Mr. Chairperson (Ben Sveinson): 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 the item 1.(b) (1) on page 68 of the Estimates book. Shall the item pass?

Hon. Darren Praznik (Minister of Health): Mr. Chair, I believe we are still proceeding kind of in a general way, and I know the member for Kildonan (Mr. Chomiak) asked for certain areas he wanted to cover in the areas of physician remuneration and some of the labour relations issues, so I am pleased to introduce today my new Associate Deputy Minister for Human Resources and Strategic Planning, Roberta Ellis, no stranger to these committee rooms, and also a very familiar face in government, the former Associate Deputy Minister of Finance, now our Associate Deputy Minister of Internal Operations in Health, Mr. Don Potter. He joins us here, as well, today.

At the back of the room, we have Mr. Doug Hardy and Ms. Barb Millar who are on the professional remuneration staff, part of our negotiating team. They join us here today.

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Mr. Dave Chomiak (Kildonan): Mr. Chairperson, I thank the minister for accommodating us with respect to our questioning. I have had discussions with my colleague the member for Inkster, and he is going to be--the initial portion of this afternoon's questions, he will be asking general questions in some of his areas. After he completes his questioning, I will then proceed down the road that we had indicated last week we would be proceeding to question on, so I thank the minister for providing that.

Perhaps at this point then, I will turn the floor over to the member for Inkster to pursue his questioning.

Mr. Kevin Lamoureux (Inkster): Mr. Chairperson, I did want to go into a couple of lines of questioning. One is to pick up where I left off with respect to Question Period. I am surprised and quite disappointed with respect to what seems to be the provincial government's position with respect to transfer payments. We could talk endlessly about, well, this amount of money has been cut, that amount of money has been cut, some has been reinstated and so forth.

I would just as soon put that issue to the side and talk strictly with respect to trying to get a better understanding of what the government's position is exactly with respect to cash transfer payments.

Does the Minister of Health believe that, in order for the federal government to ensure standards, there has to be a significant cash component in transfer payments?

Mr. Praznik: Mr. Chair, first of all, two issues and they are related. I gather that from the member's question and the way he has put the question. First of all, the issue of federal support, the means by which the federal government provides financial assistance to the province.

As the Minister of Health, my role is to identify the need, how many dollars I need to provide an adequate, appropriate, efficient level of health care services to the people of the province. As Minister of Health, I go to Treasury Board. How they find that money, I leave to them. I need a certain amount, and my role is to figure out what that amount is.

How the Treasury Board and the Minister of Finance (Mr. Stefanson) are able to secure those dollars, through whatever means fits into an overall financial objective, whether it is cash transfers, taxation, tax points, et cetera, I will leave to him. The minister has that responsibility to find the supply that is necessary to meet the demands of this department. So I will defer that specific policy issue to the Minister of Finance, because its his role and responsibility to find the dollars I need.

With respect to tools for the enforcement of national standards--and I gather the member's point is that having a direct tie of cash transfers, where there is money that has been moved from taxpayers across the country through the national Treasury to be delivered to provinces, provides a stronger vehicle, at least a morally stronger vehicle. To provide a lever to ensure the provinces are meeting whatever the requirements the federal government so chooses in exchange for receipt of those dollars is a better vehicle, in the view of the member, I gather, than the transfer of tax points to a province which allows us to collect more of the money raised in our own province, although there can be a legal requirement to those tax transfers.

In fact, the federal Leader, whom I supported in the election, talked about transferring more tax points and as a prerequisite for that making a commitment to meet some uniform standard or level of service across the country. So I guess you can do it with tax points. I guess the member's point really is more along the line of which he views as stronger and probably a greater moral obligation to provide.

But let me say this. The real question for a provincial Minister of Health is what role a federal government has in setting standards. I can tell you that my experience in these months with the federal government--by the way, I have never had the opportunity yet to meet Mr. Dingwall, and I gather after last night, I will not unless it is on a social occasion--but, Mr. Dingwall I think is representative of a fundamental problem in many a federal government. He viewed that he had--[interjection] The member says he liked Mr. Dingwall. I have never had an opportunity to form an opinion on a personal basis.

Mr. Dingwall, who set out some months ago across this land to sell the Liberal government's health care agenda, one would think that he would have taken the time when he arrived in Manitoba to promote his plan, would have put on the top of his list the first visit to the provincial Minister of Health who has the responsibility of providing, administering, delivering the vast majority of health care in the province. Uh-uh. Mr. Dingwall and his staff did not bother to call to arrange a meeting.

I was asked about it by the media. I responded to the media. I made the same point then as I make today. Mr. Dingwall's staff called me, called my office, asked if I could meet with him that day. I was in the middle of a major meeting with regional health authorities, said I would be free in an hour. He said, too late, we are getting on a plane; can we come right now. He had only planned his trip for I do not know how many days. Well, we could not come right now because I had people who travelled a long way for that meeting.

He came back during the election, visited Concordia Hospital. I met with their board shortly after. They were under the impression that there were all kinds of federal dollars to save Concordia. The federal minister never met with the Winnipeg Hospital Authority, which now has a significant role in delivering services. He went to visit the Concordia Hospital--I imagine it was political reasons--but, again, never bothered to stop in and say hello or to chat.

I would hope whoever the Prime Minister appoints as the new Minister of Health would do the courtesy of visiting their provincial counterparts and entering into some real discussions of how we can work co-operatively. I would say to each of the Health critics in the four opposition parties that they are equally welcome in my office, whatever their political stripe. I am more than prepared to offer my thoughts and opinions that they might find useful, because it comes down to the essence of the member's question, the imposition or enforcement of national standards.

What are national standards? Where will they be of benefit? For us in Manitoba, we have heard the Liberals campaign on a national pharmacare program of some sort. Well, I will tell you, they are never going to find the money to be able to match the program we have today in Manitoba.

Whether we argue whether it is adequate or not adequate, it is still one of the richest in the country. So if they are prepared to write us a cheque for new money to pay for it, I would be glad to accept it, but if they are talking about including it in medicare, they are going to tell me what we have to do with our program and then not put any new money in it but stretch the existing money farther, I think that does nothing to enhance medicare; it serves to diminish it.

The same thing is true in home care. Each province has developed what it can afford and what it finds useful in its own model. For Manitobans to have the federal government walk in and offer some standards in home care, again and not add any new money, I do not think serves any purpose whatsoever. They are just stretching the dollars that are there.

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There are at least six or seven areas that I have identified in my few short months in this job where a federal government can have a huge and productive role to play in delivering some national direction in health care, some very practical and useful areas. For example, in the pharmacare area, we are as provinces crying out to have a better mechanism for sorting out the value of drugs to include in our Pharmacare program and also to negotiate better prices with drug companies.

I have one on my desk this morning, a case where we are looking at how we are going to handle what we view to be a particular drug that is priced beyond what it should be, and each province's committees are recommending that we put a cap on that drug. Well, I will tell you, if we had a national institution of some sort where we negotiated for drug prices with the power of 30 million people instead of one million people, we would have a great deal more clout in working to get certain drug prices down because we had a common buying approach and could guarantee a certain level and have some negotiating clout. That is one particular area.

In the area of aboriginal health, the federal government has a direct responsibility. When they talk about finding two or three hundred additional million dollars for pilot projects, I would gladly not have a penny of that if it was to be directed into dealing with aboriginal health needs in First Nations communities, developing and funding on a regular basis a home care program for First Nations people, better public health, which they now do provide the service but I would argue not adequately.

So if the federal government is serious about improving the health care of Canadians and developing some national approaches, there are a lot of very legitimate areas which they can be in that I would welcome them in rather than getting into the saviours of medicare when they continue to diminish our funding. We know that is a reality of federal budgets but do not try to be two different things.

Mr. Volpe, I think it is, who is the parliamentary secretary to Mr. Dingwall, who I note was re-elected last night, and I had a brief conversation in Ottawa to this effect. I invited him to visit me, and he might do that after the election, and we will share some of those ideas.

So there is a legitimate federal role. I think the issue of tax points versus cash is one that is best for ministers of Finance to work out. The need for federal governments to set national standards, I think, is passing very quickly as an issue because we are all delivering, by and large, pretty good health care needs out there, and there are areas that the federal government should be involved in that they are not.

So it is a long answer, but I think it puts things, I hope, into a better perspective for the member.

Mr. Lamoureux: Can the minister indicate the cash transfer from the block funding for the 1996-97 fiscal year?

Mr. Praznik: I am going to quote on a national basis from a renewed vision for Canada's health system which was a conference of provincial, territorial ministers of Health. It is interesting to note here again, you know, if health is truly a federal-provincial partnership, even if the federal role is a declining one in cash, the Prime Minister, surely to goodness, should have acceded to the request of the provinces and territories to co-chair the federal review committee that he put in place, but he did not because, really, what was it? It was a Liberal election ploy to say, we want to be saviours of medicare. He did not want to share the chairship of that to get down to a serious discussion.

But in the document that was put out by the Conference of Provincial and Territorial Health Ministers that federal cash contributions to provincial/territorial medical health expenditures in total from 1977-78, which was the introduction of EPF block funding, they accounted for 25.9 percent of our expenditures. They rose to a high of 27.9. They have been in decline ever since '79-80, and '95-96 they accounted for 15.6 percent of total health expenditures.

Now, I recognize very fully within this mix that part of the federal government's argument going back to the '70s and '80s--that is, wherever they provided dollars on a you-spend-it, we'll-pay-half basis--they had no control over those expenditure levels. Built within the Canadian health care system, I think if you study it going back to the 1940s, you discover that various federal funding contribution plans were predicated on building and funding institutions and that, whether it be back in 1948 when the federal government provided assistance to municipalities--I think it was 50-cent dollars--to build hospitals, in the early days of medicare it was 50-cent dollars, by and large, for hospital and doctor services, not personal care homes or home care or those things. No one's fault, but we had a funding formula that was institutionally driven, used to pay 50 cents on the dollar, I guess, for those things, but when we got to this new method of funding that created the block with wider parameters, that percentage, obviously, was going to fall, and you want to make sure you are comparing apples to apples.

At the end of the day, you realize that the federal government never had control, by and large, on how money was spent. They had to move to another way to force the economy and savings. It was not until that happened, when the provinces did not have sort of a guaranteed 50 percent commitment for institutions, that they started collectively to start addressing the need to move from institutions to community-based care, where we probably should have been 20 years earlier.

Funding models often do drive systems, and I would hope that they would always be as neutral as possible and also encourage people to find efficient ways of delivering things. What we take great offence to is when a Liberal Party or any party gets up and wants to be the saviour of medicare, impose a host of standards on delivery and pay less and less money and take the money they are paying and add to what we are supposed to provide under their rules with the same dollars. That is what we find offensive.

Mr. Lamoureux: Mr. Chairperson, I do not know if the minister is saying it or if I am the only one at the table who is seeing it. He is, in essence, starting now to touch upon the reason why the cash transfer payments are important. You make reference to '77-78 of 25.9, to '95-96 of 15.6. What the minister did not recognize is something which I personally oppose and as a political party in Manitoba that we feel is not in the best interest of health care, and that is, back then they gave the provinces tax transfer points.

Those tax transfer points were very real back then, but governments--and you are not the only Minister of Health--ministers of Health prior to you acknowledged that those tax points might have been there, but they do not acknowledge that since then, I believe--and I am just going by my figures--it was over $400 million that have gone into those transfer payments, but those are never recognized.

So how can you enforce when you do not even recognize, and if you continue to move in that sort of a direction, well, the role--because as the minister himself points out, we are now at 15.6, and the lesser amount of money that is being coughed up from Ottawa, the less attention the Ministry of Health is going to give, I would ultimately argue.

I would also argue that it is the federal government that should be paying the lead role in health care in ensuring that there are standards. That is the reason why I believe it is absolutely critical for them to maintain that cash transfer, and I was surprised when the Premier last week had indicated that at least it gave no reason for us not to believe that his position is that it does not matter for him, that he would be quite content with the tax transfer points. I think it is a critical issue, and the reason why it is a critical issue is because we are going into all sorts of discussions in the future with respect to constitutional devolution of powers. We see it in different areas, and I am suggesting to this Minister of Health that it is not acceptable to see any continual shift or decreases to the transfer payments.

I would ask the minister if, in fact--like, the number that I was given is toward that block funding; it is approximately $603 million for '96-97. The tax transfer payments come up to somewhere around $432--or not the cash transfer. The tax points are somewhere around $432 million. Now, that is for the block funding, not just Health. The department or the Treasury Board determines where it is that it goes, so I would ask if maybe the minister could comment on the legitimacy of those two numbers that I have just pointed out.

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Mr. Praznik: Without accepting the accuracy of the member's comments on those numbers, we will endeavour over the next while, I will have my ADM, Associate Deputy Minister of Finance, check those numbers with Treasury Board. Obviously, you have to be fair on these things; if there is a transfer of tax points, that accounts for something.

That happens and has to be worked into the system, but ultimately, I think where the role of the federal government exists, the member talks about standards. I have heard that term used ad nauseam with respect to federal governments, and when I ask my staff what standards does a national government have imposed on us or required us to meet in delivery of service, the reality, most of them, if any, have to do really around the area of payment, private clinics, private hospitals, who can pay and how you pay, but when you talk about standards of health care and delivery, you are talking about the way in which you deliver or provide service and what you have to do to meet and accept providing an acceptable level of service.

We do not have any of that going on. I have not detected any interest by a national government in developing a common sense of standards in delivery in the true sense of the word. I have heard a lot of rhetoric. I have heard: We are going to guarantee medicare for all Canadians; we will set standards. I have heard that from his former leader, the former member for River Heights.

The reality of it is, other than paying and co-payments and those types of things, there has been a decided absence of the federal role in developing those standards by most federal governments. To be blunt with you, many of those, of course, are dealt with accreditation agencies with respect to institutions and many of the noninstitutional care areas are relatively new and a lot of work or some work has gone on in sort of developing standards in the true sense, but the provinces have a--there is a real need at the national level. It may be a co-operation of provinces but to develop some of these kinds of common standards of delivery of a particular service.

So if you were delivering a home care program or operation of hospitals or any of these things, these are the kinds of things you have to meet to make acceptable standard, but other than rhetoric the federal government has not been very much involved in those areas anyway.

Mr. Lamoureux: Mr. Chairperson, I guess I would beg to differ, whether it is the National Forum on Health which the minister illustrated that he might have some problems with. I can recall reading a federal report on community health which talks about the role of community health clinics, and if the minister does not have a copy of it, what I will do is attempt to get him a copy of that.

I believe that there has been some guidance, maybe in a limited way, from Ottawa with respect to the delivery of health care, but the leading role that Ottawa should be playing, I believe, is more so of the guaranteeing of those five fundamental principles with respect to the health care services and, ultimately, arguing the best way that they can guarantee that is by ensuring that there is a straight cash transfer.

I would ask the minister if, in fact, then, he can provide me--and even if he can even put some sort of a time frame; like, it would be wonderful if we could get it later today or, if not, some time this week--the actual amount of dollars that is allocated out to the province of Manitoba for '96-97 towards that block funding in which the Treasury Board determines how much goes to health care, along with the tax transfer points, and maybe in brackets put how much the tax transfer points were.

I will say right off hand, if the minister now tries to say that the government acknowledges those tax transfer points, I would say that this is the first Minister of Health who is really doing that. Others might have made reference to it but did not genuinely believe that that allowed Ottawa to have any influence whatsoever in terms of what it was they were doing. That is the impression that I have been given from this government in the past. So I would very much appreciate to get those numbers from the minister if, in fact, he can make them available.

Mr. Praznik: Mr. Chair, I am going to leave that to Mr. Potter who will talk to Finance in his old department. I am not going to get into acknowledging what was done because as a Minister of Health, quite frankly, I am more concerned with delivery of service and what I need financially. Mr. Stefanson, the Minister of Finance--his concern is to find out how to raise those dollars through whatever vehicle possible.

The fundamental issue for most provincial ministers of Health, who I have had the opportunity to meet and work with in a variety of capacities in relation to the federal government, is there is always this very strong and, I think, very real fear in dealing with national ministers, particularly in the area of health, that they try to come in with a one-solution-fits-all approach. They often operate as if they run the whole system when they do not. Even with their financial contribution, they are still under half of the system. How much under half, we may dispute or facts may vary from time to time. They are going to come in and develop and deliver a system that may not be applicable or meet the need of a particular province.

There is a very significant attitudinal problem there, and I have seen it in my short tenure in this office. The fact that Mr. Dingwall would be advancing a national vision of health care and would not bother to come and even talk to me in the province speaks volumes about attitude. I worked for a national Minister of Health for a period in my career, and we always made it a point--my minister, Mr. Epp, always made it a point to be speaking to provincial ministers of Health by telephone regularly, dropping in and seeing them when he was in the province no matter what their political stripe, because he viewed his role very much as a partial funder, a co-ordinator and certainly took very seriously his role in health promotion and protection, which is very much a federal responsibility. So he got it right and everywhere I travel, mentioning I worked for Jake Epp, he is always noted as having been one of the best ministers of Health the country has ever had.

The two Liberal ministers of Health we have had to deal with--and I have not had the opportunity to work with Diane Marleau, but my observations from the side, very much like Mr. Dingwall, that they were off on their own agenda not talking, not working co-operatively, trying to make themselves the saviour of a system for political reasons, rather than dealing with real needs. That is what I take objection to. Over the years, I am sure there were Tory ministers of Health who may have had that same approach, too. Jake Epp, I flag, is a very unique individual who really understood his role and handled it well. I was pleased to work with him.

Mr. Dingwall just represents that same particular view. I have seen it in other federal ministers through other governments and partisan politics. All partisan politics aside, there is always a tendency by a national minister. I saw it with Mines ministers, for goodness sake, having meetings of ministers and the national minister pretending to play a big role in mining when they only had two issues: co-ordination of environmental standards between federal-provincial jurisdictions and federal tax policy. Everything else was provincial, and yet somehow federal ministers were going to be leading the charge to develop mining in Canada because they are a federal minister.

That attitude just does not work, and yesterday's results in the federal election, for better or for worse, I think, have demonstrated how divided a country we are regionally. We are that way perhaps because of the nature of our system, that the provinces, individually and collectively on every area of jurisdiction, many areas of jurisdiction, have difficulty working with the federal government. I am talking about jurisdiction for which they are responsible because of an attitude in the federation that Ottawa knows best, Ottawa will dictate, Ottawa will buy you off whether you need it or not.

In fact, if you look at the history of the Maritime provinces, with so many of the economic development programs, even western Canada, developed over the years, we are there; we know best; we will come and do; and we will deliver and say that we are doing something; and, if you do this and this, we will provide the money--says Ottawa. Of course, who can afford to say no.

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So you take the money, even if the program was doomed from the beginning. We have a real problem in our federation in sorting out who is responsible for what and working co-operatively in a flexible manner that takes account of the different needs of the country. Taking into account the different goals and objectives and operating styles of various provinces, I think, is much more a practical way of dealing in Canada than the approach we have seen in the past while.

Yesterday's results, I think, demonstrate that again. Yes, we welcome a national contribution in health care that ensures--probably the best way of ensuring a more equitable delivery of health care is using the federal tax power to redistribute some wealth between poorer and wealthier regions of the country; but, when you get into the specific details of how every system should be run, if you are not prepared to bring the parties to the table and work with them co-operatively, then you are an impediment to improving health, not a conduit of improving health.

The fact that the Prime Minister of this country, when he created a forum to talk about health care in Canada and have the commitment of the provincial governments, the provincial premiers to participate in that forum, if they had a co-chair which was very important to make sure the process was not hijacked for partisan purposes of a national government, but to have a provincial co-chair, whom they all agreed on, by the way. I mean, we all had to put our partisanship aside to agree. I think it was the Health minister of Saskatchewan--is that right?--who was to be the provincial co-chair. I cannot remember.

We put our partisan differences aside, and that was turned down by the national government. They said, no, we cannot do that. You can participate, but you cannot co-chair. So that is why we have the provinces now off doing our stuff. Which is more valuable? The provincial-territorial stuff, because we run the system.

So there is the national government now talking about, lo and behold, a national pharmacare program. For Manitoba, unless they are adding new money, that is not going to be useful to us. Unless by pharmacare they are talking about putting together some sort of agency that can do some assessments of new drugs for registration or is able to negotiate better prices in a mass way, it is not very useful to us. If it is just telling us what we have to do for the same amount of money they give us, it is a step backward.

We have them out there saying we need a national home care program. Well, again, if they are not prepared to contribute with new money to that but are stretching our existing dollars and tying our hands with so-called standards that may not be in any way reflective of the needs of Manitobans or Newfoundlanders or British Columbians, well, then they are an impediment, not a conduit to that.

So my advice to anyone who will listen and certainly to a new national Minister of Health is, be co-operative, work with the provinces and be flexible. We know that a blood agency is a perfect example. Quebec is not willing to be part of a national blood agency. So, fine, no province has to be. We will find the right grouping of provinces who are committed to making it work, and we will run with it. If it is five, six, seven, eight, nine or 10 provinces, we will, but let us not get hung up on it. Let us just move forward, because if we do the right thing and we do it well, others will join.

But if you want to come in and say, no, this is what we are going to deliver and this is what we are going to establish--and we saw that this winter with the national blood agency, Mr. Dingwall again, trying to take a role to push us into a system that we were not ready to accept or concerned about, not in a co-operative chair role but, basically, telling us where we should be, with many of us, particularly the western ministers of Health saying, whoa, whoa, whoa, we are paying for this; Ontario saying, we are going to be paying for half of it. You are not telling us how to do it. You are the regulator. We will work with you, but we pay for the system.

Again, that is reflective, and I think what happened in the national election is that there is a real, strong sense that the co-operation needed in federalism often rings very hollow. I give the same advice to a new national Minister of Health, and I hope this time to meet that new minister in relatively short order.

Mr. Lamoureux: I, having been involved over the last number of years, do believe that there is a problem and the problem quite often comes from the provinces themselves, where there is a natural tendency to have as much influence and power as possible and, quite frankly, are content at seeing responsibilities offloaded.

The provinces, in the past, when they sit down and they all have their own personal agendas--and when I said that the government in Ottawa should be playing the leading role, I think there are certain areas, health care being the one and most important area in terms of where Canadians really want to see national standards.

I look at the Minister of Health and would ask for concurrence, if he believes as I do that Canadians, generally speaking, want to feel that if they are in B.C., Manitoba, Quebec, whatever province throughout Canada, that we have, in essence, a health care system that follows those five fundamental principles, if that is something which this Minister of Health believes is essential, not as Manitobans, but as Canadians proceed ahead.

Mr. Praznik: Mr. Chair, I think what Canadians want when they travel to jurisdiction to jurisdiction is, I do not think they are so concerned with the specifics of the five principles. Those are very important for those of us who build and operate the system.

I think what they are more concerned about is that they can receive quality care in an efficient and convenient fashion that is successful and deals with their health needs and is part of our publicly funded system such that they are not burdened with bills or costs or certainly onerous costs on some of the things for which there is a co-payment or deductible. I think that is what Canadians are looking for, knowing that care is there and they charge those of us who run the system with the responsibility of ensuring that is delivered.

A lot of the very operational issues of the system that affect people in their daily lives are not issues of administration. They are not an issue of publicly funded. Their issues are: Is the service available, can I get access to it. That is why we have issues with emergency services right now. I get very few calls on issues related to the Canada Health Act. I get many, many calls on, is that service going to be there? Is there a doctor available? Why do I have a waiting list? If we are going to overcome many of those things in our system where we need to have rationalization or rethinking on how we deliver services or switches, those have to happen. You have to have the flexibility to make them happen, and provinces are doing that now without the federal government's help.

In fact, they will not even be part of that because it comes with some political pain. I know the Liberal M.P.s who used to represent my area--I think only one currently does, after yesterday. Any issue that came up in health care, they would say: Ah, it is provincial issue; oh, go talk to the province; it is all their decision.

They were nowhere around. They were not walking with us, they were not talking about the need to reform health care because they are tough political decisions in many cases, but they have to take place. So you find that provincial governments know that when tough things have to happen, the federal government is nowhere to be seen unless it is running in like a white knight attempting to say, we are saving medicare with less dollars.

So federal governments have very little credibility among those who have to operate and run and manage the system. That is why there is a great reluctance--and by the way, I have seen it in many, many other areas of federal-provincial relations. That is why there is very little reluctance, or a great deal of reluctance, I should say, to be saying we need to have the federal government be the great protector and provider of the system.

If they would like to deliver health care nationally in an equal way across the country, be our guests, take it over, run the whole system. I tell you, I would be perfectly content just being the Minister responsible for French Language Services. [interjection] Finance ministers could work that out. I do not think there is a Finance minister in this land who would truly want, knowing that health care costs continue to rise--knowing that they would want to have that continuing responsibility if a national government were prepared to take it over. But there is not a party out there today with any--maybe the Bloc Quebecois ultimately. That is part of their plans. But there is not a party out there today who really understands the issue, a national party who would really like to take over the whole system.

Many of them would like to tell the provinces how to run it. Many of them would like to play the game of being the provider of standards, the supervisor, let us beat up on the provinces every time they have to make a decision and someone does not get a service. Boy, there are lots of people who would like to line up for that role. The bottom line is, if they had to run the whole system, they would not be anywhere near the negotiating table to see that happen.

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Mr. Lamoureux: Mr. Chairperson, I can think of two parties, one which happens to be in power that is prepared to say that they want to see some standards, based on those five fundamental principles, being administered throughout Canada, Why? In Alberta, they want to have a privatized hospital. In Manitoba, money has been held back from the Province of Manitoba for the collection of specific fees, where they have held back transfer dollars.

Now, I look at it in terms of, well, what is it that the public wants to see? The public wants to see a system that is unique in the world, that is spread across the country, so, you know, if I happen to be in this province, I am not going to be charged by walking into an emergency service room; if I want this particular service in Saskatchewan, I am not going to be charged for this particular service while in this province you are not charged for this particular service, that there is some consistency throughout Canada.

I do not argue that, yes, there needs to be a high sense of co-operation that is put in place for the provinces and Ottawa. But the minister should be well aware that what Canadians want, and that means Manitobans, is to have a system which is relatively similar from one coast to the other. The only way that we are going to see that happen is if, in fact, the federal government plays that leading role.

Now, why is that important to bring up in the Health Estimates? Well, Mr. Chairperson, this minister himself says, oh, I want to meet with the Minister of Health. When he meets with the Minister of Health, what is he going to tell the Minister of Health? Is he going to be saying we want more cash transfer payments? Is he going to say, quite frankly, it does not matter to me which way we receive our finances?

In the long term, it is in Manitoba's best interests, I believe, that this minister, when he does meet with the Minister of Health, when he does sit around the cabinet table, that this Minister of Health advocates that it is unacceptable to see a decline in the cash transfer payments. I did not support the cash transfer payment reductions from the past. I would like to believe I have been somewhat consistent with respect to that.

What I expect from the province of Manitoba and the government of the day is a very strong and consistent voice which is saying and speaking very clearly with the importance of the cash transfers, because there are other jurisdictions with much larger treasury boards, whether it is Alberta, Quebec, most or many would argue Ontario, that would be quite happy to sit at the table and say, fine, you give us all the tax points, transfer the tax points over to us, and we will run our own system. Under that sort of scenario, Mr. Chairperson, I would argue that Manitoba and other provinces would lose out and they would lose out greatly.

That is the reason why, when we look at these important meetings that are going to be occurring over the next few months, that we have to be very clear in terms of what direction this government wants to take. I sat through hours and hours, the member for Kildonan (Mr. Chomiak), hours and hours of the Estimates in the past. We have had Estimates go 61 hours for the Department of Health, probably even exceeded that. I sat through many of those hours. But this is, indeed, a fundamental issue that has to be addressed.

I was really surprised when I saw first-hand just how soft this government is with respect to the cash transfer payments, and it is an issue in which I have full intentions on continuing to question this government on. Unless I am interpreting the government wrong, if they are softening their approach, it is a big mistake.

I think what you should have been doing, this government should have been doing is working together with provinces like Saskatchewan or Atlantic region, regional provinces, trying to build a consensus of the importance of those cash transfer payments and not settling for anything less.

The Minister of Health can comment on that if he chooses, but the specific question is, when the minister meets with the Minister of Health, is it safe for us to assume that the minister will be talking about the benefits of ensuring that those cash transfer payments are not reduced, even if it means looking at other options such as the tax transfer?

Mr. Praznik: I noticed that the member for Inkster in his description of positions of federal parties said that there are at least two parties. He included the federal Liberal Party which would like to be able to set standards and impose the principles of the Canada Health Act. That was not the challenge that I put to the member.

The challenge I put to him was to find me a federal party other than the Bloc Quebecois which today would like to take the whole system and run it, because it is very easy to be the watchdog. It is very easy to be the enforcer of standards. It is very easy to be the person who sits on the sideline and armchair quarterbacks.

Everybody would love to do that. It is much harder when you have to run the system and make the tough decisions that have to be made and deliver the service, and I have not seen a federal party, other than the Bloc Quebecois which would like a sovereign Quebec, which has come out and said, listen, we think we should have a truly national health care system; it should be in federal jurisdiction, and the federal government through a Department of Health will run the whole health care system, and provinces, you are out of it. Whether you work out how you do the budgetary matters, you know, you work those out, and gone, and Manitoba will have no role whatsoever in health, period. That was the challenge I put to the member.

It is very easy to find armchair quarterbacks and sideline supervisors and whatever you want, but I have not detected one iota of the federal Liberal Party wanting to run the system entirely. They would like to run the system by telling us what to do, but they would not want to accept responsibility for decisions that have to be made. That is the difference, and that is a point that I want to make and I want to stress.

I also find it somewhat ironical, coming from the Liberal Party, its requirement for national standards in the area of health, because with one of the greatest areas of health promotion, one of the great killers of our time, smoke-induced illnesses, the Liberty Party, the great self-proclaimed party of national standards, of consistency from sea to sea, imposes a different level of federal tax on cigarettes. Now, let us just think about this for a moment. A consumer in Ontario or Quebec or eastern Canada pays a different level of tax, federal tax, on cigarettes than a consumer in western Canada. There is something fundamentally wrong with that. We are not talking about different levels of provincial tax, but as I understand the system, the federal government has two tax rates depending on the provincial tax, and I look to my associate deputy minister to confirm that.

So, here, where everyone was spending millions of dollars to promote health, no smoking, health improvement, when we are trying to reduce our cost, when the national government is calling for healthier lifestyles and spending all kinds of time on tobacco-advertising legislation, the same government which stands up and talks about national standards, the importance to deliver the same thing from sea to sea, that a Canadian should get the same level of service or support whether they live in Newfoundland or they live on Vancouver Island or they live in the northern territories, we should get the same from our national government except in tobacco tax. Well, it is okay to have a lower rate of tax in eastern provinces and make it easier for young people to smoke there and die of lung cancer than it is for western provinces, and it is okay for us to collect more money off cigarettes in western provinces to put in a national Treasury to redistribute among everybody, even those taxpayers in eastern Canada who do not pay their fair share on tobacco tax.

You know, I found that, in all the years since it has been brought about, one of the great hypocracies of the Liberal Party at the national level. I raise that with the member because it is so easy all the time to get up and say, I stand on that principle, and we have to have a role in telling other people what to do in their lives, and we have to give a common standard from sea to sea, and yet on a first tough test as a new Liberal government three years ago, they failed to meet their own standard because it was convenient not to meet it. Because they had a different balancing act, that is what they did.

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So I have a hard time dealing with the continued hypocrisy and, by the way, I do not just say that for the Liberal Party. I have seen that regularly. The reality of the country is it is a very different country. It requires different approaches in different parts of it. If this federal election told us one thing, it is a very regionally divided country with very different expectations across the country and very different solutions. When we as provincial ministers meet, we can agree on common goals. How we achieve them sometimes requires very different solutions.

If you are not prepared to see that flexibility and to work that flexibility through, what you will get is a country that is continually fighting itself into achieving nothing, and, you see, that is the great provincial fear in dealing with federal governments. It really is, that for very little cash, very little money, a declining amount, a national government will come in and tell us how to meet our needs with our voters, our constituents, our citizens, and they will do it in a manner that might sell in downtown Toronto or on the beltway or in one part of this country but does not mean much in another part.

We saw this in national daycare policy. We saw grandiose plans in 1993 for a great daycare program for Canada that the Liberals promised. By the way, the Tories promised it before, and when they got down to putting the details to have a national daycare standard, they could not do it because the needs were so different and the approaches were so different.

So when we talk about these issues and say Canadians want to have the same wherever they be, the needs are different in different parts of the country, and provinces respond to the needs in their communities and the needs of their people, which may be very different from areas to areas and how they provide those services.

The great fear, again, is a national government comes in with some direction that turns out in a part of the country to make absolutely no sense, and you are stuck with it if you want the cash. You know, it is interesting. When the federal government, I think, did try to launch a daycare program and they put 50-50 dollars out there, virtually no provinces took it. Why? Because it was so tied up in things that people did not need, that why would we commit our funding to these things to get these 50-cent dollars when they are not meeting our needs. But here are those wonderful planners out in Ottawa doing it again.

So that is where the reluctance comes from. It is great to get up on the high horse and say we want everything the same from sea to sea, yet when it comes to protecting people's health from tobacco, well, we will have a different tax rate because that works. That is what happened.

We do not need the hypocrisy. Let us keeping working towards, I think, a co-operative way of developing the kinds of efforts across the nation that deliver results. The four Maritime provinces have things that they can do and make eminently good sense for them in co-ordinating their services and building their systems of government that may not make any sense for us in the west. Let them do their thing; let us do ours.

Ultimately, Canadian citizens, wherever they go, will be able to secure, by and large, a core number of services. How that is delivered to them and the vehicles of delivery, one needs flexibility to meet local needs. I think that is one of the great dilemmas of the country, and yesterday's federal election demonstrates, very clearly, that it is a country that has many different approaches--and voted very much for a lot of regional flexibility.

Mr. Lamoureux: Mr. Chairperson, in fact, what I had asked the minister was what would he be advocating when he sits down with the Minister of Health, because no doubt he will get the opportunity to meet with him or her sometime, hopefully, in the not too distant future. What will he be advocating when he sits around the cabinet table? What does he believe is in the best interests of the province when it comes to tax transfer points, the federal cash transfer payments? I think those are critical questions.

In responding to the question, the minister made a couple of comments. He talks about, well, why does he not pose the question to me about the feds coming to the table? Why do the feds not come to the table, he had indicated, and take on the responsibilities? To answer his question, he did that right at the end of his remarks when he talked about the Maritimes, that what you need to do is establish a core number of services, and those core services are, in essence, what we are trying to ensure are going to be there and that they are going to be consistent from one region going into the next region.

The federal government, even though it plays that leading role, it does not have to, nor should it be attempting to directly administer. What it should be doing is making sure that those core services are, in fact, being followed by using, I would like to believe, the cash transfer payments as the levy to ensure that they are being followed. I think that is what is important.

The minister then went and he talked about the whole cigarette discussion, the cigarette tax and the hypocrisy that is there. Well, the minister takes it out of context, completely out of context, because what was really happening with respect to the cigarettes was the smuggling component, and Ottawa was responding to regional interests. Ottawa was responding to exactly the type of thing in which the Minister of Health was concluding his remarks prior to my getting the mike back.

You know, when you get 50 percent of the population in one province that is literally participating either directly or indirectly in illegal cigarettes, I think that is a problem, and Ottawa took some action with respect to it. It also provided other provinces the same opportunity to tap into those lower taxes.

I am glad the province of Manitoba did not jump in, but the minister sidestepped the question itself by going into a couple issues, great debate issues. I am prepared to--well, I should not--today I am not prepared to debate those particular issues. But the question that I pose to the minister is the one that I am most interested in getting more of a direct response to. That is: What is that minister going to be advocating when he meets with the Minister of Health and his colleagues with respect to cash transfers?

Mr. Praznik: First of all, in reference to the smuggling issue, what Ottawa was not doing was meeting regional needs. Ottawa was admitting it did not have the will or the ability to enforce its own laws. It was not dealing with smugglers. It was unable to deal with smugglers--

Mr. Lamoureux: Do you deal with all speeders?

Mr. Praznik: The member says, do we deal with all speeders? Well, we have a lot of enforcement of speeding issue on our roadways today, but I will tell you, we do not then say, well, in some municipalities you can speed, but in others you cannot because, well, we do not have enough police in the R.M. of Whitemouth or the R.M. of La Broquerie or wherever, so you can speed there, but you cannot speed in the R.M. of Springfield. Now, that is not the way we chose, as a Conservative Party, to enforce our laws.

What the Liberal government did is, they admitted that federal laws, national laws can be enforced or have two separate laws for different parts of the country, and on an issue that is part of healthy public policy, on an issue--and the cost of cigarettes is one that there is fair bit of evidence has an effect upon the rate at which young people begin to smoke.

So we had a national Liberal government say, we will not enforce the law, we will not become unpopular in certain parts of this province, we will not put resources into dealing with a smuggling issue but, instead, we will impose two levels of taxation on Canadians, one if you live in class A provinces, and two if you are in class B or class 2 provinces. You pick which province you want to live in, but then you have a different level of federal tax, and if you are a young person in Quebec and Ontario, well, so what if it means you are more likely to start smoking?

This is the point that I get at. It was not a solution that was based on the kind of rhetoric we hear continually from the Liberal government about consistent national approaches, which they pride themselves on, but one which was their failure to deal with smuggling, and so they basically created two levels of tax. Then they say, we believe in national standards, the same for everybody, except smoking tax. That was my point, that it is considerably hypocritical.

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Now, getting back to what I intend to discuss with the new federal Minister of Health whenever he or she is appointed, first of all, I would hope that they would make the trek across this country to visit with their provincial counterparts and spend some time with them in private, I think, to have some very good discussions. Obviously, we would like to know first of all if the Liberal Party is going to live up to its campaign commitment not to reduce further the payments that they make to provinces. They made a campaign commitment in the early days of the campaign to forgo some announced further reductions in contribution for health care. They said they would not do that. We would hope that they would live up to that and not abandon that promise to the electors of Canada.

We also would like to be able to know if they plan on increasing their commitment to health care, but I am enough of a realist to know that, if their election pledge was only not to further reduce their contribution, it is very unlikely it is going to be to increase their contribution. So the whole debate as to how one pays it really becomes an academic debate if they are not prepared to put additional dollars into it. Given the fact that there is a declining federal contribution, I would hope that the new federal minister is not going to, by including home care and pharmacare under their financial scheme, impose on us a host of rules that tie our flexibility or are different from what we are providing now, with no increased new dollars to fund our current system.

I would also suggest that the federal government not use money for pilot projects to help establish pharmacare or home care programs in provinces that do not have them today--Manitoba does have them--and say that we are going to help you set up these programs in your province as a pilot, without offering Manitoba some dollars to make up for the fact that we have created those programs on our own ticket today. That is another message I want to deliver to the national Minister of Health, that we would expect that, if they use pilot dollars to set up a home care or pharmacare program in any other province--that is what we are doing in Manitoba for a number of years--they would be prepared to make a contribution to our system and the costs of setting it up. So that is another message that I would want to deliver.

I also want to very clearly say to the federal government that, if there is a role to play in improving the health of Canadians or a segment of Canadians, I would strongly suggest that, instead of running around the country doing some pilot projects in areas that we are already delivering service and do not need pilot projects, and there is plenty of precedent how to do it, they use those same dollars to meet the health needs of probably the most needy Canadians in the area of health, and that is aboriginal Canadians, particularly in First Nations communities.

They have a special fiduciary responsibility there. They have a responsibility through Medical Services branch of Health and Welfare Canada, and it would be my very strong recommendation to a new federal minister, as I have said publicly, that if they do have $200 million, $300 million, $400 million over several years for pilots, et cetera, those dollars go into our First Nations communities for building up and continually funding a home care program that they so desperately need, improved public health work, certainly addressing many of the public health needs that have to be met, like diabetes, rather than wasting the money on pilot projects that are reinventing the wheel, because many provinces have done it already in home care, done it already in pharmacare. Let us put the dollars where we have the greatest need.

So I am not even asking that they flow through the Manitoba Treasury. I am suggesting they target them to a group of Manitobans and Canadians in other provinces who have a desperate health need in beginning to build their health infrastructure where the need is there.

So I have that message to deliver to the national Minister of Health. I also have a list of a variety of areas where a national government can play a significant role, obviously in providing a system for us to deal with the new listing of pharmacare products, whether or not they are efficient in achieving their use.

I know Betaseron is one he has asked me about. There is a role for this at the national level. Another area that comes to mind is the bulk purchasing of drugs for our system, to be able to cut better price deals because we are talking about having listings for 30 million people as opposed to 1.1 million or picking us off each individually as provinces. There is a role for that. There is certainly an area on the aboriginal health side, as I have mentioned, a huge role to be played that is unfulfilled.

So I have a lot to discuss with the new Minister of Health. I am looking forward to doing it. I hope that minister does pay us a visit here. Perhaps I will have to go to Ottawa to see the new Minister of Health, but I do want to have those conversations. I do not want the member for Inkster (Mr. Lamoureux) to leave an impression with those who follow this committee that the big issue coming up is cash transfers versus tax points on new money, because, given the Liberal commitment in the federal election, they are not talking about any new money. They are talking about not reducing us further in certain years, and they are talking about rejigging the system to put more requirements on us for the same dollars. I do not think that is pretty helpful. That is just playing politics with something that should not be played politics with.

The other point is, where they have had a responsibility to deliver a degree of health services, i.e., on First Nations, they have not met the needs of those communities. So, before they start telling us about standards, before they start telling us about consistent delivery of service, I would like them to show us what they have done, because there is a great list as to what they still need to do among those people for whom they have a jurisdictional responsibility.

I find it very troubling that a national government would talk about, we need standards in home care and we need standards in consistent delivery of service, when you go into many of the First Nations communities in our province where Health and Welfare Canada through medical services has a responsibility for delivery of that care, and there are no home care programs. Their public health programs are weak, and these are areas the federal government have had the power, the responsibility, the jurisdiction to do something and they have not done it.

Then they turn around to us and say, we want to set standards for home care. I look at them and I say, where is the home care in the areas that you are responsible for? We have not done it yet, they say. Well, get off your butt and do it, and if you have set aside money for pilot projects, I am not asking for a penny of it if you are putting it into that need.

So I have a lot of things to say to the new Minister of Health when he or she is appointed. I am looking forward to that meeting.

Mr. Lamoureux: Mr. Chairperson, I am going to leave that issue, because the Minister of Health has really not indicated, or I should not say not indicated, really has not given any sort of ringing endorsement for the needs for cash transfer payments, which I find unfortunate, but it is something which I will pursue at later times and other times when I get to, whether it is Question Period, and so forth.

I did want to move on to the community health clinics. It is an area which I spent some time in last year, because I do believe when we talk about health care reform that one of the areas which this government needs to move more proactively towards is the community health clinics in trying to enhance services. There was an interesting report that came out, from the Nurses' Union, I do not know if it was about a year and a half ago, where it talked about some of those key features for the community health centres, and what you are really talking about is having more and more emphasis and resources, even possibly from other departments outside of the Department of Health--for example, the Department of Family Services and others--involved in some of these community health clinics.

Over the years, we have seen very little movement from this government toward that. I am interested in getting some sort of a response as to what this minister believes the future role of community health clinics is going to be. I would ask him to comment on it in the sense of resources. Does he believe that there are going to be additional financial resources directly given to the community health clinics, so that they can, for example, have doctors, and particularly salaried doctors in most cases--that is ultimately what I would argue, is that community health clinics could have several salaried doctors. There is a need for them to be able to expand, and we have not seen the government taking any sort of a proactive approach at seeing this expansion of services realized. To a certain degree, that is somewhat frustrating, given the number of years that they have been in government.

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The other thing that I would like the minister to comment on is the Health Links program. It is something which I mentioned in, I believe it was the budget or in response to the throne. It is something that I believe, as a program, as a service offered to Manitobans, that it should, in fact, be expanded to include, for example, individuals living in rural Manitoba, a 1-800 number that allows anyone that has anything to do with health whatsoever to call this number and seek some sort of advice.

It is run through the Misericordia Hospital. It is something that, again, I would argue that additional resources need to be given, and one of the most encouraging things that the Minister of Health could do is make that long-term commitment, because through a long-term commitment, you do not have to worry, for example, about the telephone line. You cannot advertise a telephone number, and then a year and a half later, it is no longer there. That is the type of thing which, again, when we talk about health care reform, we should be looking at it in terms of what the government is actually doing. So I see that as an area, and it is one of those pet issues for me, Health Links.

I am very interested in how this minister believes community health clinics and their roles can be enhanced into the future, in particular with resources, financial resources, that I am most concerned with.

Mr. Praznik: I appreciate and have noted several times now that Health Links is a pet project or pet interest of the member for Inkster (Mr. Lamoureux). I guess we all have those in departments we are either ministers or critics of and I appreciate that. From what I have seen of it, a very interesting program and one that makes very logical sense, and I hope over time will develop as one more tool in getting people information in making their health decisions. So how that works into the system, time will tell, and there are probably more opportunities for regional health authorities in other places, but certainly a good concept and one worthy of support.

With respect to the neighbourhood clinics and many of these issues, I guess the answer I would normally give is that they are very much part of our neighbourhood health resource networks, building this in our primary health care model and the kind of planning that is there.

But one of the realities I want to talk about that stands in the way of this happening is the way in which we remunerate physicians. We, by and large, are on a fee-for-service system in the province. Our funding agreement with the Manitoba Medical Association takes into account fee for service. There are issues about transferring dollars from salary to physician fee for service. If we are funding on salary, you do not get credit for that, I understand, now on our fee for--or we get limited credit. We have not got an agreement about how we transfer those resources under the global amount, which is a problem for us.

We also know that if you are going to move to--and, by the way, I should tell you, I am generally a supporter of reforming our remuneration system. I sense a growing demand in many parts of the province, between rural Manitoba, to move toward, I would not call it a salaried but a contract position, where we are not buying the doctor's time in a salaried sense but buying units of service in a larger contract sense with an expectation that we will have certain deliverables for a certain amount of money that we are paying through the RHA for that position. So I am very supportive of that.

Roberta Ellis, who joins us today, that is part of the long-term planning we are now doing as we begin negotiations with the MMA for our next contract round. I know the Assiniboine Clinic model is out there working through as a pilot. There are a lot of issues that surround that. I know one issue I flag is the word "transparent," and I noticed the Leader of the Opposition (Mr. Doer) raised his fingers today in the House and pointed out that I had used the term "transparent" seven times in my answers to six questions in Question Period.

But it is such a key to the success of reforming physician remuneration, because one of my fundamental problems as a minister today is we have ad hocked so much out there over 30 years of medicare in this province. We have different ways of doing the same thing in different places. Physicians talk among themselves. It is not an unnatural thing. They compare notes, and one group has a deal here, the other group wants it, even though there may be components that are different.

I know when we brought in the Assiniboine Clinic model as a pilot to try it, some would argue that perhaps it was richer than it should have been, and whether that is true or not time will tell, but the fact of the matter is there was a perception it may have been richer. So, consequently, you had doctors with that story out there and developing and growing and that led to other problems.

We look at the way we provide for emergency doctors in Winnipeg versus other parts of the province and, again, we get the arguments that it is not fair. We have hospitals that, under their own governance, cut specials deals with their docs, that if they were a wealthy municipality, they funded; poor municipalities did not. They say: Why are you getting and not I?

We went through this in Beausejour when the docs there wanted a special payment and the RHA considered continuing the one that the hospital had given them, which I think had come out of their donation fund. I am not sure about that. Then the Pine Falls doctors said, hey, wait a minute. We are doing this fee for service. We have a bigger volume. Why are we not getting one? The RHA withdrew it, and the doctors went on strike in Beausejour.

So to fix all of these things or provide a tool that leads us into better clinic opportunities, we need to have, and I use the word "transparent," equitable--not equal, but equitable, that we are paying the same for the same level of service anywhere in the province, that it is transparent in that everybody knows what everybody else is getting, and the building blocks for their remuneration are the same for what they are doing and they are equitable. We need to have that kind of model.

Now, we are working on it at as fast a pace as is humanly possible and our 90-day process on emergency docs. Out of that, we expect to move to the next step which is the ability to fund clinics in a model that is with the building blocks of putting together a package that is the same everywhere in the province, even perhaps with some differentials for northern allowance and those things, but people would know what they are.

Once we are able to do that, quite frankly, I think that is the key then to being able to see a growth and advance in clinics. In rural Manitoba, most of the regional health authorities are already talking with their doctors about putting most of their doctor activities into partner health clinics based in their facilities.

In many places that happens now. That makes the recruitment of new physicians phenomenally easier because you only have to recruit a person. You do not have to recruit a person with the capital to start a clinic. You do not have to rely on a physician group now recruiting someone else to come in and make a capital contribution to buy a place in their clinic. So that is another tool in solving doctor shortages. You also know that working as a clinic model, you can use other practitioners like nurses in that, midwives, others. So you can get more service with fewer docs which becomes important in some parts of the province where it is hard to recruit.

So all of these things fit together very nicely, but they are very dependent on having a remuneration model that is transparent and equitable and works across the province.

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

We are hoping that we are close to doing that, have the framework for it, and then move on after emergency to the clinic. If we can do that, I think the tool will be then to see the clinic, the primary care clinic, take off across this province. I understand that even in Winnipeg there are current clinic operations that are in financial difficulty, that have resource issues. Some have closed already. So if we can put together the right combination of factors--not everyone, of course, is going to be happy with it, but if we can put together one that is reasonable and fair, I think you are going to see that kind of model take off in Winnipeg.

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In meeting some of the current hospital boards in some of the community hospitals, the concept is even being discussed now, that we know that hospitals are the centre of health care delivery in a community. It is the physical place people associate with health care, rightly or wrongly. That is human nature. If in rural Manitoba many of those hospitals are having physician clinics, primary care clinics built right into their operations now, that is becoming--in my riding we have four hospitals. Three of them have physician clinics. Only the Beausejour one does not today. That same model can develop for some of our community hospitals. If they have underutilized space, if they see that as a place of expanding their role in the community, putting in a primary care clinic right in that facility is another opportunity to make it more relevant to their community.

So having the model with which to fund it, working out that agreement with the MMA so that we are not moving money out of the fee for service--we have to be able to move money out of fee for service into that model today. We do not have a mechanism to do it. So anything I pay on salary right now I do not get credit for, or it is disputable whether I get credit under our MMA agreement.

We have to work that out, and we have a couple of those tools. Once we do that, I think the tools are in place then to achieve the kind of goal that the member and I share to see the clinic model go. Today there are a few too many impediments to see it work as fast as I would like it to, but once we break those I think you are going to see it go like wildfire across the province.

Mr. Lamoureux: I am glad to hear that the ministry is working towards a model with respect to the future for community clinics. I guess what was going on in my mind when he talked about that is to what degree his department would be working with, let us say, the different authorities that are out there, what sort of involvement. Is there any involvement for the public with respect to this particular model?

The second question is, today, do we have any salaried doctors, doctors on a straight-out salary? You are going to get $90,000 a year; this is your workplace. If so, can he give us some sort of number or a percentage of the doctors? The reason why I ask that is that I have heard some numbers as high as 60 percent as a percentage to work towards ultimately through reform or through change. I am interested if the minister could just provide that information for me.

Mr. Praznik: We will put that information together for the member. We will get that information, because I think even if they are on contract and remunerated over a certain amount, that is public information--[interjection] Just fee for service. If they work for the government, it would be public, but we will gather that information and provide it to the member about where we are going and the numbers that are out there today.

I cannot stress enough, though, that--and I know there are many places that do have, I think, somewhere around 19 or 20 percent. We will confirm that where we have salaried physicians working in that particular system. It is a fundamental change. We are on the verge, I would say, of a bit of a revolution in how we remunerate physicians, and it is being driven by physicians because lifestyle, certainty issues--what fee-for-service practice has done, has just created huge pressure, and we are moving, it is really driving the system in a direction physicians are unhappy with. Fee for service, by its nature, really only works in high volume areas. In many parts of rural Manitoba that is not possible.

Also, we certainly want to, in delivering appropriate service with appropriate caregivers, utilize other caregivers in that mix. So you have to have a greater sense of direction and control and a clinic-type model to make that work. All those things come together, I believe, to afford us some opportunities. We obviously want to make sure the medical profession is involved in these changes and part of them. They have a lot of contribution to make as we design these things. But I can tell the member, none of this moves quickly, regrettably. There are a lot of people out there with a lot of different issues and a lot of different frustrations and a lot of ad hoc situations.

One of the things I wish to leave after my tenure of office in this place is to do away as much as possible with the ad hockery and get to very consistent, I use the word again, transparent, equitable means of funding, principled ways of providing and paying for service so that people know if they do such, this is what they shall get, and that it is consistent across the province. Today we do not have that to the degree that we need.

So building that system and those models takes a huge amount of work, and that is why Roberta Ellis, as associate deputy minister of Human Resources, one of her prime responsibilities is physician remuneration, because this is a key building block that we need over the next number of months and years to reform much of the system. You cannot do a lot of the moving to community clinics without changing the physician remuneration. It often will not work with fee for service, because you get in that care provider struggle about who provides, and it is income for one and service for the other.

So you need to have the model. You could do it today on an ad hoc basis but, again, whatever you pay in one circumstance everyone will expect in another. So you want to do it in a manner that is equitable, the same and fair, and everyone knows about it. To do that you have to have people at the table to develop that model, because it has to be a model that is also affordable for the province. You know, if we said we would pay everyone $300,000 a year, I would have everyone signing up, but it would be not sustainable and affordable for Manitoba. So we have to find the deliverables, what we are expecting, what we are prepared to pay, and we have to find the right number to secure the number of physicians we need.

The member asked, who is at the table? Currently in our 90-day process that was designed to deal with emergency doctors issues, we have the Manitoba Medical Association, the College of Physicians and Surgeons, the regional health authorities and the Manitoba Association of Registered Nurses, and we have also asked some physicians who have been involved in these issues in specific areas with certain expertise.

So I know today if you talked to some in Steinbach or Brandon they would say the process is not moving quickly. I have been in government a long time. I have never seen an internal process move as quickly as this. We have had a number of meetings in my office with this committee or parts of it. We have looked at all the logical options to deal with emergency services. Once we fix emergency, out of that will come the clinic model. We somehow lay the basis for the clinic with emergency. There is certainly a tie.

But we have looked at all the logical options. We have taken out the ones that do not work for us as parties, all of us as parties. We have agreed to that. We have narrowed it down to the ones that have potential. The MMA, I know, has run some of these models by their group of members that they consult regularly to get a sense of their members' feelings across the province.

People are at the table working away as we are flushing out numbers, very high-level discussions. I know Mr. Laplume and my associate deputy have spoken as recently as late last week, and then it is not just a matter of the people at the table agreeing. You have to go back and make sure your members whom you represent agree as well.

So in those spots across the province where I have heard doctors say--I think Steinbach is one--we are withdrawing services, we want to put pressure on the process; listen, I say to them, that is fine, you can answer your people, but it is not going to speed up that process by one day, because just physically, in getting everyone together and running it through and crunching numbers, it takes time.

We committed to 90 days to be able to flush out an answer. I am hoping that within that 90 days that we are so close to it or have done it that we have a livable model to go forward with, but it is taking a huge amount of work, a lot of time going into it, and I am somewhat disappointed that some physician groups would say that it is taking too long or is too slow. If they are saying that they (a) do not know what is happening, or, (b) have a very unrealistic sense of how long it takes to reach a consensus on something this complex with so many people involved--but we are working for it because we really want to get this developed--the emergency model then leads us into the clinic model, and that leads us ultimately into where we are going on the whole area of physician remuneration for those who do not opt for that. So they are very much connected.

I thank the member for getting us into this very interesting area, probably the most fascinating area we are dealing with at the current time.

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Mr. Chomiak: Five-minute break?

The Acting Chairperson (Mr. Helwer): Okay, we will take a five-minute recess.

Mr. Praznik: Thank you.

The committee recessed at 4:10 p.m.

The committee resumed at 4:17 p.m.

(Mr. Chairperson in the Chair)

Mr. Chairperson: Order, please. Will the Estimates of Health please come to order. The honourable member for Kildonan (Mr. Chomiak) was up.

Mr. Chomiak: Thank you, Mr. Chairperson.

So the minister is involved presently in negotiations with the groups that he indicated earlier, the College of Physicians and Surgeons, MMA, MARN, et cetera, to develop within a 90-day time frame some form of remuneration with respect to emergency services as delivered outside of Winnipeg, to develop a model consistent across the province that will serve, as well, and, in addition, as a basis for some form of clinic model development remuneration for the future. Is that a correct summation of the minister's plans?

Mr. Praznik: I would say fairly close. As the member recalls, a couple of months ago we had doctors refusing to provide emergency services in Winkler, in Beausejour. They were talking about Dauphin, I believe at one point, a number of places, Stonewall. When we got into it, we were having a host of different solutions being thrown at regional health authorities. We had regional health authorities who had taken over agreements with a number of facilities, often under the guise of being called pilot projects, but I do not think any of them were pilot projects approved by Manitoba Health. I think that became a political term to advocate the special arrangements.

They were different. They were inconsistent. They may have solved the local problem, but they set off one group of doctors saying, well, why do you get it and not us? Why is yours different from us, et cetera, and, we are working a lot more here and you are getting this. To be honest it was quite a mess. It has developed over time, very inconsistent.

So recognizing that we had to come to grips with this and quickly--it is not something that can be left to linger, and it was a great source of frustration with rural doctors--we agreed, we asked and invited all the parties who have a piece of this to come to the table. Let us get a table together, 90-day time frame with a work plan that we could see if we could find a model or models that we could build around the building blocks to provide a transparent, consistent, equitable, fair system of remunerating physicians to provide emergency services across rural Manitoba.

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Also, my associate deputy points out that it was very critical that a fundamental principle of this was that the complaint was lifestyle, that in many cases, doctors were putting in long hours on call, or call-long hours, without getting very much for it if they did not have the volume, et cetera, and could not then afford to take off additional time because they had not made much when they were on call on the weekend. So we had that problem.

There are also some problems in the bigger volume centres as well. We recognized at the same time that there was a growing demand for a clinic model for physician remuneration for regular service, that many RHAs and doctors working in them were looking at a new way of doing business. So however we strike our options around emergency, some of the same principles, as we are discovering as we go through the process, lay some foundation for going on with the clinic model. So once we can get the emergency model in place and agreed to, I see using the same process to carry on, then, to look at the clinic model.

Now, one little interesting piece that I am sure the member will appreciate, as we develop our models for rural centres, we have some very significant rural hospitals, I think about nine. That then raises the question, whatever we do here also has to be consistent with similar service being provided in our community hospitals in Winnipeg.

So the Winnipeg piece will then have to be next in this, and we can logically see that they fit together. That is what we are working on now, and we are working toward some very tight time frames. I think that gives a little bit better sense to the member.

Mr. Chomiak: I thank the minister for those comments. I specifically used the word "remuneration." I notice the minister broadened it, and that was why I specifically used that word.

Does this extend, as well, to northern Manitoba?

Mr. Praznik: Mr. Chair, I would like to thank the member for that because I think it is an important principle to note, that the building blocks of a compensation package have to be the same and consistent.

If there is a premium to be paid for northern doctors, given costs or what have you, that that building block be part of the package, that everyone knows that if you were in a remote area, for these factors you would get paid on the same basis as anyone else in the province, plus there would be a premium for northern work, but it would be one more building block you would be entitled to, so that everyone would know that you get it if you are in a remote as opposed to a totally different way of funding.

Mr. Chomiak: Does the issue of recruitment and retention also fit into this equation, and how does it?

Mr. Praznik: Yes, very much so, Mr. Chair. Part of the issue that doctors flagged with us, particularly in the smaller 34 or so hospitals, or 20 or 30, 26 or 34 smaller centres, basic hospitals, is that the supply of physicians to do rota is very important. If you are doing rota on one in two, for example, it does not matter what you pay someone, you are going to kill them; you are going to burn them out.

So we know roughly the number of physicians we have in rural Manitoba, how many we are likely to have, and as part of this, there has to be, on the part of the RHAs, a reorganization of emergency services to make sure that we are properly using our physicians to provide the right number of centres.

That may change the function of some current emergency centres, which we also have to anticipate, but by getting down to an acceptable level of rota with a proper expectation in remuneration and service delivery, I think it will be easier to recruit physicians. It will not make the difference, but it is one more factor--it is not maybe the only factor, but one more tool, one more factor, to recruit physicians. I know it is very hard to recruit someone if they have to go in a community where their on-call rota is one in two, one in three.

Mr. Chomiak: I am not asking this question to tie the minister to this, and I am not going to run out and broadcast this, but from the minister's comments, it implies a reduction in emergency service. Is that a correct observation?

Mr. Praznik: No, Mr. Chair, I appreciate the member asking the question because that is a logical question for where we are going.

As we explore the number of hospitals in the province and their usages, we have several hospitals that are under 1,000 visits a year, I believe. We used two factors to sort of assess some cutoffs and--let me go back a step. I think what is key to looking at this model is the volume, because if we are going to pay a certain amount of money for a physician to either be in the hospital providing emergency or on call, we would expect to have enough volume go through during that time to make the physician busy and ultimately pay the cost.

That is one of our preconditions of getting into this kind of discussion on this kind of model, so we have to look at how we classify hospitals in terms of what they do, what volume, whether a physician has to be on call or be available in the facility, and as we look at some of those breakdowns, we have found that we have a category of facility that has less than a thousand visits a year and is located within the recommended half an hour, whatever the time distance is, 50 kilometres of another facility.

So the College of Physicians and Surgeons sets some limits as to where Emergencies should be located. Now, having said that, we also find that those facilities currently operated on fee for service often are very understaffed, do not have a lot of doctors. I am not saying one would do away with them and say you are going to close them today or tomorrow, but, obviously, you are not going to, even in this model, be able to get the volumes to be there, nor necessarily is there need.

One of the things that we have talked about then is developing a standard for an urgency centre that would allow some of them to be able to provide a level of urgency care to meet their community need, but, obviously, this has to fit into the mix and has to work out. Another problem we have that fits into this calculation is the number of doctors that are available, and if doctors are asking for a one in five, one in six, one in seven rota, they have to draw on a large enough regional pool to be able to do that. These are things that will have to be worked out in each region, but we want to make sure that we have agreed on the tools that will allow people to work them out.

Mr. Chomiak: How does the minister reconcile proceeding on this basis in light of the final year of the MMA agreement that the government is in with the MMA and in light of the fact that they are now, I assume, negotiating a new agreement with the MMA to take effect in '98-99?

Mr. Praznik: The member asks a question I have asked myself innumerable times. Why, when we have an agreement with the MMA that was to contemplate all of these issues and which the MMA did not ask for under that agreement--additional money is a category for Emergency remuneration--why are we dealing with this now? In fact, some would even argue that the MMA may be in breach of its agreement.

The practical reality is the vast majority, it would appear, of physicians in rural Manitoba have said that they want a new system. Whether the MMA has encouraged that or not, I am not going to speculate on. The fact is it is a very real problem that I have today, that relying on the current contract does not seem to have hit a chord with any of the people providing it.

The second part of this is we are not yet in negotiations with the MMA. That will come later in the year as we begin to develop it, and, obviously, whatever we do now is starting to form the basis of a new agreement. A very practical reason why I am there, I say to the member, the fact is doctors are not relying on that MMA agreement, and I do not think it is probably in our long-term will to take them to court to test them on it.

Mr. Chomiak: How does the minister envision this package working with respect to the funding arrangements with RHAs considering that--I am assuming that the funding arrangements with respect to physician remuneration are outside of the funding model that is being proposed for each RHA. Secondly, at what point will the funding for physician remuneration, whatever form it is, whether fee for service or salary, be moved under the authority of the respective RHAs?

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Mr. Praznik: Obviously, we are into negotiations right now. The RHAs are very much involved in that. The member asked how I envision this working. The question of how we provide those dollars from the ministry to pay for either emergency on call or for clinic matters is one that we will probably work out with the RHA. It makes some logical sense to see those dollars, the contract dollars or emergency dollars, move directly. In fact, I think the contract dollars are already there. If we expanded them into a clinic model, those dollars would likely flow to the RHA. Certainly, if we provided a certain amount of dollars for emergency, they would flow as well, and we would expect some offset in our fee for service to make up those dollars.

Those are arrangements we would have to work out, because the key to moving to paying for physician emergency call is to have an offset on fee for service and expecting a certain volume, whether it be by clinic, appointment, walk in, whatever you want to call it, happening in our hospitals to ensure that they are used fully while we have a physician available.

Mr. Chomiak: I wonder if the minister could clarify what he meant when he said that the contract dollars and fees are already there.

Mr. Praznik: To clarify, in some of the RHAs currently where they would have contract physicians--I am thinking Hamiota would be a good example--those dollars would be flowed now.

If we expand the contract model, which I fully expect to happen, where, for example, in a regional health authority all of the doctors or a sizeable number of the doctors in that region say, we would rather work on a contract than fee for service, then we would have, again, this transparent template building-block system.

Those dollars to meet that need would flow to the RHA. They would administer them with those doctors, because, obviously, they would be setting up the clinic, operating it, doing those types of things.

Mr. Chomiak: When the minister refers to contracts, is the minister referring to units of service, say, along the lines that we are familiar with, with respect to delivery of home care in Winnipeg?

Mr. Praznik: Mr. Chair, no, somewhat differently. I think what we are trying to avoid is saying salary. What we do not want to do is say, we are buying your services by hour of time, because then we have no control over what deliverables we get, other than you show up.

We are looking for a model where we will provide a block of dollars that are like a salary, but for that we expect not just your time but we expect a block of deliverables that you will--it is a comprehensive plan or contract where a physician would be providing care to a certain agreed-upon number of persons, or providing a certain amount of service, whatever we work out in those kinds of agreements, because that is ultimately is ours and the RHA's only ability to ensure that we are ultimately getting the amount of service that we need.

These kinds of details we have to flesh out and work out and negotiate, but that is kind of the direction in which we are moving now. Yes, just to add to that, by also going to blocks of dollars, which might be administered by the RHA who may sign a contract with a block of physicians or group of physicians who would also retain other staff that would be part of that block, it allows us to see the teams of multidisciplinary providers of care working together on a clinic basis. So there is likely to be a number of nurses, perhaps a midwife, perhaps a mental health worker, whatever that is required to bring together a clinic.

Whether those dollars are administered directly by an RHA, who would put together the team, or a group of physicians who would put together the team, or a group of providers who would organize themselves, there has to be lots of flexibility for that to happen. But it is likely that we would flow the dollars to the regional health authority and let them set that up with care providers in their area.

Mr. Chomiak: The minister did clarify my next line of questioning, but just to make certain that I understand it correctly, the plan, obviously not for this year, but the plan for subsequent years is something along the lines of block funding attached to some kind of deliverables that will be offered to the RHAs, presumably if they meet certain standards, which will then be left to the RHAs to make a determination as to whether they want to hire 12 nurses and one doctor to provide primary care or two doctors--I mean, along those lines.

I mean, I am looking for direction from the minister as to how that block arrangement might work.

Mr. Praznik: I hate to use the word transparent again, and equitable and consistent, but the degree of flexibility in the member's example is probably unlikely to be the case. It is probably going to be quite a bit less. There probably will be some very set template around how those will work, depending on units of service or however we define what we are purchasing.

There has to be some flexibility, but it has to be a consistent flexibility in building blocks. That is very important because the last thing I want to see happen out there is that we provide a block of money and we end up getting a whole bunch of different packages developing, and we get into the old "play it off against one another" everywhere else. That is not going to work. So in the amounts we pay for common and equitable deliverables we would expect it to be equivalent.

Now, how RHAs put together those building blocks of a package, they will have flexibility, but the building blocks will be the same across the system. I guess that is the best illustration that I could give to the member. We give them building blocks and they put them together, but the building blocks are the same across the system.

Mr. Chomiak: We are talking about emergency services in the initial stages of the building blocks, so perhaps we could just use an example of--[interjection] The minister was talking about clinic, okay. [interjection] Well, that is interesting because I thought the emergency was going to be the basis for clinic, but I see the minister was expounding on the clinic. I did use an example of clinic more than I did emergency. Can we talk examples here?

Mr. Praznik: Yes, perhaps I am misleading the member a little bit inadvertently here. The clinic model is quite different than the emergency, somewhat, because the emergency can happen at the clinic. We are trying to get some principles of consistency; the two are not necessarily alike. Our process of developing the emergency model is the same process with many of the same issues as we move into clinic, but I think the member would like me to talk a little bit about emergency because that is first off the plate. Is that a fair assessment?

I just want to just share some sense of this. When we looked at kind of defining our hospitals, because if you are going to start on this, you have to define what we are talking about--this is for emergency. We looked at the volumes of work and the requirements that the college places for physicians in that facility, and what we discovered is that we have, for lack of a better term, rural general hospital, which are facilities that meet the requirements of having to have a physician on staff, and there are nine of those facilities in the province that are large enough, that are currently required to have a physician on staff.

They are obviously looking for a set fee for providing in-house coverage, present 24 hours a day, and we are looking at numbers as to what that would be. Our expectation, of course, is that we would want, in seeing that paid, a certain number of deliverables, including ensuring that there is a sufficient volume of work that justifies this kind of support, and because they are big, it is likely to very achievable.

Now, again, part of the principle that we are trying to address here, and the member has been around a long time in health care, and I remember from the days when my father was on the Selkirk Hospital, we always made these arguments that people should stay away from the emergency ward unless it is really an emergency. When we look at our numbers in most facilities, a large number of people still go to the emergency ward to see a doctor when it is not emergent or urgent.

So we know the public human nature is such that it is a convenience issue, because you do not have to take time off work, you are hurting now, you can go see the doctor. So rather than fight that, we say, let us make use of this to ensure we have sufficient volumes working through and better service to the public that ultimately we can justify having the physician remunerated to the degree that they want, because they are providing enough work. What we are making, in essence, is ensuring that when they are there that they are busy and making productive use of the time.

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We see the public who needs the service getting the service, happy because it is more convenient and, ultimately, giving us the ability to pay for it, we hope, through reduction in the fee for service that they would get by seeing a physician outside of it or even at an emergency ward seeing the physician today. So instead of those doctors being paid fee for service, they, in essence, would know that they are going to get a set price for putting in those hours of their time. So that takes care of nine that are relatively easier to do, because they are already of much bigger volume.

Then we looked at facilities that had a much smaller volume. I do not know the workings of where we made the splits. We can get into that detail, I think, when we have concluded an agreement, because those are some of the issues we are working on. But that is a whole host of other hospitals, I think some 28-plus hospitals across the province and, in all of those facilities, their level of service is such that the college does not require to have a physician onsite. They require a physician to be on call. So it is a somewhat different degree of service. Now, many of them have a very significant volume, as well, over a year of which a very small amount is actually emergent and urgent.

Now, again, in trying to get our principles together, if the goal of this is to give physicians lifestyle, and these are the facilities that today are really the tough ones to deal with, because physicians, their volumes are such that a physician may only get one or two calls on a night, have to come down at two in the morning, they get their one fee-for-service billing. Even if there is a bonus or something paid to it, by the time they pay the tax, they say, why have I had to get up in the middle of the night? I have not made enough money; I cannot take the next day off, and if I am on a one and two or one and three or one and four rota, I am going to kill myself here. So these are very much lifestyle issues.

So what we are saying here is, okay, we want to have the physician available to cover. To do that the physician has to make enough money that they can take off other time during the week to have some free time. So in Ontario, they paid them a certain amount of money per hour to find out that in many of the similar-sized facilities they have doctors with nobody coming in or very limited on call that they are paying a huge amount of money for, at the end of the day, seeing very few people. But, of course, you have to have the emergency service.

So what we are proposing in our discussion is to make the physicians' time useful while they are in that on-call situation, and that would involve--and we are still trying to flesh this out in some way with the parties--having during that on-call period blocks of time when they, in essence, hold clinic in the facility or in their own clinic or whatever we work out so that they receive a set fee. They park their fee-for-service billing number, and over time their deliverable is to have a certain volume.

Now, whether that is a walk-in clinic advertised, whether they choose to put some of their own patients through, whatever, to see them during this time, those are all issues we are sorting out, how we ensure that the deliverables are guaranteed, those are all things we have to flesh out and we are working on now, but the end of the day is, for example, a doctor in Beausejour would be paid whatever amount of money to be on call during the weekend. It may very well work out that on the Saturday they are in the hospital from ten to noon and one to four, and they will see so many patients.

They may choose to have some of their own patients come in. The hospital may advertise that we have a doctor available in clinic every Saturday from these hours or Sunday afternoon. Of course, then we have enough volume coming in. It justifies paying what the physician wants. The physician has earned enough money that on Monday and Tuesday the physician says I worked this weekend; I do not have to open my own clinic; I have seen enough patients; I do not have to open those doors.

The same would be true on evenings, that they could see patients from six until nine or whatever, and see enough people that they do not have to come in until noon the next day or open their own office until noon, so they get something for that time. So we are trying to better organize the workload, in essence, to make efficient use of doctors' time, and doctors tell us, well, if they are going to be on call, they would like to be busy.

The other advantage in this is, I think, then, we offer better service to our communities because the hours in which you can now see a physician are expanded. If you live in Beausejour and work in Winnipeg, you do not have to have a doctor in Winnipeg to see one. You do not have to take a half day off work because you can arrange to see a doctor when they are doing their clinic time. If you are an elderly person who needs family to drive you to see the doctor, you can try and see your doctor on a Saturday or Sunday when family can take you. If you are a mom who has a child who is quite sick in the evening, and you say do I wait until the morning or not, you will not even hesitate now. You will go down to the hospital at eight o'clock with the child so they will not get sick and you have to call the doctor in at two o'clock in the morning.

So there are a lot of advantages in better using people's time. We call this the clinic model. We are trying to flesh out all the details, make sure the parties like it. Conceptually, it is gaining some interest, and over the next few weeks we are hoping we will flesh it out, but I hope I have given the member a sense of the concepts we are trying to achieve.

In studying this, we have also looked at what has happened in other parts of the province. I know the Ontario model, the Scott model, where they simply pay a fee to be there without working to make the thing busy for the physician, just at the end of the day, we are looking at a cost of--[interjection] Yes, to do an Ontario model, it would be something like $15 million or $16 million, and we really have not bought any guarantee of more deliverable.

By the way, physicians are saying to us, it is lifestyle. We want to be busy when we are on call, so we want to earn enough money when we are on call that we can take time off later in the week to have some time with our families. Also, if we do this right, it might lessen their patient load during the week so they do not have that demand to put patients through for that Monday or whatever that they want to take off if they have covered a weekend. This is what we are trying to achieve and flesh this out with the various doctors and hopefully come up with a model that people can live with for some time into the future.

I hope I have given the members a sense of what we are trying to achieve in a very complex area.

Mr. Chomiak: I thank the minister for that response. It does reflect some discussions that we have had with people in rural Manitoba. The implication can be from that model that there will be an increased need for physicians outside of Winnipeg. Does the minister agree with that implication?

Mr. Praznik: Yes, Mr. Chair, whether or not this would add to the need for physicians in rural Manitoba, we do not particularly envision that to be the case. Part of this obviously is getting--the other part of the equation is getting the right rota. Some areas argue it is one in four; I have seen it as high as one in seven, and that is something to be worked out. That may, in fact, require the grouping of physicians together in some areas to ensure that they have enough physicians to provide an acceptable rota to them.

The member may appreciate that in some areas obviously there are seasonal highs. I know that in my area, the Winnipeg River hospital, Pinawa and the Pine Falls hospitals get very busy in the summer servicing the cottage areas. We have a locum tenens program that we will on those extraordinary circumstances be able to staff to make up some of that difference.

One area that might increase volume for physicians, of course, is if in the areas in and around Winnipeg where convenience becomes an issue for seeing a physician, if physicians have a fairly regular rota in, you know, once a week an evening, for example, if you had a one in five or something or one in seven for physicians during the week, you might find people choosing to see a doctor locally because they can now see their doctor every Thursday night at clinic as opposed to taking time off work.

So we do not expect that this will add to the need. The idea is to try to make good use, efficience use, out of the doctors we currently have. There will always be issues for recruitment of physicians into various communities, but we think this may give us an ability, you know, one more tool, I think, to be a little more attractive to recruiting family practitioners to rural Manitoba, but it should not, in itself, cause an increase in the need for physicians out of the ordinary.

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Mr. Chomiak: Does the minister see a need for an expansion increase, need for other primary care providers as a result of this model?

Mr. Praznik: Mr. Chair, yes, I do, and we get back to one of the member's first questions about some of these facilities, say, that have less than a thousand visits a year to their emergency. If they have that within the 50-kilometre range of another facility or there are areas within 50 kilometres and they are already a low volume, most of those facilities are very small-bedded hospitals, 10 to 20 beds, so they already have issues of maybe only having one doctor or two doctors in their facility.

I know the member, the Chair has one hospital in his constituency, Whitemouth, that is a four or six-bed hospital. It is a six-bed or something hospital. They have one physician in the community. There is no way that that hospital can provide 24-hour, seven-day emergency care with one doctor. You will kill the doctor. So we recognize there still may be in many of these communities--I just want to confirm, it is six beds in Whitemouth. We do know that there is still going to be a need in some of them to have some level of emergency care or urgency care.

One of the things we are talking about now is developing a standard here that would see us have, say, a nurse-run urgency centre in many of these so that the duty nurse would be properly trained and there would be a nurse available there. So for certain emergencies that could come in and be treated by a nurse, similar to what is done now in northern nursing stations, there is a precedent for that.

Also, if we did develop a standard, I could envision that standard having a degree of communications equipment, et cetera. A person or that nurse could immediately be on line with an emergency place, a large facility, to be talking to the doctor who is on call there to be able to make a decision--do we move the patient; do we treat here; what do we do--so that that urgency centre then can provide a greater degree of coverage than currently is the case.

I know the member did not want to get into raising this big talk about closure, but for many of these facilities, they today cannot provide 24-hour, seven-day-a-week emergency because they do not have the physicians, nor do they have the volume to justify the physicians. So rather than see them die totally, if we can, with using nurses, for example, develop an urgency centre to meet needs in those communities that still are there and have a proper transportation link with ambulance and communication link, we can probably ensure a better degree of service in the long run than what we are going to have if we leave the status quo.

Mr. Chomiak: Mr. Chairperson, the minister had indicated earlier he saw this model ultimately--now, he can correct me if I am wrong in terms of quoting him--dovetailing together with the situation with respect to Winnipeg. Is that a correct observation, and could he perhaps elaborate on that?

Mr. Praznik: As the member may know, our agreement with the emergency physicians of Winnipeg that serves the community hospitals expired some 15, well, many months ago, and we are negotiating with them or beginning to now as to how we are going to resolve that issue.

Obviously, if our principle is to be consistent and transparent, noting that the nine facilities I have spoken about start to get--and that is one of the things we are looking at, is the level of service they provide in the major rural hospitals. Brandon would be one, for example, that his colleague the member for Brandon East flagged today. That is why in my answer in Question Period I talked about the need for transparency and consistence and equity, because a hospital of Brandon's size, servicing that kind of region, I have not checked the volumes but surely must be pretty equivalent to one of the community hospitals in Winnipeg.

So whatever our model does with those nine larger rural hospitals, Portage, Steinbach, Flin Flon, The Pas, Thompson, it has to have a consistency and transparency with what we do in Winnipeg with our emergency system there because, obviously, if we are expecting the same volume of work or the same amount of work or units of service from a physician in Brandon and one in Concordia or Grace or a community hospital here, they have a right to know what each other is getting and it should be equitable and consistent.

The Manitoba Medical Association has indicated to us that they have agreed that that should also be part of our planning as we deal with the emergency physicians of Winnipeg. We recognize, as well, that although those nine rural hospitals, including Brandon and the community hospitals, require the same standards, I gather, with the college of having physicians in house, there may be some volume issues that would be addressed. Brandon might be one too that you might need, have enough volume to have two under the same agreement as opposed to one or whatever it would be.

We also recognize that the tertiary hospitals, again, particularly the Health Sciences Centre as a trauma centre, are, again, another different league of emergency service. What I would like to be able to do inevitably is have all of this linked through a common thread that you know what kind of service, what volume of service you are expected to deliver and you are paid on that basis, remunerated on that basis and covered on that basis, and if your volume degree of service changes up to the next ladder, you know that you will move into the next ladder of funding and that there is also an equity between the unit of service being purchased in facilities. That is also very important.

We are trying to do a lot of things with this formula, but I think it is really important that we do do that to get that consistent nature. Otherwise, ministers of Health today and into the future will be continually pressured and whipsawed and physicians will be unhappy and the MMA will not be able to deliver agreements with their members because of inconsistency. So we are trying to correct probably 30 years of ad hockery, and that is what we are--it is not perfect, but we are trying our best.

Mr. Chomiak: To take it to its natural conclusion, it obviously fits in with questions that were asked earlier by the member for Inkster (Mr. Lamoureux) with respect to community clinics, but one thing I have never understood is how last year's August announcement of the neighbourhood health centres or the neighbourhood improvement zones--I cannot remember the terminology--how they specifically related, how they were defined and how they fit in with, because they must, what the minister is discussing.

Mr. Praznik: Like him, I, too, have the same questions in dealing with this as a new minister coming in, but I gather the planning was that all of these community health centres exist today and operate today, and what we are attempting to do is trying to give them a geographic region within the city with an expectation of deliverables within it. We recognize people have preferences and all those types of things that we have to work in.

What we do not want happening is having a serious of community clinics that are out each operating on its own without some co-ordination, because they are an excellent model, they are an excellent manner in which to expand the delivery of services in communities because they have a presence, a constituency, reputations that draw people to them. We are not trying to reinvent the wheel so much as make sure that all the spokes are plugged in and linked together and that they are not operating out on their own and not part of some plan.

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So they ultimately will be part of the Winnipeg Long Term Care Authority. They will be working with them. That will be the group from which they receive their funding and through which they co-ordinate their planning and how their services are there.

By the way, geographic lines do not always work here either because some of these clinics have constituencies. I think of Klinic with a "K" that has a very special community in the AIDS community, which applies to the whole city, in fact even to some degree the whole province as a place of--I am talking about the Village Clinic, Klinic with a "K." So those are things that have to be taken into account. I am hoping we are able to accomplish that goal.

Mr. Chomiak: So the minister is saying the present existing community health centres or community clinics are going to become the neighbourhood models that were referred in the Next Steps document in last August's paper?

Mr. Praznik: Yes, that is correct, and if I just may add this point, this is why our physician remuneration becomes very important because, as these expand, and whether they be these or whether even hospitals start to have community clinics based in them, we need again to have a consistent clinic funding model for physicians and primary caregivers as a necessary tool for them to be able to build their facilities and provide more services.

From what I understand there are a number of private clinics in the city today that financially we do not know if their given age of practitioners may be there, et cetera. So we are going to obviously rely more and more on the system in these, and we have to have a consistent model.

Mr. Chomiak: Is the minister saying that in places where there is a gap or where there is a nonservice applied, then the possibility exists for the development of further clinics to fill that gap?

Mr. Praznik: Yes, it does. I want to be somewhat careful because one of the things that I am trying to achieve everywhere in rural Manitoba and certainly in Winnipeg is that we make sure we utilize our space efficiently and make it relative. In the foreseeable future, my associate deputy minister does not envision necessarily new clinics being built, but we have capacity in our current system that is underutilized, that cries out to some degrees, logical places for other clinics to be centred.

I know that, in some of the discussions I have had with boards of community hospitals today, they can envision and they see it as a possibility of having a primary health clinic based right in their facility, because today they are viewed as a centre of health care in their community, and it is a logical place from which to deliver.

I know, just looking at this map, most of these clinics today very much are centred, other than Northwest Co-op, somewhat off--most are in the downtown, close to the river area, if the member looks at the map--whereas our community hospitals tend to be the northwest, northeast, Victoria, Grace, or farther out. So if there is space there, it makes logical good sense to be able to see the next growth in clinics, if space is available, centred there and that facility being more relevant to their community.

Mr. Chomiak: I guess we can assume that we are talking about clinics, be it in rural or urban centres, being operated on a 24-hour basis as an alternative service to other forms of care.

Mr. Praznik: Mr. Chair, I am not going to agree with or answer yes to that entirely. That will depend on the need for the service. I suspect the member anticipates that as well. If our clinic model in emergency happens, and if clinics inevitably get built into most of the hospitals where they are not already, it is likely that a doctor who is on call is going to practise in their clinic. The hours may not be 24 hours, seven days a week, because there may not be enough volume to support having a doctor stay there all night, but they are likely to have extended hours and a doctor on call.

In Winnipeg, as part of looking at our emergency services, the member has hit upon an area that I want to have explored, the idea that if you have a clinic service based in a hospital, having one of those physicians also part of your emergency team for your emergency delivery gives us a way of dealing with more volume in emergency potentially but, again, it has got to work and make common sense.

One other point that my associate deputy flags, as we are sorting out, emergency medical officers or doctors who do emergency in the pure sense of the word is somewhat of a specialty. But where the potential of reducing our demands on our emergency is if you have a walk-in clinic with extended hours or even 24 hours, depending on service available in a hospital, that takes a large volume of the walk-ins, convenient walk-ins, away from emergency and you may not need as many emergency medical officers in your emergency ward. So I think the member and I are on the same track. We want to see it work and develop and make common sense, but it would be, I think, a very innovative way to approach this.

Mr. Chomiak: I was under the impression that was, in fact, one of the major recommendations of the Moe Lerner report, and I was under the impression that, in fact, that was moving along, which brings me to the theoretical question of how the Moe Lerner report, with its extensive recommendations, fits in with this entire process.

Mr. Praznik: Mr. Chair, I notice that Mr. Jim McFarlane, who was seconded to the Department of Health, joins us in the back of the room. This is one of the projects that we have him working on now, and obviously keeping the Winnipeg Hospital Authority informed as they gear up, but reviewing all of the plans, the Lerner report, getting on with really getting it implemented in a logical way.

But the larger question of the clinic in those facilities, we are probably some time away, because many of those boards have to sort out that that is exactly what we want to do. We have to sort out space requirements and all of those type of things, but it is the logical conclusion as you sort of follow this thing through. I hope it is not too far away.

Mr. Chomiak: At one time, approximately two years ago, it was bandied about, the possibility of remuneration for physicians being based on a sliding scale similar to what is being done in Ontario and some of the other provinces with respect to 90 percent. Depending on the volume of service offered in an area of the city of Winnipeg, a new practitioner would be remunerated based on a lesser extent than another practitioner based on need, et cetera. I think generally the minister knows what I am talking about. Is that proposal basically dead?

Mr. Praznik: Mr. Chair, I am advised that model under our current MMA agreement is impossible. If we go to a contract basis with deliverables, there is ability to work that into the system. That would be part of the negotiations for it, and there is some possibility. I leave that to a table we are not yet at.

Mr. Chomiak: Do we have any statistics about doctors leaving to the United States that are on an up-to-date basis?

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Mr. Praznik: Mr. Chair, we will table that information tomorrow with the member. We are going to just find it. We have something from the college. We have also had the Manitoba Centre for Health Policy and Evaluation study a number of these issues. I had a preliminary report today; we will be probably making that public very shortly. They have some observations, as well, in that area that are there. I am not in a position to release that today, but I know when it is, the member will find, I think, their conclusions as interesting as I have.

Just while I have the mike, the member had asked for a list of the occupancy rates of hospitals. I notice I have been handed it here, and there may be some questions he has on that area. So I would like to table that, Mr. Chair, and there should be copies for the member.

Mr. Chomiak: I wonder if the minister, returning to the flowchart, the draft flowchart that was issued earlier on in the Estimates, under the area of the associate deputy minister, from Human Resource Planning projects, can the minister give me a short analysis of each of those specific areas--that is Human Resource Planning, Primary Care Reform, Professional Remuneration, et cetera--of the key components of those areas so that I have some understanding as to the way the structure has been set up?

Mr. Praznik: Just one caveat I would attach to the tabling of our occupancy rates; these are not to be numbers that are written in stone for policy making. They are only to reflect trends, and they, on any individual basis, would have to be examined in some detail. The reason I say that to the member is, in some cases, you may find a facility with a very high occupancy rate who will then argue that they are a well-used facility, and you will find out when you study the matter that they have a very low use of home care.

So, in essence, what you have is the decision kind of being made locally, keep people in the hospital and do not use home care, and we will show how efficient we are, in essence. Well, that kind of scenario, the member, I am sure, would agree, is an inefficient use of both the hospital and the home care system. So it only gives you some sense.

The other comment I make is, across these numbers, on average two-thirds of the occupancies are for non-acute-care purposes. So I just flag that as a number.

Now, with respect to each area on that line, we will go through them. Human Resource Planning, part of that responsibility is that we have a host of areas that require movements of staff, consolidations. The member and I have been involved with the urban shared services in the kitchens issue, and I am a very strong believer that if you can treat people fairly and work through the human resource issues, other areas of amalgamations and management, structural change, become immeasurably easier. Many of the criticisms over the years that he and his party have offered of health care reform under our administration, when you sort them out, had to deal with the way human resource issues were handled. We know that we often live under regimes that are not of our making and not of anyone's fault, but they were designed in other times for other purposes and are difficult.

So in that particular area, any major change in human resource, or any human resources issues, we try to flag through Roberta and her little group here to be able to ensure that proper care and attention is being taken to those issues to make sure they are handled well for making the resources position.

One of the other things that is part of that responsibility, as well, and it fits in in many of our other areas, is to make sure in health care that we have the right number of people delivering service, whether it be specialities in the medical field--so that is another area that comes under Human Resource Planning.

Primary Care Reform, again, is the development of the whole model for the primary care clinic. Our staff, who have been working on this for a number of years, are now working under Roberta because, ultimately, it is more than just the model for the delivery of health care. That work has been done. The critical issues now are how do you do the human resource, the labour relations issues, the remuneration issues in putting that model together? So it is now under Roberta Ellis's shop.

Professional Remuneration, again, the whole broader issue, issues of physician remuneration are part of that, as well as other contract negotiations and a host of areas in health care fit under Roberta Ellis's area.

Negotiation Services, putting together--and this is an area that I flag with some embarrassment, I must admit, that coming into the Ministry of Health we have some excellent people who do our negotiations, but we have not put a lot of thought to developing a good team approach and having the kind of training for our people in negotiation that they are able to manage a number of very complex negotiations in a logical and reasonable fashion. So we are looking at doing some upgrading of our negotiators.

As the member knows, we are negotiating now. We are beginning with MDS on a lab issue. We have issues around contract negotiations. We have service purchase agreements, those things. So we are trying to develop a body within the ministry who can manage these things and handle them in a logical fashion. I know when I was Minister of Mines and of Northern and Native Affairs, my former deputy Michael Fine and I spent a great deal of time developing the negotiating skills of a cadre of people within our shop and developing systems of being able to give them approved mandates to go forward. There is a bit of science to this that I would discuss if the member ever wanted to pursue it, but we wanted to get some rational thinking and approach to our negotiations, and we did. We were quite successful in bringing some agreements to conclusion. So I am trying to develop those skills in the department because there are a lot of areas in which we negotiate.

Adjustment and Training, again, that is part of that Human Resource Planning area to assure that wherever we are doing any change in people's roles, that we have, I think, a fair and reasonable adjustment and training strategy to minimize the effects on people who may face change.

The Academic Liaison is another area. We recognize that the universities, particularly the U of M Faculty of Medicine and the nursing faculty have a big role to play and have played, particularly in our tertiary hospitals, and we are trying to sort out with them how that will be affected by regionalization and how we can ensure that is streamlined somewhat and become somewhat more efficient.

I say this to the member, one of my goals is that we can develop our academic programming such that we can provide more opportunities for people who are learning in the system to work in smaller community hospitals, rural hospitals and other areas, rather than just in the tertiary hospitals. The Winnipeg Hospital Authority now gives us the ability to do more of that, and the regional health authorities give us the ability to do somewhat more of that.

So developing those liaisons and how we fit that piece into the puzzle is one of Roberta's challenges. The Standing Committee on Medical Manpower, which is a recruitment and retention issues, is answering--it has been in existence for some years--will now answer to Roberta Ellis; and the Manitoba Medical Services Council, which is a creature of the last MMA agreement, Roberta in this capacity has been appointed the government co-chair. She replaces Frank DeCock since Frank has moved on to be deputy minister.

Mr. Chomiak: The Physicians Resource Committee, where does that fit in all of this?

Mr. Praznik: I understand that that is a subcommittee of the Manitoba Medical Services Council.

Mr. Chomiak: Are we expecting any recommendations or any reports from that committee and when will that be?

Mr. Praznik: I understand that there is some debate going on at that committee now, so I do not know when they will report, but they are working away and debating through their issues.

Mr. Chomiak: Is the labour adjustment management committee still in existence? What is the status, and could we get a list of who is on that committee, unless it has not changed significantly in the last year or two?

Mr. Praznik: This committee is still in existence, basically the same people. I do not think there has been any significant changes in the last year. The only thing that we have asked, and Roberta in her new responsibilities has met with the management caucus group there and suggested that they may want to rethink their composition to take into account over the next year the new governance structures with the Winnipeg Hospital Authority, the relationships that will develop with the other governance boards at the faith-based and other facilities, and ensure that they are properly reflecting the structures as they develop between the WHA and the Winnipeg facilities.

Mr. Chomiak: Can I get an update as to the voluntary separation plan that is presently in existence?

Mr. Praznik: I will be delighted to table that. Tomorrow we will have that for you--hopefully, tomorrow.

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Mr. Chomiak: The minister indicated we would have a copy of the one-year agreement that has been negotiated with respect to the employees vis-a-vis the regionalization.

Mr. Praznik: I would be pleased to table since it is not too often my name appears with Peter Olfert on a document. I think we have the unsigned copies here. Okay, we have one generic copy--well, I will just explain this: Mr. Chair, I am giving you a copy of the unsigned copy. What we had was, I signed one, Peter signed it; I think we signed 11. I should say 11, or whatever, it is 10, and each one has a signature for the regional health authority.

So there are really 10, currently, originals out there, with each of us having--I guess there would be 30 original copies that we have. So I am tabling you the unsigned copy of this particular agreement, and I have a number of other copies here.

Mr. Chair, I am also told that the first part--I think I have given you the whole package--the first part of it is with Manitoba government employees. There is a separate back page, I guess, that covers the home care attendants. So I guess they are two different bargaining locals within the MGEU. I think if the member has a look at the back, this would be the home care group within it, so everybody is covered in this.

Mr. Chomiak: I have not had a chance to read the details, but just in general, this agreement takes us to the end of the period of the expiry of the master agreement with the MGEU or over the next year period. What is the time frame of this particular agreement?

Mr. Praznik: I understand that the master agreement expired on the 31st of March, one day before the RHAs were to take responsibility as employer. So what this agreement does, in essence, is it agrees to extend the current agreement for another year, and that gives a year in which the RHAs can negotiate their own agreement. Some of the bargaining issues can be sorted out, and also provided for the province for up to that year to continue to maintain or administer the collective agreement and pay salary with an accounting with the RHA.

What we did not want happen, and I know if it had happened the member would have been very critical in the House as I would have been if I had been the critic, we did not want anyone being transferred to not get a pay cheque or have some benefit problem, et cetera, because they had moved over. We wanted a smooth transition. This gives the regional health authority a year, in essence, to sort out their own bargaining issues, get their own structure in place to deal with payroll and benefits management, and also to set up their own structures, et cetera, and negotiate their collective agreements with the MGEU. This was a very convenient way of doing it, and the union was certainly very pleased to be part of putting this together. This was a smooth transition. We have not had one complaint, quite frankly, about an employee losing a benefit or not getting a pay cheque.

Mr. Chomiak: Can the minister indicate what about those employees that are not a part of the MGEU or are not a part of the master collective agreement, what arrangement has been made with those other bargaining units?

Mr. Praznik: I am just advised, Mr. Chair, that the vast majority of our employees were represented by MGEU and were covered. I am told there were a few of our staff represented by the MNU, and we have carried on on this same basis. I think we are working it out with the MNU now and will probably have the same kind of agreement, or time will overcome it, and we have carried out the same practice to no objection.

Mr. Chomiak: Mr. Chairperson, those employees that are employed and part of the MMU and other labour organizations, I assume their contracts are with the specific facilities and specific institutions. So is that why they are outside the purview of the agreement?

Mr. Praznik: Mr. Chair, perhaps the reason why we look a little unclear on this is the number we are talking about is less than a half dozen, one or two perhaps. So this is why it was--it was just a few people who are under our employ. We transferred our employees over now. With respect to the facilities, regular labour law, of course, applies. There is a successor right, the agreements continue in place, and we have signalled, I think, to the labour community that we would like--obviously, there has got to be an amalgamation of bargain units take place and a whole bunch of the normal kind of structural changes whenever you have a consolidation of facilities under one new management or these must take place. What we have said to both the regional health authorities, as the new employers, and the labour unions representing those employees, including the Manitoba Nurses' Union, we would like them to proceed to negotiate these things.

Where they are not able to do that, we would strongly recommend they use the existing labour relations mechanisms of the Labour Board, and I am hoping that approach will solve virtually all, if not all, of the issues over the next year or so. If there are some that are just not resolvable, we would then proceed to appoint the commission under the RHA act to proceed to do that but, as the member may have noticed, I have not yet appointed the commission. I have not really had a purpose yet to do it. I would prefer that the regular labour relations structures and processes get a first opportunity to solve these issues. They have happened before in the private sector and other places, and there is certainly a history in the labour movement of dealing with this.

So we hope that we will solve most of them by negotiation and some issues being mediated or settled at the Labour Board level where that is appropriate, and perhaps we may need never to appoint that commission, but if we do, we will.

Mr. Chomiak: Mr. Chairperson, are the respective RHAs in the process, or going to be in the process, of negotiating collective agreements with the MGEU, or are they negotiating agreement with the government of Manitoba through this agreement representing--are they negotiating agreement with the government of Manitoba on their behalf?

Mr. Praznik: Mr. Chair, as the employing authority of those staff, they in law have the responsibility to negotiate the collective agreement with the unions representing their employees. One practical matter, of course, is that because government is the funder, we will want to have--and the labour side obviously would like to have some consistency across the system, too. So we will have to do some co-ordination from our perspective with the regional health authorities as I am sure that the labour side will also want to do on their particular side. I gather the tables on which we negotiate this are still being worked out as to how we will do it.

The withdrawal of Manitoba Health Organizations, given the fact that they used to represent some 180 boards and today there will only be 13 employing boards, is going to change the structure, and I get the sense that the council of chairs and CEOs of the regional health authority will likely become the new MHO. We will work with them to develop their human resource bargaining so that there is a consistency across the province that makes sense.

From the labour side, each, whether it be MGEU and home care workers or whether it be MNU on nurses and facilities or UFCW and support staff or CUPE, whoever, they are likely going to want to do the same things as well. So some of the larger issues are likely to be negotiated centrally, and the more local issues will be negotiated probably at local tables. That still is going to get fleshed out, but it does not take too much to figure out that that is likely how it is going to end up.

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Mr. Chomiak: I am trying to process this and trying to ascertain what parallel situation exists, but presently, as the employer, the government of Manitoba negotiates--I guess the example of school divisions and their bargaining position would probably be the closest parallel, although that is done through MAST, a central organization, which really does not exist at this point, a parallel that the MHO at one time was, but there is no parallel organization.

I guess I am trying to get a sense of--the agreement you have tabled today extends until the end of next year. The RHAs are responsible. These matters have to be ascertained. They are obviously working on them. So what process is presently underway?

Mr. Praznik: The member has the same area that we struggle with, where are we going to--the same questions. How is this going to work in the new world? MHO fulfilled that function in days gone by, representing 180 facility boards and putting that together. Today, or very shortly, we will have 13 boards. We are fully expecting that the sort of council of CEOs and council of chairs, which now meets monthly to do a lot of their co-ordination and planning and work with government, is likely in some form, and they are sorting that out, to become the new version of MHO. They may even take some MHO functions from MHO, benefits management and others. That is for them to work out.

They have in place now, and perhaps I have omitted to mention this to the member, but they have elected from among their group a chair of the chairs and a chair of the CEOs, and the chair of the chairs is Mr. Ed Bergen from the Interlake, and the chair of the CEOs is Mr. Tom Novak, also from the Interlake. So that body, although very unofficial at this time, is starting to grow into kind of a new body for co-ordinating the regional health and labour relations. Co-ordination will obviously be a key part. When we develop any common strategy as a funder with them to deal with these issues, we will be dealing with that body in whatever legal form it takes, as we used to deal with Manitoba Health Organizations. And ultimately the unions representing employees across the system on system-wide issues, obviously rates of pay are one of them, are likely to also deal with that body for a common table negotiation and then regional issues being dealt with at a regional table.

So collective agreements, I would suspect, are likely going to have those two components just like they do now in the MHO negotiations. So I think if you took MHO and replaced it with the council of chairs or CEOs, you are probably getting a similar kind of a structure.

Mr. Chomiak: How does the minister see that relating to the issue of physician remuneration? Will that be ultimately ceded over to the regional health authorities in a similar sense and passed on to be dealt with accordingly?

Mr. Praznik: It is such a large part of our budget today and such a key part of the way in which we run our health care system and one in which we expect--it is really in a position of transition. Most of our other collective agreements are not. You are really transferring who is the employer. You are amalgamating bargaining units to fit the new way we organize things on a regional basis and life, after that is done, is going to continue very much as it has been. Physician remuneration is really going through a fundamental period of change, and it is also not a contract under The Labour Relations Act so it is not governed by the same rules.

So I would expect that for the foreseeable future at least we will still be dealing directly through the ministry with physician remuneration, but I can tell you, in practical terms, the council, chairs and CEOs, we are already making sure they are involved in our planning because they are the ones who will have to administer many of the decisions that are reached in agreements that are concluded.

Mr. Chomiak: I wonder if the minister has a copy of the list that he annually or regularly tables with respect of the various committees.

Mr. Praznik: Mr. Chair, I hope the member is not tired after all the campaigning and getting out the vote yesterday because if he goes through these tonight before he goes to bed, they are lengthy. So I would like to table this list. I have copies for my critics. It also, I might point out, includes the Manitoba Health Board which was an area that the member for Kildonan had asked about specifically. I believe it is the last board that is referenced.

Mr. Chomiak: Just looking ahead again at this point about--I am not going to be asking extensive questions from the associate deputy minister the minister brought today because we will have to move on. I believe the member for Inkster (Mr. Lamoureux) will have a few questions. I anticipate it looks like, frankly, what we are going to be dealing with in terms of the Estimate hours is Wednesday, Thursday and then possibly Monday and then that will probably wrap it up. Very unusual. [interjection] I think just for structural purposes, we should target Thursday for the long-term care, that whole area. [interjection] Yes, home care, as well. I mean, at least Thursday and that might take us into Monday, as well, and then maybe try to work around that--I will have extensive questioning there--and try to work around that for tomorrow and then Monday after that accordingly.

But, tomorrow, we can probably move down, at least from my perspective, deal with some of the--not extensively, but some of the issues with respect to Mr. Potter's area. The SmartHealth issue, probably move through a lot of the appropriations up to the Continuing Care, Long Term Care line item for Thursday, and we will deal with that Long Term Care Thursday, and then Monday probably wrap up in a variety of other areas.

Mr. Praznik: Mr. Chair, I very much appreciate the member's direction and comment. I just flag with him the MDS lab consolidation and that contract. Since that is in Mr. Potter's area, if we perhaps can deal with it tomorrow. I will also make sure, he will make sure that we have our staff who are involved in putting the negotiating team together here.

Mr. Lamoureux: Just continuing on to sort of the same line there, we are talking about doctors, salaried doctors, and one of the areas of exploration I would like to venture into is the role of some of our other health care workers.

There has always been a great deal of concern with respect to LPNs and what sort of a future role they will have with respect to acute care beds, in particular, our hospitals. I am wondering if the minister has anything that he would like to indicate with respect to that particular issue.

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Mr. Praznik: I know this has been an issue that has gone on and on and on. I think every minister has asked about this. I know our colleague, the member for Kildonan (Mr. Chomiak) has asked me about this in the House. There is no doubt on the current track that we are on that I would suspect most LPNs in their current role in facilities, hospitals, are probably going to continue to be in a diminished role in those facilities.

Ironically, despite the layoffs that have taken place, I understand many of the LPNs who have not moved either to be patient aides or moved on to train to be R.N.s have found employment with other places, the VON, other places. So there is certainly a demand there that is picking up some of that slack.

The problem, I kind of see it as this, and by the way I just point out I have spent maybe not as many hours as I would have liked to on this but certainly a fair bit given the flood and all of the other things we have on. I am trying to understand why we have a battle here going on. There is obviously a big turf issue going on within the nursing profession. I am not critical of the nursing profession. It is inevitable. Any profession that divides itself among a number of different bodies representing care providers of different roles is going to have issues about where those roles meet.

One difficulty, another part that compounds this is within our collective agreements LPNs, who by current definition and decisions of their various professional bodies are not allowed to do certain things, yet their cost to the system is very close to our ends. So what happens is that within that system they are not viewed for the dollars being spent on them to be able to provide as much service as an R.N., so facilities make decisions to eliminate LPNs and replace them with a mix of R.N.s and patient aides, at the end of the day, getting more hands physically working with patients and a skill set that is supposedly greater with the R.N.s and more hands to do physical work with the patient aides than the mix using LPNs.

Now, when you get in, and I spent a whole evening with a representative of the LPNs at my office, they made a point that one of the problems here is the way in which we, by our standards, require facilities to be staffed. We identify the positions or the professional and how many of them a facility requires to meet the standard. So we say you need X number of R.N.s, X number of LPNs, an LPN cannot practise without an R.N., et cetera, et cetera.

At the end of the day, and I have seen this happen when I was Minister of Labour and Roberta was Deputy Minister of Labour, many times how we set the standard for what people had laid the framework for, either a logical way of handling the matter or an illogical way, and a lot of turf fights. Believe me, in the Labour Department there are all kinds of turf fights in various trades and crafts. I remember my favourite one was the building erectors, the people who now take pre-fab buildings and erect the building, put them together. We never had a category for a building erector. What we had were labourer, we had pipefitter, we had iron worker, we had carpenter, and what was the building erector, right? So you had literally a square hole in a round peg, and you had to try to fit it in and it never worked. Everyone was angry and what have you.

The bottom line is what were you really trying to do? You should not have been trying to protect a craft or a trade. You should be trying to require a certain skill set. That is one of the reasons we brought Jim McFarlane in to work with us, because we have been through Roberta, and Jim and I have been through all these kinds of battles in a host of areas.

So the point the LPNs make, when we sort of start sorting this through and you deal with the arguments, well, it is R.N.s who are involved here and it is not LPNs. LPNs can train to do what an R.N. can, and that is used to keep them out of profession. You come to the conclusion that perhaps what we should be doing when we rebuild standards for our facility is not describe professionals and say you need so many of this because their training program encompasses these skills, but you should say we need people who have these skills and can perform these tasks. Then let the facilities sort out who they want to hire at what price and not identify necessarily the professional category, but identify the skill sets that they require.

If LPNs, through their professional body, are able to meet that skill set, and R.N.s can meet the skill set, it is up to the facility to decide who they hire and what mix, without naming necessarily the name of the professional, because ultimately there is probably overlap. Ultimately if one person takes a week-long course to be able to deliver a service, should that preclude them from now doing it? They may be better practised than someone who took the training five or 10 years ago. So we concluded that that is probably a better way to go. It is not going to happen overnight. It is a long-term issue.

The second part of this, as we sort it out, is that there is a void developing. As registered nurses up their training, as we eliminate the two-year R.N. program and move to the four-year university Bachelor of Science program, as this government and many others will be wanting to train R.N.s even with a Masters program to maybe do urgency care, to take on expanded roles in the delivery of care, expanded roles in administration and what have you, there is still a need for basic bedside care.

The pure economics of it are such, and the logic is such, that if you are going to increase the training requirements and have someone do a four-year university program, maybe another year as a Masters in a speciality, they are going to have a salary expectation, by and large, that is likely going to make them unaffordable in many of the aspects of bedside care in large numbers. You are obviously not going to use someone like that to maybe wash or bathe a patient unless it is some rare circumstance that requires special training. You are not going to have that person do basic hygiene, you are not going to have them deliver food, you may not have them give medication in many cases, et cetera.

So as R.N.s develop and evolve in the system, there is a void being left, and that void in terms of governance and training and where they are starts right with the lowest untrained, or least trained, level of patient aid, right up to where you eventually meet the R.N. with their four-year nursing system.

For lack of a better term, let us call it practical nursing and patient care, and the LPNs, as an association, may be well positioned to fill that void in some way as a professional body. Obviously, they should be talking and we should be talking with the Manitoba Association of Registered Nurses, how all these people fit together. Maybe within that there is a way to ensure that we can meet two needs, that they can evolve to fill a particular need, in practical nursing and patient care, and take over role and training, et cetera, and maybe the model that we require for this whole level in our hospitals needs to be developed into a unit model so that people can have always the sense of upgrading to be able to fulfill need as it develops to facility.

I do not know if that is the answer. We are playing with some ideas right now to fit it in to see how it will work out in the future, and as I get some more time, as we get through Estimates, it is an area we have got to spend some more work in, but rather than--I have been asked by some in the LPN association to issue what I would call a ministerial edict saying hospitals must use LPNs. Well, I do not intend to do that for any profession. I do not want to protect any profession by ministerial edict, and that is my word, not theirs. I want the system to have the flexibility to be able to find the right mix of care providers at the best price, and I know in our hospitals today we are short of hands.

We need hands with an appropriate level of training to provide basic patient care. I think if we could put more patient aides with an appropriate amount of training into our facilities today to take the pressure off nurses, whether they be LPNs or R.N.s, however we work that out, patients would be happier because they would figure they would get more attention and their needs being met. We would see an end of the stories about how long someone has to lie in their own urine if they cannot clean themselves, et cetera. We would take some of the workload off our nursing staff who are dealing with that.

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We cannot afford to provide that extra-hands care with Bachelor of Nursing R.N.s. We may not even be able to provide that extra health care with the current cost of LPNs and their level of training. So we know we have to get more hands on the system. We have to find the right mix. I am not going to go and pass edicts or make edicts saying how hospitals have to do it. I want them to be able to find that, facilities to find it. But my commitment to the LPNs as a profession and nurses as a profession is to help develop means of setting requirements and sorting these things out that will give them a fair chance to find their role.

As a professional body, they may decide and make the offer to take over the training and standards for aides, for patient aides, et cetera, to be able to develop a continuum of training. We have no one filling that today. That is a possibility. There may be ways of ensuring that LPNs can become more useful in the system by adding some unit course training that allows them to do the things now they say they are prohibited from doing but are capable of doing. We have got a lot of work to do on this. It is an area that I hope to get some attention at senior levels put on these matters in the not too distant future.

I must admit to the member I cannot do it today, the next few months, because most of my senior staff who I would want working on it are working with a number of other crises in progress, but as we get through those, it will be a matter which will get a great deal of attention. It is not getting it today. We are starting to talk about those ideas, but I have to get some very senior staff on it once we have worked through our latest round of crises.

Mr. Lamoureux: Mr. Chairperson, I know that ultimately to achieve quality health care delivery, one of the primary things that has to be taken care of is trying to better define the role of those individuals who deliver that particular service. What we have seen over the years is the nudging out of LPNs from many acute-care situations. Having, as the minister has, talked to LPNs, amongst other nurses, I am not convinced this is an area which is best to move towards in terms of the phasing out of LPNs. In fact, I think we do need to move towards the other end of trying to get more LPNs involved, primarily because I do see them as the bed care delivery, the best person that is in a position to deliver that hands-on bedside care.

Now, I think much like for me, LPNs and other nursing professions that are out there do need to get more direction in terms of how the province is going to be evolving in delivering health care services. I would throw into that equation nurse practitioners. I would ultimately argue that we do not utilize a potential profession anywhere near to the degree in which we should be doing or taking some sort of action.

For example, I would go as far as to say on the record that I do not believe Manitoba needs as many doctors as we have in certain areas. In other areas, I would argue that there is a role for nurse practitioners in which the government has not taken any sort of action on. I say that on the record primarily and even from within my own political party, I will get some resistance to that particular statement, but I believe the Minister of Health has to play that leading role in trying to better develop the roles that all our health care professionals need to take.

That means you have to start right off from the doctors. We need more specialists. There is a lot of work that needs to be done in that area in terms of doctors, in terms of GPs. There are areas of the province where there is a higher demand, other areas in which one might question the demand. When we look at the nurses, from the Bachelor of Nurses, the BNs, to the LPNs to the nurses aides, we need to look at the entire picture and try to give more direction as opposed to sitting back and letting it evolve in what maybe the minister, or the minister previous, would say some sort of a natural way.

That has not been the case because of a lot of protectionism that is out there from within, whether it is a union, a vested interest group. Ultimately, I think that does have an impact on the quality of care. If the government could do something over the next half year--because we talked a lot about health care reform. I spent some time talking about the institutionalization, the benefits of community hospitals taking away from tertiary hospitals, some of the operational procedures, well, that is just one side of it.

The other side, of course, is the individuals who are providing that care and trying to get a better idea in terms of who should be playing what sort of a role has not really been part of the whole discussion on health care reform to the degree which it should be.

Mr. Praznik: It is most evident the longer I am around this portfolio, and I have not been there long yet, but I have watched this for many years. The member is very right in the sense that there are many professions that are probably under utilized, but I will tell you, when you start talking about it, from one side of it you get into all the reasons why you cannot. For everyone who tells you one reason why you should, there are about three who tell you a different reason why you cannot. You get caught in these battles. What is very interesting about it is, if you try to move forward in one area, the next thing you usually get is some public attack saying you are putting people at risk because you are doing this particular area.

It is a really tough battleground in which to be in. That is why, to some degree, you have to have a sorting out of these things in a fair manner. I always have trouble when people protect their turf, and ultimately their income that goes around it, by keeping other people out in an unfair manner. That is why I have trouble with requirements and standards that say you must have a certain type of person here.

I remember when I was Minister of Labour, Workplace Safety and Health--I know Jim McFarlane will remember this--we had an issue about a first-aid regulation in one of our regs about remote mining sites requiring a nurse, having to have a nurse on staff. If you are going to pay someone 50,000 bucks a year or whatever to be around for a hundred employees, the economics did not make any sense. What we were trying to accommodate when I tried to flesh it out is we needed a certain first-aid skills set. So what we did, in fact, is we put the skills set in the regulation and how a company filled that was their business, whether they trained some of their staff to provide it who were working staff, or whether they hired someone was their business. It said to me, putting in just the title of the position, they did not guarantee better service, but it sure protected a job or created one.

So the same rule I think has to apply somewhat in our institutions and facilities. We have to move more toward standards that require skill sets and let those professions out there, their professional bodies, make sure they are training their staff to meet the skill sets, and let people find their way in the mixed skill sets, because I know that as sure as God made little green apples, if you do not do it that way, you will continually be fighting to describe professionals, one professional group to the exclusion of another.

There will always be good arguments why you should do that, and there will be good counter arguments why they should not, and people like him and I, as MLAs, will be always caught in the middle of those fights. So I would like to change the focus over the next while not to be in the middle of those fights but say: What do I really need? What does the hospital need, and let people figure out how they are going to meet that.

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