HEALTH

Mr. Assistant Deputy Chairperson (Gerry McAlpine): Will the Committee of Supply please come to order. The committee will be resuming consideration of the Estimates of the Department of Health.

When the committee last sat it had been considering Item 1. Administration and Finance (b) Executive Support (1) Salaries and Employee Benefits $594,800 on page 77 of the Estimates book. Shall the item pass?

Mr. Dave Chomiak (Kildonan): Mr. Chairperson, I think when we had left off I had asked the minister about the funding announcement on November 22 as it relates to the budgetary Estimates that were announced by the Minister of Finance (Mr. Stefanson) and the relationship between the 2 percent cut to hospitals and the Minister of Finance's assertion that the only real cut in the expenditures for the '95-96 year versus the previous year was as a result of the MMA agreement and the medical expenses being down $8 million to $9 million.

I wanted to clarify what the exact cut was. My first question is, what is the exact cut to the hospital sector which was announced at a 2 percent cut on November 22 last year by the Minister of Finance?

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Hon. James McCrae (Minister of Health): Mr. Chairperson, for the community and tertiary hospitals we are looking at a percentage reduction generally across those hospitals of 2 percent. With respect to reductions elsewhere, i.e., intermediate and large rural, small rural, all of those, a 1.2 percent overall reduction on average--overall about $14 million, but some of those dollars go back in for certain new projects going on in hospitals or certain capital improvements or expenditures. There is no way to answer that question in one or two words. It is that kind of an answer.

Also money is going for the waiting list reduction measures that are being put in place. There is money for the community health centres and additional monies for various projects and additional monies to make the nurse resource centres possible in Manitoba, the first one being the Youville satellite project going on St. Vital. In addition, there has been quite an increase in capacity in the personal care home sector and monies are going for that as well. So $1.2 billion is indeed being used differently than it was the previous year.

Mr. Chomiak: I thank the minister for that. [interjection] Madam Chairperson--after five years you do develop a rote response. Thank you, Mr. Chairperson. Do I still have it right? Okay.

The minister has indicated $14 million is being redirected towards community-based operations, and I would like to get a rough breakdown of where that $14 million is going. I know half a million dollars is going to the waiting list reduction project as announced on March 7. I believe, if memory serves me correctly, $4 million is going to the nurse resource centres which takes us to $14.5. Now, if I remember correctly, a $3-million increase is going to personal care homes but I think that is a different line item. Perhaps the minister can correct me if I am wrong.

So can the minister outline for me roughly where that $14 million is being directed?

Mr. McCrae: If the honourable member would not mind, a little later today we can have the department fax over the information that would respond to his question. We do not have it immediately available but we will make it available a little later today.

Mr. Chomiak: Mr. Chairperson, I appreciate that, and I look forward to receiving that information.

Perhaps I will go down a different line of questioning while we await that information. I would like to spend some time on the list that the minister kindly provided us last session regarding some of the committees dealing with health reform. It seems to me logical that we deal with it during this particular section of the Estimates, unless the minister feels otherwise, that it would be more appropriate dealt with elsewhere, but I think if the minister is prepared I would like to deal with some of the specifics on some of the committees that have been established on health reform.

Mr. McCrae: Mr. Chairperson, I think that we can probably deal with some of the questions the honourable member has in regard to health reform and health committees. I am not very good at deciding exactly where the best line in the Estimates is to deal with some of these questions. So if I am able to, I will answer them as I am able to if my staff are able to assist me to do that. I think we maybe have some information we can impart this afternoon on the committees.

Mr. Chomiak: Just off the top, the secondary services committee that was formerly chaired--formerly, as in past tense--by the present deputy minister, who is now chairing that particular committee, the committee dealing with the other facilities that is outside the tertiary care facilities, the secondary level hospitals?

Mr. McCrae: Yes, as the honourable member has himself alluded, he referred to it as Bell-Wade or Bell-Wade 2 and, in this regard, the KPMG consulting people are involved with the secondary review. Part of the work, of course, would be to work closely with the various facilities involved in the delivery of secondary care. We are also interested in knowing how that interfaces with the primary care sectors as well.

I do not know of a formal committee per se established for this other than to say that this is a contractual arrangement with the consulting organization.

Mr. Chomiak: I just assumed that we would be getting effectively a Bell-Wade No. 2, that that was secondary services. Is the minister saying that is not the goal?

Mr. McCrae: Sir, I think the honourable member's expectation is probably as close to what we can all expect. It is probably what is happening. We had a tertiary review, and the honourable member brandished, I think, the Bell-Wade Report there, and I can see something like that happening with regard to secondary care as well. However, I do not know yet, because the work has not been completed, and I suppose it all depends on how the process goes forward from here.

We are going to be dealing with quite a number of people, but I expect at the end of it to get some kind of a report. What form it will take, it is too early for me to be able to say.

Mr. Chomiak: On page 7 of the document that was tabled last sitting of this committee, the item we are discussing, I assume, is the Secondary Care Services Review Advisory Committee. I assume they are the ones that are charged with the responsibility of producing this.

My question is that it says the 19 members of the committee are the Urban Health Advisory committee, who I did not realize were still in operating existence. I wonder if the minister might clarify that for me.

Mr. McCrae: That is maybe a little bit of a complicated way to describe what is the Urban Health Advisory committee, which is composed of all these CEOs of hospitals and maybe board chairs and people like that. Sorry about the lack of clarity, but what we are talking about is the Urban Health Council.

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Mr. Chomiak: When I referred previously to Bell-Wade 2, is that coming out of this group or is that coming out of somewhere else?

Mr. McCrae: This group is going to be, I suggest, a little busier than it has in the past because with what the honourable member has termed Wade-Bell 2, more appropriately called the secondary care review, I guess, I would think that the members of the Urban Health Council will be playing a more active role than they have.

Things like what some people have called regionalization in Winnipeg and so on are now going to become more important topics for discussion, because I think there has been more emphasis up until now on rural regionalization. The city of Winnipeg now is going to be asked through this exercise to look at the population health needs here in the city.

We are not going to be looking at things in sort of the vertical way that we have in the past, where we have institutions to some extent, less more recently than before, but operating a little bit isolated from other things and other institutions and other things going on in the health community.

So I think you are going to see the Urban Health Council playing a greater role in the next year or two, three, four years.

Mr. Chomiak: Will the former concept of developing specific centres of excellence around Winnipeg itself be incorporated in this process, or is that going down a separate road?

Mr. McCrae: I do not think we will want to continue on with the process of looking at secondary care in Winnipeg without looking at the concept of centres of excellence. We have had some pretty positive experience thus far with the whole idea.

With respect to the kinds of things that we need to be doing, we need to be developing plans for secondary care services that are carried out in our hospitals in Winnipeg. We need to be looking at volumes of activities by service and by facility. We need to identify the current and the projected--because they are not always the same tomorrow as they are today--needs of the target-area residents by means of appropriate needs-assessment methods, including sociodemographic data, health status analysis and the opinions of the key stakeholders and constituents of the community.

You know and I know that is not an easy process. We just have been reading the last day or two about the latest report by the Manitoba Centre for Health Policy and Evaluation--extremely interesting report that says some things that now some people are saying, well, you see, we told you, we knew this all along. Other people are saying, well, now, you see, we told you--we are operating at the maximum level of our efficiency. Others are saying, oh, we cannot be operating at such a low level of efficiency, we just cannot believe this.

So any report or recommendation made on the basis of needs-assessments or on the basis of data, depending where you are, you are going to have a potentially different kind of response. So that no matter what, there is no move that can be made I suggest in these matters without a spirited debate. I expect that, I look forward to it, and I hope everybody else does. I think it is necessary to have.

Part of what we need to do is to confirm current activity and location of hospital-based secondary care services provided to patients and clients by analysing clinical utilization data and performing appropriate analyses. Here, where you can use peer groups to do that, the better likelihood of having a result that will accepted by the group.

We need to identify and describe current components within the hospital-delivered secondary services within Winnipeg and analyze for gaps, for deficiencies, duplications. We need to identify areas where services can be delivered outside hospitals.

We already know that a lot of work is being shifted away from hospitals. A lot of it is being done on a not-for-admission basis. Now there are things that actually we could do outside hospitals altogether.

The concept I guess of hospitals without walls comes forward from time to time. If we can think of one of our hospitals--or if we can think of all of our hospitals as a service for the people of Manitoba, those partnerships that we have begun to develop will begin to bear more fruit.

We need to identify and describe other models of secondary care provision. Those models might come to us from some other place in Canada or some place internationally. We hope that it will not have to come from the United States, because we will certainly hear about that if that happens. Maybe they will even have an idea there somewhere or maybe in Sweden or France or Britain or somewhere that might even be a good idea, and we might want to look seriously at that.

We need to work with clinical working groups to review the data that is available and to discuss potential other models for secondary care services provision. Again if we moved forward on those things that would involve change, and some people tend to sometimes stand in the way of change.

We need to identify and describe enhanced utilization--

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An Honourable Member: Enhanced utilization management opportunities.

Mr. McCrae: There you go. Do you want this on the record, or I do not have to go through it?

An Honourable Member: No, I have that here.

Mr. McCrae: Okay. Well, we need to do all those things as we--I did not know you were looking at the same piece of paper I am.

An Honourable Member: Yes, I just found it.

Mr. McCrae: Okay.

I think the things that you have before you, I say to my friend the honourable member, those are the kinds of things that are being looked at everywhere where there is a need to change and to make our services more responsive to what patients and taxpayers want to have.

Mr. Chomiak: I am trying to understand the process a bit here. We have the secondary care services as a review advisory committee which was co-chaired by Dr. Wade and Mr. Bell. Underneath that we have a number of working groups, the dental surgery, ear, nose and throat, general surgery, ophthalmology, orthopaedic reconstructive, urology. Within that context we are looking at a Winnipeg regionalization. I do not quite understand how that fits within this context. I wonder if the minister might explain how that process works, because I do not understand it and secondly what the philosophy is and the direction they are going in terms of the regionalization of services within the city of Winnipeg.

Mr. McCrae: I sort of maybe think I should not have used the word "regionalization" because the city of Winnipeg cannot be broken up in exactly the same way the tram, what they call the rest of Manitoba, can be broken up into. Obviously we have a North, we have a south and an east and a west. We have those things in the city too, but the distances are not so great so that centres of excellence for the whole of the city and even beyond the borders of the city of Winnipeg are possible and even desirable.

I am told that the centre of excellence for eye care has surpassed the performance expectations that there were and in the first year we did an additional 800 procedures there. I thought we had been talking about doing 600 additional, doing it and saving money at the same time. I understand we have achieved both objectives and even done better on performance of the number of procedures than we thought we would. So obviously in that area of specialty that was a good thing to do.

I still see us in--well, I will use an example. Not that long ago one of our community hospitals had a plugged-up emergency room. Of course there were people hollering away about how all that had to do with reform and cutbacks and all that stuff. The fact is that in the city of Winnipeg there was capacity in all the other hospitals that day, so why did one have to shut down.

That did not make any sense to me and I said so. I think that sort of thing can be avoided. If we were thinking more corporately or co-operatively or whatever it is called, when you have five community hospitals, two tertiary hospitals operating in a city of 600,000 people, it seems to me that we can do a better job than dealing with the situation in that way.

Similarly, where we have actually made some capacity in some of our hospitals because we have closed some beds, that means that when you have a peak period that occurs you are able to respond by opening some beds. I have been criticized for opening beds when people needed them. I do not know why I am criticized for that but I am. It seems to me that is a good thing to do rather than a bad thing to do. If you have a rash of respiratory problems coming down from northern Manitoba finding their way to the Health Sciences Centre and you are able to open some additional beds to take care of people who need the care, I do not know why I should get criticized for that. It seems to me like that is a pretty good idea. Anyway, I have digressed again.

What I mean is that I think that we have enough co-operation. We have some very, very good people working in the hospital sector in Winnipeg who have shown a willingness and an ability to work together putting the needs of the patient first as opposed to the needs of an institution. If they would do that and they are showing signs that they are prepared to do that, we have every reason to be hopeful through the kind of thinking I am talking about but also through shared services organization, which has already been announced--work is going forward on that--how we can achieve some efficiencies and spend the money saved to sustain our health system and to look after people even better when they are in our care in our hospitals.

Mr. Chomiak: I understand the minister's response. It is interesting that I had not in my notes utilized the words "regionalization in Winnipeg". I know the minister used it and people have mentioned it to me in my meetings in the communities. They have talked about the Department of Health regionalization and I have never recognized that or seen that. I do not know exactly how that would work. So the minister is saying, there is not really an attempt at a geographic breakdown in city of Winnipeg but rather he is talking about an overall co-ordination of services or sharing of services and the like but not a geographic move. Is that correct?

Mr. McCrae: Actually, I think I have to agree with the honourable member. It is probably my fault for using that word. Today I do not know if there is a way for us to identify, and there is the core area, for example, in Manitoba centre will tell you that they can delineate more or less a population there and a need there that you can see as separate and distinct from needs perhaps in other regions of the city. So for things like that, I do not know that I want to throw away the word "forever", but I am looking for better co-ordination of services, but I am also looking to health planners to look at need that can be defined and identified. If regionalizing an area for the purpose of dealing with that particular problem is the right word to use, then I do not mind the nomenclature, I am just saying that I did not mean to use the word in the same way we used it for rural Manitoba and what I call greater Manitoba, that part outside the city of Winnipeg.

Mr. Chomiak: I thank the minister for that response.

Just going through this list that was provided to us, I wonder if there is a way that we can go through this list systematically and determine which reports are completed and which reports are pending.

Mr. McCrae: The trouble with the honourable member's question is this--it is not his fault--it is just that you strike a committee or a task force or whatever all these things are called and there is an expectation that what will flow from that is a nicely bound and neatly typed-up report. Some committees never really produce something like that. They are a working kind of committee. They are not asked to do a particular study and then give you a report with recommendations that you can make public and then get criticized for not following them or whatever like that. There are some that are like that.

Some committees have produced reports that have been made public. Some have produced reports that have not been made public. Some have that will be made public at some future date.

Usually you want to be able to co-ordinate the release of a document with some kind of action that you either have taken or are intending to take. Some reports, for example, the Centre for Health Policy and Evaluation reports, they come out under their own steam. They operate independently and make their reports available, not unlike the Law Reform Commission does. Sometimes they call for action. Sometimes they just provide information and help keep the debate going.

However, I am not sure what it is the honourable member is asking for. He knows the reports that have been made public. He knows of some that he became aware of before they became public and which formed the basis of his party's platform in the election. That is all right. I am flattered when that happens. I am not critical. Just because their child health strategy is exactly the same as ours is no coincidence. I know how it happened and I think it is great. I think we can work together on a lot of things.

Mr. Chomiak: I do not really want to get into political debate. I am trying really hard not to do that. Our particular announced child health strategy I think is more comprehensive than the plan that was announced by the government. It just could be that we are farther along in our planning than the government was at the time that they announced theirs.

Mr. McCrae: Anything is possible, I suppose, Mr. Chairperson. I notice the honourable member's cheek has a little bulge in it. That is all right.

Mr. Chomiak: While Dr. Wade is with us I wonder if we could get an update as to what the status is, the specific status of the tertiary care consolidation, where we are at today with respect to the recommendations in the December '93 report.

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Mr. McCrae: The honourable member will recall the signing of the consortium agreement at that time--I forget what we called it exactly. It was an agreement between the Health Sciences Centre, the St. Boniface Hospital and the government to begin to develop these various programs, these tertiary programs. The first ones identified were cardiac and neurosciences. The reasons for that, as was felt I guess by all concerned, were that those were very, very key and very, very tertiary sorts of programs. So we have the University of Manitoba involved in the discussions through the efforts of Dr. Arnold Naimark, president of the university, have the chair and the CEO of HSC, and the chair and CEO of St. Boniface Hospital building program plans and plans for the governance of the programs, but heart and neural were the two identified tertiary programs that needed to be the subject of priority discussion and planning.

One of the major things they want to do is establish leadership for those programs. They are really happy, and I am really happy to be able to say that Dr. Bill Lindsay is leading our cardiac program, one of those doctors who returned to Manitoba. We hear about doctors leaving Manitoba. Well, here is a very well-known and highly respected cardiac surgeon who is leading our cardiac program. Similarly, Dr. Blake McClarty leads the neurosciences program.

So we have made a pretty significant beginning to address the Bell-Wade recommendations, which if you could put the Bell-Wade Report in just a short precis of what that report says, it talks about working collaboratively on these things. Instead of having two teaching hospitals working probably too much in isolation, one from the other, we now have some joint planning, some joint delivery of service, and we expect there to be great improvement.

From there we go to the issue of trauma, the trauma centre, I take it, and that will be the next major piece of work that will be done under these arrangements.

Mr. Chomiak: I thank the minister for that response. So what we have is we now have one head of the cardiology program and one head of neurosurgery at both facilities. The minister is nodding and he affirmed it.

Is there a common waiting list that has been developed, particularly for cardiac surgery?

Mr. McCrae: When Dr. Lindsay arrived on the scene, that was in the process of being developed. He has now taken charge of the matter. That process is still in process, but with Dr. Lindsay's leadership we should be able to get that ready to roll.

Mr. Chomiak: This is not a politically charged question; I am trying to get a grasp as to what the situation is. Would there be any specific difference that someone would notice if they walked into, or they are sent to St. B or Health Sciences Centre for cardiac problems? Would there be any tangible difference they would see as a result of these preliminary steps, or is it still too soon? Is there anything tangible that they would see that would be changed?

Mr. McCrae: Patients will begin to or have begun to see surgeons and support staff, if patients happen to be in both places, working in both places. In other words, you do not see the surgeons assigned only to one location anymore; you will see them assigned or working at least in both locations. That includes support staff as well. I do not know if patients see that or not, but if you hang around both locations, you might see the same people in both places.

Mr. Chomiak: On the issue of waiting lists now, as I understand it, each surgeon basically has his or her own waiting lists.

What are we looking for in terms of the consolidation of waiting lists?

Mr. McCrae: The exercise involved in building the new program dealing with waiting lists would have the doctors working together to develop that waiting list. It would be based on need, and it would be done jointly as opposed to each doctor having his or her own list and maybe competing with each. Now they are working together to prioritize that list.

Mr. Chomiak: So in natural fact the cardiac surgeons are now meeting as a group and looking at prioritizing, consolidating or working together on their list. Is that the exercise?

Mr. McCrae: That is where they are heading. I am not trying to have the honourable member think that it has already happened, but that is where we are heading under the leadership of Dr. Lindsay.

Mr. Chomiak: I guess it is difficult to put a time line on this. Is there any kind of time line that has been placed on this process?

Mr. McCrae: I kind of think that way myself sometimes, but it is not always so easy. I think when you are dealing with professionals, there are a lot of things enter into these things for them. My wish is that it happen immediately and that we have physicians looking at the cases together and making decisions that result in a better use of the list. I still think there is going to be a list at the end of all of this. Some might even argue it will be too long then, but at least I would like to have more of a comfort of knowing that the right people are getting the priority attention. I

do feel better knowing that the doctors are working toward this.

Mr. Chomiak: Mr. Chairperson, that is in fact happening now though on an individual basis. There are clinical guidelines that are in place at each institution and under the direction of each of the programs, and those particular priorities are already in place as we speak. It is just a question of consolidating those lists. Is that not the case?

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Mr. McCrae: Is it not a question though if each doctor previously was working quite individually, no matter what your guidelines and all of that, the honourable member knows and I know, too, that different interpretations can apply; whereas, if you are sitting around the same table, then you are coming to a consensus interpretation. It is questionable as to whether there were even common guidelines. As long as you were working within the parameters laid down by your professional organization, that would, I suppose, keep you okay with your professional organization, but I do not know that that served the population the best.

I do not know if the honourable member is as uncomfortable as I am talking about these extremely professional issues, but what we need to get fundamentally is very highly specialized and professional people to work together with other highly specialized and professional people and to build consensus. Dr. Wade tells me that a good description is that the waiting list methodology will be designed to meet the needs of the patients and not entirely the needs or desires of the professionals involved.

Mr. Chomiak: Mr. Chairperson, the reason I am emphasizing this particular issue is not only because it is important, but because prior to your assumption of the office, the previous minister actually had announced the program that a common waiting list would be developed for cardiac surgery. I can remember being interviewed in the media and praising it quite strongly. I did not see anything tangible come down in the process. I also received correspondence from yourself in December of last year indicating a move towards this, so I am trying to get some kind of ideas as to where we are at in terms of this.

Mr. McCrae: I am the same as the honourable member. I think some of these things take a very long time. I am glad to be given the comfort that only since, what, about the first of this year I guess, have we had Dr. Lindsay. I think that is the most significant thing to happen in the cardiac program. It is important that the administrators and trustees and everything we are talking about this one program, two sites and all of that, but the thing that was missing even last fall was leadership in the cardiac program.

That is the best I can give the honourable member. I wish I could say tomorrow it will all be resolved, but the best answer I can give him today is that we do indeed have a strong leader for that program. I think that the professionals working in the program would have been the first to say, what we need is good strong leadership in our cardiac program. That is the most hopeful response I can give the honourable member, short of saying tomorrow the whole matter will have been resolved.

Mr. Chomiak: Is a similar development happening in neurosurgery or is it further advanced or further behind? What is the status of that?

Mr. McCrae: I think two significant things need to be said in this area. It is also a priority item or has been. Now that we have Dr. Blake--well, I am going to say Blake McClarty. We will have to check that out for you. Having recruited that leadership, the two issues that are important in the neurosciences program is recruitment of more neurosurgeons and also the issue of the funding of the program I think--if problems occur sometimes it is because of funding issues, not so much how much for the program as a whole, but who gets what sometimes is a problem.

It has been, for me, very interesting to have discussions with Dr. Wade, the new--not even new anymore, but the Deputy Minister of Health has some ideas that I suspect he has probably had for some time and wants to discuss and pursue with his colleagues in the profession. I support those discussions, alternate methods of remuneration for physicians. I know that some people suggest salaries for everybody and then some people say, well, fee-for-service for everybody.

There are all kinds of ways I suggest to look at the remuneration issue. Which is the best way of remuneration for a particular program? That is the way we should look at it. There should not really be a philosophy involved. I know that salaries work well in some places and in some programs. I know that on the other hand there are going to be some physicians in Manitoba, maybe even a significant number, who will be very, very displeased to move immediately away from the fee-for-service system, which is all they have ever worked under.

So I do not know why we have to move from one totally to another system overnight when we can look at programs, and these tertiary programs might be a very good place to start looking at issues like block funding for a program or a contractual arrangement of some kind to see that Manitobans get what they need under these very, very high-tech and extremely important programs. Maybe fee-for-service is not right. Maybe even salaries, simply put, is not right, but some kind of contractual or block funding arrangement. So I have said to Dr. Wade and the others that they are quite at liberty to pursue whatever kind of option is the best one to look at as long as Manitobans get the service.

Of course, we are working within certain numbers of dollars across the whole health system in Manitoba but, there again, it is a question of, where should the monies be going, where should the priorities be? If we have been having trouble with recruiting, is that an issue of money? If it is, let us address it. We owe that to Manitobans.

Mr. Chomiak: Mr. Chairperson, I appreciate that response. There are several lines of questioning that arise from the minister's response. I think it is appropriate that the minister did talk about the remuneration mix when it comes to neurosurgery, because my people that advise us have indicated, this was one of the difficulties that resulted in the loss, perhaps, of one of our neurosurgeons.

Mr. McCrae: That was an emergency surgeon you asked me to talk to earlier today, was it not? It may help the honourable member for me to say very simply that we are looking at alternate funding and discussing alternate funding for the whole program, all of the programs of the academic health centres.

Mr. Chomiak: While we are on that point, the minister talked about, basically, a flexibility in approach which I think no one would disagree with. Aside from the academic funding, which seems to make sense, tied in with research funding I would suspect, what are the other alternatives and the other configurations that the ministry is looking at?

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Mr. McCrae: At this point it is not me doing the looking. I have asked the academic centres and the department and the university and everybody involved to feel free to look at any number or variety or permutation of methods of remuneration. I mean, as far as the government is concerned, I think it still comes out to a certain number of dollars that we are going to have to spend to provide all of these services. So it is really not my debate so much as at the end of the day to hear what the others have had to say and then make some determination based on the options put before me. So at this point I do not really have any philosophy other than to say that there are so many dollars and we know how many there are for this particular year, and we have some fairly good signals as to what the future is going to be like so that it may be even that alternative funding will allow us to find ways to live within budgets and to be more efficient with the dollars and still get a job done for the patients of Manitoba.

Just to help also for later discussion when we get into servicing underserviced areas of Manitoba, we are open to discussion on alternate remuneration formulas in those areas too. I think that what has made the change is, maybe physicians themselves have come around to the thinking that just because fee-for-service was kind of the foundation of medicare does not mean we have to not have a medicare because we insist on that one kind.

There are certain problems with certain kinds of systems of remuneration which people are now willing to address, which maybe they were not in the past. Maybe we did not have to in the past because the pressures were not on us in the same way as they are now.

We have pressures of how many dollars can be made available, but we also have very serious pressures in areas that are underserviced. So we are quite willing to look at other methods of remuneration in other areas. In fact, we have salary programs in some areas already.

Mr. Chomiak: It is no secret that workload and stress is a factor in many of these areas, particularly in neurosurgery. Can the minister indicate how many neurosurgeons we presently have in the province and what efforts are being made to recruit additional neurosurgeons?

Mr. McCrae: We are actively in the process of recruiting neurosurgeons. We have 3 or 4 and we want 6 or 7. We are making commitments to young neurosurgeons in Manitoba now. Another thing Dr. Wade tells me, that of 40 trained in the whole of Canada, 20 remain. So the problem is a national one, this issue of specialists leaving us. We want to do everything we can here to keep what we need here in our own province. The context here is a national sort of context.

Mr. Tim Sale (Crescentwood): I am not sure of the exact year, Mr. Minister, but I think Dr. Wade negotiated an agreement with the family practice unit at St. Boniface Hospital to the point where it was on the--is my mike not on? I have not often been accused of not speaking loudly enough. Do I need to go over that again for Hansard? Yes? Okay.

I am not sure of the year, but it might have been the end of 1991-92 or 1992-93, I am not certain, but several years ago. Such an agreement was virtually completed. I believe there was significant disappointment when it was not actually completely concluded. We have talked about moving away from fee-for-service for primary care physicians for a long time now.

We have talked about alternative methods of funding doctors. You are into your eighth year now in government and I do not know of specific progress that has been made. I know of general hopes and thoughts and directions.

Has there been any specific movement away from fee-for-service and on to specific arrangements either for capitation or salary in some cases of any groups of physicians? We can go on in this area for some time because there are so many different groups involved in this.

Can you first indicate in general, are there any groups that have moved from a previous status to a new status?

Mr. McCrae: It may just be that the honourable member had not heard about it, that is all, because there are a number of arrangements, I am advised, that have been in place for some time. For example, the university's Department of Family Medicine has been under an alternate block-funding arrangement for two years now, and there are alternate arrangements in emergencies in various places, obstetrical anaesthesia and intensive care, so they have these other arrangements in those. Then in addition to that is the salaried physicians in various rural locations, as well, and the northern medical unit.

Mr. Sale: I do not think most of those are really new, Mr. Minister. I think that northern salaried physicians and arrangements have been in place for a long time in Dr. Hildes's units of one kind or another, sessional fees and those kinds of arrangements.

I am asking, have there been specific changes in the last two or three years from previous fee-for-service arrangements to new kinds of arrangements, specifically as a result of the, what was it, 1993 that the Action Plan was tabled? 1992. Have there been specific changes and what have they been?

Mr. McCrae: The family medicine one we referred to is in that category.

Mr. Sale: Mr. Minister, are there any others than the family medicine one?

Mr. McCrae: No, there are not any others yet, but we are open and I think maybe even encouraging proposals in that area. I am told the university's Department of Family Medicine model is a national one, though, and is looked at with approbation.

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Mr. Sale: Could the minister then table for the committee's information the specific information in regard to the family medicine remuneration process, and would he, in tabling that information, provide some estimate of the impact of that change as compared to the previous arrangement in terms of either expenditure patterns or service utilization patterns? How has this shift in remuneration affected the delivery of health care? I ask that in a totally nonpartisan way because the literature suggests that physician-induced demand is one of the characteristics of the Canadian medicare system and that alternative salary or remuneration, let us just say alternative remuneration, would be one strategy for addressing that question. So can the minister table some information that would help us to see the impact of that change?

Mr. McCrae: We will provide what information we can to the honourable member on that. I do not disagree with anything he said. I think he is on the right track.

Mr. Sale: I thank the minister for that, and I think that that is the kind of dialogue that can be creative and helpful in terms of helping to move us forward in this, I think, very critical area.

Would the minister comment then on the impact that the five-year MMA agreement with the commitment to a fee-for-service model has on the ability of the department to move away from virtually 100 percent reliance, apart from the example given on fee-for-service over the next period of time?

Mr. McCrae: I am not sure I agree with the honourable member about the five-year deal with the MMA having such a total reliance on the fee-for-service system. I have discussed and been assured that that agreement would not prevent parties from moving on to other models of remuneration. The doctors themselves--I suggest many of them--are crying out for the kind of change the honourable member is talking about and that I am talking about, so that I do not think there is anything in that agreement that restricts us.

I do think that there are some physicians in Manitoba who will hold fast to the fee-for-service system, and I think some regard has to be had for them. I am in the business of trying to do what I can do. I sometimes wish I could do all the things I think I would like to see done, and it is not quite as simple. It is harder to be on the government's side than it is on the opposition side, when it comes to actually doing some of these things. The honourable member would maybe understand that. So that I have never felt that we could transform our fee-for-service system 100 percent in a hurry, but I think over time we can transform it quite a lot. There is nothing I know of in the agreement that would stop us from making significant change.

Mr. Sale: Mr. Chairperson, I think, Mr. Minister, one of the problems in the agreement is that while the parties to the agreement may agree to alternative things, the fact is that the MMA has the ability under the agreement not to agree and to block movement in that direction, as an association. I think that all of us who know about unions--and I guess we can speak about unions when the MMA is a union just like any other--know that sometimes the power in the union is held by members who may not have all members' best interests at heart. I think the fee schedules that have been arranged over the years have often reflected that, that some of the smaller numbers specialties have not gotten their due in relation to fee schedules. So I guess I am not as optimistic as the minister that signing this agreement has not in fact locked up a lot of your flexibility that you might otherwise have had if this agreement were not in place. That aside, I take your point that you think that it is possible to move ahead.

I want to ask about Ontario's capitation arrangements. In Ontario, under the Conservative government, the Liberal government and the NDP governments of the last--whatever it is--12, 14 years, there has been a slow but steady evolution of capitation formally. I think that when I last looked at them--and that was not in the last year--but when I last looked at them, there were well over 100 capitation-funded group and solo practices in Ontario. The model was a case-mix model in which people's case mixes were normed, projections made of what the cost ought to be, and they were paid on that basis. There were some disincentives in the system. If patients left and went to other doctors, then the physician of record lost. There were some incentives in terms of reducing hospitalization.

As far as I know, there has been no open exploration of that model in Manitoba. At least there has been no public exploration. Is the minister now undertaking a specific initiative to explore capitation, models of remuneration, either for group or solo practice.

Mr. McCrae: Mr. Chairperson, I think it is probably somewhere in between. It is probably not as bad as the honourable member says and not as good as I say, in terms of the flexibility--I am talking about the flexibility in the MMA agreement. I am just going back to that part--I wanted to sort of get in at some point to say to honourable member that so far, we have enjoyed a co-operative effort. We are now into the third year of that five-year deal. We are working co-operatively so far and I certainly want to keep it that way if I can. We seem to get more done when we are not fighting. That is good because we need to get some things done right about now in our history.

I do not know that the vested interests will be able to stop meaningful change when faced with population health reports from the Manitoba Centre for Health Policy and Evaluation. Those reports do get the discussion going, but that is a good thing and not a bad thing, in my view. That is a question of--I do not know who is right, whether the honourable member is right or I am right, but we will keep working away to try and make the thing work for Manitobans.

The capitation arrangements to which the honourable member refers is something you see in regard to pharmacy arrangements for our personal care homes now. Again, the Manitoba Centre for Health Policy and Evaluation and its advice will help direct us to which models or model are the right ones in any particular application in the future. Nothing, as far as I am concerned, is ruled out as long as the population health is somehow the beneficiary.

Mr. Assistant Deputy Chairperson: The honourable member for Crescentwood, before I acknowledge the member, I would just remind the honourable members of the committee that any remarks should be made through the Chair rather than back and forth for the benefit of Hansard.

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Mr. Sale: Thank you for that correction. We new members need help and we appreciate all the help we get. Then to the minister, I take it the answer is no, that there is no active exploration of capitation as an alternative strategy in Manitoba. I understood the minister to say, anything is possible, we will look for advice, but I think the minister said no. If the minister said no, Mr. Chairperson, why? It is a recognized, a well-recognized model for remuneration used in a number of places in the world. Why are we not exploring it?

Mr. McCrae: I do not think I did say that. I said that it is one of the methods that we are actively involved in discussions with others in. So that if the honourable member felt I was dismissing it, I was not doing that. I have not dismissed anything in this area.

Mr. Sale: Mr. Chairperson, when a government is undertaking development of a new initiative in an area as big as health, as complex as health and an area as complex as the remuneration of physicians, I would think there would be something more formal than, we are open to exploring ideas.

Is there a written outline? Has the minister reviewed the Ontario guidelines or the British guidelines? Is there a possibility of a pilot project?

This is not an arcane notion, capitation. Is this really on the table or is it simply, well, we are open should it come down the road?

Mr. McCrae: I do not want the honourable member to misunderstand here. The tone of the question seems to suggest that he wants to push me along further than we already are. That is all right. He is doing that.

Yet, you see, if you move with inappropriate or even indecent haste you can get yourself into all kinds of trouble. I am trying to maintain partnerships in this province, and it is not for me to judge how I am doing, but I am working at it pretty hard.

Specifically with the development of rural health associations, the discussion of this method will be more pointed, I suggest, as we go through the secondary review of our hospitals here in Manitoba. This will become more focused on this topic as well.

These things, in terms of the history of our system, while it might seem like a long time for the honourable member, who has maybe embraced these ideas for some time, not everybody has. So building consensus takes a little time. Thank goodness we have a little time here in Manitoba, not a lot of time, but a little time in order to do the best job we can in our consultations with the various parts of the system.

Mr. Sale: I thank the minister for that thoughtful response. I guess I am going back to the minister's own comments a few minutes ago and my experience with younger members of the medical profession, in particular women who have become doctors.

I agree with the minister that many younger physicians, indeed not just younger physicians, are open to alternative practice styles and alternative remuneration. We know that in Ontario nobody coerced the numbers of group practices and solo practices that are in capitation remuneration models. No one went to them and said, you have to do this. It was an option that was offered.

In my not expert view but my sort of layperson view, it was an option that was extremely expensive at the time for Ontario because they made the carrot too rich. They gave an incentive that was too high, so I think it needed some fine tuning. I am not sure that it constitutes moving too fast or breaking partnerships to offer options, particularly when there are so many younger physicians who do not want to practise 70-hour-a-week, volume-driven medicine, and capitation offers the option for that, or at least it offers an option, not the option.

There is no one right method. I agree with the minister on that. I am simply asking the minister, would the minister and the department more actively explore putting forward options in an open way, so they can be looked at and discussed rather than perhaps waiting so long for these alternatives to be available to some of the physicians, who I am sure might well welcome the chance to be a pilot project in a capitation model.

Mr. McCrae: Mr. Chairperson, I appreciate the honourable member's urgings and knowing that there is that kind of support there makes it easier for me to urge that discussions go forward in these areas. I will take his question as a strong inducement for me to encourage these kinds of things to happen. I appreciate what he said too about younger doctors. That has been my experience, that younger doctors seem more amenable to new remuneration ideas, and some others too. I can also appreciate, you know, if you happen to be a physician in a certain practice and it is built, it is an ongoing thing, I can understand maybe not wanting to change for the duration of one's career either. So I think we can probably benefit from both systems for the time being, and it may be that some day we will look back and fee-for-service will be the exception rather than the rule. But I will take what the honourable member said very seriously and discuss it further with my department.

Mr. Chomiak: Mr. Chairperson, following this line of questioning, I wonder what active efforts the department is making to deal with what I think is a crisis of morale in the medical community in terms of--particularly amongst family physicians and general practitioners. I wonder what specific steps are being taken to deal with that particular issue.

Mr. McCrae: I guess I have to ask the honourable member to put some point on this question. I know there are areas where there are morale issues. I know that and I do not deny that, but to say that it is a general crisis of morale when we are simply working together like never before with the medical association, and we are working with the members of the medical association that have accepted the direction of the agreement that we arrived at for a five-year period--I would ask the honourable member to be more specific about his crisis. It is his crisis. It is not mine. It is not the people's and it is not the doctors' until you can be more specific than that.

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Mr. Chomiak: Let me be more specific. In the constituency I represent there are several family doctors that have recently picked up and moved to the United States. It is rumoured that there are several others who are going to be picking up and moving to the United States. Several weeks ago I encountered a family physician in the parking lot of a building who told me of three or four other physicians that he knows that are contemplating moving to the United States. There is another doctor adviser to me, who is a lifetime Winnipegger, who told me over dinner that he would accept any offer to buy his particular practice despite the fact that he is a long-time Winnipegger, likes his practice and likes Winnipeg. He just does not feel that he is appreciated--that is the choice of words.

Finally, I was advised by a patient of Dr. Rifkin, the matter I raised in the House today, that it is his dissatisfaction with what is going on in Manitoba--I did not confirm that; I was told this on hearsay. I also tried to contact Dr. Rifkin myself prior to his departure but was unable to do so to confirm the reason as to why he was leaving. Maybe this is anecdotal, but my impression is there is a sense of morale problems, shall we say. This is not a political question, and it is not an attempt to debate the merits or the pluses or deficiencies of the MMA agreement. It is just a general question that I think it is incumbent upon me to ask based on what these people have told me both in social and in working relationships with them. Maybe it is all anecdotal and maybe I am wrong, but that is not the impression that has been passed on to me.

Mr. McCrae: I can partly go along with some of the things the honourable member has said. In this line of questions he is singling out physicians. If you are a nurse, working in our hospitals where changes are happening, there is a sense that, you know, I wonder if these things are going to affect me in some terrible way. If you happen to be the cleaner of a ward in a hospital that gets closed in these days of changes in the acute care sector, you are going to be worried about that, too. I appreciate the cleaner, too, and I appreciate the nurse, and I appreciate the doctor as well. They are part of a team, all of them. The doctors, of course, are important members of the health team, and they are an essential part of the health team.

How we treat them is important in the same way it is important how we treat everybody else. They are valued. Just saying it is not enough though. Something has to make them feel valued and appreciated. If they want opportunities in Canada to reach the potential that they know that they have and that they trained for and studied and worked very hard to get to, your career does not end the day you start being a doctor. There are a lot of things you want to do to develop in yourself the potential that your learning has taught you that you have and you want to bring it out so compensation is an issue. The fee-for-service system has come kind of full circle.

Tommy Douglas, I knew him personally, and I have a lot of regard for him. He and I had a number of very interesting chats, a wonderful man. However, the health care system that he got going was based on that fee-for-service system and it has outlived its usefulness in a lot of places. I hope my honourable friends do not get too upset for saying that. It is certainly not to fault Tommy Douglas or the drafters of medicare, but in those days in order to get that, you had to get the doctors into the tent. The way to get them into the tent was to show them that the system of fee-for-service billing does not have to change.

Well, now you get the government paying the bills--back to what the member for Crescentwood (Mr. Sale) said--it can become a disincentive to the best operation of the health care system.

So what started out as something really good--it is interesting that a lot of other economic issues had their beginnings just around the time of the birth of medicare too. Those were the days when I guess we felt that we could do all these things. We could raise the money somehow. Even if we could not generate it, then we would tax for it or borrow for it, to get the money that we wanted. That is where we kind of get off the track, the two different philosophies on this.

The one philosophy says, well, just take it all from the rich or, you know, tax people some more or whatever. That is where we get into a divergence which everybody is very aware of, and I can respect people who have a different view than I on that point.

I happen to come down on the side of living within your means, which means we have to look at the fee-for-service system for a number of reasons. It does not work for some docs in the same way as it works for other doctors. In a market that is close to saturated in some ways, it just does not work very well at all.

If you are a new player, how do you break in? How do you get into a system where Dr. So-and-so and his or her partners in the clinic are getting all the medical business? I can see the reason for wanting to look at some changes. The members--I got their support for this. It is important for me to have that because I think that there are ways to improve this.

If you happened to be a doctor at the time of the birth of medicare, you are not as likely to want to be changed overnight. I hope honourable members can appreciate that too. Some will, but there will be a number that have done well enough by the fee-for-service system that they do not see any need to change. I am not wanting to run them out of the country by imposing change on them.

You cannot on the one hand argue that too many doctors are leaving and then on the other hand argue that we should not change. I know honourable members opposite are not doing that. They are pushing for change in this area, and I accept that, and I appreciate it because I think change is needed.

Dr. Wade tells me that of the physicians in the United States, 17 percent of them are family physicians. You know why they are actively recruiting Canadian doctors. We are at 50 percent. There is a very big difference there. I will not ask honourable members to put themselves, but put somebody they know in the position where you are doing not too badly or making a living in Canada and somebody comes along with a really juicy package. You are trying to raise a family or whatever it happens to be, and you have got commitments. I can see people being lured away by that.

But I also see some people coming back, and it is nice to see that. They go there, and they find out that malpractice insurance is a pretty big item, and maybe over the longer term there are some things about us that really lure us back to where we came from. It happened to me.

At the very base of it all, we are still human beings, and we are Canadians, and we value some things that go on in this country. We want to maybe come back and fight for them or come back and preserve a quality of life that we once enjoyed. I do not know how many come back, but when we hear statistics on how many leave, I wish they would tell us how many came back too, because I think that is probably relevant. Some do.

I do not know if I finished everything I was going to say, but I am very sensitive to these issues. I am more sensitive to them in areas where the undersupply is just screaming rather than just crying out. There are areas where we need to put priority attention. With all due respect, we probably have--I do not know what percentage--more physicians practising in the city of Winnipeg today than 20 or 30 years ago, but the fee-for-service system built it to that kind of a level where now it is getting to be maybe not such a good-paying proposition.

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We will probably get agreement on the point that we have enough physicians. We just need them located in the right places, we need them practising in the right specialties and if we listen to the Centre for Health Policy Evaluation, which is probably a good idea most of the time if not all the time, we would forced to address the issue of physician resource. Because even after the fee-for-service system some day is not a large part of the remuneration aspect of health care, doctors will still be driving our system to a certain extent, driving the costs in other areas, so it is going to be important that we have the right numbers in the right specialties and in the right places.

Mr. Sale: Mr. Chairperson, there are so many things in the minister's response that open up avenues, and I guess I want to ask one very concrete question. I suspect that the commission, well, not the commission, now the department actually has those data to which the minister referred, that is, how many doctors have returned from the States. I think that those are actually, in fact sometimes I have seen such data, so I suspect they exist about the people coming back. It would be interesting for all of us to know what that is.

I do know that there are numbers of family physicians who have said that it is not so much the malpractice suit or malpractice insurance level that is frustrating in the United States, it is the fact that you spend a very considerable portion of your time negotiating with insurance companies for appropriate coverage for your patients when you know they need care, they know they need care, but the payer in the situation is obviously facing an expenditure which they would rather not make.

There is a standing joke, I am sure that the minister is aware of, that when you ask a psychiatrist how long a patient will be in hospital, the answer is virtually always until the insurance date runs out. That is the situation that is in the States, so the minister is quite correct in saying that quite a few find that the greener pastures have turned brown after some experience.

I want to just put on the record though--for the sake of history that Tommy Douglas and Woodrow Lloyd who was actually Premier--I think Woodrow Lloyd was a very critical portion of bringing in medicare in Saskatchewan. The compromise around fee-for-service was a compromise with the physicians. It was not in any sense something that the Saskatchewan founders wanted or welcomed. They saw it as a political necessary trade-off in the day and saw it as a flaw. In fact Douglas described this as a flaw at the heart of medicare, and I think if I am not mistaken, I am not as sure about this, I think Mr. Justice Hall made similar comments in his initial royal commission report.

(Mr. Edward Helwer, Acting Chairperson, in the Chair)

I think virtually everyone who took a kind of economic or system look at our system recognized that when you provide all of the infrastructure and guarantee the payment and then say to the main player, go on a volume basis and do your business, that we have essentially put at work a mechanism which only works when you have a shortage, and in the condition of the shortage of physicians it works by driving them too hard. It works by driving doctors to work at a level and at a number of hours per week that is damaging to them. So on an economic base, fee-for-service is sustainable and affordable when you have a shortage because the human limit is such that you can only practise that 70 or 80 hours a week and then you burn out. But when you have either enough or a surplus, fee-for-service is a ruinous method of remuneration, and I think Douglas and those who advised him and Lloyd understood that.

I understand what the minister was saying, but I just want to put on the record that I do not think the founders thought fee-for-service was desirable. They thought it was a compromise politically required at the time, but in the long run not sustainable.

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Mr. McCrae: Mr. Chairperson, there must be something wrong here today; we are just agreeing on too many things.

I accept the honourable member's version here because I was very young then--very, very young then. I have a vague recollection of that debate, and I think the honourable member is right about that. Part of the Canadian history and legacy is compromises that get made sometimes. Dr. Wade tells me Cecil Sheps, a Manitoban, was the real planner behind that thing. I do not know anything about that. I would accept what the honourable member says about that as it having been seen by some of the early pioneers of medicare as a flaw. Yet it was felt by them and obviously others to be worth the risk because it did at least allow Canadians from coast to coast at every level of income, and so on, to be spared the catastrophes that can happen in a health situation. I accept that, but if it was a flaw then, it is a flaw now. I accept also that it is this generation of politicians that is going to have to do something about it. I just hope we will have some support when we do.

Mr. Chomiak: Earlier on in these debates the minister indicated information would be forwarded concerning the $14 million or so expenditures. Have we received that information? During the early part of questioning, the minister indicated that data would be forwarded to him concerning the balance of expenditures that have been reallocated from the acute care sector to other forms of care in this year's estimates.

Mr. McCrae: A little while ago the honourable member for Kildonan (Mr. Chomiak) and I were talking about the reductions in hospitals to make dollars available for other things and I have, I think, a little more detail for him now. I told him that the urban hospital reduction would be 2 percent and that comes to about $12.8 million. These are going to be a little bit round because, at the end of it all, I think we are going to be missing a couple hundred thousand dollars here, and I have not figured out exactly how it works. Either we are going to be missing or we are going to have $200,000 too many, I am not sure which it is. In the rural hospitals, the reduction is 1.2 percent for $2.1 million--that comes to $14.9 million.

The redirection plan--this is for the whole year and it is projected, and at the end of the year we will have to see whether it came out that way or not, or whether we are underspent. We are more likely to be underspent than overspent though because of the balanced budget requirement. We are expecting that $2 million would be an increase for the personal care home sector. The capital issue that I referred to earlier will take up $4.7 million. The community health aspect, which includes the nurse-managed care, would take up $3 million.

Then there is the issue of waiting-list management, increases for dialysis, the trauma centre, child health initiatives and labour adjustment, should that be required, which there probably is reason to think that it is going to be required again. Another $5 million for all of those things. Here is where I get mixed up because it only comes to $14.7 million. That last one should have been $5.2 million, I am advised, which will bring us to our $14.9 million. These are perhaps a little better breakout of the numbers.

Where you will find these things--I guess if you go, you will see an increase in the PCH area. I hope that bears fruit, and if it does not, then we will have to deal with it when you raise it.

Mr. Chomiak: The minister indicated $4.7 million in capital. Can he outline where that capital is expended, which programs, which activities, which facilities?

The Acting Chairperson (Mr. Helwer): Would you like to speak into your mike, please.

Mr. McCrae: This number will appear in various lines and in various ways. It deals, to a large extent, with the costs related to capital, additions and expenditures in hospitals and in personal care. It amounts to $4.7 million and a big part of that is interest rate adjustments. So that it is a kind of a catchall that will apply in various places throughout these Estimates relating to capital matters.

(Mr. Assistant Deputy Chairperson in the Chair)

Mr. Chomiak: The $3 million remaining to community health that the minister referenced--I believe it is $3 million--that would be the sum total of the nurse-managed part? Can the minister maybe delineate the expenditures under that $3-million umbrella?

Mr. McCrae: Again, Mr. Chairperson, that $3 million applies to a number of initiatives, some in the stages of development; it includes changes at the community health centres and changes for the Youville idea, the nurse-managed care. So it includes all those things, and to be more detailed with it, the honourable member will have to give me a little more time to get that information for him.

Mr. Chomiak: I do appreciate that because if memory serves me correctly, for example, the nurse-managed centres, I thought, were an expenditure of $4 million. I thought that was the announcement. Would that include--

Mr. McCrae: Sorry, Mr. Chairperson, I am just going by recollection too, but I thought the Youville one was $1 million.

Mr. Chomiak: And then there are three others in addition that are supposed to be up and running.

Mr. McCrae: Then there are three others in addition. The development of the nurse resource centres is something that takes some time to do. So I do not know how much of this will be spent this year doing that. We know the Youville one is going to be up and running. The other ones, we will see how far along we can get with those, working with our partners.

Mr. Chomiak: Included in this is, of course, the half million dollars for the waiting list reduction program. I wonder if the minister might elaborate as to--because this is so fundamental to some of the issues in health care--how this project is functioning. What is the end result? What is the plan at the end of the road to deal with waiting lists as a result of the six-month trial period?

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Mr. McCrae: With respect to waiting lists, the honourable member asked for some discussion about it. We identified that we could make available this year $500,000 to find ways to reduce the wait for people in three or four areas. The cardiac area, hips and knees, cancer, surgery, radiation and MRI services, which is magnetic resonance imaging.

What we needed to do was something fairly immediate for the purpose of finding ways to reduce the lists on a short-term basis, thus giving the hospitals and specialists some time to get a better handle on. What is it about these waiting lists? What makes them, why do we have them, why do we put up with them, all of that sort of thing, and what are we going to do in the longer term future?

It is not altogether clear to anybody, it seems, whether those waiting lists are an accurate reflection on what is really happening out there. I hear from patients waiting for surgeries, the honourable member hears from them. The member for Crescentwood no doubt does too. Some of those people, it is suggested, I do not know if it is true or not, are on more than one list in some case, depending on the system managing those lists. Some people are on them because their doctors prescribe that where other doctors do not, which goes back to our discussion about the cardiac program. If we had people working together, it would be really a lot better--keep talking about it, and keep hoping and waiting, financing waiting list reductions, in the hopes that these protocols will improve.

I do not know if honourable members see all the things I do, but I saw a really interesting article on cardiac surgery and a study done that compared the city of Brandon with the city of Winnipeg. I see the honourable member for Crescentwood (Mr. Sale) nodding his head in the affirmative. So that says, what are the goal posts that we are using here, all of us, the yardstick for our discussion. I am just like anybody else. It is unacceptable to me that somebody who is frightened about their heart has to wait a long time for an operation. Should the doctor have said that they need to have an operation? Maybe so, likely, because they are the doctors and we are not, but are they operating with the same practice guidelines as other doctors who may be telling another patient, you do not need an operation, not for another four or five years. We will do all these other things in the meantime.

I do not think I am telling honourable members anything new but maybe putting something on the record here that makes sense to somebody who does not happen to be waiting for an operation. If your knee is sore or your hip is sore, it does not matter how much talking you or I can do, Mr. Chairperson; it does not make the hurt go away. It does not make their impatience for getting something done about this. It does not make it go away. The only thing that will make it go away is the surgery that they have been promised.

I am very mindful of the way people approach these issues. I am very sensitive, too, to those issues for a number of reasons. One of them is that I get as many calls as anybody, probably more, on issues relating to health, hips and knees. A lot of people maybe jump to the conclusion that a knee replacement has to be done right now, and I am told knee replacement technology is relatively new. It is new and it brings a lot of relief to people. So they want it and they want it right now. I do not blame them, because their knee joints hurt. It does not make them feel any better to be pumping all kinds of medicine into them to reduce that hurt. It does not help their mobility.

I guess what I am trying to say is that we are sensitive to the issue, and hopefully that the shorter term injection of funds to assist in making operating rooms, staffs and time available so that we can shorten these lists somewhat in the short term will give us some time also to develop strategies to look at it in a longer term way. It does not give me any pleasure to be compared with other jurisdictions and found to be not doing so well in some areas. That does not give me any pleasure at all. Yet I do not know what the practice patterns in those other jurisdictions are either.

I am not just being pesky by asking for answers to all my questions, but I do need to justify pouring huge sums of money into something that may not be being run right. If it is run right, then we should be able to prioritize those people who are waiting patiently, and sometimes in pain, and sometimes in fear for their lives, on surgical waiting lists. Those are just a few comments if the honourable members can make any use of them.

Mr. Sale: Mr. Chairperson, one of the frustrations of the minister, I am sure, and of those of us who have been, for at least a decade in my case and maybe more like 15 years, involved in some ways in health reform and pushing for health reform--one of the frustrations is the tendency to feel that we have to reinvent wheels. I am very frustrated that in Manitoba we seem to feel the need to develop practice standards for clinical disease entities and procedures, as though this had never been done before anywhere else in the world. These standards exist in HMOs in the States. They exist in other countries. They exist, at least in part, in other provinces.

I guess I am wanting to ask the minister, to what extent is his department exerting significant pressure towards the development of the most urgent practice protocols and practice standards? They might be the highest cost ones, or they might be the ones with the longest backlog, or whatever. I completely agree with the minister that every time that we pump a bit more money into the system, the goalposts move. I know that is very, very frustrating. The only way that we can manage a universal medicare that preserves access is to have agreement among all the players about what constitutes appropriate care. A critical component of that is, what are the practice standards towards which then appropriate care can be measured?

So we have this discussion. I do not mean that I have had this discussion with this minister, because I have not. We collectively have this discussion over and over again. My sense is that the medical profession is quite unwilling or at least it is very slow in being willing to develop such standards.

I just say again that we have given away a lot of our clout with that five-year agreement. I know the minister feels that you can get more flies with honey than with vinegar. To some extent you are right. But why are we taking so long to bring in from other jurisdictions, to push this process of protocols and standards in an aggressive way because it is one of the central keys to control costs and to make sure that access and equity are the twins on which we kind of assess the goodness or badness of our system? They are fundamental to this.

The minister, I think, agrees with this. What are we doing specifically to push development? Where is the timetable? When are we going to see some movement in this area? We will have this discussion again next year, and we will both agree. I am sure the government and the opposition will agree, but what we are concerned about and maybe what you are concerned about too, Mr. Minister, is when--when is it going to happen?

Mr. McCrae: I sense the honourable member's impatience in his question and I share it. I share it. I am trying to be very frank and honest with the honourable member. One of the reasons I am trying to be so very forthright about some of these things is I think that we have a better chance of resolving some of these problems by people like the honourable members and I working together instead of always at each other's throats. We are always going to be at each other's throats over one thing or another I know, but on some of these things I really agree with honourable members opposite.

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I share the impatience about the when are you going to have developed a consensus on this or that or the other. I am told that we have developed a consensus on tonsillectomies. Well, I guess you have to start somewhere. So we have done that. Now we are more likely to develop a consensus on hearts and on, well certainly hearts. I think we are closer on that now that we have what we talked about earlier with respect to Dr. Lindsay and the program at the tertiary consortium idea. That is not the only thing though. There is more to it, because we still have a volume situation that even if we have everybody agreeing, we are going to have X number of needs to fix in this province. With an aging population, that is going to happen, with hips, and cancer, unfortunately, is still with us and all of that sort of thing. I am told by some, and I have always to weigh whom I am getting my advice from, of course, that the MRI is clearly an expensive diagnostic tool, but it is clearly a very good one. I am told by the professionals too--I have heard stories about people that, if the MRI had been used instead of something else, something might have been caught just a little sooner and maybe the outcome would have been better. You have to listen to all of those things, and that is what I am trying to do.

I guess I will have to ask the member for Crescentwood to point out to me again why it is he feels that our arrangements with the MMA stand in the way of progress. If I am right, that agreement notwithstanding, that we can look at the fee-for-service system and make changes to it, then we should be doing that in an effort to bring attention to the priority areas that need attention. I happen to think that fee-for-service could work against our waiting list problem; I think the fee-for-service maybe contributes to some extent to some of our waiting list problems in some areas. I accept what the honourable member says, although I am not going to be specific because I do not have any allegations to make. But the honourable member senses it, and so do I, that there are times when, under the fee-for-service system, that method of payment can sometimes be seen to be driving the system in the same way that some can argue that in the Legal Aid system somebody will use a preliminary hearing maybe when they do not have to simply because there is money in it now.

It is not something I want to be very specific about because I do not have any specific allegations to make, but I think that these things go hand in hand: a review or a change to the fee-for-service system with respect to specific problems. If we had a tonsil program in Manitoba, we could have deliverables, or a block funding method. The remuneration could really have an impact on people's observance of practice standards and so on like that. If you are a salaried person, for example, you do not need to do so many gall bladders this week, do you? Especially if those gallbladders do not need attention anyway, then why give them the attention?

I am on dangerous ground as usual but it is just that I do not have any specific allegations, so I guess it is okay to speak in abstract like this.

Mr. Sale: Well, I would just, Mr. Chairperson, say to the minister, I am enjoying this exchange immensely because I think it is productive and constructive, and I think the minister, even though he said he was answering in generalities, answered his own question very eloquently and clearly, that the fee-for-service model does drive volume, and volume excesses are one of the problems that practice protocols are suppose to address. That is why I raised that question, and the minister, I think, has very well answered the question, even though he may not have intended to answer it in that particular way.

Mr. McCrae: I did not answer very clearly the question about when. I do understand what the honourable member is saying. He is pressing governments, this one and governments everywhere, get on with this issue and deal with it. I accept that, and I will take that as support for forward motion in this area.

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Mr. Sale: The minister is right. That is what we are doing, is pressing. May I just put on the record, though, that practice protocols are not quotas and practice standards are not quotas. The content of standards and protocols are at the medical or sociomedical indications for something needing to be done. I think it would be very dangerous if the record suggested--it would be dangerous to the minister, as well as to the progress of reform, if the record of these Estimates suggested that we were thinking about quotas for numbers of procedures such as hips, or silent gallstones, or tonsils. The issue is the clinical requirements for those, and those clinical requirements will vary as practice evolves. They will vary from region to region, and they will vary over time as disease entities change. For the system to remain responsive, we have to keep evolving those things.

What I am specifically asking the minister, if he will undertake, is to table at some point in this session--and I know it cannot be tomorrow--a roster, a list, of specific protocols that are being proposed to be pursued with a time line, with some deliverables attached, rather than taking what I think is a pretty laissez faire approach to the physicians themselves doing this work without a time line and without hard expectations from the minister, that this is a critical priority for the government and for the maintenance of medicare.

If I can just say, in closing this particular comment, if we do have such a protocol on tonsils, I would urge the minister to announce it and then to do an initial--and here we will not argue with you spending some money to advertise, to help Manitobans understand why this is a sensible, effective, proactive process of setting up the clinical guidelines for tonsils. Parents will understand and Manitobans will understand that we are moving in a constructive direction because we are going to have go down--tonsils will be one of the easier ones. There are going to be a lot more difficult ones in time to come.

Mr. McCrae: Some of the things the honourable member said toward the end of his comments I think we can be responsive to, but not tomorrow as the honourable member said.

We agree with what the honourable member says about information being public. In order for us to build the kind of understanding that we need out there, I think the honourable member's frustration is the same as mine in that area.

We need public support for the things we do and, in order to get that public support, we have to be very open and let people know what it is we are trying to achieve. He talked about a list of protocols being pursued and, indeed, we are planning with the College of Physicians and Surgeons and others, things like a plan and a time line and a budget for just what the honourable member is talking about, but I accept his whatever-you-call-it with respect to quotas.

I did not take from what anything they said, he and his colleague, as implying that they would impose quotas or that I should or anybody should on the number of procedures. That is not what our health system is supposed to be all about but, also, the comfort that they should get is that in the development of protocols we use the services of the College of Physicians and Surgeons and they have no interest in things like quotas, so you do not need to worry about that.

Mr. Chomiak: This has been a very useful afternoon and so I want to very carefully phrase this next question so as not to--and I put in that general introduction because, again, I do not want this question to be misconstrued but, if we look at the March 7th announcement to reduce waiting lists, what it effectively does is it--and by the way, I agree with it, so I just want to be understood, I agree with this process--effectively buys $500,000 more services to reduce waiting lists.

That is what this project reads to me and I am only reading from the press release. So, we buy an additional 58 hip and knee replacements, we increase the number of cardiac surgeries, we extend term positions at the Manitoba Cancer Foundation and we extend the operation of the MRI. Great.

We know that that will help. What am I missing? How will this $500,000 project, what will it teach us to reduce waiting lists, because we know that if we buy more time in the operating room then, of course, the waiting list will presumably lessen. What else can we learn from this project?

Mr. McCrae: If I knew the answer, I would not need the project. What I am trying to do here is to take some pressure off while the professionals work together to examine their own practices, to ask themselves, is there something we could have done to have prevented the build-up of this waiting list in the first place? It is to challenge the people in the system to address this problem that has been allowed to develop--this announcement, combined with other announcements--notably, the February 27th, I think it was, budget that came from Minister of Finance Martin in Ottawa.

The same people who are running these surgical programs can see what is happening, too, across the country. They know that we are all going to be trying to be doing as much, or more, with fewer dollars in the future. They know that. It is not just me, and it is not folly to argue that it can be done because it can be done. That is where we sometimes get into a tousle, the honourable member and I, about--you cannot just have more all the time. It cannot be done that way.

Even in Health, where I would love to be able to say Health is exempt from the amount of dollars we can raise, but it is not. That is the bottom line cruncher that I think was very much part of our election and elections in other provinces on the health issue at least, and others. There is a limit to what we can make available everywhere. The people who run these programs know that too. We have given everybody, I think, with this infusion of capital, a chance to assist the patients for the time that we are doing that, but also to re-examine the way they do their work.

I have just come back to the APM project, the one that really got criticized a lot. It is the people in the heart and the other programs that are going to spend some of the time that this gives them to look at how they run their programs. There is such a thing as restructuring to bring about quality management throughout the operation--it can be done. You cannot have it all ways. You cannot look at doing things better--well, you can--it happens in this province--and be criticized for it, and then make improvements and be criticized for taking too long to make them. There is always another angle. That is the way it is in the business that the honourable member and I are in.

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I hope that the time that is made available, while this backlog reduction effort is going on, will be used well because I do not think that we can just keep doing announcements like the one on March 7 all the time. We are not asking people to see this simply as, here is an infusion of money that will help in the short term. If it works well in the short term, then we will just keep it flowing in the long term. I do not think that is what was implied. I know it was not. We are asking them to look very seriously at many aspects of the performance of this function. I know that improvements are possible. I have heard some less helpful people say we cannot squeeze any more out of this. I do not believe it. I have seen too much, I am sorry to say. I have heard too many stories, I am sorry to say, about things that go on in the system that tells me that, yes, there is room for more improvement. It took us years to build up a lot of inefficiency, and we did it. We did it very well. We built up lots of inefficiency, and now it is time for us to learn to build in efficiency again.

So it is a tall order. It is asking a lot. It is asking people to examine the way they do their own work. The honourable member does not like it if I or one of his constituents tells him what he is doing wrong. He is probably more responsive to his constituents than he is to me, but I do not like it when I am told that I could be doing something better; and yet if we take that advice and start adjusting our way of doing things, we are probably doing more of a service than just saying no, I cannot do it any more, I cannot do any more than I am already doing.

I heard that one day at one of the debates. I heard it from a nurse clearly speaking there for the Manitoba Nurses' Union, and the comment was I cannot do anything more, cannot make any more changes. Well, I said, I am very sorry to hear that because a lot of your colleagues are quite prepared to roll up their sleeves and try to make changes and serve the patients of this province better. That response was not very much appreciated by the person who suggested there was no more room to move here or to reduce or to improve. I just cannot accept that.

It is a hard argument to make, but it is something that has to be said. In Manitoba, I have said it before, we outstrip the other provinces when it comes to our commitment. Now let us use those dollars well, more wisely and get a result. Get a reduced waiting list with the same number of dollars, if possible. In the meantime, while we are still thinking the old way, we will put $500,000 in and hopefully that will help in the short term, but I do not see that as the long-term solution just putting more and more money in. Cannot be anymore. Those days are over.

Mr. Chomiak: Just to return to the line of questioning we commenced on, a return to some of the committee details. Can the minister tell me who is the co-chair from the province on the Medical Services Council?

Mr. McCrae: It was Dr. Wade, and when he became deputy, it was felt appropriate to ask someone else, and Dr. Harold Wiens, a former president of College of Physicians and Surgeons, is now the government's representative as co-chair.

Mr. Chomiak: The Central Bed Registry system working committee, which is one of the list of the 110 that the minister presented us with last--[interjection] It depends on which list. I may have different lists than you.

Mr. McCrae: You depend on one list and a further 110.

Mr. Chomiak: Yes, just by way of clarification, the list the minister is looking at, I do not seem to have a copy of officially. I wonder if there is--

Mr. McCrae: What is the point here? I am sorry.

Mr. Chomiak: I am just wondering if the minister might want to table that.

Mr. McCrae: I would like to take some time to review whether I want to table it at this point. It must be getting late in the day, Mr. Chairperson, because I am usually--well, if you want me to take time to think about it, or I could think about it now, but it might put some dead space on the microphone if I think for very long here.

Mr. Assistant Deputy Chairperson: Is it the will of the committee to recess for five minutes? [agreed] We will recess and return and resume at ten minutes after five.

The committee recessed at 5:05 p.m.

________

After Recess

The committee resumed at 5:18 p.m.

Mr. Assistant Deputy Chairperson: Will the committee please come back to order. We are in the Estimates of Committee of Supply and discussing the Estimates of Health under 1.(b)(1). Shall the item pass?

Mr. McCrae: Not that I would like to hold up the passage of Item 1.(b)(1) or anything like that, but the honourable member has asked for a copy of the document that I am looking at and, frankly, in the brief time that we have had to review the matter, I have not made a decision to date. I usually tend towards making information available, so let me think on it overnight. We will be meeting again tomorrow and then either I will give it to the honourable member or explain why, one or the other.

Mr. Sale: I am going to move the discussion, if I may, into some of the federal-provincial areas in regard to the minister's activities as a minister among his colleagues with other provinces.

I just want to start by sharing with the minister a table from a government system that he may be familiar with, or he may not, and I will not blame him if he is not because I know it is not a system that is shared widely within government, but I will just share that information.

This just to preface this question, Mr. Chairperson, the FMS system of financial management in government is a system that is maintained by Statistics Canada. It is an on-line data system, and it is a system that provincial and the federal governments use when they are having what might be called in-house as opposed to out-house discussions. That is, it is the government's own system. It is done on a slightly different accounting basis to deal with some of the federal, provincial and local transfer questions.

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This data is available, though it is not generally circulated. It is available in the Department of Finance, and the minister may want to ask his colleague to share the appropriate information with him from the system. It is a relatively closely guarded system because governments use it in their own internal negotiations and discussions with each other. It generally also contains, although this copy does not contain, projections for the future. That, of course, makes it very sensitive from a policy perspective, especially around election time. However, I want to assure the minister that these are data that I have not developed; these are data that are internal to governments.

My own perspective is that they should be more widely shared, and I would commend the Finance department for sharing it with the Department of Economics at the university. They have made it available to them for research purposes. Ultimately, that is how I come to be in possession of it because I was a member of that department over the last several years. So I am not trying to use this information for political purposes, and I am not proposing to release it publicly or anything like that. I just think that it is useful to be talking about apples and apples and not apples and oranges, so I will just preface that.

If the minister could look at Table 15 (A), which I think I gave you, he will see that the provincial local expenditures on health by the 10 provinces, two territories and Canadian total are contained in this table. I have pencilled in the actual figures for the two provinces that were missing for '95-96 when this information was available. He will see in the top corner this was January 10, '95. Of course, Manitoba's budget and Quebec's budget were not then public, so the information was not in those two lines and I pencilled in the two budgets. The figure for Quebec, I believe, is $10.5 billion, although it may be slightly lower than that.

On the basis of those numbers the total spending adds up for medicare to about $45.5 billion. The minister will see that this has been essentially flat for four years now. For all intents and purposes it has been flat.

These numbers are the basis on which I have expressed, during the election campaign and prior to the election campaign in a variety of settings, my concern that while I take the minister's point that the pot of money is not endless--and I certainly agree with that--nevertheless, we have had stable to declining funding in actual dollars, that is, in nominal dollars, not in dollars dealing with inflation, nor in dollars dealing with growth in the economy. We have been absolutely flat in Canada as a whole for four years, and the increases in the previous two years, '90, '91, the pattern is that, whatever the increases of the '80s were, it is pretty clear that the brakes have been put on and there is no pattern of rapid expenditure, out of control, spiralling expenditures.

I would ask then the minister drop down for whatever these are on the left-hand side, to percent of GDP, that is, percent of gross domestic product, and he will see here that Manitoba is now back--and certainly check these numbers and have staff check these numbers. My calculation is that Manitoba is now back to where it was in 1989-90 as a fraction of GDP. Canada is roughly the same situation but slightly higher than it was in 1989-90 as a whole.

First, could I just invite the minister to comment on these numbers as to whether, in his view, this is new or whether this is as he knew it to be? Could you just respond? If this is unfair in terms of just having seen them, then I will say, take it as notice.

Mr. McCrae: I do not think the honourable member is being unfair. I think I know where he wants to take me here. I heard what he said about the spiralling costs, and it is never an always one way or the other situation. I think that in years previous to the last two or three across the country and certainly in Manitoba there was a spiralling cost situation in effect.

I am not sure which column to look at, having looked at this for the first time. When you look at just percent changes in spending--I am looking at Canada here for the years '89, '90, '91; those are large increases. I would call those spiralling. Even though Manitoba and others--I mean, look at Alberta's numbers--my goodness--and Prince Edward Island and some of the others. There have been clearly some efforts made to do something about that, in other words, go in the reverse for a while to make up for those years when it appeared that things were spiralling. I do not deny that in those years there were costs that were spiralling, costs that the health system could only respond to. I recognize that. Pharmaceutical costs, for example, and the changes in technology have just resulted in terrible cost increases.

I think though where the honourable member might be leading me--and I do not think he is trying to trick me--is to say that as a percentage of GDP, things have not really got so far out of line. He may be coming to that. Let us remember that the cost of servicing debt as a percentage of GDP is unacceptably high in my view. Others will argue differently on that point. I am not a very good person to debate economic numbers and things with anyway, but interest costs as a percentage of GDP, I have heard it argued, are not all that bad in this country and in this province.

In fact, in Manitoba I think the Leader of the Opposition (Mr. Doer) in the Leaders' debate made a reference to this at that point that interest costs in Manitoba, I think at around 11 percent or so, were not such a big deal when compared to elsewhere. That is where the philosophical rubber hits the road because there are some of us who would argue that, well, why does it need to be 11 percent and why could it not be 2 percent or 0 percent and, hopefully, after 30 years that is where it is going to be--at 0 percent.

So my comments are that these tables seem to reflect a fairly significant priority amongst Canadians, in my view, for health care. The question of how bad has it got, are we only now responding to circumstances that are really bad? Well, we are responding year in and year out as governments to the need to juggle, if you like, the number of dollars we can bring in with the number of dollars we can spend. I welcome this discussion. I could probably learn something from the honourable member because he is more used to having this kind of a discussion. So maybe I should quit and listen for him to tell me some more things, and then maybe I can be in a better position.

But if he is trying to lead to the point where he is going to say that the percentage of GDP--which he already did say--is no different from what it was in 1989-90 according to what he has pencilled in there, which I take him at his word is correct at 6.8 percent, well, we are in precisely the same position, are we not? But I say that too much of our GDP goes into debt payments, and if we could ratchet that down, I have heard it said we could either spend more on health or we could cut taxes, you know, all kinds of things. We would have more flexibility.

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It goes back to a very basic sort of argument that people like I make. In your household budget or your business budget, if you are not carrying a whole lot of debt, then you can have a better quality of life with the dollars that you are able to raise each and every year. That may be a difference of philosophy or approach too, which I respect.

I just happen to think that the more debt-free we are as a country, the better we can say that farther into the future can we guarantee services for our people in our country. As long as we are saddled with debt, that is a bit of a drag, especially a drag of what we can do, especially when harder times come along when we really need the money badly to keep our programs going, yet in those hard years we are putting away hundreds of millions for debt repayment.

I know why we got into it. I know we are there. I cannot wish it away, but I would like to ratchet that down. And thinking about this country, I say that, with all our resources and the people we have and the assets we have, we should be able to operate with a balanced budget every year, saving the need to borrow money or to operate on something other than a balanced budget for those kinds of circumstances that will be reflected in our balanced budget legislation, i.e., things like war or very, very unusual drops in revenue or disasters. Those types of things.

You can always argue for that. You can argue for a mortgage on your house or to borrow money for your car, and I guess we borrow money to build hospitals, and we borrow money to build hydro dams and things like that. Then hopefully we can show that there is a way for us to pay those things back because you never know when we might have to borrow again.

The trouble with the 80s, I remember arguing this with my friend and colleague and opposite number in Brandon East (Mr. Evans) who likes to argue that. I caught him in mid-sentence one day, and he stopped himself in his tracks because he was arguing that in bad times we should be able to borrow money to make sure we can provide what we need to provide. But then when times get better--and he stopped right there and then because times were getting better, and we were still borrowing big-time right here in Manitoba.

I should find that Hansard quotation because it was interesting. He stopped dead in his tracks and sort of got off the topic because we were in better times, and we should not have still been borrowing all that money.

Now I have given you a sense of my thinking. I would welcome a little further discussion because I feel I can get educated a little bit on these types of topics.

Mr. Sale: I wanted to say that I have participated in Estimates debate as staff in the past. I find this a very helpful debate, and I appreciate the candour of the minister and the way the staff is working at the issues. I think this is the way we ought to do Estimates. We can be as partisan as we want in the House in Question Period, and we will, as the minister has said, disagree on some fundamental issues, but I find it very helpful to have this kind of exchange, and I would like to see it continue. So it is a very constructive process. I do not see myself--but I would certainly say for the record, I am not a trained economist. I have some background in it, but I do not pretend to be an expert in this area.

I do not think the minister has anymore to learn from me than I have from the minister. So let us not make this any kind of up-and-down thing, but a mutual exchange.

(Mr. Peter Dyck, Acting Chairperson, in the Chair)

I take the minister's point about the need to manage deficits in times when we need to pay for services that we cannot afford at that particular moment. That, of course, will be one of our very great concerns about the draft balanced budget legislation that is being introduced because it is not cyclical, it is every year. That will be one of the deep concerns we will express.

I just draw the minister's attention to the alternative model that Saskatchewan has put forward. I think it is a very important debate, and I am looking forward to it. I hope it is a useful debate for everybody in Manitoba and for both sides of the House.

I would say that historically the Douglas government ran 16 consecutive surpluses in Saskatchewan, and I think no one was more fiscally conservative than Tommy Douglas. He was a prairie--[interjection] Pardon. Well, it could be Allan Blakeney. We all remember, Mr. Chairperson, who dug Saskatchewan into its economic problems, and I hasten to add, it was not Allan Blakeney nor was it Tommy Douglas.

So I think it is important, again, in a nonpartisan way, to put on the record that we were in the 1980s on track to a balanced budget and according to the Provincial Auditor there was a balanced budget the year we lost government. So the notion of a Keynesian approach, which is exactly what the honourable member for Brandon East was referring to, and I suspect he would not be loathe to say this, there is nothing wrong with a Keynesian approach, and governments have traditionally been very good at running the deficit side of Keynes' models but rather less effective at running the surplus side because it is always tempting to spend the money you have but then when you get into a bad time to realize that you have to borrow.

(Mr. Assistant Deputy Chairperson in the Chair)

I have no problem with the idea of needing fiscal discipline. I would just say personally, that is the way my wife and I have always worked. We have always lived under our income so that we had the flexibility to deal with situations that arise and they do arise.

So I am leading the minister towards the GDP question, and I do want to get on the record that spending on medicare in Canada, not on health, because I think this misleads--well, not misleads--this distorts the debate. Medicare is the only thing that governments have control over. They do not have control over the number of aspirins people buy or the number of times they use home health remedies or make other purchases. The only thing we control is our public sector expenditures, and Canada has a record second to none in the world in controlling the public side of its health care expenditures.

If you look through the '80s and into the '90s you will see that we have accommodated a rapidly aging population, new disease entities, fiercely higher technology, skyrocketing drug costs, and we have done that for less than 1 percent of GDP. If you go back to the beginning of the '80s--and this chart does not do that. I apologize to the minister. I had another chart which I obviously left in my office which does go back further and it shows that the line for medicare in Canada and in Manitoba is virtually a flat line. There has been no escalation over that period of time in terms of GDP. Certainly, there have been nominal increases in costs. The real dollars spent have grown, of course, because there has been inflation. There has been growth in the economy. But as a fraction of our economy, both nationally and provincially, there has been virtually no change. I think staff would confirm that for the minister.

I guess what I am wondering is--in the spirit of the discussion we are having, I do not want to keep talking when the minister needs to share something. I know that that can be done, but I do not particularly want to do it--if the minister would be willing to suggest some sort of target level that he thinks would be something that we ought to strive to sustain, in terms of our health care expenditures as a proportion of our overall income as a province, in the light of the fact that we have a rapidly aging population?

We are sitting up against a health care system that is utterly out of control in the United States. There is great pressure from that. We are sitting in a rapidly escalating technology cost environment, and we are sitting in a rapidly escalating drug-cost environment. I am not suggesting we can afford to match that, but does the minister, or does the department, have in mind a band or a rough idea of what we ought to be spending in terms of GDP to maintain our health care system?

Mr. McCrae: Mr. Chairperson, I want to get an understanding from the honourable member, because he is the one who produced this for us today. I do not claim to understand everything about how these figures are arrived at. One could, I am sure, raise all kinds of questions about this; this is not something I agree with or what, so I look at the numbers the member put in front of me at their face value for the purposes of the discussion. Whether I, ultimately, can show that they are somehow wrong somewhere, I do not think really matters very much.

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Things like due transfers from Ottawa form part of Manitoba's GDP; I do not know things like that. That is the kind of discussion I would be interested in knowing--interested in seeing the honourable member get into a discussion with our Minister of Finance about those kinds of things. I do not pretend to know all that.

The thing that I think is the most important thing that I have to address is the direct question the member asked, which I am going to get to.

Mr. Sale: If the minister would allow me, I just would say that, yes, in the 6.8 percent figure, for example, either at the beginning or the end of this period, the transfer from the federal government of monies to Manitoba to spend in that area are included in that, because the 6.8 is the measure of our total spending, which of course includes whatever we get from Ottawa coming into our general revenues and you then disburse it through the various appropriations.

The GDP, the gross domestic product, of Manitoba is contained in here in another chart. I am just assuming the minister can have access to whatever he needs out of this rather than my photocopying it for him. I would be happy to do that, but it maybe is not appropriate for me to do that. So these numbers do reflect the federal participation in Manitoba's economy.

Mr. Assistant Deputy Chairperson: Just for the benefit of the committee and Hansard, may I ask if it would be in order to table that submission for the committee, just for the record.

Mr. Sale: Mr. Chairperson, I have no trouble since it is the government's data. I will just caution the committee that this is an on-line data system, so January 10 is the date it was printed and so there will be a more recent--and the numbers change precisely because it is an on-line system. I have no problem making a copy and bringing it tomorrow to Estimates if we are up. This is my only copy. I could just tell the minister that it is a standard reference in Finance that they use. I wish it were more broadly used because it is useful.

Mr. Assistant Deputy Chairperson: If the member would wish to just submit the page that you are making reference to for the benefit of the record.

Mr. Sale: Mr. Chairperson, that is the page, and I am certainly glad to have it submitted. I do not know what the words are. What do I have to say?

Mr. McCrae: Table it.

Mr. Sale: Table it.

An Honourable Member: It is for Hansard, because you see we are making reference to it.

Mr. McCrae: Hansard can then make sure that they get the numbers right that we are referring to and stuff like that.

Mr. Sale: Mr. Chairperson, do I have to just simply move to table it or what do I do? Okay, for the record I will table the information contained in Table 15 (A) for the benefit of accuracy in Hansard.

Mr. Assistant Deputy Chairperson: I thank the honourable member for Crescentwood (Mr. Sale).

Mr. McCrae: I would just like to maybe carry on and deal a little bit with what the member was talking about because he still asked a question which I think I want to answer because I think the question is relevant, and I think my answer is relevant too, even though it may not fit the question the way it was put.

I mentioned Tommy Douglas first here today. I do not want to overstate my sense of hero worship here and stuff like that. Do not get me wrong. My job in Ottawa was that of a Hansard reporter as some people may know. It was my job to write down in shorthand and reproduce everything that was said there. Mr. Douglas was clearly the very best orator in the House of Commons during the years that he and I were both there. That is a pretty positive thing to say about the fellow.

But he also, in his final speech to the House when he had made his plans to retire from politics known, made the point that his story was the story of a man who had been a preacher, a printer and a politician--what he called the descent of man. That is what Tommy Douglas said.

But the honourable member said that he put in 16 consecutive surpluses. I think that is really good. That is the way it should be, and I think that is the way we are trying to get it back to. What about all the other governments of that time? I think you probably could find that happening everywhere.

My theory, and it is mine alone here--maybe not--I feel that the spend-and-tax era in Canada started perhaps near the end of Lester Pearson's term in office in Ottawa, and the leadership for this idea that we can have it all and we can have it all right now came from that point onwards.

I lay a lot of blame at the feet of the Trudeau administration with particular emphasis on the years '72-74 when David Lewis was holding the balance of power in the House of Commons. David Lewis was a New Democrat. We are still reeling in trying to recover from decisions made in those days.

It was not that many years later that somebody could see the error of their ways, i.e., Pierre Elliott Trudeau, and he began ratcheting back the kinds of transfers that were then in vogue in this country. The land was not strong enough for Pierre Trudeau and that kind of thinking, certainly not over the long term.

But I say, Tommy Douglas probably was not the only one running a whole bunch of surpluses year after year. I think other governments were too. Certainly D.L. Campbell, rest his soul, was of that particular variety of politician as well.

I do not even want to take issue with the suggestion that in the '80s we were on track for a balanced budget. Now we can sort of finagle over that year's budget. I have my version of it. But I think we were going in the proper direction around that time. We started to smarten up generally as a population, even if you happen to be a New Democrat. The only thing with having said that is we then came along in 1988 and started to carry on that tradition of bringing us back to a balanced budget, and we have been on course ever since.

We have achieved it, we allege, this year, but over the wails and the screams of the New Democrats who wanted us to spend, spend, spend and especially their one-time partners the Liberals here in this very Chamber. We were keeping a running total of what the two parties were asking us to spend. Actually I think the Liberals were ahead of the NDP in those times.

If they were on track for a balanced budget, if they did in government what they said they would do when they were in opposition, it would not have happened. So maybe that is partisan politics and the way it works. I just wanted to address those comments.

I say also in answer to the honourable member's question, what ought we to be spending as a percentage of our GDP. The document the honourable member tabled says it was 6.8 percent in 1989 and 6.8 percent in 1995. He says federal transfers are part of the GDP. We have been able to keep it at 6.8 percent even in light of some seriously shrinking federal revenues. The honourable member is nodding. Hopefully, maybe we could be given some credit for that, because we have replaced the dollars that the feds have not sent us. That is good, bad or not. Maybe it is not that good though because the answer to the honourable member's question is, what do we need, not what ought we to be spending, should it be 6.8 percent or 7 or 6.5 percent--what do we need.

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I know the honourable member for Crescentwood (Mr. Sale) supports a needs-based approach, although he does bring this question in. It is a very interesting one, and one that should be pursued versus the needs-driven approach that I am trying to put across. Ever since The Action Plan in 1992 came out, in the spring of '92, I believe that is the direction we have been trying to go in and it is a hard sell. Reform, change, is a hard thing to get through, but I think that if the member's question had been, what should we be spending on health, as opposed to health care--and I noted he said health care, maybe it was a slip I do not know--what percentage, I do not think we can measure results by percentage or even by dollars. I think we have to look at improving outcomes.

I am saying if we stayed at 6.8 percent of GDP every year, if we are doing the right job, we should be spending ourselves out of business in the sense that we should be getting better and better outcomes so that 6.8 percent in future years could be used to finance even higher technology and maybe even an expansion of the services that we can ensure.

I do not know also, with the numbers that have been presented, how many dollars of these--does this count dollars that are spent on keeping our water pure and the environmental issues that go with health? Is this money spent on genetic research which would keep people from being born with a predisposition towards diabetes or whatever it happens to be? Those kinds of questions are really important too. So the honourable member's question is a huge question and my answer, I think, is a fairly huge one too because we need to look at what do we need, not what do we want. I know we all fall into the trap of arguing sometimes for what we want as opposed to what we need, but if we look to the true needs-based system, would 6.8 percent be the right number? Would it be too high or too low? I honestly do not know. It would be nice if we had a better system that we could spend 6.8 percent on because, boy oh boy, would we ever get some wonderful, wonderful results to talk about.

There was one other thing that I wanted to add. I am not trying to talk down the clock here, I am just trying to give you a full answer. When you ask the question, I bring in the comparisons with the other countries like I guess it is around 14 percent in the United States. Do they have a better system than we do? Absolutely not. No way in the world do they have a better system. Do Japan and the other countries that spend less have a better system than ours? I do not know. I suspect maybe they do. I suspect they have a system of health that is better than ours in that it must be the diet of the people in Japan or Sweden or France, wherever it is, they spend less than we do on health care and still get better results.

It is time for us to stop saying, well, because we have so many CAT scans we can make you live longer because I do not suppose they have so many more CAT scans. Maybe they do, maybe it is the wrong example. But you know what I am getting at, that fewer health care type services do not give your population a longer lifespan. If we could find a way to help communities in their development, if we could find a way to get the moms to be looking after themselves from the date of conception onward, we would have a whole generation of healthier people. Those all have to be worked into my answer, too.

Mr. Sale: Mr. Chairperson, thank you to the minister for that answer. I think it is a very thoughtful answer and I think in the main it is one I would agree with.

The reason I was putting it on the record is that the Prime Minister of Canada was musing. He actually more than mused. He said very bluntly and then reinforced it in subsequent remarks that Canada should ratchet down its spending on health care by at least one full percentage point of GDP. He said that on Morningside in an interview with Peter Gzowski that we should ratchet down our spending by at least 1 percent.

I wondered whether the minister shared those views that there was some kind of target because the minister will see that we have moved our percentage spending down here, and I will anticipate staff's response in pointing out that the apparent reduction here is not a reduction in health care spending, but the fact that we went through a deep recession. So when you calculate any percentage, there is a numerator and denominator. In this case, the denominator was changing radically because of the recession. The numerator did not change much at all. So when you see a pattern of GDP shift up and down, that is what you see from 1980 about to about '95. You see the pattern of growth and decline in percentage of GDP, not tracking health expenditures predominantly but tracking GDP growth and decline with the economic cycle. So I am very glad to hear the minister say that he does not have a target level and that we are not headed for some kind of British, for example, level of spending on public health which is well down in the 5 percent region.

On the other hand, the minister will perhaps know from OECD data that countries like Sweden, France, Germany, Belgium, The Netherlands generally spend somewhere between 8.5 and 9.5 percent of GDP in total on health care, but their public sector coverage is higher than ours.

That is, in Canada historically we covered about 76 percent of our total health expenditures from the public sector. In the United States it is well under 50 percent from the public sector. Sweden, Germany, those countries, covered more like 84, 85 percent.

Now the thing that troubles me, and we will probably close on this question, is that the recent Health Canada data--and here we are speaking about national not provincial data although there is provincial breakout of these data--shows that Canada has shrunk from a high of 77 percent of all health care expenditures covered by the public sector to between 70 and 71 percent in the most recent period.

This is why those of us who are on the left of the spectrum, or the social democratic side of the spectrum, are so concerned about the overall spending patterns. We see a steady erosion in the coverage of health care as in the public sector, and we see that is leading, and I think inexorably, to a two-tiered health system.

I am very happy with this debate this afternoon because I think it is very productive. My question, and we cannot get to it today, but we will get to it another day, is how do we achieve those many objectives which you have of appropriate cost containment, appropriate reform, but maintain public confidence so that we do not move into the two-tiered system from whence I think there is no return. I really think once we get into it, it is very hard to come back out.

I am sure the minister does not intend us to go there, but when we move from 77 percent coverage to just over 70 percent in less than a decade, that is a very big move. It does not sound like a lot, but in systemic terms that is a very big change.

So perhaps when we resume, and I guess this will be up tomorrow again, I hope the minister could make some comments in terms of Manitoba's coverage and the degree to which we are seeing the same kind of erosion in total health expenditures, what strategies might be productive to bring that to a halt?

Mr. Assistant Deputy Chairperson: The hour now being six o'clock, committee rise.