The Acting Chairperson (Mr. Peter Dyck): Order, please. Will the Committee of Supply please come to order. This afternoon this section of the Committee of Supply meeting in Room 255 will resume consideration of the Estimates of the Department of Health. When the committee last sat, it had been considering item 21.1. Administration and Finance (b) Executive Support (1) Salaries and Employee Benefits on page 68 of the Estimates book.

Mr. Dave Chomiak (Kildonan): Just in general, we had mentioned yesterday that we would be dealing today with a number of issues, some issues left over from yesterday and broad general issues. Just for edification, basically I have discussed it with the member for Inkster (Mr. Lamoureux), what we are planning to do is we will stay for certain in this section all day and probably tomorrow as well, and we will be asking general broad policy questions and related questions between myself and the member for Inkster.

I had also promised the minister I would forward to him a list of some documents that are normally tabled, and I will be doing that forthwith. Also, one of the issues that we had left off with was of course the organizational chart as well as the issues around the blood agency, so I kind of leave it to the minister where he wants to start off at this point.

Hon. Darren Praznik (Minister of Health): First of all, I think I would like to table to the committee--I hope we have some extra copies. What I will do is I will table two with you. The Clerks may wish to make copies, but one for the member for Kildonan directly and one for the committee.

In tabling this today, just by way of a bit of an explanation because it does not provide all of the information that the member requested, this is in draft form. The reason why, of course, is although the upper parts of it, the minister, deputy and senior associate deputies are in place--Perhaps if we had an extra one. I know there are members of the press here. It would be easier for them to follow. My friend Alice Krueger will get a copy.

Although certain individuals are in place today in the reporting structures here, people like the Chief Medical Officer of Health, Dr. John Guilfoyle, and I believe there are statutory requirements in reporting there, what I did not want to do in reorganizing the department was to get into a massive process of reorganization today that for the next six months have the department all worrying about how we are going to reorganize and concentrating on that internal matter.

I wanted to be able to basically restructure the senior part of the department because we had positions, people retiring and leaving, and we needed to be able to restructure our executive in essence, and in reassigning some responsibilities we wanted those areas to basically just be moved under different associate deputies without any real disruption to their work as well because our associates are going to take some time to, over this year of transition with so many things on the go, assess their needs within their sphere.

We did not want to get into necessarily identifying everybody who is in particular charge of each area today because there may be some changes coming as we sort these things out. So we have not attached names to each director or person in charge of a program. Some of that is shifting somewhat as we sort of reassign responsibilities, but the draft chart we have today, which is up to date, indicates the major restructuring into the three line areas of the department. As I have outlined again, there are the external operations, services that are delivered outside of government, outside of the ministry, through regional health authorities, for example, the internal operations which are, in essence, the Ministry of Health and the human resource planning and projects because I am sure, as the member would agree, human resources are a huge part of health care. We need to be spending, I think, more effort on how we deal with our people who work in the system, and we assigned that to Roberta Ellis, as well as some special projects, because of her expertise as a former deputy minister of Labour. So that gives some background again to the chart and where we are at, and it is status as we work it through over the next while.

The second area--if I may--is on blood, to give the member an update on our meeting in Montreal over this past weekend and Monday. The purpose of that meeting--we had a number of issues as provincial and territorial ministers. We have our regular scheduled meeting with the federal government for September, I believe, in New Brunswick, and what we wanted to do was to have an opportunity to develop our own provincial, territorial positions on a variety of issues in preparation for that meeting with the national government.

Blood, of course, is one of the most pressing that is facing us today. I do not think there is a major city in the land that has not had some shortage of blood supplies over the last while. We are advised by the Canadian Hemophilia Society that we are down somewhere around 400,000 donors across the country. So we are facing a problem, a major problem. A lot of it stems, of course, from the whole issue around HIV and hepatitis C and the procedures in screening blood in the 1980s. The blood system up until that point was really left to the purview of the Red Cross as the delivery agent and the Government of Canada as the regulator. We recognize that change is very much needed.

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We would have liked, of course, to have had the wisdom of the Krever inquiry in April as was expected, but as members know the Red Cross and another agency, I believe, have appealed some aspect of their ability to provide that information. They have appealed it. They are in the Supreme Court now and there is some delay. The fact is we have to develop a strategy as to where we want to go, and because it is important to have the strength of as many provinces together to make a system economical and safe and I think well practised and uniform as much as possible across the country, we are trying to develop, some call it a national blood agency, others an interprovincial or interregional blood agency to the best of our ability.

So what we did in Montreal was do a number of things. We have looked at all of our options, including the future involvement of the Red Cross, if any there should be, how, in fact, and what each option would mean. We have assessed those. We have looked at data with respect to how we would go about setting up an agency, obviously, if that option is being pursued and come to some common view as to where we want to go. We would expect, following the federal election, whoever should win or whoever should be appointed Minister of Health, that we will be meeting specifically on blood with them within a couple of months of that election to sort of put together what our options are. Obviously, we would like the federal government, who has talked a great deal about their role in a national health system, to be at the table with some dollars to help us move forward to where we think we want to be and we also would like, of course, the advice of the Krever inquiry which we do not expect until September.

I would put on the record today for both my critics, if they would like to have a confidential briefing with our staff on some of the detail in those assessments, I would be very much prepared to provide that. I think that is important in the interests of democracy. One difficulty that we as provincial ministers have been privy to is a great deal of information that I think affects bargaining positions with various people, including the federal government, over the next number of months that we have not made public. I am somewhat unwilling today at this committee to get into all the detail of that in a public forum, but I would be prepared to ensure that is sufficiently shared with my two colleagues if they would like to avail themselves of that opportunity, if that is acceptable to them.

Mr. Chomiak: I thank the minister for those comments. I do have a series of questions with respect to the meetings with the blood agency, but I may delay those pending discussion with the minister in terms of the briefing session. I do have one question with respect to the fact that after last year's meeting, the ministers had arrived at some kind of an interim arrangement with respect. There was a plan in place, as I understand, agreed to by the ministers, and there were dollar figures attached to the implementation of such a plan. I wonder if the minister might outline what the status of that plan is.

Mr. Praznik: I believe the member is referring to the stated public position of the ministers to move forward on a national blood agency of some form which would look at how we would go about setting up that kind of system and what the role would be of how we would go about setting up that particular blood agency, what role, if any, the Red Cross would have in that. Also, there was a recognition, and I think this is an important point to make in meeting, and I have had the opportunity to meet with a number of the blood consumer stakeholders in the last while, those people who are regularly dependent upon the blood supply. One of their great concerns is that whatever agency we set up has sufficient independence in its operation, I guess for lack of a better term, independence in its operation, that it could proceed to act quickly in a timely and factual scientific-based manner to ensure that testing of blood is carried out such that we reduce as much as humanly possible potential and newly discovered risks in the blood supply.

Their concern with any type of agency, obviously where government is funding, is that our universal budgeting, our ability of providing a grant, budget restraint that we live in, overseeing decisions, minutely managing that blood authority, could interfere even if it was not intended to cause problems but could cause problems and difficulty that potentially could undermine the safety of the blood supply or unnecessarily put people at risk.

We have agreed, in whatever manner we do move toward that, accepting that there has to ultimately be a financial accountability in this system, that that kind of independence of decision making be there and that comfort be given. We are exploring a variety of ways to do that. One suggestion that has come forward is that currently we pay by way of block dollars for our blood supply, so that the blood, in essence, is supplied free of charge, virtually free of charge to the system. It is not free. We have paid for it up front in a block way.

One method that has been suggested, and I know in speaking with representatives of the Hemophilia Society, when I was in Montreal they had a representative to be around or available at the conference, that by moving to--once this is established--a unit pricing system has the advantage of taking that universal budget and watchdog approach away from that decision making, thereby giving it independence.

It also, and I raise this with the member, has another interesting side effect. It then encourages the use of alternative methods of dealing with blood, bloodless surgery, recycling of blood so an individual's blood is being kept and recycled back into them, et cetera, and it provides an incentive for that in fact to happen. So these are some of those kinds of issues that have to be sorted out and debated in the next while. The information I am interested in providing confidentially to the member has more to do with some of the economic sides and liability sides and those types of things that may be of interest to him and why we choose some options over others.

Mr. Chomiak: Mr. Acting Chairperson, the danger of putting a chart like this in front of me is I really want to actually go down this road, but I am going to resist the temptation because we do not have our normal 60 hours, and we really should use our time expeditiously here. So I just have some general questions on this organization chart. I may come back on some specifics, but just in general. This strikes me as a relatively significant change in structure, not necessarily negative as well, because I see some merit in the actual way that the department has been structured, and it has been no secret that publicly for some time I have been critical of the departmental--not the people of the department so much as the management of the department and overall management, so I see some merit in some of the draft provisions made.

It is interesting that, under the external programs and operations, each of the areas has now been broken down to consist of a transition team and specifically I wonder if the minister might comment as to--I mean, it is obvious that transition was chosen than a formal structure of a branch or department. I wonder if the minister might comment on that.

Mr. Praznik: I appreciate the member's comments, because in coming into the department, again, as I pointed out yesterday, the previous minister spent a lot of time with me on offering his comments and suggestions, both the things he felt were strengths in the department and issues that he felt were weaknesses, and obviously, with the change in ministers, did not have the time to complete, and he made a number of suggestions to me. One of the problems that I have seen, and I know the member will appreciate this fully, given the enormity of the issues with which we have to deal, is that the previous structure--I know the previous minister had the same difficulty--never lent itself well to having an executive group within the department who could meet regularly and, on a more regular basis, deal with major issues that touched on a variety of areas and have that kind of input and come to a decision and then be carried out in, I think, a rational way.

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So this system gives us and it gives myself as minister an ability to meet regularly with a small body of my senior staff and to include other people whose issues are there for discussion to have a good general discussion with my staff how it affects all areas of our department in a co-ordinated way and then make a decision and have it implemented, with everybody knowing what the decision is.

In a department this big, from time to time one of the complaints that I have picked up and I know Mr. DeCock had found in his role as an associate deputy, often it was hard to keep everybody up to date on what was happening, and often people did not know necessarily when decisions were made or the reasons behind them. The member may also be interested to know that one of the other changes that I have made since I came in, again on the advice of the previous minister and of Mr. DeCock, is every four to six weeks or so we now have an extended management meeting of probably 150 people, of all of our senior staff in the department. It is a chance to update everybody on the initiatives, where things are going, why things are happening, and I am trying to overcome some of the problems of a large organization with just pure information flow and everybody being up to date. So I hope he notices over the next year or so some improvement, and I would appreciate his comment on that at that time.

With respect to the transition team, specifically to his question, the reason why those are there, the hospital and community services, is we are dealing now with regional health authorities. The idea of the transition team that Sue Hicks is responsible for is to sort out with them in, I think, a common sense, logical way, what things they will run best and what pieces should still remain in the department and are best served in the department.

Obviously things like the enforcement of standards will remain in the department. The development of those standards, et cetera, has to be a co-operative approach. The service deliverables stay within the department, and some of our staff, as I have discovered, have been working on all of those things. So how do we sort them out and make sure that those lines are there?

I do not know if I have answered his question, but that is the approach that we are trying to use with identifying transition teams.

Mr. Chomiak: The minister did answer the question. It will make for interesting developments in terms of how the program-spending side works and co-ordinates with this, but that is for something that will be developed in the next few months.

I notice there is a category for Health Information Network SmartHealth. That appears to be a new addition, and I wonder if the minister might explain that.

Mr. Praznik: Yes, that is there because we are reaching the point with the Health Information Network where I guess some of the first elements of it are scheduled to come on line at the end of the year, certainly before the end of the fiscal year I would expect. That is why the privacy legislation is being brought forward in this session. We have housed it currently and, again, when we set up this chart, one of the things I assigned to my three associate deputies, and I am a great believer in delegating managers with the responsibility to do their job, was I charged them and my deputy to get in a room and sort out what they wanted under each category and the reasons behind it. It was placed here initially, I understand, because it is in the developmental stage and a lot of the work is how it would react between people in the system.

Once we have got past that hurdle that the users of it, in essence, are comfortable, then the day-to-day operations, I understand, will be transferred over to the internal programs and operations side to be housed in the ministry.

Mr. Chomiak: That does anticipate my next question and, in fact, I probably will desist from getting into those organizational questions that I do have because of the transitory nature of it. I want to go, though, to the issue of the--actually, I overheard the minister doing an interview on this issue, so some of the questions that I had have actually been answered. So I do not want to, again, go over territory that has been generally covered to my satisfaction, but I have a number of questions with respect to the aboriginal health unit.

There was formerly a branch called the aboriginal health strategy and at one time, certainly in the last, under the last Supplementary Estimates, John Ross was responsible for it. I wonder if the minister might outline for me whether the new aboriginal health branch or agency or whatever the correct term is that the minister announced yesterday, exactly what the function and role of that agency will be, where it will be located, who it will report to, et cetera, all of the operational, organizational functioning of it.

Mr. Praznik: Mr. Chair, I apologize to the member and to Ms. Krueger from the Free Press because I had only met one individual in that unit, a Loretta Bayer, but I understand there is a second staff person by the name of Elaine Isaac and also Mr. Ross, whom he referred to, is working with us on contracts. So, in essence, that is the unit they report to and are managed by John Gow, who heads up our rural and northern transition team. This particular unit, I guess, is--the member overheard my interview, and I am glad he did because it does save us some time. The point is to have a group to deal with a number of these aboriginal-related issues that come up, and often we get into difficulties because of jurisdiction.

My experience as Northern Affairs minister is jurisdiction can so easily be used not to do anything and not because people choose not to; it is a big problem. It is very hard to roll into an area where you do not have the jurisdiction and say, I am here to help you now, without people saying, please, this is our problem.

So my experience has been you have to recognize the appropriateness of people's jurisdictions, their right to make decisions, and then figure out how you build working relationships. So that is one of the challenges of this particular group today as the First Nations community negotiates with the federal government to take over what is currently funded through Health and Welfare Canada and how they organize themselves to handle those dollars and programming.

We want to make sure that we are able to dovetail with our regional health authorities, so that is one of the jobs that they are doing. They are housed in the external programs today because so much of their work has to do with the regional health authorities, the delivery of programs through them, their relationship with aboriginal health organization today. So they will be there. Once that work is done, it is likely they will move perhaps within the ministry. We will see where they are particularly needed.

On that question of relationships for a moment, one of the things we have explored--and I have no problem putting it on the record today--is even some joint cross ex officio appointments between the regional health authorities and aboriginal health organizations however they organize that.

So, if they decide to organize on a tribal council basis, those tribal councils will probably have a person or two who sits ex officio on the regional health board, and the chair or vice-chair or one or two people from the regional health board are likely to sit ex officio on their board so that there is a good working relationship and people are not working in isolation, because for aboriginal people in the province, Status First Nations people, their health delivery system comes out of two different jurisdictions, and the community health side will be theirs, federal, the hospital doctor delivery system to some degree is provincial. So we have to make sure that--I do not want jurisdiction in two different boards to be not resulting in good service, and it would not be right to not recognize the jurisdictions that are there.

That is the approach we are trying to use now, and the ball, to some degree, is in the court of those First Nations organizations and rightly so because they are still sorting out how they want to organize themselves and deal with the federal government. Once they have done that, I think we will be ready to move very quickly on building relationships.

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Mr. Chomiak: Can the minister indicate specifically where we are at with respect to the integration of the aboriginal community into the regional health boards?

Mr. Praznik: I think the original plan had recommended that at least one aboriginal person be appointed to boards where there were aboriginal communities within the region. That has happened in a number of cases; there have been appointments. It has not been, I think, the success that was initially hoped for, and one of the reasons, very strongly, is that as a province we do not have the power or authority or jurisdiction to be able to manage that area that is currently managed by Health and Welfare Canada in federal jurisdiction for aboriginal people in First Nations communities. I guess my advantage in this is that I am a former Native Affairs minister and worked on many of these kinds of issues.

The First Nations community, which wants to have a role, and I would argue strongly has to have a governance role in health care if they are going to feel that these programs are theirs, if they are going to be able to deliver them and actually reach people in a meaningful way, and they have--the federal government has the jurisdiction and the ability to delegate it, assign it, transfer it, recognize it, whatever terms you want to use. So as those First Nations communities, in whatever forum, take control of that jurisdiction that is now federal, with the dollars that come with it and set up their organizations to run it, I envision those organizations having a good working relationship with the regional health authorities.

As I have suggested, one idea we are floating now to see if it has some merit is to have those aboriginal First Nations health authorities, or whatever they envision, to have cross-appointments so that people are sitting on each board so the boards are not working in isolation. Obviously, the CEOs have to have good working relationships, because we want to make sure that we can build a continuum of care for people. We are dealing with two different governance structures, and so it is harder to do but not impossible. I know of no other way that has been presented to me today that is going to get over that jurisdictional hurdle. We want to make sure it works rather than see it stand in the way of building relationships. So there will be some problems with it, no doubt, but we will just have to work to overcome them.

Mr. Chomiak: Mr. Chairperson, can the minister indicate what overtures have been made toward First Nations communities either through MKO, Assembly of Manitoba Chiefs, or other organizations? What overtures have been made from the department to First Nations people as opposed to the communication in the other direction? I have attended a conference sponsored by AMC that dealt with regional health, but I do not know if the reverse has taken place.

Mr. Praznik: Mr. Chair, I cannot remember if it was a month or six weeks ago, it was before the flood, I had over the space of a week--we had arranged meetings with, and I do not know who initiated them in each case, but I had a meeting with MKO. I had a meeting with the Assembly of Manitoba Chiefs in which MKO representatives like Grand Chief Muswagon were a part of that meeting. I have also had some tribal councils in to see me, Southeast Resource Development Council being one. I think Swampy Cree--I cannot recall if Swampy Cree has been in. We have talked about how do we make this work. They have let me know they are negotiating with the federal government to take over the Health Medical Services Branch dollars and programs, and they want to say: How do we make this thing work?

We have played around with that idea of them and our regional health authorities and their health authorities, councils, however they set it up, building those relationships, having cross-appointments on an ex officio basis, et cetera, and co-ordinating together. They seem to be very responsive to that. They like that idea, but one problem that was evident was they have not quite sorted out internally how they want to proceed in taking that over, whether it is going to be on a province-wide basis, whether it is going to be on a tribal council basis. I know Southeast Tribal Council has been very well developed in its health area over the years; Swampy Cree is. Others may not be. So they have to sort it out. If they choose to deliver their programming through tribal councils then those tribal councils will be matched with regional health authorities and each having their own piece of the jurisdiction. They have to kind of sort that out today.

The way we have left it is that our Ms. Bayer will be co-ordinating on our part with them. So we are exchanging information administratively, and when they are ready to sit down again with us to sort of formalize this kind of arrangement, we will. But they have to take some time to figure out how they want to organize first so that we then know on what basis we are setting up the structure.

Mr. Chomiak: So you are calling this branch or the aboriginal--what are you calling it?

Mr. Praznik: We moved so fast on some of these things in the last while that we have not got around to giving it a name yet, to be blunt, and we will sort that out when the appropriate name strikes us, but right now it is part of our policy development area in aboriginal issues, and we have not given it a name yet. I will have one for you by next year, though, I will tell you. We will know a little more about what we are going to do with them

Mr. Chomiak: I was encouraged yesterday when in the minister's opening statements he indicated the establishment of this branch. I guess we will get to see how, in fact, it will function and how it will interact. It is clearly in the initial phases. For what it is worth, it seems to me that given the significant policy issues involved and given the significant effect that this could have on programs and the ramifications in terms of--and I am going contrary to what I said earlier about giving advice on the organizational structure. In this case, it seems to me that it is at least an item and a priority that would be on-line in terms of directly, some kind of direct relationship with the minister; it would seem to me as well as because of the significance that aboriginal issues are and will have on the evolution of health care in Manitoba and the devolution of health care as it moves from Ottawa.

So yesterday I was under the impression there was a branch set up that was going to be perhaps fairly significantly involved--and the minister can correct me if I am wrong--and I now see an agency that is fledglingly starting out in a co-ordinating role and may or may not institute programs like the wellness program that is being instituted at the aboriginal centre. So, for what it is worth, those are my comments in that regard. Maybe the minister may want to comment on that.

Mr. Praznik: I appreciate the member's question. It is not our intention, just by way of definition, to set up a branch that will actually be delivering specific programming. It is a small unit obviously, and it will probably remain such, but its job is to co-ordinate, to champion particular issues and ensure that however best we meet need, we are doing so, whether that be through regional health authorities and programming, whether it be through funding outside services like the Wellness Centre. I do not suggest the member is saying this, but I do not envision it being a large part of the department that is delivering a host of programs in the manner of actually seeing patients and visiting homes, et cetera, in that extreme of it. I see it as our champion or policy group that is flagging the problems, finding solutions, working with people to deliver solutions and making sure these issues are being met as best we can.

The delivery mechanism for a good deal of health care, particularly public health, health promotion, et cetera, is going to come at the regional level, including the aboriginal delivery mechanism. If you ask me to gaze into the future somewhat, I would think if First Nations communities are able to reach an agreement with the federal government to move dollars directly to their network, you will find many of those networks that are up and running now like some of the tribal councils, Swampy Cree and Southeast particularly, who already have health people and do a delivery of certain programming and promotion, that the mechanisms are there. We do not want to reinvent them. We just want to make sure they have the people, the resources from where they are found to be good delivery agents and do the job.

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That is how I kind of envision this unit, and who we put into it obviously becomes important because they have to be individuals who are able within the department to continue to command attention and get things done and move things forward, because in a big department it is very easy for issues to be lost in the shuffle, and we all know that happens. I am looking for this group to really be a champion of these issues within my department as a tool, a resource, to provide the information, move things forward and continuing to meet needs. So that is the way I envision it being, as opposed to a specific delivery-of-service branch.

Mr. Chomiak: Mr. Chairperson, what about the function of outreach and co-ordination, which may in fact be the most important role, wherein will that lie?

An Honourable Member: Can you explain a little more what you mean by that?

Mr. Chomiak: With respect to the aboriginal communities, whether intentional or not, there certainly is a gap between the aboriginal communities understanding of where health is going and perhaps the Department of Health's understanding. There seems to me to not be clear lines of communication or in fact a real working relationship. I guess that is where I am trying to--that is what I am trying to go down.

Mr. Praznik: Mr. Chair, I am glad the member clarified because you know some of the priorities our group has identified are, obviously, midwifery, under our legislation and how it is going to be set up in aboriginal communities, home care, obviously, and First Nations is important, diabetes, child health, aboriginal children's health needs, aboriginal AIDS strategy, mental health, First Nations communities, all those things. I think he flags in his clarification a broader issue, and that of communication.

My experience as Native Affairs minister, and I think it is borne out here, and the member, I think, is very keenly aware of this as well, is the aboriginal community is not a single community or speaks with a single voice. There are many, many organizations out there pursuing their goals, and I do not want to, in any way, take away from those goals. One of the difficulties government always has is who do you talk to, and who can deliver. In the space of a couple of days, I had, and some of it was by accident, that I had the Assembly of Manitoba Chiefs, I had MKO and Swampy Cree, I think, in to see us, and then a few days later, I had Southeast Tribal Council, all First Nations organizations, all coming to see me more or less about the same issue; about how we have a relationship with the RHAs, but not one voice.

The Assembly of Manitoba Chiefs, which is the provincial-wide organization, is made up of its members, you know, has members who are at different degrees in their governance. Some of the tribal councils are very well advanced in delivering health programming now; others are not at all. So those are issues that they have to sort out. You know we have agreed that they have to come back and decide how they are going to deliver that program. It is not my decision; it is theirs, and when they do that, we have to plug them in.

The member has rightly flagged one of the difficulties because I know as well there are groups within the city of Winnipeg who will be promoting aboriginal health and we need to do this, we need to do that, et cetera. Who out there do you deal with? That is part of the difficulty. How do you arrive at a flow of information and communication when you are dealing with a variety of groups? The fact that there is a variety of organizations is no one's fault. It has evolved over time, but I think it is incumbent upon the leadership in that community in the next number of months, and if they are going to negotiate an agreement to transfer dollars for First Nations communities, to the bands, in essence, how they are going to spend them and administer and organize that system becomes very, very important. I do not think that dollars will flow until that is sorted out.

Once that is sorted out, then I know who we can deal with at a minister's level, with which leadership, and be able to reach agreements that are going to give us the principles of administration across the province. Today I cannot do that, and if the member gets, I think rightly so, the sense that there are a lot of voices that are not all saying the same thing, and the communication with the government is not good, I would agree with you wholeheartedly. I think a lot of that comes to do with the fact that there are so many players and it has not really been sorted out.

Again, I have met with Grand Chief Fontaine, with Grand Chief Muswagon, actually in the same meeting, and I have met with a number of tribal councils. We have agreed on some principles and left it with them having to sort out how they want to organize to deal with the province. We are lucky I guess; we are already organized.

I hope I have given the member a sense of where I am coming from here.

Mr. Chomiak: In the throne speech, the government made a commitment to the Aboriginal Wellness Centre. I wonder if the minister could table or outline the commitment to the programs and a general description of precisely what that is.

Mr. Praznik: I am having to refer to my notes on this particular issue. This is one that the previous minister, I know, had worked very hard on with staff. So I am inheriting this and I am very happy to do so, but I understand that we are looking at a funding of approximately $1 million, which we have approved for this facility, which will be housed at the Aboriginal Centre of Winnipeg.

The overall goal of the Wellness Centre, in what will be a 36-month pilot project, is to improve the health status of the urban aboriginal population by providing access to resources and services that are based on a comprehensive wellness model of service, culturally based, culturally appropriate and responsive to the particular health needs of the aboriginal people who will use that particular facility.

The Wellness Centre will offer programs and services within three main areas of community development, education and outreach, and primary health care and services as well. So community development, education and outreach and primary health care services are the three areas that they were addressing. I understand they will have physicians as part of their area and be accessible.

If I may just add one comment from my days as Native Affairs minister, I am looking forward to the next batch of census data from the last census, but my recollection of the previous data was that, if you look at the aboriginal population in the city of Winnipeg by census district, there is a trend that you find that the high unemployment, the greater health needs, et cetera, tend to be related, obviously, with the core area. If you look at aboriginal people who reside in suburban census districts, I seem to recall statistics that demonstrated that they would have a higher employment level than the general population in those districts, often a higher income level and, I would suggest, probably as good as, if not higher, health status. It just comes back to make the point, as the member has done many times in the House and I think we all agree, that the issues really relate to poverty, lack of information, lack of education, lack of, often, resources to be able to have a healthy lifestyle.

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So I have somewhat of a difficulty when we talk about urban aboriginal population. What we are really talking about is the core area urban aboriginal population or a population that is in poverty or in transition from northern remote communities and coming into Winnipeg, that the trend is that aboriginal people who are here do receive an education and become employed, become very much a part of the regular community, the city of Winnipeg, and have, in the case of employment and education and income, above average actually in the census districts in which they live.

So it is just an interesting point that I make because we often tend to look at a whole community as aboriginal when really we are talking about a component of that, albeit the majority component today, but, certainly, it does tell us that if we are successful in allowing people to get education, have opportunities to develop and grow, that many of the other problems that we treat today become resolved. I do not think the member would disagree.

Mr. Chomiak: It is not clear, but I will ask it: Will the Wellness Centre be offering clinical services?

Mr. Praznik: Mr. Chair, the short answer is, eventually, yes, I believe that is their plan.

Mr. Chomiak: Historically, one of the difficulties with pilot projects is when the funding runs out, they tend to die on the vine, and I am wondering what the criteria are for this project that have to be met in order to have this continue as an ongoing function.

Mr. Praznik: Mr. Chair, the member's comment is an excellent one. I think all of us have seen projects that sound great. We fund them and then--the federal government has a terrible habit of doing that in so many areas of funding pilots. The money dries up and they never get refunded, and they come to others to look for dollars to continue on.

It is our intention if this can be demonstrated to be very good and efficient--and what I mean by efficient is that it is being used by the community it is intended to serve--if that is the case and it is getting the results that I think everyone predicts will happen, it will be popular, well utilized, efficient in affecting the health life of aboriginal people in the city, then our intention would be to carry this on as a regular program of the Ministry of Health and continue funding.

With respect to coming up with the criteria by which we will judge it, I am advised that we are currently working with them to establish those criteria by which they will be judged to measure their efficiency over the next number of years. Again, just so I am not misunderstood, what I am looking at is to ensure that this facility, obviously, can operate and be well managed. That is important, but, also, and even more important, that it is able to attract and be relevant to the aboriginal community in the city of Winnipeg, that they will use it, that they will find it meets their health needs, and that we can measure, ultimately, improvements in the health status of the people who are using this particular service.

The details of that have to be put together with them so that they are comfortable, but that is our intention, and if it all works out, this would become a regular part of our funding and probably move into a relationship with one of the two regional health authorities at some point, who we would then flow the dollars through that health authority to them.

Mr. Chomiak: It probably goes without saying, but I will say it, that within 36 months is a difficult, short period of time in order to measure the success of something that is geared towards wellness, and it is a longer period of time that we clearly have to look at, and I am sure that officials and the minister are aware of that. Which line item in Health will this centre be funded under?

Mr. Praznik: Mr. Chair, today it is being funded under the Healthy Communities line, and I agree with the member, 36 months is a relatively short period. I think what 36 months will prove is that the centre can administratively run efficiently and well and that it can build up a client base. Obviously, it is going to take some time to demonstrate that they have affected the health status of that client base, and I recognize that and it is worth putting on the record.

Assuming success, we would eventually see this move into the budget line of the Winnipeg Long Term Care and Community Health Authority and for that, as well as our local, our rural and northern regional health authorities, there will be in their budget a number of services obviously that become really a flow through of dollars. Personal care homes is one that comes to mind very quickly, and this would probably be very similar to that.

Mr. Chomiak: Just then, generally, will the presently operating community health centres in Winnipeg, therefore, come under the Continuing Care advisory board or will they come under the--

Mr. Praznik: The member is correct. They will come under the Long Term Care and Community Health board.

Mr. Chomiak: On the draft organization chart we see a new creature, the health implementation strategy committee. I wonder if the minister might outline for me what that is.

Mr. Praznik: Well, I am glad the member has asked this question. One of the difficulties--this is somewhat my temporary creation--when I assumed this portfolio on the 6th of January and my mandate was to get on with implementing seven or eight major initiatives, the Winnipeg health authorities, lab consolidation, a host of issues, physician remuneration changes, et cetera, what I--and at that time the member should appreciate that I was in a transition period with deputy ministers. My former deputy was about to retire. We were recruiting a new deputy. We had some other changes coming in senior staff with secondments of people out, and recognizing that my mandate to achieve many of these objectives, particularly with the rural and northern health authorities taking over effectively on the 1st of April of this year, I felt what I needed to do was have a committee that reported to the deputy and myself directly, that I would actually be part of on a regular basis where the issues related to implementation can be brought, sorted out and decisions made.

So what I did is, with some consultation with some of my colleagues, put together--it is rather informally a health implementation strategy committee that consists of a number of people--my senior people as needed in the department. We have Lynn Raskin-Levine from KPMG, who worked on many of the plans involved in that to make sure there is a continuity there. We have involved our Treasury Board. We have involved our Policy Management Secretariat in the Executive Council, so that I had literally all of the people who are involved in significant decisions at the table on a weekly or biweekly basis to deal with issues as they arise.

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Just to give the member one example of how I have used this committee is, sometime earlier in the year, I know he was critical of the original funding targets that the department had put out to regional health authorities. I think in total they were somewhere near 6 percent, 4.5 percent on budget line in the first year, an additional $20 million or something or $2 million out of the system--I do not remember what it was--for a fund to be moved between groups. That was far too high. When I got out in the field and talked to people, I realized it was not really going to be achievable; it was probably detrimental. We thrashed it around as a group and came to a conclusion that we would have to go to Treasury Board and change our recommendation since the Treasury Board, having staff from Treasury Board there, helped ease that decision, and we got a very quick decision to go to a 2.25 percent target for the beginning of October, I believe. So I have been using it in that role. It goes up and down depending on where we are in implementation, but it is a group. I can pull together a variety of decision makers really quickly to make some recommendations and decisions that have to be done. In any implementation process you need that.

The other comment I just make that the member may be interested in, in the internal operations of the ministry, is there were a lot of issues that I was using this committee--and by the way, I attend the meetings of the committee and also my legislative assistant, Mr. Tweed, joins me at those meetings, and effectively we chair this group when it meets. Many of the issues that went there initially often were administrative issues in the department, because we were in a transition. With my senior executive changes now, we deal with those at that basis. So the issues that come here really are those that deal with the major implementation issues, and the work is diminished somewhat over the last number of weeks. So eventually when most of those are well underway and running, this committee will just, quite frankly, disband.

Mr. Chomiak: Can the minister explain the presence of the Co-ordinator of French Language Services? Did that come over with the minister?

Mr. Praznik: I am just looking at the chart. I think he is referring to Edmond LaBossiere. Yes, I am still--is that the position you are referring to? [interjection] Yes, I am still the Minister responsible for French Language Services in the province, and so that budget line gets transferred to Health. My assistant, M. Godin, looks quite relieved by that fact.

Mr. Chomiak: Can I read any significance into the fact that there is an appeal-panel structure now under the Manitoba Health Board?

Mr. Praznik: Well, yes, perhaps prematurely it has significance. There are a number of appeal panels that we have created to deal with--home care is one of them, obviously, and I certainly would not want to lose those functions. We sort of lumped them in this chart temporarily over there. The Manitoba Health Board, despite its name, is in effect an appeal board on fees for personal care homes. So at some point in the next year, I would like to have a look at how we organize these things administratively so that we have some commonality in process and forms and those kind of things so we maybe can streamline and make it easier to operate.

So, currently, we have just put those appeal panels and advisory committees and things sort of over in that particular area, because they really are answerable either legislatively or where they are created administratively, I believe, the daycare--not the daycare, the Home Care Advisory committee that Paula Keirstead now chairs is one that was created by ministerial policy and, under that policy, reports and advises the minister. So we kind of lumped those things because they answer to the minister as opposed to come under another line.

Mr. Chomiak: I am actually reading into this chart here. I note that the advisory committee on Continuing Care and the Appeal Panel for Home Care is at one end of the chart, and there is a new function under Manitoba Health Board for appeal panels and, I guess, that was my--

Mr. Praznik: Oh, I am sorry.

Mr. Chomiak: Perhaps my question was not as clear as it should have been.

Mr. Praznik: You are right, and I apologize to the member that some of these have been put on the other side of the chart. I believe there is an appeal function to the Manitoba Health Board on residential charges and boundary changes for health districts. I think that is why it was just put in that way, but I do want to indicate that at some point we may look at how we handle appeals generally to get--you know, if we can make them better and give the people a comfort that there is an appeal mechanism for many of the decisions that are made in the system and they obviously have a commonality in administration to them, that might be a way of raising their significance somewhat and give people a greater comfort level that they are not left to arbitrary decisions.

Mr. Chomiak: I am wondering if it is possible for the next time or the time subsequent when we meet to have lists of who is on each of those, who is on the Manitoba Health Board, the appeal panel, the advisory committee on Continuing Care, the Minister's Advisory Committee on AIDS and the Appeal Panel for Home Care.

Mr. Praznik: Yes, Mr. Chair, I would be delighted, and I think we have some copies, too, but we would like to get copies made. If the member is fine, we can have them for tomorrow and I will table them with the committee.

Mr. Chomiak: Has the minister had occasion to have any meetings recently with the faith-based institutions, and can he update us as to how those have gone?

Mr. Praznik: Mr. Chair, I have had a host of meetings and I have more planned. We have discussed this somewhat in the House from time to time. There are some issues arising out of faith facilities with regionalization. I think the issues that we face, quite frankly, when we get down to it, are going to be easily worked out, or worked out I think without too much difficulty, between facilities and regional health authorities.

Obviously, when you are changing a system or the governance of a system--and I would like to say, Mr. Chair, by way of background and by way of history, we as a society, and the member well knows this, always organize ourselves to fill a need in the best way that fills that need at the time, and we are constrained by the technology that is available to us. Our current health system is largely, up to the last number of years, organized around institutions, because for many hundreds of years that was a very efficient way in which to organize the delivery of health care. The flow of information on paper supported that. Bringing batching services together to be able to provide a complete package was certainly there. Most of our health care services have been delivered on an institutional basis as opposed to a community basis in the last 75 to 100 years. So we built our system.

Also funding mechanisms supported that, were created for that, and continued to foster that. Today the trend--changes in technology, computer systems, the ability to move information electronically including diagnostic information--has broken down the walls somewhat of institutions. The rediscovery of home care, the Grey Nuns tell me, Sister St. Yves tells me that the first health care provided by the Grey Nuns in Manitoba was really going home to home to deliver. It was really, truly a home care program. As we develop those systems, we need to better integrate both our facilities with each other and noninstitutional services with the institutions.

So regionalization is a model that I think lends itself well to that. Now, having said that, in the case of the city of Winnipeg for hospitals, we have four faith-based facilities with long traditions in this city and in our province with great contributions by their founders and their volunteers, and we certainly do not want to lose that.

The faith-based agreement that the government entered into last fall with those facilities recognizes the authority of the Winnipeg Hospital Authority in operating programs, in dealing with finance, in directing the system. It also recognizes the importance of respecting certain faith principles in the operating of those facilities, of those four facilities maintaining a role through their CEOs and other things.

What I am hoping is that within that context of the faith-based agreement, within the context of the objectives that we are trying to achieve, which is to improve the delivery of health care for Manitobans and also to keep those things we do really well now, that we are going to be able to work out in an operating way many of the issues today that some of these facilities or some in these facilities view as highly contentious. In examining them, I really do not think they are.

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I met today with the chair and vice-chairs of the Winnipeg Hospital Authority, and we will be meeting together later in the week with the faith-based organization on that agreement, and I think when they get down to actually working out their day-to-day arrangements, everyone at the end of the day, I think, will be quite happy with the result.

With respect to two other areas where faith-based institutions fit into the plan, one is personal care homes, obviously, and there is a concern by some--I know in the member's own community, Holy Family, that board--I know it is south of his constituency but still part of our common Ukrainian community--has some concerns about regionalization. I say very clearly on the record today that personal care homes have virtually 100 percent occupancy. They deliver a very direct type of programming. Often because people live there in their latter years, the cultural, linguistic, religious milieu of a facility is very important to those people.

It was never envisioned by our plan that those facilities would have to be governed by or changed or evolved into regional health authorities. For those that wish to remain in their own governance model, I think the only difference they will find is that their relationship, rather than being with the Ministry of Health directly, will be with a long-term care authority and that the cheques they receive will not be Province of Manitoba but will be the Winnipeg Long Term Care Authority. They should see virtually no change.

There will, of course, be the ability to do better purchasing and have some savings by working in a larger group, and I do not think that is a faith issue or affects any of their principles. It may be from time to time that the authority may want to have them deliver some additional programming--it might be an adult daycare program, et cetera, out of their facility--which would have to be negotiated and worked out and funded for them to do that. So I say that clearly on the record, and I have said that to them personally.

The third area is faith-based facilities in rural Manitoba, and many of them have issues around culture and language. I think of Ste. Anne, for example, the hospital. I am pleased to tell the member today that we have worked out with the regional health authorities and many of those organizations a variety of provisions that are working their way into their operating agreements that will continue to respect faith, culture, language in facilities that are evolving into the regional health authorities, so that those are not lost in those facilities, and as the member knows, in many communities that is a very important aspect.

In the legislation that I am about to introduce to the House with respect to amendments to the regional authorities act, we will be putting in some provision to ensure that regulations can be made to protect the French language services that are required in a variety of our facilities in the province pursuant to the Gauthier report, and that was an oversight in the last bill that we will want to correct now. I have had meetings with the Société franco-manitobaine, and they have helped in producing those regulations. The concern was, of course, that smaller facilities with local boards would protect and enhance the Gauthier report, whereas regional boards may not take that into effect. They wanted some protection for that, and we have been prepared to do that. So that is sort of the overview. I know the member may have more specific questions.

Mr. Chomiak: I thank the minister for that informative response. The minister, I believe, chose deliberately to distinguish the relationship between faith-based institutions in the acute care sector and faith-based institutions in the personal care home sector. Am I correct in that observation?

Mr. Praznik: Yes, absolutely.

(Mr. Ben Sveinson, Chairperson, in the Chair)

Mr. Chomiak: How does the minister see the functioning of nonfaith and private personal care homes interacting with the regional health authorities?

Mr. Praznik: We may want to explore a little later the hospital personal care home issues. But with respect to the personal care home issues the question that he asks is many of the facilities, whether they be proprietary, nonproprietary, who wish to maintain their own governance, will have to--they will contract or they will work with the regional health authority who will be delivering the funding, in essence, and working with them.

In rural Manitoba our experience has been many of the personal care homes are neither faith based nor proprietary, that they are often municipal, that they are sponsored by their local municipalities. The vast majority of those have evolved into the regional health authorities today and so are literally governed by that regional health authority. In Winnipeg some may choose to do that. Most, I would suspect, will remain to be governed under their current basis, and their operating relationship, funding relationship will be with the regional health authority.

Now, one caveat I would like to put on that, because the member is raising the issue after the Holiday Haven incident, a new minister coming and examining this area. I recognize very fully that it is important that there be consistency in how we treat facilities, et cetera, and, obviously, issues like what we pay for service. Since we will be flowing dollars through the Winnipeg authority, we will want to make sure that there is a consistency and a transparent approach, and we obviously are going to have a very large role. If there are any changes in funding formulas for personal care services, that will be done, the ministry will have a large role to say, and I look at Mr. Potter who knows this issue well to date. So I hope that gives him a sense of where we are coming from.

Mr. Chomiak: With respect to the role and functioning interrelationship between personal care homes, acute care centres and the respective authorities, is it correct that the relationship will be one of a contractual nature? In other words, an acute care sector or a personal care home--the minister can correct me or clarify if I am wrong--will be offered a contract between themselves and the regional health authority to provide a certain amount of service, a certain kind of service over a period of time. Is that a correct interpretation of how the relationship will work?

Mr. Praznik: Mr. Chair, with respect to personal care home facilities, it will be a contractual relationship, whether it is one that is a contract for a set amount of deliverables or whether it is for service provided, is something that obviously may evolve or change over time as we look at how we fund personal care homes and how we purchase long-term care beds. It is somewhat different for hospital facilities, and we may want to get into that discussion just by the nature of their facilities.

Mr. Chomiak: Yes, I thank the minister. Perhaps, we can pursue that for a moment. If looking at the specific issues of faith-based institutions, if an acute care hospital: (a) wishes to offer a wide range of programs and the regional health authority designates that there is an excess or there is no need for those wide range of programs, presumably will it be that that faith-based institution will only be paid for the programs that are acceptable to the regional health authority; and for those programs that are unacceptable or not deemed appropriate, they will be on their own, they are on their own hook, in order to provide those programs?

Mr. Praznik: Mr. Chair, I think by the nature of a regional structure, and this is perhaps why there has been a lot of discussion with the four facilities under the faith-based agreement with the interfaith group. It is going to be a very mixed system. I want it to be practical, I want it to make common sense, and I want it to be able to deliver what is best most efficiently for the citizens of Winnipeg and Manitoba, and I am sure the member wants the same.

Why I say it is going to be mixed is because even under the faith-based agreement, the decision as to program delivery is with the Winnipeg Hospital Authority. It is our interpretation, view and plan that the Winnipeg Hospital Authority may, in many cases, be the deliverer of that program, although the program may be housed in a variety of sites in those facilities.

I will even compound--and I am sure the member will appreciate this organizationally--the issue somewhat because the indication we have from the Health Sciences Centre is it is their intention to evolve into the Winnipeg Hospital Authority. So I would suspect some of our facilities will not even have boards after this process and do not want to have boards, while others, like the faith based, will still have a board of governance and a role to play in governing their facility. So it is going to be very much a mixed system.

But the Winnipeg Hospital Authority, where it views itself as being the deliverer or best able to deliver a program, obviously, things like heart surgery already are one program on two sites. Obstetrics is one that comes to mind. Emergency service is another that has to be considered. Where they will be delivering one program in one or multiple sites, they have that role. They will not likely be contracting; they may be in essence paying for space in a facility or funding space for that program. Those are details that they have to work at what works out administratively best to be able to do it.

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Some programming may be directly contracted with current boards or faith-based facilities to deliver, if that is a very good mechanism with which to do it. Obviously though the budget for the system will be housed by or transferred from us to the Winnipeg Hospital Authority. Even under the faith-based agreement, there is a recognition that financial decisions is that purview of the Winnipeg Hospital Authority. So if a faith-based facility wanted to offer certain programming, they would have to ensure that the delivery mechanism was agreed with the Winnipeg Hospital Authority and the funding was in place with them in order to do that. If it was not, then that would be a decision on which they were on their own and would have to find another source of dollars. In very practical terms now, those facilities really cannot deliver programming unless they have approval of the Ministry of Health, who funds, so it is not a huge change in that matter.

Just to put some perspective on this, as we look at where roles are to be, I know in some of the discussions that I have had with some of the faith-based facilities and people who have been involved with faith-based facilities, I think it is really important to identify which needs those faith facilities, or faith communities, wish to address where there is a need that they are best to fill it or is unfilled today, and I would be most encouraging. I know in the area of palliative care, for example, there is a very large role for faith organizations to play, particularly religious orders in palliative care. That is an area that we have to address.

There are other areas that come to mind. I know we have issues in the chaplaincy program that the member has flagged. As we have shorter stays in hospital, how do you ensure that the spiritual needs of someone who is facing maybe a terminal illness or a long period of recovery, even if it is at home with home care, are plugged in to get that other kind of support? So there are a lot of these issues that have to be worked out operationally. One of the difficulties I have had in sorting some of this out, as a new minister, is that often we want to argue or debate a particular principle, and whether you take one side of the principle or another or accept or reject it, when you get down to operational decisions, often that will settle an issue in a very practical and simple way.

So I do not want to get into my preference. It is not to get into debating every principle as to how this works. I am not trying to say that to the member for Kildonan. I am saying that in terms of some of the relationships we have had with some individuals in the faith community, but take the faith-based agreement as we have it, take what our intentions are of trying to improve a delivery system and get those faith-based facilities through whatever mechanism with the Winnipeg Hospital Authority--board to board, chair to chair, CEO to CEO-- whatever they decide collectively, and start figuring out how we are going to make this thing work. It is going to be a mixed system. I think that method will give us the best of all worlds, and that is what I am trying to achieve.

Mr. Chomiak: I thank the minister for that response. Is the minister saying or suggesting that the present board of the Health Sciences Centre is going to evolve into the board of the Winnipeg Health Authority?

Mr. Praznik: Mr. Chair, I do not want to speak for that board. They have to make a decision. There has been some discussion or some indication from that board that that is an option they are very seriously considering. It is one that they have to obviously come to, and I do not want to prejudge what decision they will make. But, if that is a decision that they make, one can obviously see how that compounds many of these issues, because the Winnipeg Hospital Authority, then, in essence would be truly operating our largest facility directly rather than through another corporate entity.

Mr. Kevin Lamoureux (Inkster): One of the things that I have always respected is the co-operation that I get from the member for Kildonan (Mr. Chomiak) in terms of facilitating questions that we have as a party to this particular Ministry of Health.

Having said that, I have done what I can in terms of listening in on some of the comments that the minister registers in the committee, and one of the things that he provided or offered was that there are some discussions that are held in confidence, and he had indicated that he would in fact be prepared to bring us in. I do appreciate that, and it is not necessary to say no if the circumstances arise in which it would be deemed necessary for me to do that. I just might take the minister up on those types of suggestions.

Having said that, I take a great deal of pride in being charged with the responsibility on behalf of our party to look at the whole issue of health care and the direction that it has been going over the last number of years and its future direction in the province of Manitoba. There always has been a great deal of concern for my part in terms of how we manage the change that is necessary. We acknowledge right up front that we do have to acknowledge that there is a need for change. I would argue it is a question of how we manage that change. There have been areas in the past with the former minister where there has been some disappointment. At the same time, we were pleased with the minister.

More than any other issue, personally I thought that it took a lot of political courage for him to change the recommendation with respect to Seven Oaks Hospital, as an example. I think that is the type of courage at times that it takes for the politicians to ensure that the right thing is, in fact, done.

I guess that is where I want to start off with some of the questions that I have with this minister. I go back to a very personal, good friend of mine Gulzar Cheema, and the minister knows Mr. Cheema well, who has moved on to B.C. for whatever reasons, but he and I had many discussions on how wonderful it would be--[interjection] Nothing to do with the weather, I am sure--how wonderful it would be if a provincial election came by, and there was nothing but positive things to say about health care. I still believe to this day it would be wonderful. Is it realistic? I am not convinced that it is. I think that there is so much that is happening within the Department of Health that it is always going to be an issue during elections.

The question then becomes, is it possible to minimize the types of controversial issues that could arise if, in fact, the government was not doing a good job at managing that change which is necessary. I think that we see, whether it is in by-elections, provincial elections, that the government has not been as successful as it could have been in managing those changes.

I want to go to some of the core areas and go back to the Action Plan. Gulzar, at the time, had indicated on behalf of our party that we supported the Action Plan. Why did we support the Action Plan? The simple answer is because we really do believe that the best way in which you can enhance the quality of health care and at the same time reshuffle some of those valuable dollars is by bringing it closer to the community.

I can recall campaigning on that back in 1986 when I first looked to seeking office, Mr. Chairperson. That is, in essence, the core of any sort of health care reform, and in order for us to be successful, we have to be able to address that issue head on.

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In the past, I have talked a lot about community health clinics, for example, as one of those things which we need to expand upon. I had the opportunity to visit the province of Quebec, and I was fairly impressed with just what the CLSCs, as they refer to them in Quebec, are doing, everything from home care delivery to very limited tertiary care, Mr. Chairperson, and the staff who are brought into the community health clinics is most impressive in terms of their backgrounds. I think that in Manitoba we should be moving more toward enhancing those services at our community health clinics.

I have one, Nor'West, which is located in my area, and I have seen it over the years and ultimately believe that there is a lot more that it could be doing if, in fact, we had a department or an infrastructure that was playing more of a supportive, enhancement type of role for these particular facilities, and maybe we will see more of that in time.

The other issue, our hospitals, and I think that is what touches the hearts of so many Manitobans, is the whole hospital debate and what is happening within these hospitals. I think it is because they are so high profile. You see the big H, and so many of us drive by them; we have family, friends, who use them on an ongoing basis. We have to get away from the idea that the hospitals are the be all and end all to our health care services, that there is a lot more to it.

But the hospitals are, in fact, important. The community hospitals are very important, and I do not like what we have been seeing over the last couple of years with respect to the government relying less and less on some of our community hospitals. In fact, we should be seeing a more expanded role in certain areas of our community hospitals.

You know, it has always been interesting with some of the CEOs that I have had a chance to talk to. They will say one thing on the record and it is another thing off the record, and I will not say which CEOs I have talked to. But what I find interesting is that off the record the talk is very positive towards community hospitals. On the record, what I detect is a lot of turf protection, and I think that is in essence the biggest challenge. That is what I want to talk about, the challenge that the politicians have is to try to get over that turf protection and try as much as possible to do the right thing.

The minister, I am sure, and I, could go back and forth on the right thing. How many teaching hospitals does the province of Manitoba need, for example? How many acute care beds should be in our hospitals? There are many very controversial issues that do need to be addressed, and some of them have to be political. Some of these are up to the politicians to make the decisions. That is why when the government came up with the regional boards, as a political party, we opposed them, primarily because we felt that the government was going to be using these regional boards in order to make the decisions and allow them to pick up all of the flack.

Well, I would argue, Mr. Chairperson, that these regional boards are an extension of the government and do need to be given some sort of guidelines. A clear example of that is with what is happening over at the Grace Hospital. At the Grace Hospital we have the recommendation, even though it is brought from the community board, but for many different reasons, that the obstetrics leave that particular facility. I would think that the obstetrics should be playing a role in that particular facility.

I would even go further and argue that the Seven Oaks Hospital, and one might even want to consider the Concordia Hospital, depending on their acute care beds and other programming being provided, should be delivering an obstetrics program. What is that based on? Look at The Action Plan itself.

How many births are given at the Health Sciences Centre that could in fact be delivered at other facilities, in particular the Grace and the Seven Oaks hospitals? Now, the minister could come back and say, well, look, by doing it in this one concentrated area, we are going to save this amount of money. Well, for all intents and purposes, the obstetrics unit, for example, at the Grace Hospital adds a lot more than just the delivering of babies for that particular facility. It is a part of an infrastructure. It is a part of what I believe the public wants to see, and that is births being made available within the communities, and for what cost? Well, even though on the surface one might be able to argue that the cost would be less by having more babies being delivered at the Grace and Seven Oaks than Health Sciences Centre, which is the most costly hospital in terms of average stay or overnight stays, if one digs a little bit deeper you might not necessarily be able to validate that particular argument. So there might be an additional cost, potentially, that could be talked about from within the ministry. We do not know that. It has never been talked about. I do not know if the government has actually looked at some of those hard numbers. I would be interested in finding out, failing the government being able to demonstrate the cost, because there is a valid argument to be said that the costs are actually less by having it in the community hospitals.

Well, if, in fact, that is the case, then it makes absolutely no sense whatsoever for the concentration of obstetrics, Mr. Chairperson. If that is not a valid argument, well, then let us talk about the politics of providing a valuable service in our community facilities and how that service complements that particular facility in many other ways, whether it is food services, indirectly, to the more very direct in terms of a community service of obstetrics. So that, in itself, could justify remaining in the Grace.

So why do I bring it up? Because these are the types of guidelines that I believe that the province has the responsibility, not the regional board. The province, the Ministry of Health and the minister responsible, should ultimately be deciding whether or not obstetrics is warranted or not at the Grace Hospital, whether or not it does make some sense to have it at the Seven Oaks Hospital.

I would acknowledge if the Minister of Health said, well, you know, the member for Inkster has some valid points, and, yes, we are going to look at the Seven Oaks Hospital, there would be phenomenal resistance to it, resistance from within possibly the teaching hospitals to other groups that might be out there. You might even get some resistance from the local Seven Oaks Hospital, but it is a question of whether or not it is the right thing to be doing.

When I look at the Action Plan, Mr. Chairperson, I think that it clearly demonstrates that, yes, there is merit to having these sorts of services. The Manitoba Centre for Health Policy and Evaluation, and I brought this up I believe in last year's Estimates, had an interesting report on tonsillectomies done between '89 and '93. What was clear in that particular report is that there was a growing reliance on this particular operation being done in our teaching facilities as opposed to community facilities. Yet many doctors would argue that this is the type of service that could be done in our community facilities.

Well, here we have something that is moving in the other direction. Now, again, it might be because of the Children's Hospital, over at the teaching facility. There could be other arguments as to why it is being done, but the other side, I believe, is not being listened to.

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The reason why I believe it is not being listened to is because of the biases from within the system, in part, not entirely but in part. That is the reason why, again, I argue that the minister, more so than any other person, has to be very sensitive to those particular arguments.

You know, again, I would go to another report that came out from the Manitoba Centre for Evaluation, very interesting comment. This would have been hospital case mix costing project '91-92 in which it states in part of the conclusion on page 74 that less expected perhaps was the finding that teaching hospitals also treat a considerable portion of low acuity, low resource intensive cases suggesting they function, not only as a tertiary care institution, but also as large community hospitals, particularly for pediatric and obstetrics admissions.

I did not raise this in Question Period, and it would have been a wonderful thing to support, for example, what was happening at the Grace. This comes from the policy guru, if you like, of the Province of Manitoba. It gives phenomenal credibility, to a certain degree, to those who would advocate that we are not doing what we can to sustain those community facilities.

That is the type of thing which I believe that the Minister of Health has to take into consideration. That, I guess, I would leave open as somewhat of an open-ended question to the Minister of Health, that being--and my questions will be shorter from this particular point, but to emphasize that we think the government, in particular the Minister of Health, has to look more at the role of community hospitals and provide clearer guidelines, a better definition of their future in the province of Manitoba.

Maybe just to conclude it on a very positive note, we applaud the government on its actions with respect to the Boundary Trails hospital, something long overdue. It is more than money that keeps doctors in rural Manitoba. Here is a facility, once it is complete, which will be able to attract and retain doctors in a better fashion, and we are going to see two other facilities, from what I understand, converted into some other possible usage, but we are going to have a first-class facility in rural Manitoba.

That is on a positive note. Now I will let the minister respond to the other part that might have been a little bit more negative.

Mr. Praznik: The member for Inkster has made a very long statement with a host of things, and I appreciate that, in fairness to him, he did not avail himself of an opening statement at the beginning of the Estimates process, and it is his opportunity to, I think, put things in context. It is very important to have these kinds of discussions, so I in no way am critical of the length of his statement. I appreciate where he is coming from.

One of the observations I have made in the few months that I have been a Minister of Health is that there is no shortage of advice for ministers of Health, and it comes not only from colleagues in the Legislature and from critics--and I am sure our colleague Mr. Chomiak who has been a critic for many years probably sometimes feels the same way as I do as he gets bombarded with much advice as a critic as to where he should be taking on government. Sometimes, I am sure, some of it is contradictory from the organizations which ask him to advance causes, as they are with ministers.

Often the advice I get is very, very technical, often contradictory to the same kind of advice I am getting or advice being offered on the same subject. I do not, for one moment, profess to be an expert in medicine or many of the technical aspects of medical care. So sorting out how one makes things work is often a very difficult task, and we will never have a shortage of critics in the delivery system because you cannot receive so much contradictory advice and in a decision satisfy everybody.

It is a reality that I have come to accept. At the end of the day, I hope when we do make decisions that they are based on some common sense and that the consuming public out there for whom we are all doing this work, the people who require health care, are generally satisfied with the service that they receive, and it is delivered in an efficient, cost-effective, health-effective, well-practised manner.

With respect to regionalization and the decisions that one makes, this is often the great dilemma of how we organize the system. If you asked me today what was the major issue facing health care or the major area of change or controversy, I would easily concede that it is how we organize the system. That may seem to some not to be an important issue because it does not, in their view, affect delivery directly, but I would argue that how we organize the system will have a huge effect on the outcomes, the way we deliver the system.

The way we operate today, because we do not do these things in a void, from my observation of working with it, is--and the member for Turtle Mountain (Mr. Tweed) works with me very closely as my legislative assistant and we have often shaken our heads at how the system works today--it is probably one of the last ways in which you would ever organize a health delivery system in the last years of the 20th Century. It is one really caught between two different waves of technology, two different eras. Today we have multiple facilities and multiple services with, in essence, one publicly funded system, publicly funded, and with funding--and I cannot emphasize this point enough--comes ultimately so much of the direction as to how a system will operate. Although there are many who argue that governments should just be the funder and others should be the deliverers of the system, that we should say we need so many babies born, we will pay so much, you go out and manage it, ultimately that kind of system does not necessarily always lead to efficient delivery--[interjection] My colleague from Whitemouth is lobbying me for a facility in his constituency as we speak. But it does not lead often to the efficiencies that you need.

If you look at the Canadian health care system, and this is one area I think we all agree on, compared to most of the western world, we have one of, if not, the best delivery system for health care. No matter what standards you look at, health outcomes, we are pretty high, maybe not the highest, but in health outcomes we are pretty high, certainly better than the United States, and in cost-efficiency of running the system, way better than the United States, and moving up the ladder in the world. When we started these exercises of reform a few years ago, we were probably the second most expensive system--we are now probably eighth or ninth on that list--so we have improved in the cost-effectiveness of our system. We have one of the best health outcomes. We have virtually universal coverage for so many things, and we have areas of service that we provide that even other industrial countries do not. We are not perfect. There are people who do things better than us, but overall, Canada--and I would argue Manitoba within that context--is pretty high up on that ladder. That does not mean you rest on your laurels with that reality. A good reason why we are that way is because we have had a one payer, centrally planned and directed system, by and large, that we are able to deliver services efficiently, particularly high-cost technological services.

You know, I had occasion when I worked for Jake Epp, who was then minister of national health, and certainly as Workers Compensation minister, because we had a health care component there--I had an opportunity to compare our system with the American system, for example, and one of the great benefits of our system is the ability to utilize resources. Because they have multiple-payer, multiple-delivery mechanisms, they have way more capacity in high tech and facilities than we do, much of which is underutilized, all having to be paid for and maintained. One of the great savings in our system is that by having a one-payer system, public system, we are able--they call it rationing; I do not at all, I term it good utilization--to make determinations that we need a certain amount of resources for our community and direct how we fund it and put it into place.

MRI is a good example. I think there are two or three--I do not know how many MRIs in North Dakota--I heard six at one time--Magnetic Resonance Imaging--six in North Dakota with half our population. We have one today, soon to have two. Properly utilized, they should manage our entire capacity. Now, we may get into some debate--are they properly utilized today, because there are some waiting lists and those things? I imagine a very strong case could be made that we have improvements to do there, and I would concede that. I know there were some issues around that when I was Workers Comp minister, but certainly with two now in the province, we should be able to manage that technology, state-of-the-art technology very efficiently.

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What worries me--and Gordon Webster, our new CEO at the WHA, we got talking about this, and his great fear is that the next wave of new technology coming into the system is going to be so very expensive that our ability to be able to pay for it and provide it is going to be difficult unless we properly manage it and get maximum use out of it.

The American system is going to lend itself to a lot more inefficiencies and much higher costs, and that is why they are spending now $3,000 or whatever it is per capita for health care, and we are at $1,800 or $1,900. They just keep going up, and then their health is not any better. They may not have waiting lines like we do, but they also have 30 million Americans who have very limited health care or charitable health care. So we are doing pretty good, because we have that central system, and I do not think we would be well advised, and though we may debate parts of it like privatization of some pieces of home care or certain supplies, we will have those debates, and they are there.

Generally speaking, if we were to privatize our health care system holus-bolus, our delivery system, I think we would give away one of the best advantages Canada has in a globalized world, and that is our ability to deliver efficiently one of the major needs of our citizens, which is health care. The cost of health care ultimately ends up in the cost of doing business, in the cost of competitiveness of a nation. The United States today has a huge competitive problem because of a health care system that is out of control, not operating efficiently and making poor use of very expensive resources. So, for Canada in a globalized world, I would argue very strongly that our central system, one-payer public system, which is by and large the principles of the Canada Health Act--there are a few problems with that in flows and other things--but by and large is a huge advantage to Canada as a nation, and certainly a huge advantage to our population in giving them a decent health care delivery.

There will always be problems, and we have to keep working at them, but in that overall objective. So you come back to why, and again it is because of the way we structure our system, and in that context of regional health authorities, that is the next step to which we go to again get better efficiency, particularly in anticipation of many of the new high-cost technologies that we inevitably will have to purchase for our citizens to make them operate efficiently.

I will give you one example today that is on my desk. I had a group of physicians from the Concordia Hospital led by Dr. Krahn, who I believe is their head of surgery, coming to make a pitch to me as minister for an additional ultrasound for that facility. Under our current way of governance, although we are centrally planned, we have 180 boards of directors for facilities across the province. When I come in as a new minister I have got 180 facility boards that I potentially could be meeting with. They work today under MHO, Manitoba Health Organizations, for many of their issues, but still when they have a specific problem for their facility and they have dealt with the department and not got the answer they wanted, their ultimate appeal is to come to see the minister. So here I am, a new minister, and you are experienced, sitting down, saying, Mr. Minister, please fund another ultrasound for our facility because we have a nine-month or 15-month or seven-month waiting list.

Well, I sit there and my first question when I get into it is what is the waiting list across the city? Well, they vary hugely. In fact, there is a very short waiting list, I am told, at Selkirk, all kinds of new requests, which is out of the city. So when you start exploring, and I ask some more questions, I am told the story by Dr. Krahn or by one of the doctors that they have a patient who lives in St. James, sees them at their office downtown--they practise at Concordia Hospital--needs an ultrasound, not urgently but needs one, calls the Grace Hospital where we have two ultrasounds, I guess, and are told that the waiting list is much less there, but the doctor does not practise at the Grace Hospital and so you cannot use our ultrasound.

Well, something is wrong with this picture. The issue is not the ultrasound at Concordia Hospital. It may be. We may need to have two there. But, when you start asking the questions, you realize you cannot answer an even more fundamental question: How are we using all the ultrasounds in and around the city of Winnipeg? Are they at their maximum today? I do not know because I am dealing with a whole bunch of different corporate structures delivering the service and looking after their own turf, as they should within that structure.

So the regionalization, just with respect to my example of ultrasounds, where the Winnipeg Hospital Authority will now be sorting this out, can determine, or develop a system by which all of those diagnostic tools--by the way, every facility needs at least one ultrasound for emergency so I am not saying you would not have one. But ultimately, are we co-ordinating so that any physician in the city of Winnipeg, in and around Winnipeg, can dial in on their computer to one central place and find out what is available for ultrasounds, and make a booking for their patient, for whatever day works, so they can get an ultrasound, whether it is in Victoria or Seven Oaks or Selkirk or wherever, and that the results will be available to that doctor through our information network on computers inevitably, and we know that we have an acceptable period for waiting for ultrasounds for nonemergent purposes across the whole system?

The only way to ultimately do that, because the hospitals under their current system have not been able to do that easily or well, and even some of the administrators who are not as accepting of regionalization have said to me that, yes, they have made progress but nowhere near as far as they should in co-ordinating these services. By the way, in fairness to those hospitals, I understand the Ministry of Health kind of imposes those guidelines, I am told, or something on who gets ultrasounds in what facilities. So it even gets more complicated.

My point is this organizational tool will give us the ability to be able to ensure that, whatever services, we are maximizing the use of our resources as much as possible within the system. Now does that mean the minister escapes the responsibility? Absolutely not. If the Winnipeg Hospital Authority, after coming in and being able to deliver this, is not maximizing the use of its resources, then I have an administrative problem with that health authority, but if they are maximizing the use of the ultrasounds and we ultimately need another, and that has to be purchased out of public funds, then that is my responsibility and I will accept that. Today, I cannot justify to a Treasury Board whether I need an extra ultrasound, or not, easily because of the diverse nature of how the system operates.

So the long and the short of it with my visit from the Concordia doctors was that there is a need to improve the system. Whether we need an ultrasound, or not, we have to sort out, but the current model of organizing the system was not really an efficient one. They pointed out to me a host of other examples from having to do with the installation of pacemakers at St. Boniface, rather than Concordia, when they practise at both hospitals, because the item comes out of the stores budget at St. Boniface, rather than being included in the budget for Concordia. It gets even more complex.

Those are delivery items that do not affect principles of faith. They do not affect the principles that we want to maintain with faith-based agreements, but they do improve, if we are able to achieve that kind of efficiency, a better use of our system. It may not seem so important today, but I will tell you, it will next year or the year after when we are faced with the next big rounds of technology that are extremely expensive, and we have to make sure we use to their maximum.

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Just one other example I give you, because it may come up later in the Estimates, and that is the area of bone marrow density testing. I know we have discussed this in the House, and the format of Question Period does not lend itself well to the kind of detail of question or answer that a matter like this deserves, and I appreciate that for both of us as critic and minister, but we know we have a waiting list. We spoke to St. Boniface about it. They have the one position now, and I think the initial proposal we had was for $500,000 and four new machines, et cetera. Wow, this is huge. Well, we started to ask some questions, and what comes out is we have one machine with a 0.2 staff year attached to it. It is a technician we are talking about. So we ask: What happens if we can give you a full staff year for a technician? Well, all of a sudden, they can do 15 procedures a day. We do a quick calculation on how long it takes to do a procedure and we think they should be able to do 32 a day or 30 a day.

So for $30,000 to $50,000, we can probably bring that bone density down in months, but remember when we went out there and said how do you solve the problem. We had a proposal for half-a-million dollars. If I had just accepted that right away and did not do the questioning, I would not have had the money I am going to need to improve some of the other waiting lists.

I do not want to cast any doubt on why people put in that proposal. The answer was so simple, and then the system now, should ministers who run $1.8-billion budgets be having to ask those questions and make those decisions? Yes, if no one else is doing them. I am hoping, by establishing things like the Winnipeg Hospital Authority where instead of negotiating with seven or nine boards and everybody is looking for what do I get in my facility within that system, that we will have people who will ask those questions and find those economies and make things work without every one landing on my desk. But, yes, I am ultimately responsible and will continue to be, and if the Winnipeg Hospital Authority does not have the resources to do the job, we are responsible in government. If they administratively cannot do the job then I have an obligation to replace them because I am responsible.

We are not doing this regionalization to pass off bad decisions to others. Yes, politically that sounds great and sounds easier to do, but ultimately the buck stops here and it will always stop here. In terms of getting the tools to do the job, the more I have gotten into this, the more I am a very strong believer that regionalization gives us a chance to deliver a better system. And rurally, now that we are into it, I think somewhere near 90 or 95 percent of the facilities in rural Manitoba have either evolved in the process of doing their agreements or have indicated a date by which they will evolve within the next year to their local health authorities.

Already in meeting with the chairs and the CEOs as they start looking, how do we better deliver services, some of their proposals that are coming up just make such eminently good sense, could never have happened without a larger organizational base with which to do it. I just give you one example we are facing now is in emergency docs. You know, we have a problem. We have 34, or so, small facilities in rural Manitoba, some of whom, including Beausejour in my own constituency, are on strike today and will not provide emergency services.

We have committed to a 90-day process to find a solution. We think we have the makings of a very common-sense solution without a huge price tag that solves the problem of most of the doctors. We are working with the MMA now to see if we can put that together in the next few weeks. One issue doctors raise, in rural Manitoba with lots of small facilities, there is not enough doctors needed in the communities or available to provide 24-hour, seven-day-a-week coverage in every current hospital in the province of Manitoba.

The chair's committee, the chair, for example, the member for La Verendrye (Mr. Sveinson), in the Whitemouth Hospital, they have one doctor in Whitemouth.

An Honourable Member: Let us go to Ste. Anne.

Mr. Praznik: Well, you have eight in Ste. Anne, I think. But if you go to Whitemouth, they have one doctor and yet I recall reading a letter to the editor in one of the local papers where a citizen said we recruited that doctor. How dare they do emergency service in Beausejour. They should be doing it in Whitemouth. Well, you are going to kill that person if you expect them to be on call seven days a week, 24 hours a day.

The regional health authority gives the facilities within a region an opportunity to be able to put together a plan that will give them the right number of emergency centres to meet the standards that are there of how far to be away from an emergency centre, that can give seven-day-a-week, 24-hour emergency care to a region of the province in a sustainable fashion because they are utilizing a larger physician base than attempting to keep 24-hour emergency in absolutely every facility where you have one and two doctors. You are not going to be able to do that.

Although I recognize the argument about passing off decisions, ultimately the decisions--and my party will be judged in the next general election on how we handle many of these matters, and I am sure there will be criticism, but ultimately regionalization is an organizational tool that I think time is proving today, in this context, is the appropriate tool to be able to deliver better service and make changes in the system.

I work very closely with those boards, and ultimately I will hold some responsibility for their decisions, but if we do not do it, the alternative quite frankly is continued frustration over and over and ad hocking decisions and funding projects here and pieces of equipment there without a rational approach of whether we need it. What is really coming down the line is higher costs, particularly diagnostic equipment, that this province will not be able to afford unless we can purchase it to operate on a province-wide basis. So in the long run, I do not think we have a choice. I appreciate the discussion with the member.

Mr. Lamoureux: Mr. Chairperson, I want to pick up on one of the examples the Minister of Health said, and that is ultrasounds. Now in his comments he said, you know that in Manitoba maybe what we do need to do is have a better organized approach at dealing with individuals that are on waiting lists because in some facilities the waiting period is nowhere near as long.

But then at the tail end of his comments with respect to that, he says, but of course we would have one ultrasound in the different facilities.

Mr. Praznik: For emergency.

Mr. Lamoureux: For emergency uses.

Mr. Praznik: Where appropriate.

Mr. Lamoureux: Now the point that I want to pick up on is that by making a statement of that nature what we are talking about is saying that, look, a facility has a certain expectation by this government. So if we carry that on, one could ask does the government have an expectation, for example, that an obstetrics program should be delivered in community facilities? If the regional health authority decided, once it has its powers, to take the ultrasound out of a couple of the community facilities, the minister, given his comments, would say, no, no, you cannot do that. We want you to put them back in.

Well, does the minister, or the ministry, have guidelines as to what it believes are those core services that some of these facilities should be providing?

Mr. Praznik: Mr. Chair, just to get back to the ultrasound, the reason I made my comment about the expectations is the ultrasound is a diagnostic piece of equipment. It is fairly commonplace, very much a part of standard of care in a facility. Why I made the comment is there is still expectation if you have a facility delivering a standard of care such as a hospital, it is like an X-ray machine, you need certain medics. If you have someone who comes into a hospital in an ambulance and is in an emergency situation, in that case you need that technology or level of technology, unless it is highly specialized, there and available.

The question is--so every facility needs a certain level of diagnostic equipment, depending on their level of facility, to meet that emergency need. The question though at this hospital is that where it is not emergency, do you need to have every facility geared up for all their caseload, or can you better utilize the system?

So please do not take that comment with respect to an ultrasound at Concordia out of context. Any facility operating as a modern hospital today is likely to need one of those pieces of equipment for emergency situations. You are not going to put somebody in an ambulance to take them to St. Boniface for an ultrasound to bring them back if they are in an emergency situation.

What I am talking about is nonemergency diagnostic equipment. We should have a more rational way of delivering that so that because my doctor practices at Concordia, I have to wait six months, but if your doctor practices at Seven Oaks, you might only wait five weeks, you know. We are all taxpayers. It is one system, so we would expect some rational way of ensuring proper delivery of service. That is why I put it in that context.

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The member's question, if I gather it correctly, is will the government direct what services will be offered in what facilities? Well, there are obviously guidelines if a facility is going to be a hospital, and I do not mean to put off the member, but I think it is worth just noting. If a facility is going to be a hospital, it has to meet certain standards of service delivery to be a hospital, whatever class of hospital it is or however we rate hospitals. So if you are going to be that facility there are certain things you have to offer to meet. But the question is, in discretionary service, are we going to direct hospital authorities to do that?

There are two sides to that coin. We have appointed regional health authorities and we have charged them with being able to develop rational delivery mechanisms for service, rational programming. I do not want to be in a position as the minister to be second guessing them all the time. I do not want to be in a position as the minister where on every single program issue I have to spend hours and hours to study every detail and make the decision.

First of all, I do not have enough hours in the day. The people that I appoint, ultimately, because these are ministerial appointments, I have to have enough faith that they will be able in their bailiwick to be able to sort these issues out rationally and be able to make decisions. If they are making decisions that I ultimately think are way off base and in the long run are not very helpful, then I should change the board or I should talk to them about it. But, by and large, I want them to sort these things out not because I am evading that responsibility, but the practical matter in so many of these services, and we get this as MLAs, is that we all represent areas and communities.

People can sometimes get caught up in, we need to have a service here today because we have always had it, et cetera, and at the end of the day the numbers, the service needs of a community do not justify it, but it becomes really, to be blunt, a political decision. What I am trying to do here, and we all recognize politics is part of any system when government is involved, yes, but I am trying to take as much of that out as possible, because I do not think at the end of the day that serves the health needs of Winnipeggers all that well, and if we are going to have a system that works, it has to have some rational planning behind it.

Just to give you an example. You know, when the Misericordia Hospital ended its obstetrics, if you look at the number of babies born at that hospital in '92-93 there were 794, less than 800. This year it was 452; that was the number. Last year it was 615. It has been a declining number of births. Some would argue, well, maybe that is because the place has been uncertain in practicing patterns of physicians. Others may argue it is demographics in a community. But there is a constituency for the Misericordia to deliver obstetrics. When I attended their dinner the sister from the Sisters of Misericordia who I sat with reminded me very strongly that the Sisters of Misericordia came to Winnipeg at the turn of the century to look after unwed mothers, to meet the needs, the birthing needs of unwed mothers whom no one cared for. That was their mission. That was their purpose in coming to Winnipeg. That is what inevitably led to the creation of the Misericordia Hospital. Of course, it has grown well beyond that, but that was their need.

She reminded me of that and was gravely concerned, with the closure of obstetrics, that this was not their mission. The fact of the matter though is, the numbers did not warrant maintaining that particular service. The politics said it is great, let us keep that service in that community hospital. The numbers did not warrant it. So these kinds of factors have to fit into making those decisions.

(Mr. Mervin Tweed, Acting Chairperson, in the Chair)

Now, in fairness to the community hospitals--and I do not know what the decision today is going to be ultimately for the Grace. They are down to 1,000, 1,100 births a year there. I am told that we have found, or they have found coverage, or they are working on it. They have identified some physicians to extend the coverage period to the fall to give the Winnipeg Hospital Authority a chance to make a decision as to how they are going to deliver the program, but what is incumbent on us with respect to community hospitals--and it comes back to the member's question, what is a community hospital? As we move to a Winnipeg hospital region, I think the distinction between community hospital and teaching hospital is going to start to change, certainly blur. This is my prediction. The reason being is because programming will be very much controlled centrally by the Winnipeg Hospital Authority. Many programs are going to be one program with a program head, delivered in a number of sites. What I would like to have that system be able to do, particularly with programming that is age-specific or age-sensitive, things like obstetrics, there is only a certain portion or age group of the population that requires that service.

The demographical need for that service around the city is going to shift from time to time. St. James, I understand today, has an older population. Certainly there has been a decline in the need for obstetrics. There are other parts of the city, in the northeast, in the whole south area where there has been big suburban growth, lots of young families. That is one of the reasons why the Victoria Hospital is up, in fact, I think continues to increase its number of obstetrics. It is one of the few hospitals that has because of that.

The Winnipeg Hospital Authority, with that one program delivered in the number of sites, has to have the flexibility over time to maybe change those sites to meet the needs. So at one particular time maybe it will not work at the Grace; it is in the Victoria Hospital. Twenty years from now, 15 years from now that part of the city may be, by and large, an older part of the city, and St. James may be a booming suburb with young families because of how people have moved into that housing and that program may want to move. It may be Seven Oaks, it may be Concordia.

What my objective is in charging the Winnipeg Hospital Authority is to have that flexibility to adjust the delivery of programming, the sites where we are delivering programming as time requires change. Now, in fairness again to the facilities, that does not mean if you take a program out of a facility you are going to have a cavernous empty space where it once was. The challenge for the Winnipeg Hospital Authority is to get the best use out of our space as well. That is another part of their mandate.

If you are going to say we are no longer going to do this service here and we are going to move it over here because that is where it makes sense, the question is: What are you backfilling with? If a population is no longer as large in the child-bearing years but has a host of other issues because they are an older area, then a service should be moved in there that is appropriate.

I do not want to see the time when we have unutilized space. I know at the Grace Hospital, there are three, four, five operating rooms. I look to the member for Kildonan (Mr. Chomiak), perhaps he knows better than I, that are locked and are not used today. Why would we build new operating space in one facility if we have underutilized in another? Is there operating space at Seven Oaks Hospital today that is underutilized? There is as well.

So that is another part of that dynamic that the Winnipeg Hospital Authority--I know we have some major work to do at the Health Sciences Centre, but we will be reducing their operating space. I think we are taking out--how many operating theatres? Two in total, or more, whatever the number is. We are going to be revamping and rebuilding them, but they will have less operating space than they have today. That slack I would like to see the Winnipeg hospital be able to take up an existing underutilized operating space.

They have to be able to manage those things and all those pieces together. The practical matter is, if we sat here as government and said we want this community hospital to deliver this program here, and this one here, and that is your entire mandate, why would I have a Winnipeg Hospital Authority. I am responsible for those decisions. If I have some trouble, I will express that to them but, by and large, I do not think it is appropriate for the minister to be doing all that under a system where we have created a hospital authority. If I am going to do that as minister, then I should be running the system.

Today, I am sort of doing that through boards and through the ministry and through funding. I will tell you the real shortfall in this, and Frank is losing even more hair and I am starting to, it is turning grey, because we are dealing with so many different facilities in a very fragmented approach and ad hocking so many decisions without necessarily rationale, and even the question of obstetrics is a perfect example. It is all tied up in a lot of local politics about what is our community hospital. What should it be? Should we have two teaching facilities and two community, or three and one, or whatever the ratios, and often the logic behind it is lost. What becomes important is the politics of what I have in my community.

I can tell the member, rurally, I have some communities that come in to see me because they want a new hospital. You start asking questions and you realize the current one has a 50 or 60 percent occupancy rate, and they are half an hour in one direction from a hospital and half an hour from another, and they have a thousand or 1,200 people in their community and, oh, by the way, they cannot raise the 20 percent community contribution, it is too high. Well, why is it too high? Because we do not have enough people to raise it.

If you were starting with a clean chalkboard, you would never build a hospital there in the first place. Can you justify building a new one? That is a question, but I tell you the politics of doing that are very good. Is that good health care? Is that good use of resources? I think not.

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So what we are trying to do is deliver a system that is well organized. I accept the member's comment that, yes, I am ultimately responsible if the Winnipeg Hospital Authority is delivering a product at the end of the day, which is election time, that the people of Winnipeg or Manitoba are very angry at, as the party and the government that appointed them and ultimately has to take responsibility for their actions. I, ultimately, when they do that, will have to defend those in the House to your questions, but ultimately if the people are unhappy, they will turf us out and they will put you in, or Mr. Chomiak in, and you can reorganize the system or make those decisions.

But I believe sincerely at the end of the day there will be a logical, rational approach to that, that generally speaking I think most people will be satisfied, and I think to the facilities and the communities around them, that they will not find their facility with cavernous voids where things used to be. What they will see is, from time to time, change in services, and I would expect and hope and have charged the Winnipeg authority to make sure that they are delivering, given the space requirements and given what facilities have--because you know, if you have operating rooms and we want to use them, that they are relevant to their communities as much as they can be within that system. So that is what I am hoping happens. We may disagree on a few things, but at least that is my vision of it.

Mr. Lamoureux: As the Minister of Health speaks, there are a number of things that go through my mind. I would not like to comment on each and every one of them, but, you know, I would put a challenge to the Minister of Health and that is that over the next couple of days--the minister has resources. Certainly there is a lot more than what I have as a critic, and I am sure he will more than acknowledge that. Can the minister and his staff clearly demonstrate that it costs less at the Health Sciences Centre than it does at the Grace Hospital to deliver a baby, and if in fact the minister can say yes to that, if we can actually get a comparison towards the two costs, that would be most interesting to see, and I am prepared to wait a couple of days before I actually receive that particular response, or he might even have it right now, which would be great.

(Mr. Chairperson in the Chair)

He is putting up his hand indicating yes, but I do want to continue on--

Mr. Praznik: Let me just answer this and then I will--

Mr. Lamoureux: So, short questions, sure.

Mr. Praznik: The poor member for Kildonan (Mr. Chomiak) has to listen to our debate.

Again, you know, remember it is easy to say one hospital is cheaper than another or a community is cheaper than a teaching. If you do one birth a year--I am just talking in the theoretics here--at a community hospital and you have a whole ward geared up, staffed, and you do one birth a year, it is the most expensive birth in the province, right? If you have a high-tech, high-end, whatever we call it, tertiary care birthing facility and you put through a high volume of births, you ultimately will probably have the cheapest per-case delivery, and that in fact is one of the issues. However you build your facility, you want to maximize its use.

In urban facilities, where distance is not the factor that it used to be even 10 or 15 years ago, if you have built a facility that has a maximum capacity, you want to get as close to that maximum capacity as possible because it brings your cost per case down. There are always exceptions, of course, in tertiary facilities where you have a premature baby or you have other things.

So part of the rationalization in obstetrics is to take the 10,000 or 11,000 births a year we have in the city of Winnipeg and to be able to provide, given our space requirements and all those other factors of what you need, and staffing abilities, et cetera, to be able to maximize the use of a certain number of facilities to get the unit cost down to your best and most efficient level. That ultimately is part of it because, now, again, you do not necessarily, you do not want bad service and all of those things. You have to provide a good and acceptable level of service, but that is what you are attempting to do. You could operate an obstetrics unit in every hospital but, if you are only putting through 1,000 births a year or 600 births a year, your cost per birth would be probably very, very high. We will endeavour to get some of those numbers.

I am a little reluctant because I always question whether all the costs are worked in, capital and all administrative costs and all those kinds of things, but I am advised that on a per unit case that our tertiary hospitals today have less cost than Grace because of volume. Now, in fairness to the Grace, if the signal has been out there for a few years that they are going to close and obstetricians or practitioners change their practice patterns and they do not get the volume, well, it is very easy to show they are very expensive.

What I have done in buying this time--I hope we are able to buy it. If we cannot find practitioners, they will have to close, but if we do have practitioners, and I am trying to appeal to those who keep making the argument that the Grace should stay open to give them a chance to prove it, to get the numbers up to deliver the service, let us see if they can. That is part of where this is.

Mr. Lamoureux: Mr. Chairperson, it would be interesting. The number, the dollar figure that I would be most interested in is the cost difference between delivering at Health Sciences Centre to the Grace Hospital, and it could be very easily done in terms of getting the numbers up because, quite frankly, a lot depends on the doctors and referrals, availability, convenience, and so forth. What we are talking about is the convenience of the public and what it is that the public ultimately want to be able to have. That has to be factored in. Why does it have to be factored in? Because the minister says, well, the most cost-efficient. Well, some might argue the most cost-efficient health care system would be one huge gigantic hospital in the city of Winnipeg and have all of the services administered in that particular facility, but we decide that, no, we want to be able to have these types of facilities out and about within the different communities. So sometimes it is worth paying that little extra in order to deliver a little bit better of a service possibly to more communities, and that is why I would be interested in knowing.

When the minister said, for example, Misericordia Hospital's births have been going down, well, Health Sciences Centre's births have been going up. Has the Health Sciences catchment area been enlarged? I would argue that, yes, it likely has been enlarged because, at one time, Seven Oaks Hospital used to provide obstetrics services. If you had more doctors facilitating the community facilities, that in itself could see the numbers go up. If the government says that we want to see and we believe that obstetrics can be delivered in our community facilities, well, then, challenge the civil servants and whatever boards might be out there to prove otherwise and then part of proving that otherwise, they can factor in the cost element because, as I stated right from the beginning, I believe that there are biases that are out there that do not necessarily favour community hospitals.

Our job is to hold the minister accountable and the best way the minister can respond to that accountability question is by holding the civil servants accountable and whatever other boards that might be out there. The minister himself said, he indicated that if the regional health boards are way off base, well, then maybe he should talk to them. I guess the question then is, does the minister believe that obstetrics cannot be worked in some other way or facilitated in some other way? Does he have to wait until a recommendation, like if this would have been the Winnipeg Regional Health Authority making this recommendation. The department, within the Ministry of Health, they should have some sort of an idea. I would be interested. The minister did say that he did have some guidelines. If he can provide me with the guidelines for the hospitals in terms of equipment and if he has anything, if the department has anything else with respect to services that he as minister or as government they believe should be provided at our community facilities, I would be interested in receiving that also.

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Mr. Praznik: Just to put some factual information on the record, I think the member may find interesting as do I that from '92-93 until today with I guess our actuals here I noticed the number of births at the Health Sciences Centre has dropped almost 400; St. Boniface has dropped, again about 400; Grace is down between those years; Misericordia was down significantly before its closure. Victoria Hospital is the only one that is up, and it is up a couple of hundred. The fact of the matter is we have dropped down almost I think 900 births in the city of Winnipeg during the same time. Well, 900 births, just looking at the number, is more than Misericordia and almost the equivalent of Grace. So what he is missing in his analysis is the fact that Manitobans are not having births in hospitals--or probably children to the same degree--as they did just a few years ago, so the number of births is declining. If you take out, just a quick look here at my numbers--just looking at those numbers of some 900 births, that is just under the equivalent of one of those community centres.

So obviously you have an issue here, and we can debate a lot of parts of it, but I am just looking at my numbers, so that has to be taken into account of how you manage these particular systems. Another point that I would make that I think the member has to take into account is the two tertiary hospitals in Winnipeg are also community hospitals, in the sense of community, that St. Boniface is a centre for Francophone services for the province. That should not be forgotten and it has that role and it attracts a client base because of it. The Health Sciences Centre as well in many ways is the hospital of choice for the aboriginal community in the province, both from northern Manitoba and again especially because it does have a very high percentage of its customers are from the aboriginal community. That is one of its challenges is to be responsive to the needs of that base. So those two facilities both have a role in that effect.

If I may just get back to a comment that the member made, and I touched upon ever so briefly in my last response, is the lines between community hospitals and tertiary hospitals. I had mentioned that I see those blurring, and I think I should expand on that a little bit. Because as you move to one hospital authority and you get into issues of privileges for practising, specialists and practitioners, generalists, as you get into program delivery as opposed to program delivery in multiple sites, single programs, multiple site delivery as opposed to a variety of programs, instead of having four or five obstetrics units, you have one program delivered in a variety of sites. It will make it immeasurably easier to integrate the teaching university components on a city-wide basis than the way it now currently exists, which are in two so-called teaching hospitals. So the Winnipeg Hospital Authority is, in essence, a teaching hospital authority. Of course, there is lots of detail to be worked out with the university and with the Winnipeg Hospital Authority and with facilities about how you do this, but at the end of the day, whenever that should be, somewhere down the line I would expect that physicians or students or residents or whatever within the system are going to have opportunities within programs that they may not just be at what currently we call the Health Sciences Centre or the St. Boniface General Hospital for that matter, that they will have learning opportunities at a variety of sites operated or working under operational agreements with the Winnipeg Hospital Authority. I make the difference, the distinction with respect to the faith-based facilities.

So that is going to change the way that operates as well. You are really looking at the evolution over a period of time to one more integrated and unified system, taking into account some of those differences with facilities under faith-based principles. But you are looking to one more unified system delivering services to the public in numerous sites. That gives you a great deal of ability to overcome some of those reasons today that you have concerns about community versus tertiary.

The member is very right. I share with him that same concern that there are biases with the system, and there are many who advance the cause of the super hospital; everything at the Health Sciences Centre. That is not what we are trying to see happen. Obviously in our capital program we will reduce the number of operating theatres at the Health Sciences Centre. As we take a whole bunch, refurbish them, they will have less at the end of the day. I would imagine, in fact our intention is to see the Winnipeg Hospital Authority utilize the ones we have already built and paid for which are in the so-called community hospitals.

So, as we integrate these facilities under one hospital authority, I think the distinction between community hospitals and teaching hospitals is going to start to blur a little bit and that will grow over time until inevitably five, 10 years out, or whenever, you really will not make the distinction. They are sites of different sizes, delivering programs for a whole host of reasons: capacity, need in a community that they are nearby, space available, whatever, so that you do not have those kinds of rivalries and those kinds of things, and you are delivering service on a rational basis.

So, the long-term vision, I think, really blurs that distinction. I think I would be loath to get into saying a community hospital should deliver this to be a community hospital. That is going to change, and it is part of a greater operation. I think the concerns about what makes a community hospital over time will also change because the public, I would hope, will find that their services are being met in a very practical way and in a reasonable way.

I might just add, as well, if you do some crystal ball gazing here, it is very likely, as we look at new methods of physician remuneration, as we look at ways of improving service to the public, that space in many of our so-called community hospitals today will see integrated into them physically the community health clinic because it is a centre in that community, not because it necessarily gets taken over by someone but it is a logical place to deliver service, that people may see themselves going to those for much of their primary care that may not involve an overnight stay or even a day-surgery program.

The opportunities are as endless as our imagination and the practical ability to make it happen. So I think we have to start looking at it from that objective. I say to the member, I have been immersed in this for a number of months and seen a lot of these possibilities, and I think as we move to this that people are going to find that this gives us an ability to not diminish community hospitals but make them very relevant. They may not get all the services that they used to get. They may get new services, different services, things may change.

I want a system that is flexible and able to respond to changing needs. I underline the demographics issue because if you look at the history in the city of Winnipeg of demographic change, suburban, core area, different suburbs--St. James, a classic example. During the '50s and '60s, lots of young families, big growth in schools; by the '80s that generation--the kids were now grown up; people were still living there. It was their home, a much older area--closure of schools, different health needs. I would suspect in the next 10 or 15 years a lot of those people will choose other kinds of housing as they get older. Those homes will come on the market. If they are bought and become a preference for young families starting out, you could have a whole other new baby boom in that part of the city while in another area you might have a decline, and the hospital authority has to be able to maybe alter its resources around to meet those kinds of needs. I am hoping, at the end of the day, that is what is going to happen. I would not want to see those dictates made strictly because of the politics and the debate of what goes on, and I think the public, as we get into this, will be more comfortable with that approach.

Mr. Chomiak: I am just wondering if we should just take five minutes for a break.

Mr. Chairperson: Is it the will of the committee to take a five-minute break? [agreed]

The committee recessed at 5:08 p.m.

The committee resumed at 5:20 p.m.

Mr. Chairperson: Order, please. The honourable member for Kildonan, I believe, has the floor.

An Honourable Member: No. Inkster.

Mr. Chairperson: Okay, the honourable member for Inkster.

Mr. Lamoureux: Thank you, Mr. Chairperson. I appreciate the flexibility and the name change there.

Mr. Chairperson, just prior to breaking we were having some dialogue with respect to what I refer to as guidelines, and I guess I would emphasize to the minister that I really do believe that you need to have controls from within the system in which we can feel comfortable that any expectations the government might have of these regional boards are in fact being met. The best example that I could give is what we were talking about for the last 45 minutes, and that is, if the government believes in community hospitals, it has to be able to clearly demonstrate that belief to the regional health authority. If it does not do that and it does not give it some direction, what I refer to as some basic guidelines, then I feel a little bit uncomfortable primarily because you have what I believe is a very fairly significant potential of having a bias which would be to the detriment of some facilities.

It is not to call into question the integrity per se of individuals, but it is just to realize what I have experienced by having discussions, and I think the minister himself has acknowledged this to be the case in some areas where there has been a bias. That is the reason why I requested the minister to provide some sort of, whether it is government policy, government guidelines. I am not too sure exactly what it is that the government would have that, in essence, sets the course of what they believe community hospitals are about and the type of services they should be delivering, so that one day we do not look at the Seven Oaks Hospital, for example, and it is doing something which is completely politically unacceptable.

An easy way of getting an overall assessment with--such as strictly geriatric care. A good way of getting at the core of the issue, if you like, is to say, each facility, when we started talking about the health care reform in a very significant way, in terms of with respect to acute care beds and the closing of potential hospital facilities, at that time, and this would have been I guess November of '95, and the Health Sciences Centre had 854 beds, St. B had 557, Seven Oaks had 290, the Grace had 261, Misericordia had 224, Victoria had 221 and Concordia had 136. We had a total number of 2,543 acute care beds.

The discussions that I had with the previous Minister of Health was that we have too many acute care beds. At the time, I concurred with the minister. We did have too many acute care beds and we needed to work that number down, and there is a reason why we had too many. There is a lot more ambulatory type care out there today, but if you do not have those control mechanisms, if you do not have some sort of basic beliefs on what those community facilities should be providing, I believe you are giving just too much control over to the regional health boards and you are going to be reacting far too often and potentially trying to pass the buck in terms of public opposition to something that is happening from within the health care services.

I think the very best or one of the best examples that I gave already and would reiterate by just stating is that of the obstetrics. The government needs to give more direction, and that is why I ask if in fact they do have anything of that nature so that the regional boards have a basic idea of what they are supposed to be doing.

Mr. Praznik: I appreciate where the member is coming from and the balance that one has to strike. I would concur with him that I think within the system one can see individuals who do have that view, whether it is expressed directly or privately that so many more things should be centralized in one major facility. There are others who have argued with me that no, many more things can be decentralized, and the debates are made each way and yes, one does not want to see a system where everything ends up being centralized, and what we today call community hospitals have an extremely limited role within the system.

What I do not want to do is--and again, it is finding the right way to balance things and that is what I suggest the member is getting at and he has proposed, if I read him correctly, we put some guidelines and some direction as to this is what we would like in so many centres and where we want them directed.

I am a little loath to do that, but I recognize his concern that is there. One of the things we have done and are doing in establishing the board is that we have canvassed each in terms of the Winnipeg Hospital Authority which I think, where this is a really critical matter, it is not so much the issue with the long-term continuing care board but with the hospital authority for Winnipeg. We have as we did rurally--trying to balance the boards to make sure that a wide variety of interests are represented on them.

The Winnipeg Hospital Authority, we approached each of the current nine facilities that will be operated under this new regime either directly or with operational agreements. We approached each of those to provide me with three names for a nomination. We have gone through that list with cabinet, and as each of those facilities works out its intention with the Winnipeg Hospital Authority, whether it be to evolve into it directly or whether it be to have an operating agreement as the faith-based facilities agreement calls for, once that direction is there, we will be appointing from their list of nominees one of those individuals to be on the board. So the board, when it is completed through this transition year of its 21 members, will have at least nine who are from facilities. So the so-called community hospitals today, the two long-term care facilities will have people who have--in fact, I think all of their nominations were people who serve on their current boards. So they will have individuals who come from that, which I think will give a balance.

The community people whom we have appointed, several of them are fully cognizant of the need to have that balance. So we are trying to ensure that the blend or the flavour of people on those boards will be reflective of that balance so that that becomes part of their decision making.

I know, in terms of the chair and the two vice-chairs of the Winnipeg Hospital Authority, the current chair, the first chair, Mr. Neil Fast, is the outgoing chair of the Concordia Hospital; M. Paul Ruest, who is a vice-chair, comes from St. Boniface, although a teaching hospital but very much a community hospital for the Francophone community; and Mr. John Langdon, who comes off the Victoria Hospital board, again another community hospital.

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So, although Mr. Gordon Webster was a vice-chair of the Winnipeg Hospital Authority, is now CEO, the chair and two vice-chairs of the board are very much from a community hospital vein, and I include M. Ruest in that. So, again, that gives that balance, and I know in discussions I have had with them, you can see that balance starting to come out as they deal with issues to work them through. So I am hoping that addresses some of those particular concerns.

What we cannot know going out into the future, particularly in a field like medicine and health care that is so much tied to technology, where technology is moving to such a rapid degree, we do not know five years from now or 10 years from now entirely the opportunities that technology will give to provide service differently. What I do not want to tie today--and if he detects a reluctance to say, yes, we are going to say these are the services that will be provided in these facilities, why I am reluctant is not because I do not want to do that, not that I am reluctant to see obstetrics delivered in a number of sites, the community hospital system that the member is talking about, it is because if you asked me to characterize how I envision this regionalized system, what my personal flavour that I would like to give this is I would like to have a system whose primary characteristic is it is extremely adaptable to change.

Let me just expand on that a moment, because I think it is important to understand what I mean here. That is not to say a system that is very likely to continue downsizing because of budgets, that is not what I am talking about. I am talking about adaptable to change, whether it be change driven by technology and a new piece of diagnostic equipment, for example, or a method of treatment can dramatically change how you organize the delivery of that service. We have seen that time and time again in health care. Laser surgery, for example, has dramatically changed the way we deal with surgery, because it has taken it from being a very intrusive big-cut method, long hospital stay to make many, many surgeries, day surgery, short-term stay. That has had effects on how many personnel to deliver that service, how you deliver it, a greater need maybe for home care, all those things. It has revolutionized, to some degree, how we deliver that service, also demographics, changing needs of a population, demands in a population because of demographics.

So I would like to see the system, and the flavour I would like to give it is that it can adapt to the changes that are required to meet technological change and demographic change in an easy manner, so that every change does not bring a jolt to the system. It does not result in a major hardship for anyone, does not result in battles within the system, but the system can change to meet the demands of changed technology and demographics easily and remain effective and does not require reviews and huge interventions to make change happen

Today I would argue our system, the way it is structured and the components of it, change does not come easily. It is not well structured for change. One particular area that I flagged--and that is why I have an associate deputy minister for human resources--one area that we probably, collectively across Canada, have not managed well is human resources change in health care, and I do not blame anyone for it. We have organized on institutional basis, our collective agreements that we have been known for, of course, labour relations get organized, how we organize the system.

Our collective agreements, when they were originally negotiated, I do not think ever contemplated massive change in the system. So we have collective agreements and systems with respect to seniority, within the system, with bumping privileges. I know talking to some who have been in the system for over 30 years, they tell me one of their greatest difficulties in making change is that the system makes it difficult even to move people from one floor or one ward to another. You set off a chain reaction in seniority rights and bumping, et cetera, that make it extremely painful for not only the administration but for all of the people who deliver the service.

If you try to be able to move a program or a piece of equipment from one facility to another--the public out there thinks we can move a program--and the one I have been talking about and very, very valid is heart surgery. We have a heart surgery program, one program delivered in two sites. Today, we are under pressure at Health Sciences Centre, because we do not have enough intensive care space to maximize the surgery program there. We do have capacity at St. Boniface Hospital. So the people who would run these programs say the logical common sense answer is move a surgical team from one facility to another so that we maximize our intensive care needs at St. Boniface and continue to maximize the number of heart surgeries you can do. It sounds simple. The public out there thinks we can do it, because it makes common sense.

The reality of it is--no one's fault--that our labour relations structure means we cannot move a team because the employing authority issues; and only in a real crisis, I guess, like a flood, we were doing that. On a temporary basis we can do it, but we cannot do it on any longer basis than that, so it makes no sense. What I am hoping that we can get out of the system is we can deal, and I have spoken to some of the labour leaders in health and they recognize that. It is not going to happen overnight, and it is going to take a lot of time to give people a comfort level and work out seniority issues and other things. But I am hoping over a number of years that we will have a system that allows us to be able to move people around that system, respecting their rights and their concerns and seniority but giving the system the ability to be able to move people as we best need them without having to lay them off, delete their positions, ask them to re-apply, et cetera which does not make any common sense for them or for the system.

That is one area that I make reference to, so I am looking to see us create a system that can deal with change easily and be able to move our resources around the system, within its facilities, between facilities, to be able to deal with those changing needs that are going to be there because of technology and demographics. So, if I seem reluctant to spell out specifically what I want where, it is because I am trying to build a system that is flexible for the long term. Yet, I appreciate the balance that the member talks about. Yes, I would not want to see the Winnipeg Hospital Authority say our community hospitals really are all going to be single-purpose geriatric facilities, or single-purpose whatever facilities, that there is a community around that hospital that views it as its primary centre of health care, that that has to be worked into the planning, and we are ensuring that there will be enough people on that board to give some balance. Ultimately, that is some of the charge and direction I will give to them. Some of it may appear in writing. I will be looking at their decisions and operations, but I would not want them to expect that the planning will really be done by the minister and they will just administer it. There has to be that right balance.

So I share his concern. I guess, what we are really debating is the best way to give it effect, and I appreciate there are differences.

Mr. Lamoureux: Mr. Chairperson, I did want to move a little bit over, but before I do that, just very briefly. The types of commitments that we talked about in obstetrics, there are other things such as number of operating rooms in a particular facility to emergency services. These are things, to a base number of acute care beds, where the government could give some direction and the regional boards would then be obligated to follow that. I really do think that this would, in the long run at least, allow for some accountability in terms of what is actually occurring or more accountability in terms of what is already there.

The minister--and this goes on to the regional boards themselves--made reference to some individuals who were on the board saying they are from this community hospital, this person is from that community hospital, and so forth. I would be interested in knowing if anyone, for example, who sits on the board lives in the north end or lives out in the Elmwood area or in the Rossmere area, because that is something that also needs to be taken into account, and the minister can respond to that if not today maybe some other time.

The idea of elections of these regional health boards has been something in which we have advocated, and I must say right at the beginning we did not want the regional boards in the first place. Having said that, the idea of having these regional boards elected is something in which we believe the government should be moving on. The government's response to that has been, well, what do the Liberals have to say of taxation rights and, quite frankly, I do not believe it is necessary for them to have to come up with the dollars or levy the taxes, and the minister might have some problems with that. That is a point in which we might agree to disagree on.

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But there is something that the ministry can and should be doing and that is moving much quicker towards some sort of an election of the super boards. Now, it can take many different ways it can be done. When I was in Quebec, it was interesting to find that some of the elections were done through professional groups that would through a nomination, in essence, they would elect a person who would be going on to that particular board. The government of the day has a certain number of appointments to that particular board also. So there are many different ways in which we can ensure that the minister, ultimately, will have the influence that is necessary or through the minister's office having that necessary influence but to the degree in which they have it currently. I do not believe if you want to try to say that, look, these regional health boards are going to set the future direction or they are going to be, in essence, the deciding group that comes up with ultimately recommendations because that is, in essence, what they would be because the government minister could overturn them. If these regional boards are going to have that, then why not allow assurances through some form of elections that we are getting individuals that are on there in which a wider number of people would be supportive of? In Saskatchewan they tried something in terms of direct election right from the public as a whole. That might be a way of doing it. There are many different ways that could be approached.

We had suggested to the minister a while back to include it into the municipal elections. We have municipal elections coming up in 1998. If not all, a percentage of the board members could be elected much the same way in which we have school trustees that are elected during municipal elections. That could be taken into consideration. You are going to have a much higher turnout, I would ultimately argue, than what Saskatchewan had. If the minister's concern is in terms of having that direct government input, you can have a certain number of them being elected and a certain number of them being appointed, but what we are not hearing from the government is anything other than, maybe someday in the future we will have them elected.

That is in essence all we are really getting from the Ministry of Health. I think that what we need to hear in a more tangible way is what the government is doing to ensure that there is going to be broader input brought into the process through some form of an election, if not in whole, at least in part for these regional health authorities. That applies both to rural Manitoba and the regional health boards in the city of Winnipeg.

The other thing that I would like the minister to comment on is the current boards. I know the member for Kildonan (Mr. Chomiak) has brought up to a certain degree this particular issue and especially those based on Christian faith or other faiths, if you like, that are already today on boards or make up the boards of some of those 150, 160, 170, 180 boards that are out there.

What sort of a role do they see them playing? I say that thinking of the government--the Minister of Education, Mr. Manness, had, the report escapes me, but it in essence said, you have parent advisory councils, and here are the responsibilities of parent advisory councils, here are the responsibilities of principals, here are the responsibilities of the school divisions, here are the responsibilities of the Ministry of Health.

Do the minister and the department have something of that nature? I am interested in hearing some very specifics. Again, because of the time, and I think both the member for Kildonan and I really to a certain degree regret we could not have more time in the Estimates to deal in more detail on some of these issues, but I am interested in knowing if the minister does have these? Great, maybe he could table it now. If he cannot table it now, it would be nice to be able to get these sometime before, let us say, the end of June. If he does not have them, maybe what the minister should be looking at is trying to convene some sort of an open public meeting that would facilitate people to have some input on the type of responsibilities, if in fact the minister currently does not have them, or at least indicate to us to what degree he has been soliciting for input on it.

With that, I am sure that will likely be my last question for the day.

Mr. Praznik: First of all, I would like to deal with the issue of elected versus appointed boards. We have debated this in Question Period in our exchanges, both him and the member for Kildonan, on numerous occasions. We have some very fundamental differences in principle. We have acknowledged that. We agreed to perhaps disagree. I think they are very fundamental to the success of any board, and I would like to discuss that somewhat.

First of all, by way of context, let us not for one moment dismiss or ignore the reality in which we operate today. There are virtually no popularly elected boards in the province of Manitoba delivering health care. Many of the boards that we have are self-perpetuating boards, in many cases. Some of them, in fact probably the vast majority, are municipal based where the municipalities who are elected appoint representatives to their board. That is the case outside of Winnipeg, largely. They appoint representatives to their board and they are ultimately responsible for the deficits of those facilities to go back to their taxpayers to raise the dollars. So there is an accountability.

There are many organizations that own or sponsor hospitals, various religious orders, for example, that do that. They ultimately appoint as the owners of facilities of those boards, because they ultimately have a financial accountability and responsibility for those facilities. They are not elected boards.

We have some that I consider to be very strange, actually, not by way of history but by the reality of today. One was the former Dauphin board. I think something may be similar in The Pas where they have an incorporation and are run by, in essence, their governors. In the case of Dauphin, I think anyone who lived in the community who paid a $5 annual fee became a governor and then the governors elected the board of directors. In the case of Dauphin, I think you had 43 or 46 governors of record, three of whom had passed away in the last year who contributed their $5 each and were responsible for running a hospital for 14,000 people, the funding of which all came from the public.

So let us make no mistake about it; we do not have a system today of popularly elected boards across the province where the public are voting for their administration of health care, the people who would be administering it for them. They are not. So the creation of our regional health boards is not taking away something that people have today. It is replacing it, to some degree in many areas, certainly in rural Manitoba, with publicly appointed boards that the elected officials appoint.

Previously, and as I said, in rural Manitoba in most cases it was municipalities, elected municipal people who appointed the boards, and should there have been a deficit it went on their taxpayers. So today the provincially elected people are appointing the regional boards, and if they are in deficit or in financial difficulty the responsibility comes back to those politicians. So I do not want it to appear that people are somehow losing popularly elected boards today or directly elected boards. They are not.

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When the previous minister drafted this legislation and brought it to the House, I remember this debate quite well. We had it in our caucus and we saw it move to the Legislature, and the bill in fact does provide for appointment initially and at some time in the future for election, and that is a decision that at some point may be made. I do not disagree with that. There may be a role for popularly elected health boards. I do not oppose that, but I think one has to have some parameters around it to make it work.

First of all, I do not think you would get a disagreement from me or anyone else that, if you decided to have popularly elected health boards, it would be inappropriate to elect them at community meetings, because that is not in effect a one-person, one-vote system. That is who goes to the meeting and it is very open to various interests groups.

I think the community of Dauphin over the years, the member for Kildonan (Mr. Chomiak) may remember, from time to time in Dauphin the battle over whether they will do abortions or not in the hospital broke out in terms of who bought memberships to be governors and meetings to elect boards of directors. That was not a democratic decision in the sense that the 14,000 people who live in the region participated in. It was those who had their various interests. So that is not a way to do it.

So, if you do move to popularly elected boards, then you have to have an elected system with secret ballot where everyone has a chance to vote, and the most easy way to do that, I suspect, is to have it at municipal election time and elect health trustees. You would probably have to devise wards to ensure that there was a distribution of members throughout your region to elect health trustees. It is all easy to do from that perspective. There is some cost, but that is fine, and you could do it very easily as part of your municipal election process. We do not disagree with that. In fact, the act anticipates that.

The difficulty comes in in terms of responsibility and authority. When you appoint someone to fill a role, unless it is an arm's length role with no ability to remove them, et cetera, such as a judge where a person has true independence, they are ultimately--if you have the power to appoint them and remove them--responsible to the person or group that appoints them. When you are elected, your responsibility is to the people who elected you, the constituency you were elected to serve. The boards today have a mandate to organize and implement regionalization. They are responsible to me as Minister of Health and I to the cabinet in the Legislature for that task. If we were to move to an elected system, those elected would be responsible to the communities directly that elected them.

The Ministry of Health is the funder. I have the financial responsibility with the money voted by this Legislative Assembly to deliver health services. What, in essence, I would be doing in that case is contracting with those boards to deliver that service. Those boards, if they should overrun the contract price or not deliver the services as per the contractual agreement that I was prepared to enter into given the mandate of the Legislature to spend money that I have received, would have no means to make up the difference or to be financially responsible. They would require, just like school boards have today and municipalities who are also a creature of this Legislative Assembly--they have no constitutional standing other than an act of this Legislature. They have, granted by this Legislature, a taxing authority. They have the ability, the responsibility, in fact, to go back to the people who elected them to meet and be responsible financially for the decisions that they make.

We were all elected and as elected people we have a taxing authority, and I believe--and this is where the Progressive Conservative Party differs significantly with the Liberal Party on this issue--[interjection]Yes, we did freeze it one year with respect to school divisions. We did, because they are, in fact, a creature of our Legislature, and we have a right to do that. But, ultimately, if we were to create an elected body responsible to their constituents, as they should be, without that financial taxation relationship, I would think--and from the experience of Saskatchewan--we are setting up a relationship that is not at the end of the day going to be as productive as members of the Liberal Party would suggest.

So that is why the point I have made is the day that we decide that we would like to move to an elected health care system, and I would argue very strongly--we may disagree on it--that the time to do that is once you have established the regions, gone through all of the issues of regionalization, of getting communities to think regionally, of working out all the battles of communities that happen in that system so your system is now functioning, I would suggest that is the time to look at moving to publicly elected boards, broadly based elected boards--I am not adverse to it--but with that must also come a financial accountability of the boards you elect.

You know, in a small way, I saw this in my own constituency some years ago when we were amalgamating. We saw the Lac du Bonnet District Health Authority, which was appointed by their municipalities, and the Pinawa General Hospital, which is appointed by the LGD of Pinawa when they were amalgamating to create the Winnipeg River Health District, and they looked long and hard at the issue of governance and how the Winnipeg Health Board would be appointed, and very much they looked at electing board members actually by way of community meetings, et cetera, to serve on the board.

Then they started, because the municipalities were the founding groups here, to recognize that in doing so, they as municipalities, three or four municipalities who constitute that health district, had a financial responsibility that they were going to turn over to people who were elected in the community and they financially would have to answer to the taxpayer for the decisions of that board who did not have to stand there to defend their decisions. It was amazing how quickly that board decided, no, no, if we have to go back to the taxpayers for the decisions of this health authority as municipal people, then we will appoint that health authority, because if they screw up, we can remove them. If they make errors we have to go back and explain, they should be our appointments. So although not all the board appointments were councillors they were appointed by their constituent municipalities.

We believe in this party that it is a fundamental part of democracy that there should be a taxation power or authority that goes with elected office, so that people who are elected are responsible to the taxpayers for their decisions. That is one of the fundamental reasons why in fact the Senate of Canada does not have the power to defeat a government on its money bills, because it in fact has no direct financial accountability to the taxpayers, because it is not elected. It is a fundamental principle.

If we are at some point to move to elected boards, and I can envision that happening, then with that, like school trustees, would have to come some power to allot a tax levy should that in fact run a deficit or badly manage. Because, remember, if they are badly managing their district in their three-year mandate, the minister does not have the power to remove them, because they are elected, nor should I have the power to remove them. But an appointed board that I am today responsible for, I have that power to remove them. So right now, the trade-off is, if you do not want me to have the power to remove them, and they would have the longevity of their term, they have to have the power to go back and be responsible directly by way of taxes for their errors and mistakes to their ratepayers. We may disagree fundamentally on that point, and I accept that, but that is the logic behind that.

The mechanism for election, I do not think the three of us as critics and ministers would be far off on agreeing on an elective system. The only probably controversial issue would be where you draw ward boundaries within the health district, and that will always be controversial. The method would not be hard, how you do it would not be hard. The one fundamental issue is taxing authority, and I recognize that. It is our position as a party and as a government that with elected office would have to come a taxing authority. By the way, the Union of Manitoba Municipalities, when we have discussed this with them, in exchange at meetings, I do not think they are particularly too keen on seeing another taxing authority.

Mr. Chairperson: Order, please. The time being six o'clock, committee rise.