I guess there were no amendments made to it either that would include it.

MR. D'ENTREMONT: Well, there was no interest for amendments so we let it be. Like I said, any information that's going to be provided to us as we roll along there. I'm just wondering if there was an opportunity that the deputy could speak to the minister, we'll talk to the minister as well, to maybe run a policy that goes along with that accountability bill in order to have that happen.

MR. MCNAMARA: We are doing regular updates through Abe's work so that we know what's going on on a regular basis, so that has started.

MR. D'ENTREMONT: Yes, because in my mind, for our information, for the public's information, a report placed in the House once a year doesn't help a whole lot when it comes to accessibility to service.

MR. MCNAMARA: I would also add, I think we can talk to the DHAs through the monthly meetings and ask that they be open. I know that Capital Health is very open with the information they have on their Web site and we could ask others to do the same.

MR. D'ENTREMONT: My last question will revolve around diversion of patients in an ER where they're not in the ER for the reasons that an ER is constructed. These are the Level 5s and 6s. I'm just wondering, the idea of HealthLink 811 was to try to help with some of that diversion, getting people in a mindset to call 811 first and then be able to say whether I should go to the emergency room or whether I should go see my practitioner. I'm just wondering what the take-up on HealthLink 811 was, because that was designed for trying to cut down.

[10:45 a.m.]

MR. MCNAMARA: The uptake has been much higher than we expected, particularly lately, it is getting up to 3,000 calls per day, which is not the norm, it's about 10 times what we were anticipating. But there was uptake on a regular basis. What we do know in the feedback that we've received is that individuals were calling about whether they should go to an ER department or wait. Also others were calling for information which could be given and they could get it without having to go see a health care practitioner up front. It has been very positively received by most people that accessed it.

MR. D'ENTREMONT: Thank you very much.

MADAM CHAIRMAN: Time allotted for the PC caucus is complete. I will turn the questioning to the NDP caucus. Mr. Whynott.

MR. MAT WHYNOTT: Thank you and to the guests here today, in particular, Ms. Hall who works out of the Cobequid Community Health Centre, a facility that's not only near and dear to you, but also to the people who I represent, and to me as well.

I think that people - certainly over the past number of months as the MLA for my area - people want and feel there's a sense of professionalism with the Department of Health, the Cobequid Community Health Centre. They feel there is a good steady hand on the wheel and that the service being provided is a good service. I certainly hear from my constituents that the Cobequid Community Health Centre is a fantastic facility and, as a community, how do we work together to make it a better place for everyone.

It's not only important to the people I represent, but also the surrounding constituencies of Sackville-Cobequid, Waverley-Fall River-Beaver Bank and Bedford-Birch Cove. It's sort of the catchment area for the centre.

It's hard to believe the new facility has been open for three years already. I remember so long ago, back in high school, when there were plans that the new facility was going to be there. In fact, some other students and I came on board to raise money. There was a commitment from every high school within the catchment area of the Cobequid Community Health Centre to fundraise, and I believe, if I remember correctly, over a five-year period, it was $80,000 from students. That's something very impressive and what it did was it showed the commitment that the students shared. I know that's the approach the foundation took, it's not only there for adults but it's there for young people in that area. I just wanted to lay that out. When the new facility came on board it was certainly a commitment from the foundation, the health board, the DHA, and the province and as well, of course, the community, because they wanted to see a new facility. I just wanted to open with that and say those few words.

I do want to go back to Dr. Ross for a few moments. Mr. McNamara, can you explain why it is important for the Department of Health to have an ER adviser?

MR. MCNAMARA: Well to me, what the ER adviser is going to bring to us hopefully is some intimate knowledge of what's going on in the different emergency rooms around the province. I think one of the things, we've been working through different interpretations, depending on who provides the information, and by having one individual look at all the ERs in the province, at least the information that comes forward would be in a consistent format, be in a consistent way of advising us, versus having information that comes from different emergency room physicians, from different CEOs - not that they're doing anything wrong, but at least we get something consistent to be able to try and drive forward a new strategy to deal with as issues go forward.

MR. WHYNOTT: Absolutely, and I think you used that word "consistent" - I think that's what the people of the province want to see.

Can you explain or just mention possibly when was the last time that the province's emergency rooms were reviewed at this level, or like this?

MR. MCNAMARA: They've been reviewed as part of other reports, but never with the single purpose that I am aware of - I could be wrong - that there was one individual to look at all the ERs. I don't believe that that has ever happened in that concentrated a manner in the past.

MR. WHYNOTT: And do you see that as an important feature of Dr. Ross's . . .

MR. MCNAMARA: Definitely. As I said, if we're going to try and come up with solutions we need to have good information that is consistent to all of us. The solutions that come out of it may not be the same - as I mentioned, there may be different reasons to different things, but at least the feedback that will come to us will be from one person who has reviewed everything.

MR. WHYNOTT: Okay, thank you. Can you just go into why Dr. Ross is so well- suited for this job?

MR. MCNAMARA: Why he is well suited? I think from our perspective, having gone through the interview process with him, that he is extremely knowledgeable, he is well respected both locally and nationally, he has international and national connections to be able to have access to information, he has peers who are extremely supportive of him, particularly in the metro area, and we know that he will be building that same respect to the rest of the province. The other thing is he has tremendous knowledge of how ERs can work and what some of the roadblocks are that are there and some of the frustrations that he has felt, and we believe that bringing this all together will give us good advice that we don't have at the present time.

MR. WHYNOTT: Great, thank you. Ms. Hall, I have a question for you - can you just explain to the committee and to all Nova Scotians the importance of the Cobequid Centre for the DHA?

MS. HALL: Well I used to be really proud of it and say it was the largest free-standing ambulatory centre east of Montreal. I don't know if that's true or not, but I say it. What it is - and I think it's a great model, having emergency services, ambulatory care, and diagnoses all in one building - I think, and I don't want to pre-empt what Dr. Ross is going to find, but I think that access to diagnostic services is a big thing for family docs and for people who show up. So we talk about Level 4s and Level 5s - people who come to the emergency department don't know what level they are when they come, right? They come as citizens who need care, sometimes they come because they might need - you know they go to their family physician and the family physician says you're going to need an X-ray, or going to need a blood test, and they end up having to go somewhere else anyway. So having everything together in one spot has been a huge advantage - it is kind of like one-stop shopping.

So although the emergency department is a big chunk of what is done there, the other services, all the ambulatory care, being able to get appointments like the next day follow-up, the lab services - it's the same as the lab services at the Path Lab, so they get the same tests, it's immediate, we have a CAT scanner there, so there's very little that people have to go on for. It's a great model that you may want to look at for the rest of the province, actually.

MR. WHYNOTT: Great, thank you. Can you explain just a little bit about what you hear from patients who go to the Cobequid Centre?

MS. HALL: I tell you, they like the convenience, they like the parking, even though there is a small charge for it, but it's easy to park. They can get in and out. They don't have to go all the way into the city. Are there waits in line-ups? Sometimes there are, depending on how many people show up, but it's a pretty efficient system. If you've ever been out there for diagnostic tests, you see we use the same system as the motor vehicle registry where you get a number and you can see where you are. It's comfortable and I believe the staff know what business they're in, and they're very caring, and so people get treated well when they're out there. It's clean, it's open, it's nice, it's not fancy, but it's open and it's a very welcoming environment.

MR. WHYNOTT: I think right across the province, I know, in particular, people say to me, as their representative, they say Cobequid Centre is a great place to be because of the staff. They're so professional, and they care, and that's what people want in a health care system.

Can you just explain in these last few minutes how the Cobequid Centre itself, the staff, you as the VP of Person-Centred Care, how you work with the Cobequid Community Health Board?

MS. HALL: The health board sort of looks at all the issues that affect a community. I used to actually be responsible also for the Cobequid Community Health Board so I had a lot of conversations with them and went to a lot of public meetings. What's really interesting is that the citizens of the area, although health services are one thing that they have, you know, they have concerns about wait lists and times, a lot of the things that concern the Cobequid Community Health Board are things like transportation, education, child care, home care, how to get access to mental health services.

It's not always about the centre itself, in fact, the centre is probably a fairly small part of what the Cobequid Community Health Board talks about. They talk about all the things that affect their health as a community, walking trails, physical activity. Very rarely does anything actually come up in public meetings around the centre other than, please keep it going and please keep adding services, et cetera. We get very few complaints from the public around the services out there.

MR. WHYNOTT: That's good to hear because that's certainly the recap of exactly what I hear all the time about the centre and the work that the folks there do. Thank you very much to all four of you for coming today and we really appreciate the opportunity to ask questions.

MADAM CHAIRMAN: That does bring the time allotted time for questions from the three caucuses to a close. I would ask if either of our guests who made opening statements would like to have just a little summary, you can see we're pretty short of time, but I'd love to give you a couple of minutes to close. Yes, Mr. McNamara.

MR. MCNAMARA: I'll just be a couple of seconds; first, just to thank the committee for the opportunity to appear and talk about emergency rooms, also interested and intriguing hearing Ms. Hall talk about Cobequid Community Health Centre being the largest free-standing ambulatory centre east of Montreal. When I was involved in the original Cobequid Multi-Service Centre, we used to talk about being the only free-standing in North America, so the thing has changed completely. Anyway, thank you very much.

MADAM CHAIRMAN: Well it's very nice to hear of us being leaders in that way. Yes, Ms. Hall, did you have a few words?

MS. HALL: I just really want to impress upon the committee that you can't look at just the emergency department without looking at the entire system of health care, and so although the focus has been on our emergency departments and overcrowding and closures, it really is around the entire health system and how people come in and come out. It's about flow, so just please keep that in mind.

MADAM CHAIRMAN: There have been a number of requests for information and our clerk, Ms. Henry can give you that list. She's been keeping notes of who asked for it and what was requested, so if you could get back to our clerk in response, when you're able, we don't set a time limit on that, but our guests are usually very quick about it.

With that, I thank you very much and we'll just conclude our business today. We don't have any administrative work for the committee. There will be a sub-committee meeting right after this for agenda setting and procedures. Just for the committee members, next week is November 11^th so we have no meeting on the holiday, of course, and our next meeting is listed on your agenda, November 18^th. We'll be speaking to Capital District and Pictou County Health Authorities about their pandemic preparedness and the on-the-ground plans.

So with that, I would ask for a motion to adjourn.

MR. CLARRIE MACKINNON: I so move.

MADAM CHAIRMAN: Thank you. We are adjourned. We'll take a couple of minutes and return to the subcommittee.

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