1993 Legislative Session: 2nd Session, 35th Parliament HANSARD
The following electronic version is for informational purposes only. The printed version remains the official version.
(Hansard)
FRIDAY, MAY 7, 1993
Morning Sitting
Volume 9, Number 20
[ Page 6007 ]
The House met at 10:04 a.m.
Deputy Clerk: Pursuant to standing orders, the House is advised of the absence of the Speaker.
[E. Barnes in the chair.]
Prayers.
H. Lali: I would like to introduce a friend of mine to the members of the House. Her name is Jackie Tegart. She is chairperson of the South Cariboo School Board and also the new president of the B.C. School Trustees' Association. Will the House please make her welcome.
K. Jones: Visiting with us today is a group of students from Zion Lutheran School in my riding of Surrey-Cloverdale. There are approximately 20 grade 5 students with their teacher, Mrs. Heather Epp, and 14 grade 6 students with their teacher Mr. Jonathan Mellecke. They have several parents with them on their tour of the precincts. Would the House please join me in welcoming them to Victoria.
EDUCATION IS ESSENTIAL
C. Serwa: There isn't a member in this assembly who at one time or another hasn't spoken about the importance of education in our children's future, yet 50 government MLAs in this assembly now seem to feel that education is not essential. As a matter of fact, they feel so strongly that education is not an essential service that they struck it from the labour code last fall. Education was deleted as an essential service under Bill 84. The education of our children was deemed to be of secondary importance to the collective bargaining rights of teachers. The right of teachers to strike was elevated above all other rights: above the right of students to receive a proper education, free of disruptions caused by heavy-handed, nineteenth century trade union tactics; above the right of parents to ensure that their children receive the level of instruction they need at a most crucial period in their lives; and above the right of taxpayers to ensure that their tax dollars are spent wisely. The right of educators to strike was deemed essential, while the right to be educated was deleted as an essential service. The question is: why? Why would something so fundamental as the education of our children be removed as an essential service from the labour code.
The answer is as simple as four letters: BCTF. Indeed, it's ironic that the B.C. Teachers' Federation is the organization most responsible for the removal of education as an essential service. Their primary concern has not been for the welfare and education of students, but for the pay packages and working conditions of teachers. This is an organization that pretends to be neutral, while shelling out big dollars in 1991 to help elect this current government. The BCTF have always supported the NDP and always will, because they see the NDP government as the ticket to higher public sector paycheques.
Deputy Speaker: The hon. member for Richmond Centre rises on a point of order.
D. Symons: I desire to hear the points being made by the speaker, and I'm unable to, because of the din that's in this place.
Deputy Speaker: The point is well taken. I would ask all hon. members to conduct themselves accordingly.
C. Serwa: Critical to the process of getting those higher paycheques is the right to inflict maximum pain -- on students and parents alike -- through the right to strike and withdraw education services. They gained the right to strike, but that right is now being used irresponsibly by the BCTF. Having won that bargaining tool, the BCTF is now using it to bludgeon students, parents, school boards and taxpayers into submission for higher salaries and smaller class sizes.
During the first three months of 1993, nearly 11,000 workers have been directly involved in school work stoppages, more than 20,000 teaching days have been lost, and 140,000 students have had their schooling interfered with -- 25 percent of British Columbia's entire student population. Strikes have shut down schools all over the province. Students in Port Hardy have been out of class for a month now. Some Gold River students haven't seen their teachers in five weeks. In New Westminster, the Education minister's own constituency, students have been subjected to nearly a month of strikes. Classes were shut down for more than six weeks in Quesnel. Forty-six thousand Surrey students faced six weeks without instruction. Fifty-four thousand students in Vancouver are faced with a full-scale strike. Districts such as Alberni and Smithers are threatening to do the same.
It's not acceptable that kids can't study for scholarship exams, that parents have to scramble to find day care, that students are threatened with the loss of their school year and might miss out attending university in September. Unbelievably, the BCTF's brief to the Korbin commission states that strikes and lockouts aren't a problem for students. It states that strikes present no long-term impact on students' progress. Well, I can tell you, hon. Speaker, they certainly do.
Strikes hurt students who fall behind in their studies and may never be able to catch up without expensive private tutoring. School strikes place an added burden on working parents. They worry themselves sick seeking a trustworthy alternative for their children during normal school hours. Strikes hurt taxpayers, who pay the bill for the enormous waste of time, energy and money that any labour dispute involves.
We know that the BCTF is a powerful force. If they had the interests of students at heart, they would demand that education be immediately restored as an essential service. They would voluntarily pledge not to
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engage in strikes. The school boards want to see education restored as an essential service under the labour code; so should this government. Section 72 of the code gives the minister the power to direct the Labour Relations Board to designate as essential those services that are necessary or essential to prevent immediate and serious danger to the health, safety and welfare of residents of British Columbia. In fact, the chair of the Labour Relations Board recently ruled that grade 12 is an essential service in School District 85. The minister, however, stonewalled the decision and acted, without any mandate, to refer the issue back to the Labour Relations Board for further consideration. The Labour minister's refusal to accept the LRB report will delay any resolution of the strike and place the students' education in jeopardy.
Education does fit the bill as an essential service on all three counts: health, safety and welfare. A stable education environment develops the mental and physical health of children, provides a safe surrounding in which they can learn, and a place where their welfare should be first and foremost.
The government can and should exercise its authority. This would guarantee that education services would be maintained, future strikes and lockouts would be prevented, and currently striking teachers would be ordered back to the classroom. Our children deserve this basic protection. The government must immediately move to implement provincewide bargaining, as the B.C. School Trustees' Association has recommended.
D. Streifel: It's a pleasure this morning to rise and respond to my friend off to the far right, on education being essential. As a matter of fact, this member, as well as all my caucus colleagues, agree that education is essential to get along in this life. I think the education of this hon. member is another essential service that we may perform this morning.
We've gone through some times of labour unrest in this province and difficulties within labour codes. We heard the question this member off to the right addressed. This government brought in the Labour Relations Code, and it's in place in this province to set a framework to fairly decide labour relations issues. The emphasis in that Labour Relations Code, is on fairness. In this case, parties can make an application to the board. That has happened, and a decision is in place.
[10:15]
This House, this province in particular, and this hon. member from the third party -- who sometimes has a need to conveniently rewrite history to serve his own political needs -- must clearly recognize that the Social Credit Party, along with him. nd two of his caucus colleagues, were in government when that government gave teachers the right to strike. I guess we may as well face up and address the number of days that education has been interrupted since that right has been in place. In fact, 0.7 days per contract year is the total disruption since that right has been granted. This hon. member would like to conveniently rewrite history to suit his party's own needs. We have never ordered teachers back to work, because we respect the right of collective bargaining in this province today.
We must all understand that there is no more money for this set of negotiations. I am sure that the parties involved, the teachers and boards, will bear that in mind throughout these tough times and difficult negotiations. We must keep in mind not only our own interests and welfare but also the needs and aspirations of the communities. In particular, I'd bring that hon. member's attention to the needs and aspirations of the children in our communities. The hon. member talked about heavy-handed tactics and about the history in this province around labour relations. He has a poor memory with regard to political action in this province. As we enter these difficult times and work through them, I'm sure that the parties involved will bear in mind the best interests of the communities and the children they serve.
C. Serwa: In conclusion, how supportive are teachers of the BCTF's policies? Not very supportive, if one interprets the strike vote recently held at Argyle Secondary School, where only 325 out of approximately 1,200 teachers attended the meeting. Committed professional teachers continue to have a strong commitment to the learner and are uncomfortable with current tactics. However, unless this majority group is willing to stand up and be counted, both the rights of students and the public's image of teachers will continue to be eroded. The teaching profession and students are being subjected to the tyranny of the minority.
Are teachers poorly paid in British Columbia? Members may be surprised, but they must recognize that the average teacher has an income, including wages, benefits and pension contributions, that exceeds the interest received on a $1 million capital investment. That's the wage structure at the present time.
We must move away from the whipsaw method of bargaining which plays off one school district against another. Education is a provincewide right for all of our children, which makes provincewide bargaining a provincial government issue. All students deserve to receive a quality education without disruption and without being treated as pawns in professional labour disputes. Students can't afford to lose an extra day, not even an hour, to wage disputes that should rightly be mediated or otherwise resolved through the bargaining process.
I urge the government to put the welfare of students and parents first. I urge it to immediately bring in amendments to the labour code to restore education as an essential service.
Hon. E. Cull: Hon. Speaker, I ask leave to make an introduction.
Leave granted.
Hon. E. Cull: In the gallery are some students from Frank Hobbs Elementary School in my riding, along with their teachers and some parents. Since the statement we heard this morning was about education, I'm sure they were very interested. But I might mention
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that I asked them what laws they would pass if they were sitting in this chamber, and they did say no more schooling. Would the House please make them very welcome.
B.C. FESTIVAL OF THE ARTS
E. Conroy: Hon. Speaker, it's my pleasure today to rise as the MLA representing Rossland-Trail and speak about a wonderful event that will be taking place in Trail from May 26 to May 30, the British Columbia Festival of the Arts.
The B.C. Festival of the Arts is the largest festival of its kind for emerging artists in Canada. It features competitors, performances and exhibitors in the disciplines of music, dance, visual art, theatre, video and film. The festival gives community-oriented amateur artists both provincewide exposure and the opportunity to compete on a provincial level.
During the year leading up to the festival, over 75 regional events are held throughout the province for competitors to advance to the festival. Approximately 60,000 artists compete to become one of the 1,200 or so delegates who participate in the festival. The opportunities and experience for these young artists are unlimited.
Over 50 venues are used to feature 350 events, ranging from a week-long art exhibit, drama workshops and master classes in music to seminars, competitions and concerts. The participants in the festival are guided and critiqued by over 50 professional artists from B.C. and other parts of Canada.
Events such as the B.C. Festival of the Arts show the remarkable willingness of our province to come together with our energy, time and support. Over 100,000 volunteers are involved in the festival -- 100,000 people from all regions of the province who have realized the importance of this event to our emerging young artists. They should be congratulated, and all British Columbians should be proud of their hard work and dedication.
Five provincial art service organizations have also been actively involved in the success of the festival and should be recognized. They are the Association of B.C. Drama Educators, Pacific Coast Music Festivals Association, B.C. Association of Performing Arts Festivals, Assembly of B.C. Arts Councils and B.C. Student Film and Video Association. The B.C. government is proud to be able to help make this festival possible along with major sponsors, individual donors and local businesses.
Trail, the home of champions, is proud to be this year's host community. The host communities are chosen based on their ability to house the event, and in conjunction with the provincial office, they will coordinate the venues, meals, hotels, promotion, technical aspects and hospitality for the participants. Trail, with its warm, responsive residents, surrounded by the natural beauty of the province, is the ideal community to provide the participants with an incredible festival experience throughout. Trail reflects the aspirations of these talented artists in their never-ending striving for perfection.
I join with the Minister of Tourism and Minister Responsible for Culture, Hon. Darlene Marzari, when she says that the B.C. Festival of the Arts is a leading example of the close relationship that exists between the arts and the well-being of our communities. The festival this year will not only bring enormous economic benefits to Trail, it will demonstrate the massive community support and fellowship generated for the arts and culture. The festival provides a unique opportunity for B.C.'s emerging young artists to gain exposure and receive feedback from the leading professional artists who act as festival adjudicators.
I strongly support the B.C. Festival of the Arts, both for the opportunities it provides for up-and-coming artists and for the economic and social benefits it creates for the host communities. I recognize that because of the dedication and involvement of local arts organizations and the provincial arts service organizations, the B.C. festival has been able to achieve such a remarkable level of achievement during the past decade.
In order to ensure continued community and artist involvement in the festival, this government is committed to maintaining the funding provided to professional artists and arts organizations through its cultural services branch. I hope that, through this partnership between the community and the government, the B.C. Festival of the Arts will continue to be the largest and most successful event of its kind for many years to come.
In fact, today the Minister Responsible for Culture, Darlene Marzari, will be announcing the appointment of eight new members to the B.C. Festival of the Arts board. These appointments have been recommended to the minister by the five provincial arts service organizations that organize the regional competitions leading up to the festival. The new members will ensure additional, community-based representation on the board and will bring a new degree of involvement from the organizations and individuals who have contributed to the festival's success.
The commitment of this government to the arts and regional participation is reflected in the success of the events within the B.C. Festival of the Arts. My constituents in Rossland-Trail know this festival will be a memorable one for artists, guests and the entire community. With that knowledge, we welcome the entire province to our home during the eleventh annual B.C. Festival of the Arts.
This year's festival has particular importance to me, because it was one of my constituents who initiated the festival in Trail. I'd like to pay tribute to Lloyd Wilkinson, a former councillor from Trail, for the great work that he did in getting the Festival of the Arts.
C. Tanner: Members on this side of the House would also like to thank the residents of Trail for their tremendous efforts in preparing the venue for this year's Festival of the Arts. The five contributing organizations -- the Assembly of B.C. Arts Councils, the Association of B.C. Drama Educators, the B.C. Association of Performing Arts Festivals, the B.C. Student Film and Video Association and the Pacific
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Coast Music Festivals Association -- should feel proud of their work and commitment on behalf of developing artists.
The B.C. Festival of the Arts is not just a showcase for talent or an event providing needed workshops and master classes for young artists; it is an event for the public. As professional artists know, one of their first hurdles is to educate the public. For that reason, I would ask all members of the House to encourage their constituents to take advantage of this marvellous opportunity to learn and enjoy on May 26 to 30 in Trail.
For making the opportunity possible, our warmest thanks are extended to the participants themselves. Last year it was held in Vernon; this year it's in Trail. I'd like to advertise that next year it will be in Campbell River on Vancouver Island. I urge all members to urge their constituents to take part.
E. Conroy: I'd like to thank the member for Saanich North and the Islands for his response and his support for the Festival of the Arts.
I'd just like to conclude by again welcoming everyone to Trail for this festival. There has been a tremendous amount of hard work by many local citizens on behalf of the city, and everybody feels confident that it's going to be a big success story. Again, thank you for your support. I welcome you all to Trail for the B.C. Festival of the Arts.
MANUFACTURED HOMES
W. Hurd: I'm pleased to rise in my place today to talk about a subject that is important in my own riding of Surrey-White Rock, and it is also an important housing issue throughout the province: that is, the future of the manufactured-home industry and manufactured-home parks in the province.
I first got involved in this issue shortly after my election, when I was asked to attend a meeting of the residents of five manufactured-home parks in my riding. They soon educated their new MLA as to some of the difficulties they were facing with respect to ownership, selling and just plain living in manufactured-home parks. Many of them are seniors who live on fixed incomes. They find that when it comes to some of the basic protections afforded by the Residential Tenancy Act and benefits such as the SAFER program, which protects the incomes of seniors on fixed incomes who are renting, they don't apply to them.
[10:30]
There are a number of issues relating to manufactured homes that I want to talk briefly about today. There's a lack of security and a lack of control over the pad rents, and over a period of time, that drives up the cost of living in manufactured-home parks. I've been told that people have great difficulty financing and selling manufactured homes within existing parks. It is difficult to secure bank financing in order to purchase one and difficult to move the manufactured home should that become necessary because of conditions in the park. Furthermore, the changes that result when a home within a park is sold and the ability that a park owner has to raise the rent for that particular pad has the effect of creating a variety of rent structures throughout the manufactured-home park.
At the meetings which I attended there was a real feeling that while this was an excellent form of housing, particularly for seniors, it suffered from a lack of policy direction from government. It wasn't even remotely reaching its potential as a form of affordable housing, which could be accomplished not only in the lower mainland but throughout the province. The cost of land, servicing and standard frame housing construction is soaring almost every year.
It is also important to mention that the park owners themselves are facing their own problems. Escalating property taxes and the increasing cost of services create an upward pressure on rents. In the past there has been some reluctance on the part of municipal governments to zone land for this type of housing, because of its past reputation and the impression that councillors might have about this type of housing construction.
All these problems are a shame, because if you look at our neighbours to the south, there is tremendous potential for manufactured housing. It's a type of housing that is supported in parts of the United States with generous financing options for purchasers. In turn, that has brought forward numerous design companies who are bringing forth innovative designs for manufactured homes. In parts of the United States it's a real alternative where land costs are soaring and people want a more compact living space but do not want to go into apartment living.
I certainly commend the hon. member for Malahat-Juan de Fuca, who conducted a survey of many manufactured-home owners throughout the province. I've had a chance to review that survey in depth. It's a very useful document. I understand there were more than 230 submissions from concerned manufactured-home owners. More importantly, there was tremendous support for the initiative from the park owners themselves -- the people who own the land and administer the pads and deal with the tenants. What's clearly needed now is a commitment from government to recognize that this form of housing is underutilized. The rules governing manufactured-home parks need to be reviewed, and clear government policy is needed to say to municipal governments that we support this type of housing, we believe it's an important type of affordable housing, we're prepared to take steps to protect the people who own houses but must rent pads, and we are going to make a real commitment to ensure that there is a viable and productive future for manufacturing housing in British Columbia.
R. Kasper: It was one year ago tomorrow when I rose in this House and made a private member's statement on this subject. I raised similar issues and concerns regarding manufactured housing, and I'm pleased that the government has responded to the issues raised by me and the hon. member for Surrey-White Rock.
The minister appointed me to conduct a review. There was a tour of some nine locations throughout the province. Thirteen hundred and fifty people presented at those hearings. We had close to 600 submissions. We
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had 185 oral presentations. A fairly extensive detailed survey was sent out. We had a 35 percent response rate to that survey, which far exceeds other types of surveys. We completed the work and the report in November, and the report was released by the hon. Minister of Labour and Consumer Services. There were 30 recommendations forged by a coalition of homeowners and park owners and, unlike the coalition that the hon. member for Surrey-White Rock dreams of, this is a true coalition of the people who live in the homes and the entrepreneurs who are building the parks for the future of housing for British Columbians.
They submitted a series of 12 joint recommendations urging the government to put forward a mediation resolution committee to deal with rent review; to increase compensation to up to $10,000 for parks closing down; to increase the notification process if a park does shut down to one year from the current six months. Those are just some of the issues from that group, who signed off with the grateful assistance of Joe Degagne, president of the United Manufactured Homeowners' Association of British Columbia, and Doug Hallet, president of the Manufactured Home Park Owners' Association of B.C. If it wasn't for those two individuals, who accepted responsibility and involvement in dealing with this crucial issue, my job would have been made considerably harder. That shows that there is a spirit of cooperation.
I might note that the hon. member for Surrey-White Rock has mentioned to the Minister of Labour and Consumer Services that he recognizes that there is a new spirit of cooperation with this government. He also notes in correspondence to me that he fully supports the provincial government's initiative to launch an official review for manufactured-home parks. That has been done. I can assure the hon. member that the consultation process is proceeding. There have been meetings with representatives from both stakeholder groups working closely with ministry officials, to forge a new direction to make the manufactured-housing industry one of the most viable and manufactured homes one of the most secure forms of housing within this province.
W. Hurd: I'm pleased to hear that so much is happening with respect to addressing these serious issues on manufactured housing. Unfortunately, it's the case for many park residents that they've heard the story before. The hon. member well knows that one of the things he heard during his tour of the province was that there has been a series of reviews of manufactured housing in this province over the last number of years. While everybody agreed what needed to be done, there was little will on the part of governments to make it happen. I certainly hope that in this case the owners of manufactured houses, who have such high expectations that legislation will come forward, perhaps as early as the next month, will not be disappointed by yet another assurance on the part of another government. They recognize that this form of affordable housing is vital to our future in British Columbia; but the rules and regulations, and the commitment from government that would make it so, will not wait for another day, another time and another session.
COMMUNITY FORESTS
P. Ramsey: Today we're drawing near to the end of National Forest Week, and in 130 communities across this province people have been participating in events to celebrate the importance of forests to their economy and to their lives.
Forests have always been at the heart of economic activity in this province, and at the heart of political debate as well. Therefore I thought it was appropriate that I brought to this House a concept of managing forests, community forests, which is growing in importance across our province. Increasingly, British Columbians want to be involved in decisions on how we use our forests. They're participating in such resource management plans as local resource use, whether they're large areas or small ones. They're getting involved in land use decisions through the Commission on Resources and Environment and through many other vehicles. The interest in community forests grows out of that desire to participate in decisions, and out of a desire for increasing local control of the use of our forest resource.
At the end of March, I was privileged to attend a workshop on community forests sponsored by the Malcom Knapp Research Forest, and put on in the community of Maple Ridge. That workshop brought together community leaders, forest managers, academics and researchers and just a lot of people who care about our forests, how we use them and how we value and cherish the land we depend on. I want to report to the House on the discussion about the evolving concept of community forests which took place at that workshop.
In its simplest terms a community forest is an area of forest land, usually one of high visual value and possibly of high recreational value as well but with significant timber values. That's essential because it's the economic value of the timber which makes the other uses possible. It must be an area that's defendable over time and not dependent on development or alienation from forest use. Therefore choosing boundaries of community forests is a sensitive task.
The workshop developed three or four general principles that should guide development of the concept of community forests in this province. The first was a clear desire that community forests be managed for diversity of use and that that use must be set by a community. Sustainable harvesting of timber is a primary use of all community forests, but they are also seen by some as a source of community drinking water. Others would value them principally as a venue for recreation: hiking, camping, fishing, hunting or perhaps outdoor sports. Still others would enhance their use for such purposes as education on forestry issues, or for participation in on-the-ground forestry management, stream maintenance and wildlife habitat renewal. Finally, others would place the emphasis on using the forests for research on forest practices, including better
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harvesting, silviculture and management which would better respect all values on the land base.
All of British Columbia's forests are managed to protect a diversity of values, and that trend will continue with the implementation of new forest practices codes incorporating new biodiversity guidelines. But community forests and their advocates see a step beyond that to holistic forest management.
The second principle of community forests is, of course, that communities must be doing the decision-making. Advocates of community forests do not see that happening outside provincial guidelines and regulation. No exemption from codes or responsibilities is sought for community forests. But advocates of community forests say that priorities for use must be set locally, and those priorities will vary from community to community. Some will value recreation more highly, others, research. Others will value their forest as a source of pure domestic water, still others as a place where you can do education. But the goal is clear: to bring in a broader range of interests and have the community as a whole set those priorities and make those decisions. In some instances it seems like CORE, bringing together a diversity of interests, and I suspect that like CORE, community forests will face many of the same problems. Who is that community? How do we bring together diverse interests to make decisions on how we use our forests?
The third principle of community forests is that they must be financially sustainable as a unit. Advocates of community forests do not see them as preserved areas permanently set aside from industrial use. A community forest is not a park. The harvest of timber in a community forest supports other activity, and management of community forests must recognize that. The cost of managing for diversity and the cost of intensive management may be higher. Some of those costs could be offset by volunteer labour and contributions to management of a community forest, but in the end, community forests must stand alone as economic units. In other jurisdictions, some are sources of revenue for the communities that manage them, not a drain on public funds.
The fourth principle is that community forests are part of B.C.'s managed forests. They are not set aside; they are managed under the legislation and regulations of the province. They must submit management plans and be subject to the control of the provincial forester. They would pay stumpage like other working forests and contribute to economic activity. There would be community control of decision-making but no abuse of provincial principles allowed.
I believe that this concept of community forests is of particular interest to people from resource-dependent communities around the province. It's an idea and a concept that deserves more intensive examination. As we conclude National Forest Week and conclude our celebration of the importance of our forests, it's a concept that we should discuss more as we consider how to use our forests wisely for ourselves and for our children.
[10:45]
W. Hurd: The concept of community forests is one that I think is interesting many communities in the province, particularly in resource-dependent areas. I had occasion to attend a workshop on community forestry near the city of Quesnel, the Dragon Mountain community forest proposal. For some time on a Friday evening I sat in on a meeting in which members of the public came forward with their concerns and ideas. I think it's important to talk about some of the difficulties that they saw in trying to bring forth a community forest proposal.
One of the things they talked about was the need for a change in the Forest Act, particularly with respect to the tenure system. The longest licence in this province is 25 years, with a five-year renewable term. People in Quesnel talked about an 80-year licence because they were addressing a number of different values in the land base, such as hiking trails and limited harvesting and education opportunities, and the whole range of community activities.
One of the greatest barriers to community forests, however, continues to be escalating urbanization in the province and erosion of the immediate forest land base around communities and towns. This is a particular problem on Vancouver Island, where privately held forest land is being redesignated for housing use. I believe there is a concern building on Vancouver Island about the need for a forest zone within municipal governments. I hope that this government and the Minister of Forests will sit down with the municipalities and urge them to designate an urban forest zone so that we can at least protect some of the forested areas around our cities and towns. Then when we do have the legislation in place to deal with community forests, options will be available to towns and communities.
P. Ramsey: I thank the member for Surrey-White Rock for those thoughtful comments on some of the barriers that face those who advocate the establishment of community forests. I think he's quite correct that we have a problem when we talk about community forests.
There are two major problems. First, how do we ensure the stability of that forest over a long period of time? If we have a harvest rotation of 80 or 100 years, how do we ensure that the forest is managed sustainably over that long period, and managed not only for timber values but also for a diversity of values over a time span that exceeds the human life span? That is a real problem.
The member spoke about the need to protect community forests from growing urbanization and the alienation of land from forest use. I agree completely. I'm not sure I agree with him that an entirely new type of tenure is required. Participants in the community workshop were divided on that issue. Some saw the need for a new form of tenure; others, including the dean of forestry at UBC, thought the goals of community forests could be accomplished within our existing tenure system.
The second problem that I see is defining the community. A community is going to manage a forest, but who is in that community? Traditionally our forests
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have been managed largely by industrial interests and by the B.C. Forest Service. They consult with others, but those others are not intimately involved in decisions on land use. The wider the range of those who are involved, the more difficult it becomes to reach consensus on land use and forest management decisions. That, I think, is one of the primary challenges facing advocates of community forests. It will be more difficult to establish community forests here than elsewhere in the world. In Sweden, community forests are established largely on private lands. Here in B.C. we must devise a way of establishing community forests on Crown lands that are provincially owned but locally managed and controlled.
Still, I think it's an idea that deserves further consideration. It's an idea whose time, I believe, is coming. In the near future the mayor of Prince George, John Backhouse, and I will be pulling together some people to look at the establishment of a proposal for a community forest in the Prince George area. For many years we've had an organization called Forests for the World that has set aside an area adjacent to Prince George to educate the public on forest use and forest management issues, and encourage public participation in those processes. The mayor and I want to pull people from Forests for the World together with representatives of industry, the B.C. Forest Service and others who value our forests, to see if we can put together the concept of a community forest for Prince George.
Hon. D. Marzari: Hon. Speaker, I now call Committee of Supply.
Deputy Speaker: And the vote, hon. member?
Hon. D. Marzari: Resolved that a sum not exceeding $419,400...
Interjections.
Deputy Speaker: Please proceed.
Hon. D. Marzari: ...be granted to Her Majesty to defray the expenses of the Ministry of Health and Ministry Responsible for Seniors....
Deputy Speaker: The member for Richmond-Steveston on a point of order.
A. Warnke: Hon. Speaker, I just want clarification in terms of procedure. I believe the Chair of Committee of Supply should be sitting in his seat prior to the mention of.... The next stage is to call for Committee of Supply, is it not?
Deputy Speaker: Thank you, hon. member. You're quite correct -- we should have called for the Chairman at that time.
The House in Committee of Supply B; D. Streifel in the chair.
ESTIMATES: MINISTRY OF HEALTH AND MINISTRY RESPONSIBLE FOR SENIORS
(continued)
On vote 47: minister's office, $419,400 (continued).
L. Reid: The issues I intend to cover this morning are the Medical Services Commission; the College of Dental Surgeons of B.C., with reference to a particular case; and eating disorders.
I'd like to begin my comments this morning with reference to a report on alternative payment and delivery systems, dated October 19, 1992. I'd like to make reference to a particular section. As stated by Dr. Carole Guzman, past president of the CMA, four of the eight coordinated provincial-territorial policy directions announced by the ministers of health in their Banff communiqu� of January 1992 deal with issues associated with remuneration, thus underscoring the importance of this issue. Two of the coordinated provincial-territorial policy directions specifically address the issue of alternative payment and delivery systems.
There are two points that I am going to be in discussion with the minister on: replacing fee-for-service wherever that method of payment aligns poorly with the nature or objective of the services being provided, and increasing the utilization of alternative service delivery models. I'd be interested in the minister's comments on where British Columbia currently sits in terms of the general direction as outlined.
Hon. E. Cull: The ministry has released a discussion paper on alternative payments for physicians, alternatives to the fee-for-service system. There are in fact a number of alternatives already in place in British Columbia. We are piloting something called the rostered group practice in three different communities. About 1,300 of the 6,500 physicians -- give or take a few -- are on salary, as an alternative payment. So there are already a number of physicians in the province who are not practising under fee-for-service.
Over the last year we have had an increasing demand from physicians to talk about alternative payments. We want to respond to that demand, but we want to do it in a way that ensures that the service we're purchasing, whether it be through a salary or some other form of payment, is one that we and the taxpayers of the province are getting good value for.
We have released a discussion paper, we have established a group of people to look into this and we have started a consultation process with both physicians and the workplaces of physicians around the province, so that we can come up with some guidelines and criteria to start to move into alternatives that suit the physician and the needs of the patient in terms of the quality of care that's provided.
R. Neufeld: I ask leave to make an introduction.
Leave granted.
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R. Neufeld: As a reminder to most members, Sunday is Mother's Day. If there are some who haven't taken care of it, they should.
I have the pleasure today to introduce to the House three individuals who are very special to me. I'm one of the more fortunate people in British Columbia, because I have two mothers. I have one who is home right now watching this on TV, and I have another who is here today from Calgary, with her husband, to visit the Legislature. I'd like the House to please welcome Frances Saynor and her husband, Frank, from Calgary; and also my best friend and my wife, LaVerne.
L. Reid: The minister just made mention of rostered groups in British Columbia, and practices currently underway in three pilot communities. Could you expand on that a little bit, and also tell us the composition of the committee?
Hon. E. Cull: The three are: the James Bay clinic here in Victoria, the Reach clinic in Vancouver, and, I believe, the United Church clinic -- I'm not sure if I have the name correct, but it's in Hazelton. So we have two urban communities, which I guess you'd describe as inner-city areas, and one small rural community in an isolated part of the province. We have a number of positions in each of these clinics. They are piloting the concept of a rostered group practice where a fixed amount of money is available, and they manage that money on behalf of their patients. We're monitoring it and we'll eventually evaluate it to make sure that not only do we get reasonable value for the money we spend there, but the quality of care is as good as or better than with the more traditional form of payment.
L. Reid: Could I draw the minister's attention to the composition of the committee -- the individuals who are working on possible alternative methods of payment?
[11:00]
Hon. E. Cull: There is an alternative payment steering committee, which is composed of six individuals representing all of the program areas within the Ministry of Health and includes six physicians. Then there are a number of subcommittees: psychiatric services in the public sector, community health centres and information management in alternative payment situations. These include individuals both inside and outside the ministry, people who have the particular expertise. I don't have the names of the members. If the hon. member is interested in who is on there, I'm sure I can arrange to have that sent to her office.
L. Reid: With reference to the six physicians that you mentioned, are those employees of the Ministry of Health or are those physicians working in the field?
Hon. E. Cull: The six physicians on the steering committee are employees of the Ministry of Health. But it's the subcommittees -- involving people who are not employees, and therefore physicians who are not employees -- that are looking at the details of all of this.
L. Reid: Just a clarification from the minister. I understand that there are physicians who are not employees, but are they physicians who are currently working in the field?
Hon. E. Cull: Yes.
L. Reid: In terms of expanding the discussion, certainly it seems we have fee-for-service, salary, capitation and now rostered group practice.
Hon. E. Cull: Same thing -- capitation and rostered group.
L. Reid: Perfect. Are there any other alternative methods of payment that are being considered in the province? Are there other areas we should be addressing this morning?
Hon. E. Cull: I was just, unfortunately, in private conversation talking across the floor to the hon. member pointing out that rostered group and capitation are the same, just different terms. So there are the three that she's mentioned, plus sessional payments, which is non-fee-for-service. Those are the four that we are looking at.
L. Reid: "Rostered group practice" is probably a better term than "capitation," which tends to indicate all kinds of other areas.
Health services organizations which are mentioned in this report -- and certainly it's stated they can be for-profit or not-for-profit.... Is that something that you as Minister of Health will be fleshing out, in terms of possible direction, or will that be something that comes up under the regionalization discussion?
Hon. E. Cull: There's an obvious linkage there between what's happening in the communities and the desire to have greater control and integration of health services, and dealing with things like health services organizations and the need for the Medical Services Commission, which pays the bills of physicians, to interconnect there. So there is work going on in both areas.
Quite honestly, I find the terms HSO, HMO, CHO, CHC -- all these three-letter names for organizations that employ physicians -- to be somewhat confusing, because sometimes people use the terms interchangeably and incorrectly. What I have been doing is referring to the whole thing as community health centres, so that there is some concept of an organization in the community that might employ physicians and other health care professionals. Rather than working as independent private practitioners, they could be on salary, part of the roster group or sessional. So if you and I can agree to not get into those details of HMOs and all the rest of it, I'll think we'll probably have a clearer debate on this, because I do find that people use those terms quite differently.
We're looking at the concept that communities are interested in having a health centre that might have physicians as part of that service. We're very interested
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in supporting that. Indeed, that's the kind of proposal coming to us from communities like Keremeos, where they are looking at their diagnostic and treatment centre and saying: "Let's expand that so it can be something larger than just the diagnostic and treatment centre." Perhaps the physicians in the community might like to have their private practices as part of that facility. Perhaps the pharmacist, the dentist or the Social Services ministry staff would be involved in that same location.
I mention Keremeos, but it's just one of at least a dozen small communities that are starting to look at their building, their facility, in a new way and saying: "How can we organize ourselves within this facility to provide a wide variety of health services that are well integrated?" Once you start to ask those questions about co-location and partnerships and people working together as a health care team, you then start asking questions about: "How do we pay these people, and how do we make the financial arrangements necessary to make this all work?" Again, that's where the linkage has to happen between what's happening at the regional level, which we are supporting as it comes up from the community, and the work we have to do at the Medical Services Commission in making sure that we are flexible enough in our payment arrangements to be able to support these community initiatives.
L. Reid: The "Report on Alternate Payment and Delivery Systems," dated October 1992, was followed, I believe, by "A Strategy for Physician Remuneration in British Columbia," dated December 4, 1992. If there is indeed documentation between those two, I'd be happy to have my comments addressed to either of those.
In terms of a vision for health care -- and I understand this is the strategy -- it states: "In presenting a strategy for physician remuneration in British Columbia, a vision for the future is created in which all health care delivery moves into an environment associated with a significant reduction in fee-for-service." Is that the position of the ministry? Is the priority to reduce fee-for-service, or is it to offer a number of different choices in which fee-for-service may or may not be maintained in its original form?
Hon. E. Cull: I don't think there's any doubt that fee-for-service will continue to be the dominant method of payment for physicians in the province. It works well in many cases for physicians, and it works well for health care. What we are trying to do is address two needs. One is the need of physicians who want a different payment mechanism, who have come to us and said: "We want to do something different." The other is to recognize that sometimes the fee-for-service system makes it difficult to practise some kinds of medicine in a particular way. Some people might say that fee-for-service has perverse incentives in some cases, because it's somewhat like the piecework system of paying workers: you do so many things, you see so many people, and you get paid on a per-thing or per-person basis.
In some practices, particularly family practices where the patients may be older, the physicians often find that they have to spend a lot of time with the patients who are coming in and that the problems presented are not obvious. They are tied into mental health, into the drugs that may have been prescribed to them over the years, into family situations; they may be related to aging and the need to link them up with continuing care providers. They become rather complex social management issues as well as medical issues.
In many of those cases physicians point out, quite rightly, that the fee-for-service system, which gives you so much money for the office visit, does not really recognize the value of what physicians are doing in those circumstances; for instance, when someone who sees a patient with a sore throat -- which could be a very quick thing to do: have a look at it, take a swab, send it to a lab and figure out what needs to be done -- gets the same amount of money as someone who might have to spend half an hour working with a patient. There are arrangements under the Medical Services Plan for counselling, but that doesn't really address it either. So we're trying to look at those situations where physicians say: "We would practise medicine differently. We want to practise that way; we do practise that way. We want to be recognized in terms of our financial remuneration for practising that way."
There are other circumstances where it just makes sense, too. Emergency room physicians often end up going onto an alternative payment mechanism because of the nature of people who present themselves at emergency. Often these people are not covered, and it creates problems for physicians in terms of collecting the money for those patients who may not be covered. When someone comes into emergency you don't ask for their CareCard and turn them away if they need that kind of care. In fact, the physicians are ethically bound to treat people. And psychiatry often lends itself to alternative payments.
So there are a number of practice and patient situations where the health care that could be provided can be better and can be assisted by the payment mechanism, as opposed to being thwarted, in some cases, by the payment mechanism.
L. Reid: This document repeatedly refers to HMOs -- health maintenance organizations. Are you defining health maintenance organizations as community health centres? Will they have the same abilities as listed?
Hon. E. Cull: The staff paper that has been prepared talks a lot about HMOs and the other forms of health organizations throughout North America. As a policy of the government, we have looked at the concept of health organizations without getting into the specifics of HMOs or CHOs -- community health organizations -- or health service organizations. There is a variety of them, and they all have different attributes. I can't keep them all straight. We are looking at the concept of community health centres, which may have elements of some of the other models that exist around North America. We're looking to create something that will work for British Columbia.
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L. Reid: The opposition is in support of what will work for British Columbia -- no question about that -- and certainly we stand very much behind the opportunities for choices in different alternative payments, services, remuneration and all of those issues. My concern is that the document seems to reflect, throughout, some kind of evaluative statement which may or may not be possible to put in place. There are comments that suggest where quality of care and resource use become more measurable and closer to the optimum. I think that's the ideal. I think that is exactly what all of us in this province would like to see. My comment and my question would reflect whether or not any of these alternative payment strategies would allow us to come closer to some kind of reasonable evaluation of the process. It seems we will have more choices if the intent of this document is carried forward. But will we be any closer to deciding how best those resources are utilized?
Hon. E. Cull: One of the major thrusts of the royal commission and of the New Directions paper that we released is to improve the evaluation that is done on the health care system. We do some excellent evaluation in some parts of health care where we really do know whether the service being provided is a quality service and is being provided as efficiently, effectively and as compassionately as possible. In other areas we don't know, because good evaluation has not been done in the past. When programs have been started -- for example, the TRY program in alcohol and drug that was started by the former government -- as part of the setup, there wasn't the kind of evaluation that was necessary to ensure that at the end of the day those projects actually achieved what they set out to achieve. So I think we have to do a better job. I was at the University of British Columbia yesterday meeting with people in the faculty of medicine and some of the other health care faculties, talking to them about the role the university can play in providing us with support around research and evaluation.
If we're going to add new directions to health care -- new models and ways of doing things -- I think it is very important that before we launch out onto them, we make sure what we're putting in place is part of the evaluative framework. We can try it for a period of time and then look back and say: "Have we improved things?" If we can't, I'm not sure that we can then ever answer those very fundamental questions about: "Are we spending our health care dollars as wisely as possible?" So as we move into alternative payments, instead of simply saying: "Well, salaries must be a good thing" or "Rostered group practice must be a good thing," we have gone to a strategy that says: "Let's try it. Let's evaluate it before we spread it any further." I will say quite honestly, in looking back at the ministry over the last 18 months, we have not done that nearly as effectively or as consistently as needs to be done. There hasn't been a history of that built into health care or into the Ministry of Health. That's something that we're gradually trying to change, and this is part of that change.
[11:15]
L. Reid: I don't think you would find anyone, hon. minister, who would disagree that we need to evaluate practice. I would ask you to expand on the best way, or the ways that your ministry has explored, in terms of evaluating practice. Are we looking at clinical trials? Are we looking at anecdotal reporting? At the end of the day we're talking health promotion. How best do you evaluate health promotion, and what are the plans?
Hon. E. Cull: I'm not an expert on evaluation procedures, so I'm not going to go into this in much detail. But essentially what you need to do in most cases is establish a pilot that at the beginning allows you to say: "This is what we intend to achieve. These are the objectives. This is how we will measure those objectives." You carry out the pilot for a number of weeks, months, or years depending on how long it takes to show the benefits that would accrue from any particular change. Then you measure at the end to see whether you achieved what you set out to achieve. The most important part of evaluation is getting it right at the beginning, so that you know what it is you're trying to do and how you're going to know if you've done it -- how you're going to measure it.
We have a variety of health statistics that we can collect for the local health areas. I'm not sure how many local health areas there are, but I'm sure you've seen the vital statistics health indicators report that was just released, and we can see wide variations in health care right across the province. In some cases emergency procedures, like having your appendix out, may be three or five times higher in one community than another. If you can look at that and say, "Well, it's not the people who are creating that; there's something else happening here; we're not sicker as a population," then you can start to zero in on some of those things and say: "Can we find out what's happening here? Can we try to bring things to the norm? Or, if not to the norm, can we at least do what's needed by that population?" -- because some populations may need more of some health care service than another.
Some rates are quite questionable. Caesarean rates -- I'm sure you've seen the statistics on that too -- can range dramatically from valley to valley in some parts of the province, with no appreciable understanding of why women need more of that surgical intervention in one community than another. If you're looking at good maternal care, you can say: "We want to increase the number of live births, of good full-term births, of babies who have a healthy birth weight, with minimal medical intervention." You can set those statistics up, monitor them over time and find out whether the things you did to achieve that were effective or ineffective. You can do it through controlled studies, by looking at one community or another. You can go to clinical trials on issues in some cases. It's really a question of making sure you've thought through how you're going to get to where you want to be and how you're going to know when you get there.
L. Reid: I'm going to deduce from your comments that we're both in favour of the Medicine 2000 program at the university, which is going to take a look at
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ensuring that practice is always optimum, perfecting service delivery and understanding how to evaluate programs and the like. Certainly the program has a lot to offer in terms of medicine in the next ten, 20 and 30 years. So I trust we will discuss that in some detail later on in debate.
Again with reference to the executive summary, I would want to pay particular attention to a paragraph that talks about strategies because I think that this is the issue that has caused some concern in the field. Perhaps we can touch on that for a little bit.
"Strategies to be deployed in the shrinkage of fee-for-service would include the early introduction of successful projects into supportive environments, minimization of conflict with the medical profession, investment of sufficient resources to establish successful projects and physician encouragement to make the decision to abandon fee-for-service practice."
This strategy being proposed doesn't reflect your earlier comments, and I'm interested to know if your original comments stand, or if this particular strategy is going to be put in place. I deduce from your earlier comments that we're not interested in abandoning the process, but simply in expanding options in terms of alternative service models. Was I correct in that assumption?
Hon. E. Cull: Our objective is to try to get the best health outcomes. What we want to do is to make sure that if the way we pay physicians is getting in the way of those health outcomes, we examine that and provide alternatives.
As I said a few minutes ago, we're responding to two basic objectives. One is the demand -- certainly coming into the ministry -- on almost every hospital in the province that I have been in. One physician has raised this with me, taken me aside and talked about the need to get on with this. More often in the more distant past than more recently.... They've been talking to the task force because now they're aware that the strategy is being worked on; some of them have been working on the subcommittees. But a year ago I had a surprisingly large number of physicians come to me and say: "We've been trying to talk to your ministry about this for some time. We're not being heard. We need to have something happen in this area." As a result of that demand, we established this group to start looking at it, and to start working with the physicians.
The other is to focus on health outcomes, and recognize that in some cases the fee-for-service system doesn't encourage good medical practice -- it sometimes gets in the way. Again, physicians will bring that to your attention. It's clear in some situations that we would have better medicine and better health care if physicians could operate under an alternative to the fee-for-service system.
L. Reid: Again with reference to "A Strategy for Physician Remuneration in British Columbia," December 4, 1992:
"Advice will be sought from leading HMOs in the United States on the establishment of innovative health care delivery systems. The establishment of non-fee-for-service systems will be congruent with the concept of regionalization of health care service delivery. Consultation with, and education of, all stakeholders will be an essential component of the strategy."
With reference to that comment, is Kaiser Permanent from United States involved in discussion with this Ministry of Health? Are there other agencies of that nature who have come to British Columbia to consult with our Ministry of Health, or have our ministry officials travelled to other countries to have those same discussions?
Hon. E. Cull: There are a number of models around North America, and we've been examining them all. I don't feel we need to try and recreate the wheel here if we can learn from what's been happening in other communities. I'm particularly interested in avoiding the mistakes that have been made in other communities. So, for that reason, we have conducted an analysis of the systems in place in Ontario and some of the states in the United States. We have sent staff to talk not only to Kaiser Permanent, but also to the Sault St. Marie Health Collective that has been established there for many years, to Puget Sound to look at the group health co-op that is in existence in that area, and probably some other areas which I'm not totally familiar with at this point. But I think it's important that we know what's worked elsewhere and, most importantly, what hasn't worked elsewhere, so we can build a system that reflects B.C.'s needs but also avoids the pitfalls that others have already fallen into.
L. Reid: I understand the minister's comments but have a concern regarding the report. I understand it's going to be expanded and that we're not going to repeat the mistakes of other areas, and I certainly welcome the insight that this ministry has sought. In terms of implementation it states here in the report:
"An implementation plan envisages increased activity in the area of negotiations with appropriate groups of physicians in both primary care and specialist practice and appropriate institutions, with early identification of areas of practice most amenable to, or supportive of, transfer from fee-for-service. Planning of both a metropolitan and a rural HMO will begin immediately. Existing contractual and salaried arrangements will be extended and supported. Similar arrangements will be instituted in areas of greatest need. Community health centres will be opened as salaried services. Some of these will later be converted to HMOs. Orderly transfer of physicians from fee-for-service will continue over at least a five-year period.
"Where fee-for-service persists, the fee schedules must be reviewed with the intention of introducing incentives directed at improving the appropriateness, effectiveness and efficiency of care remunerated in this fashion. This is the role of the Medical Services Commission.
"It is envisaged that a major initiative to move physicians off fee-for-service will provide an enormous contribution to the evolution of the health care system of British Columbia into a more responsive, higher-quality, more cost-effective system than has existed previously."
Those comments cause me great concern, hon. minister, because they do not reflect your earlier comments which looked at choice, which looked at
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incorporating a new care delivery into an existing care delivery. This speaks directly to abandoning the fee-for-service model and to putting in place significant strategies to ensure that the fee-for-service model does not exist. I understand that this is a strategy. I ask again if the minister will address whether or not it will be employed or indeed will we be continuing with choices in this province?
Hon. E. Cull: What we need to focus on is the complete title of the report that the member is reading from, which is "A Strategy for Physician Remuneration in British Columbia." This discussion paper has been prepared by staff. It has not been reviewed by me in terms of giving a blessing to the strategies that are in here at this point, because there is a process of consultation going on around the province. It has not come to cabinet for any final decisions.
There are some suggestions and some very strong statements in this paper about what should be happening. They are designed to get the whole matter under active discussion in the profession and in the broader health care community. As we go through the work of the task force and the subcommittees, we will come back with decisions that will then have to be brought to me and ultimately to cabinet for a government decision on how to go about implementing them.
At this point the ideas in this paper are out there for discussion. We're looking to meet our objectives, as I've stated on a number of occasions. I need full input not only from the medical profession but also from the larger health care professions to determine the best strategy to pursue here and to determine how we can meet the needs of physicians and patients and provide good quality health care.
L. Reid: I appreciate the minister's comments. I would like this next comment also to be considered in the harsh light of day. "The HMO would develop care plans for the common diagnoses and treatments and would therefore influence the practice patterns of both primary care physicians and specialists." This is a significant issue in terms of respect for practitioners in their field. I do not take issue with the discussion, but I certainly take issue with the strength of the statement. It certainly seems to be a common thread in terms of the treatment that physicians in this province have received from this government. My question is why: is this a valuable exercise? Why is it appropriate to suggest that individuals in the field are not doing a good job? I certainly support that everybody can do a better job in any profession, in any line of work. I don't take any issue with that. But the underlying theme of this report, of this strategy, appears to be disrespect for a profession. I would certainly welcome your comments on that.
Hon. E. Cull: Certainly there is no intent on the part of my staff or the Minister of Health to imply disrespect for the medical profession. The vast majority of physicians in this province provide an excellent service to their patients. But we are committed to implementing the Royal Commission on Health Care and Costs, and one of the things they recommended that we do and that we have accepted is to examine alternative methods of paying physicians. We are also committed to the national agreement on physician resource management that came from the Barer-Stoddart report, which again recommended looking at alternative mechanisms, something that's happening right across the country. Indeed, in some provinces, fee-for-service is not the dominant method of paying physicians.
We are also committed to responding to those physicians who have, in growing numbers over the last year, asked us to look at alternatives and who have said quite frankly to me in discussion that they could practise better medicine if they were paid differently. This is not to say that the majority of physicians in this province have indicated that, but a significant number...enough of them have made that point to me to have grabbed my attention on this issue, and I have asked the chair of the Medical Services Commission to give the matter some priority so that these alternatives are available.
[11:30]
I'll repeat again, though, that no matter what alternatives are provided to physicians.... Let me remind the members that about a fifth of the physicians in this province are already on alternative payment mechanisms, but whatever expansion occurs and whatever new alternatives may be added as a result of pilot projects, I still expect the majority of physicians to be on the fee-for-service system.
L. Reid: One last point from this report: "By reducing the consumption of hospital days, diagnostic tests, specialist referrals, etc. as a consequence of the provision of optimal care, the HMO would generate excess revenues from its capitation rate." Are we in a for-profit model in terms of universal health care in this province, or is this an item that's going to be discussed in greater detail by your committee?
Hon. E. Cull: A study done in Saskatchewan -- I'm sorry, I don't have the date or the reference for you, but perhaps I can get it -- that looked at the approach we're now piloting in James Bay and Hazelton showed that not only was it more cost-effective in terms of having a less expensive form of health care but the outcomes in terms of the health of the people who were served by that particular organization were as good as the traditional method of providing medical services.
J. Weisgerber: I'd like to examine a bit further the way that physicians are paid, particularly with an interest in attracting doctors outside present concentrations of physicians. As the minister knows, we have had in place for some time a payment schedule that attempts to make it more attractive for people to move outside of concentrated areas. In Dawson Creek, for example, which I represent, physicians get a 10 percent premium for their services. In smaller communities it's 20 percent, I understand.
I'm curious to know whether, as the minister examines the way we pay physicians, she is prepared to
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look at that and to expand it. I raise the issue because clearly it's not totally effective. It's still very difficult to attract physicians to certain communities. We see a large turnover in certain communities. In a lot of communities the only way to attract physicians is to attract them from outside of Canada. There's nothing with that, except that if we have an excess of practitioners already, I think it's counterproductive to attract new doctors from outside of Canada, who perhaps work in rural parts of British Columbia for a few years and then drift down and simply add to the oversupply in some of the more attractive climates -- if not communities -- in British Columbia. So I'm wondering, as we look at salaries and fee-for-services, if the minister is prepared to look at expanding the differentials in fee-for-service.
Hon. E. Cull: The member has talked about the northern isolation allowance, and that's one of a number of programs that are available to encourage physicians and other health care practitioners to practice in northern and smaller communities in isolated parts of the province. Indeed, I've got seven pages here of briefing notes that go through all of the programs that do try to address this well-understood, well-known problem in those communities. I'd be happy to share that with the member if he'd like to have more information on it. But you're right: despite the fact that there are quite a number of programs that try to attract health care practitioners and retain them in smaller communities, in northern communities, that try to get people who live there trained so they may go back and practice in the communities where they grew up, we still have problems. We still have shortages, particularly of certain kinds of specialists in communities, and certainly in the Peace River area, I'm quite familiar with some of the problems up there that constituents have brought to my attention.
So we need to do a better job. One of the things that we have identified in the New Directions for a Healthy British Columbia program -- one of the 38 strategies to try to change the face of health care in this province -- is to have a northern and rural health strategy. We want a strategy that takes all of this stuff and knits it together, instead of having ten or 15 programs that have been put in place over the years -- many of them probably by your government -- but have not become well-integrated and are not in fact doing the job. I want that task force to be of people who live in those communities, who practice in those communities, and who understand what the problems are so they can advise the government how to do a better job.
We believe that there are a number of things we have introduced, and are in the process of introducing, that will start to assist this problem. Certainly alternative payments can help attract doctors into smaller communities. In some small places the problem is that you haven't got enough patients to support, on a fee-for-service basis, the number of doctors you have to have if you want to have a reasonable lifestyle and not be on call every night because you're the only doctor in town or you're one of two doctors so you're on call every other night. It's a pretty horrendous life, as you can imagine, to be placed in that situation. A community may not be able to afford to have, on a fee-for-service basis, the right number of doctors there, and we might be able to address that through alternative payments.
Under the new Medical and Health Care Services Act we have the ability to make differential payments based on where a physician is practicing in the province. That will allow us to pay physicians who practice in Dawson Creek or Fort St. John or Fort Nelson more than they would get for the same service provided in Victoria. So there can be an attraction to those physicians who want to go and live in those communities to make a bit more money. We're going to look at that. It has not yet been acted upon but I think will come out of the work that the northern and rural health policy task force is doing.
I think one of the most powerful things that we can do is training, and we have got to address that over the long term. I think the best way to get people to practise medicine and health care in the northern half of the province is to have people who live in those communities get the training. They already know the benefits of living in small towns. They are not having to be dragged out of Vancouver or Victoria because they or their families have already made those decisions on where they live, and they know you can have a very high quality of life in the smaller towns of this province. If we can get more of those people trained, I believe we will get more of them practising in that area. That's why it's very important that we expand the family practice training in other communities and why we are putting money into Prince George this year to do that -- so that doctors can be trained in family practice in a northern community and see the benefits of working in those communities.
J. Weisgerber: The minister has touched on a number of points, and I think they are legitimate ones. Doctors practising in small communities face a number of obstacles. As the minister mentioned, if there are only a few doctors, the call-out and the night service are stressful. I think the other thing the minister would recognize is that in a very small community, doctors feel somewhat isolated from their peers. They don't have the opportunity to relate regularly, there is perhaps a small number on staff and the number of patients that they see is clearly a problem. I'm not sure that I'm as enthusiastic about putting doctors on the public payroll to address that. That's a personal bias, perhaps.
It seems to me that the differential may have to be greater -- that we may have to look at something more than the current differentials. I understand that some jurisdictions use not only a premium from the norm, but at the other end of the scale there is a payment of less than the prescribed rate. From talking to some nurses at the meeting the other day, I understand that in some jurisdictions the range can run from 70 percent of the prescribed fee to something in the area of 140 percent. Doctors in those small communities may not be moving there simply to make a little more money, but I think they do expect some compensation -- some
[ Page 6020 ]
adjustment for the fewer number of patients that they see -- so that they don't suffer an income loss. They don't want to be putting themselves in the position of moving to a small community, enjoying all of the attractions that are there, but also putting up with the concerns about lack of peer relationship, night call-outs and all those things.
I wonder if the minister is open to looking at expanding that avenue, as well as alternative forms of payment.
Hon. E. Cull: There are a number of avenues that we can explore. The Medical and Health Care Services Act does allow us to make differential payments, which could be paying less than the standard rate in those areas which have a very large surplus of physicians. The ability is there under the legislation to do so. We have not done that over the last year, partly because the negotiations with the BCMA have still not come to a conclusion around their working agreement. But that certainly is there.
I don't know whether the member is suggesting that we do the kinds of things that have just been announced in Ontario in terms of restricting new doctors from practising in the large urban centres, or whether he's suggesting the Quebec approach, which does force young new doctors out of the urban areas. I think there would be a lot of concerns raised if we went back into that, or indeed even back into the approach that your government used in controlling billing numbers. I'm not sure if that's where you're leading, but we are aware of what other provinces are doing and we think that we can -- through the act that we have -- affect the kinds of policies that will encourage more health care practitioners into smaller communities without having to take that kind of draconian step.
J. Weisgerber: I'm sure that most people would prefer a mechanism to reach the goal you are seeking -- that is, to move more physicians and surgeons out of the areas where there is an overabundance of them into those areas that are suffering from a shortage. If you can do that with financial incentives and other kinds of incentives there might be -- for example, the kinds of contracts that various health groups sometimes enter into for training in return for a commitment to come back to the community at the end of the training time -- all of those things, I'm sure, are preferable to some kinds of legislated restrictions. But at the end of the day, I think that the well-being of the people in the communities has to come first. So I'm not necessarily advocating the restriction of billing numbers, although I do believe that the billing numbers system did at least contribute to getting people out into the community, so I don't have any great bias against it.
But I'm looking to see -- and I think I'm hearing this from the minister -- that the government and her ministry are seriously looking at every avenue to get more doctors -- preferably more doctors trained locally. It doesn't make sense to me that we have our medical schools full of bright young people in training, are suffering from an overdoctoring in communities, and still have to attract people from outside the country to practise in the rural areas. So I'm interested in the solution -- something that will in fact work. It is a big problem.
Dawson Creek is fortunate. It has a core of doctors who have decided to make their homes there. Many of them have practised there for 25 or 30 years. So in that community it's not a problem. There are other northern communities that aren't so fortunate. It's a very real concern, and I simply want us to look at all of the options and find a resolution to it.
[11:45]
L. Reid: In my concluding comments I will come back to what I perceive is the negativity in this report. Again I'm referring to the methods-of-remuneration report. It certainly lists all the perceived disadvantages of the current British Columbia model of fee-for-service: it is inflationary, it carries a disincentive for physicians to spend unbillable time with patients, it carries a powerful incentive to avoid the sicker, and it carries an incentive to provide invasive interventions. Hon. minister, I believe that these are just gross assumptions. There's no basis for this kind of negative comment, and it certainly doesn't seem to be in keeping with creating some kind of cooperative enterprise.
If I were a physician in this province, I would be offended by that. I don't believe that the majority of physicians behave in this way. Certainly the standards-of-practice committee which looks at abuse in the system is currently looking at one-third of 1 percent. If that's changed dramatically to permit this kind of offensive statement, I'd be more than interested in hearing that. But as it stands, to me this is not the way to encourage cooperation. What was the intention of laying it out in this format?
Hon. E. Cull: A lot of what the member has been reading from today has been drawn from the literature on this particular item, and also from other reports such as the Barer-Stoddart report, work that went into the Barer-Stoddart report or background reports to the royal commission which addressed this issue. In many cases there are strong opinions expressed by individuals, both physicians and patients, about the quality of care. Some of those opinions are held very passionately and tend to get expressed in that fashion.
But I think what is most useful is for us to have a group of people who are looking at alternatives and recognizing again, as I said a number of times this morning, that the system of fee-for-service is going to continue to be the vast majority of the payment system into the future. But there are doctors who will benefit from alternatives, and we need to aggressively pursue those and make sure that we are not getting in the way of some of the solutions that may address problems of care, problems of access and problems around the good practice of health care in this province.
L. Reid: I find the minister's comments intriguing in terms of the fact that all of this was pulled together from research. I'm sure that I could be provided with the research documents to support this information. My concern is that this report seems to have a very negative
[ Page 6021 ]
slant. I'm not convinced that it's all that objective. I too could find negatively slanted pieces of research to include. My only comment is I trust that any deliberations that go forward on that question will be very objective.
I will finish with a paragraph that states:
"The conversion of remuneration from fee-for-service to salary or capitation alone will not contribute to an increase in the quality of care."
The flavour of the discussion this morning seems to be about improving the quality of patient care.
"The U.K. experience, where primary care practitioners remained independent, although on a capitation system, and where specialists were salaried and entirely hospital-based, is that of little professional accountability and a virtual absence of measurement of quality or outcome of care. The specialists are not paid by the hospital in which they are employed and appear to have little organizational loyalty."
That, I think, is a significant comment, because part of the discussions over time will be how to best ensure that people have a decent working environment and that patients are the primary issue for the Ministry of Health and all caregivers in the province.
I'll move now to a case considered by the College of Dental Surgeons of B.C. It's a fairly extensive case, so I will take few minutes to enter into the record the background of it so that it may be better understood. I will begin with a letter of February 12, 1991, that was written to Hon. John Jansen, Minister of Health, by Stan Hagen, a previous minister.
"A constituent of mine, Mr. John Evaniuk, has brought a matter to my attention which I believe merits your serious consideration. In 1983, Mr. Evaniuk received dental work from Dr. Derek Duvall. Subsequently, various symptoms arose, including restless sleep, chronic pain in the face and neck, numbness and loss of strength in his arms, and a nervous shake."
"In 1985 the College of Dental Surgeons referred Mr. Evaniuk's case to a review committee, which recommended that Dr. Duvall should pay both for the work that was done and for the corrective work required, the latter estimated at $10,000. The college has informed Mr. Evaniuk that it cannot enforce this recommendation upon Dr. Duvall, insofar as reimbursement and payment for corrective measures are concerned. Indeed, Doctor Duvall did not abide by the recommendations, and Mr. Evaniuk is now forced to resort to litigation, for which he has limited financial resources."
"My own concern, beyond the college's inability to enforce its own recommendations, is that this dentist is still licensed to practice in British Columbia. Mr. Evaniuk is not the only individual to raise concerns pertaining to this practitioner. My office is aware of at least three other people who have alleged similar problems and have accordingly passed their concerns on to the college."
"I believe the college's option in such a case as this ought to be clarified, as the institution is responsible for licensing its practitioners. It is also responsible for their discipline. Mr. Evaniuk has lived for the past eight years in considerable and constant pain, and every effort should be made to ensure the safety of other patients in British Columbia."
There are a number of pieces of correspondence referring to this case. An MLA in this House wrote to the Minister of Health on November 25, 1991, on behalf of a constituent: "I am writing to you on behalf of a constituent who has been in to see me concerning the College of Dental Surgeons of British Columbia. My constituent, John Evaniuk, has suffered for many years because of dental surgery he underwent some time ago." Again, the same content is in this letter.
We have different correspondence written on January 17, 1992, by the Minister of Health to the MLA for Comox Valley who currently sits in this House.
"Thank you for your letter of November 25, 1991, on behalf of your constituent Mr. John Evaniuk. I understand from your letter that Mr. Evaniuk has suffered complications as a result of dental surgery and has been dissatisfied with his ability to obtain compensation through the College of Dental Surgeons of British Columbia."
There is certainly sufficient information here. However, I believe that the first letter makes a very strong case in terms of what the issue is.
We have correspondence dated May 14, 1992, from Alan Moyse, associate director of the financial analysis, planning and budgets branch of the financial and management services division, to the MLA for the Comox Valley. There was ongoing correspondence -- May 22, 1992, and a follow-up on April 1, 1993 -- to Mr. John Evaniuk from the ombudsman's office, which says:
"We are writing to you regarding your difficulties with the College of Dental Surgeons and the Ministry of Health. As you know, the ombudsman's office does not yet have any jurisdiction over the college or dentists. I advised you that once the government gives our office jurisdiction over self-regulating bodies, you may wish to contact us again with your concerns.
"Regarding the role of the Ministry of Health in this matter, we understand it is actively involved itself in looking at possible resolutions. Mr. Alan Moyse provided us with some of the file information which outlined steps that were taken by the ministry. It is our understanding that the ministry (1) focused on resolution of your dental problems, (2) reviewed your concerns about the college and (3) considered the college's effectiveness.
"We understand from Mr. E. Diersch of our Vancouver office that you are pursuing the issue of dental coverage with the Ministry of Social Services and wish you success in this."
There is enough paper on this question to suggest that the British Columbian in this case has certainly pursued his particular issue through all possible modes of contact. If I may, for discussion.... A chronology of events in this matter is summarized by two documents in this file, one a memo from the Hon. Stan Hagen to the Hon. John Jansen which I've entered into debate.
It is a very complex case and it's an incredibly sad case. Ten years ago this individual was treated by Dr. Derek Duvall, then practising dentistry in the Comox Valley. Mr. Evaniuk sought redress in the College of Dental Surgeons of B.C. which -- pursuant to the Dentists Act -- exercises self-governing powers over dentists in British Columbia. The college referred Mr. Evaniuk's case to a review committee, which ultimately recommended that Dr. Duvall should repay Mr. Evaniuk for the dental work which had been performed and for the corrective surgery required -- the latter being an estimated cost of $10,000. The college,
[ Page 6022 ]
however, is unable, by the terms of the act, to enforce the recommendation upon Dr. Duvall. Indeed, the good doctor has withdrawn from practice, so the college now exercises no jurisdiction over him at all.
In terms of this particular constituent, Mr. Hagen's office in Courtenay made many recommendations on Mr. Evaniuk's benefit both to the Ministry of Health and the College of Dental Surgeons, specifically, the registrar, Dr. Rocky. At that point the college's response was wholly negative to any sort of notion to compensating Mr. Evaniuk on some grounds relating to professional responsibility. That is the issue I'm particularly concerned with. I believe there must be some ability to ensure that professions -- whoever regulates them in this province -- can be held accountable. That is the issue that I hope the ministry can shed some light on as we move through this case.
The ministry yielded greater hopes, especially once Bruce Strachan was appointed Minister of Health. I have no records of the particular date, however the ministry and a number of individuals came together: Frankie Carpenter, Dr. Malcolm Williamson and Alan Moyse. At that meeting, several matters were agreed upon.
Firstly, the ministry would approach the college with proposals to resolve Mr. Evaniuk's specific dental problems. One of the possibilities was that the college maintain a slush fund -- as it was termed -- from which the college could draw to assist patients who had suffered as a result of the negligence or malfeasance of one of its member. The other possibility to be raised with the college was that it pay Mr. Evaniuk's fees simply as a good faith gesture.
Secondly, the ministry was prepared to review the Dentists Act in consideration of the college's ability to enforce it's recommendations upon its members. I was told that this process would likely take a year. Again, for the record, in terms of its level of frustration, this case has been ongoing for more than a decade. Unfortunately, the election intervened. I spoke with Mr. Evaniuk the day after the election. He was talking about other areas he could proceed in. Again, following the election, the hon. member for Comox Valley became his MLA.
It seems to me that as serious legislators we need to take some action on this case. I don't know how aggressive we can be in promoting this particular case, but I think this will be a true test of how this government is able to resolve conflicts and to bring these individuals together. Mr. Evaniuk's case involves $10,000, which is a tremendous amount of money to him. It also involves the independence of the college and the rights of people to expect adequate service at the hands of a licensed professional.
Insofar as these are conflicting interests, I believe it is the role of government to bring parties together to resolve these disputes. We've discussed litigation -- and many, many items of documentation suggest it. We've also discussed the fact that the limitation for litigation has expired.
In terms of amendments to the Dentists Act, perhaps the minister could touch on the college's power to enforce the recommendations on its members and whether or not professional organizations ought to be given the power to enforce certain standards on professionals. Certainly it's my understanding that only the government at this stage can bring about any sort of redress for this individual.
I truly hope that we can work together to resolve this issue, because in my short term in office it's been one of the most painful cases -- when you realize that someone has come to their MLA and to ministers of the Crown repeatedly, hoping for some kind of redress to the problem, and absolutely needing to seek redress. This individual, Mr. Evaniuk, is in pain sufficient to keep him from working. He is not able to accrue dollars to pay for the services, and unless he gets the corrective treatment, needed as a result of the very poor treatment at the outset, we will see no resolution to this problem. I await the minister's comments.
Hon. E. Cull: The member has raised a specific case that I think gets us into the broader question of self-regulating professions, and how we as legislators can ensure that they are regulating themselves in the public interest. That is a matter that was addressed by the royal commission. It's a matter that we have been seriously addressing over the last year.
The College of Dental Surgeons is one of the few, if not the only profession -- I'm not sure whether there are others, but it's certainly one of the major ones -- which has not yet had that separation of college activities from professional activities, such as with the B.C. Medical Association. The Medical Association has the College of Physicians and Surgeons to regulate the profession in the public interest, and the BCMA looks after the physicians' interests. That clear distinction has not yet happened with the College of Dental Surgeons. It has to happen, and we've talked to them about the need for that to happen.
[12:00]
We've also been looking at the whole question of discipline and the power to enforce discipline across the professions to make sure that all of the professional acts -- because some of the acts are very old; they were put in place when thinking was different -- provide the professions not only with the ability to discipline and to do so properly, but also with clear rules and procedures so there are fair hearings and due process in keeping with modern thinking on that.
We've also been looking at increasing lay representation in these bodies to ensure that there is a greater public presence there, and therefore reminders that the responsibility of these colleges is to regulate in the public interest. That addresses the larger issue, and we're very conscious of that.
I'm not personally familiar with Mr. Evaniuk's case, but from what you have read in terms of the chronology, the number of people who have been involved over time, and just the time that it has taken to get any answer to this, it sounds dreadful. It sounds like a very serious issue which, for one reason or another, hasn't been handled.
I can't answer today whether it's a legal issue under the act, a question of liability or just a question of people not being able to come together to resolve who
[ Page 6023 ]
should be responsible now that the dentist appears to have removed himself from any ability to be held accountable. You can't pull his licence if he's not practising any longer. I agree that while going to court is a route that is open, it's not the desirable route if we can find alternative methods.
What I would like to do is take this information you have given me, get a full report from my staff and see what the options are to finally draw some resolution to this situation.
L. Reid: I would appreciate that immensely, because I think you understand the frustration that this individual feels, and the court process is no longer open to him. He believed that the other protocols would effect some kind of positive response, and he did not proceed within the allowable time limit. So he does not have any other option. Certainly this is somebody who has suffered for a decade and sought out medical care without some reasonable response from the only individual -- and in your case, the Minister of Health -- who could make a difference. I will certainly work as closely with you as possible to ensure that there is some resolution to this question.
In terms of the next item of consideration for today, I'd very much like to touch on the area of eating disorders. There are a number of situations that have come up over the last 18 months that I have been aware of. The documented case histories on Vancouver Island and throughout British Columbia allow for tremendous uncertainty and misinformation in the care and treatment of individuals with eating disorders.
Hon. minister, you will recall that on November 12, 1992, individuals came to the steps of the Legislature to make a presentation about the need for a definitive treatment program, and the need for the public to understand more clearly what the issues were surrounding eating disorders. That particular group -- the B.C. Eating Disorders Association -- continues to advance the issues, continues to speak out in terms of what is required, and their families and friends are supportive. The general public does not seem to have a clear understanding of where we need to go. When this particular group came this past autumn, they were making the case that there had been four deaths in four months on Vancouver Island of women 16 to 22 years of age, who were unable to receive needed help from our health care system.
We're going to look at the broad brush this afternoon, but also at more specific treatment intervention. The minister knows that I am tremendously supportive of putting some options in place for individuals with eating disorders. I believe this is one of the cases where there is no particular strategy that may be the most effective.
From my understanding of the issues, there are approximately 42 different symptoms of anorexia and bulimia, and any given patient may only reflect ten or 20 at any one time, so there are lots of dissimilarities in how the disorder presents itself. Based on that, I believe there needs to be as many different treatment options in place and as many different opportunities for young women and their families to seek some kind of counsel. The issue is a family concern, and the services surrounding the needs for families to be supported in their communities and schools are lacking -- not just on Vancouver Island but around this province.
[E. Barnes in the chair.]
We need to take some definitive action, and I applaud the minister on the first step that was taken last year in putting some dollars towards that. I believe we need to expand our understanding of that and look at different treatment options as a result. There are a number of issues that I'm going to try to cover this morning, because I understand there are a lot of different proposals available for consideration. I don't take any issue with the community hospital partnerships. I believe all of those are very important, but I believe we need to look at increasing our understanding of the disorder so we can put in place treatment models that are more effective.
We have looked at the institutional model, and both you and I have discussed the need for an interdisciplinary model regarding the treatment of eating disorders. In British Columbia we tend to fund the hospital model for eating disorders, yet I think we can both find research that suggests the hospital model is not particularly effective. The rigidity of some of those interventions and the actual physical plant does not allow any comfort zone for a number of young women in this province.
We need to be more responsive. Speaking as an educator, the issue of counselling in the treatment of eating disorders is lacking. That is the significant issue in elementary and secondary schools in this province, and it's certainly a significant issue in general communities where people are not able to find someone with the skills and abilities who is prepared to take forward their particular issue.
A number of young women I have met over the last number of months did not believe that their care was going to be optimum in a hospital setting. They had a certain resistance to and a certain discomfort with that setting. From the outset, they were not prepared to receive service in that setting, which made it very difficult for them to achieve any kind of success in terms of a weight gain or a reduction in some of those behaviours.
As the Health critic, I'm looking for some ongoing commitment from this government regarding how best to put in place a variety of options for the treatment of young people with eating disorders. I share the minister's interest in this area. I share her passion for this area in terms of how best to put it in place, and I can strongly make the case that we need to be very open-minded in terms of other possible options for the delivery of health care. I await your comments.
Hon. E. Cull: I think this area of the estimates debate is one where the opposition critic and I are going to have no disagreement with each other. I know we both share a very strong interest in improving services in this area, and indeed it's something that I have been working on almost from the minute I became Minister
[ Page 6024 ]
of Health. There has been a tremendous improvement in the number of services that are available, including services that have been put in place just over the last year. I want to take a minute to put those on the record before coming back to some of the specifics about family support counselling, treatment options and the link with education, all of which are important.
Last year, in our 1992-93 budget, we made a tremendous improvement in the number of services that were available, particularly in various parts of the community. Over the last number of years we've had an excellent program developing at St. Paul's Hospital. Indeed, sometime in the last year I was over there for the opening of the provincial resource centre, which provides services not only to people in the Vancouver area out of St. Paul's but also provides support and outreach to other health care providers around the province.
We fund Camp Elsewhere, a summer camp on Gabriola Island for people with eating disorders, and we've been working towards the consolidation of child and adolescent psychiatric services in Vancouver. In addition to that, though, over the last year we have expanded eating disorder programs in a number of communities: Duncan and Nanaimo on Vancouver Island; and the Capital Regional District, where last year I announced a grant of $320,000 to get an integrated program in place here. That's a partnered program with the hospital society, the Capital Regional District, our mental health services and some of the local physicians who work with patients who are eating-disordered. We've provided funding to the North Shore in Vancouver, to Port Coquitlam and Surrey. Again, these programs have been developed in conjunction with the hospital, but they go far beyond just providing hospital-style services. As the member indicates, it's not only hospital care that people with eating disorders need, but they need the services that these particular programs are supporting, such as direct counselling, support groups and follow-up counselling after hospitalization. We've also provided funding for counselling, again linked with community health providers in the local hospitals, in Kamloops, Salmon Arm, Trail, Nelson, Cranbrook and Penticton. Just in the last couple of weeks we opened a new program in Prince George, which integrates counselling and consultation with the Intersect Youth and Family Services in that community.
So there are a number of things that are going on. In the 1993-94 year we will be spending over $700,000 on eating disorder programs. That's in addition to what's already there in the hospital budget, so it's much more difficult to discern. But certainly through mental health and the programs we have been funding in these various communities, we're up to over $700,000, which is about $50,000 or $60,000 more than last year. Last year we made a tremendous increase. Last year we increased by almost $600,000 into the mental health area. So there was quite a large increase made last year, and we're building on it this year as those programs get up and running.
However, you raised a number of things that I think are important for us to pursue. Clearly the education link is one. My ministry staff are working with the staff of the Ministry of Education to make sure we're addressing this issue at the earliest possible stage, when young women -- who are mostly the eating disorder victims -- are in the school, so that they get identified early and get the support they need, and so that we link this to the related self-esteem problems and start to work with the educators in the classrooms. I had a very compelling presentation from a parent of a young woman who was eating-disordered. She's a teacher. She said that once her daughter was diagnosed, she became aware of other young women in the school where she teaches who were at risk. She could see the signs, having had them brought home to her. I think we can work with teachers to make them sensitive to these issues. We also have to address all of the other more subtle things that go on around the treatment of young women and affect their self-esteem, whether it's body image or the whole question of lack of control in many circumstances in their lives. We have to start to address those mental health issues with them early on.
One of the areas that you mentioned was family support. This is not something you can deal with just in terms of an individual. I think that goes for many issues related to mental health. It's not only the patient who needs support; the family also needs support. They need that support so that they can go on supporting the patient.
Yesterday I met with a group called the family advisory council that is newly established to advise our mental health services on these very issues. These are the families of people who have mental illness problems. There were representatives there from a group that represents people with eating disorders. Their very clear message was that they need support to help their loved ones to stay together as a family and to work through these problems. In our budget this year we have recognized the need for caregiver support and for respite services so that caregivers can refresh themselves and carry on doing the sometimes very difficult work that they have to do in supporting their family.
On treatment options, I agree with you. The dominant treatment option that has been pursued in this province is the medical one. It works in some cases; in other cases it doesn't seem to be as effective. Over the last number of months the ministry has made contact with people who are working in eating disorders outside of the hospital medical setting to learn what they can do, what they are doing, what success they're having and how we can integrate their treatment methods into our program of addressing eating disorders. I think we'll have to go at this on a number of different levels.
[12:15]
Our commitment is to find the funding within our budget as a priority to assist people in communities who want to develop programs around these issues and to try to hit on the facets that you're raising around education, counselling and family support, as well as recognizing that from time to time these people will be hospitalized. We need those very specialized services in our hospitals with staff who are sensitive to their needs,
[ Page 6025 ]
and then the follow-up and support. Unfortunately, like many disorders of this kind, people tend to cycle through the system. They're into hospital, they go home, they get well, they get sick again, and they go back into hospital. That's why we have to make sure we have all parts of the care system in place to support them. Hopefully they will get well and never return to the hospital, but I think we also have to accept that for some period of time, some of the young women suffering with eating disorders will need to access different parts of the health care system and have a continuum of care available to them.
L. Reid: The comments that the minister has made are extremely well taken in terms of the need for a multidisciplinary approach. Authorities in the field look at the fears and low self-esteem, and they understand that it occurs very early on -- young women of eight and nine years of age. I appreciate the minister's comments in terms of education. Many of these young women are not diagnosed until they're in their late teens and early twenties, and a lot of them have been dealing with this condition for more than a decade. I think it's during that particular decade, from ten years to 20 years, that we must ensure there are counselling services in place. At that point it's a manageable disorder for them -- i.e., they have not had to seek medical intervention. I think we run the risk of ensuring that they end up in a medical model unless we put some of those counselling services in place before their condition deteriorates to the extent that they have no other options.
My concern centres particularly around the number of women who enter the hospital in a very serious state of health and who weigh less than 50 pounds. That issue needs to be recognized, and I support your comment that we need to ensure there are medical models in place for that particular scenario. My concern is that we allow that scenario to run its course until we have no other option. I think that's where we are today. We have ensured that we've covered off some of the bases in terms of putting in place the medical model, but we have not taken a very active step to decrease the number of women who will at some point require medical interventions. Certainly the emphasis on an outpatient program speaks to me, but speaks very strongly to the young women who have come to my office and said that what they're looking for is a comfort zone, an opportunity to receive some kind of interaction -- without being contained in the medical model -- in terms of understanding their disorders. They wish to have access to counselling services; they don't wish to be hospitalized overnight; they wish very much to participate in day programs. If we're going to talk about the economics of the question.... All of those individuals are able to participate in managing their disorders in a very cost-effective manner. We tend to ignore a lot of the patient-initiated management until they are not able to manage their own disorders. At the end of the day, all we've done is increase the cost of the system.
There might be ways we can expand on the pre-hospitalization model, and I would even go so far as to suggest that the majority of the dollars should be put into that because I think it fits in very clearly with your New Directions in health care -- with a commitment to community-based health care -- and it commits very strongly to understanding the needs of the patient in some respects. I think at the end of the day there is so much misinformation out there about eating disorders, so much difference of opinion, that probably the best source of information -- virtually ignored over time -- is the patient. We haven't said: "How best do you wish to be treated?" Certainly we've done that in other areas of endeavour: we've done that in education and we've certainly done it in this area. Is it possible to create an advisory panel of not just the families but of young women who truly understand what they're looking for on this issue and how some treatment options can best be put in place?
Hon. E. Cull: As I said, we're not going to get a lot of disagreement on this issue. The involvement of the consumer in mental health services has been one of the driving principles behind the changes that we've put in place over the last 18 months. That goes for eating disorders as well. We have been involving the clients of the services in reshaping and redirecting them.
When you talk about the need for the majority of the money to go into the preventive services, that's clearly in line with the direction we're going in. I think I can illustrate that we're doing that from last year's figures around this. Last year, St. Paul's had $341,000 in its base budget for eating disorders. That wouldn't have been all in the hospital-medical model, but the vast majority.... Just to make the point here, let's assume it all was. The new funding that went into the mental health centres, which would be the preventive, the counselling and the follow-up services -- the kind of services you're talking about -- was $329,000, and that was added to a base that was already about $340,000. So we have provided the lion's share of the new money into mental health, even in the decisions that we started to make last year where we began to dramatically increase these services. The mental health budget for eating disorders doubled last year and has increased by a smaller amount this year but is still increasing so we can keep pace with the growing need. I agree that we've got to deal with prevention and early intervention; we have to ensure that the consumers are giving us information about what works and what doesn't. This is an issue that we'll continue to work on as a priority in mental health over the months ahead.
L. Reid: Many of you will be aware of Peggy Claude-Pierre, who is featured in the February issue of Focus on Women. She looks at a counselling model for the treatment of eating disorders. I would certainly like to enter into debate today on a proposal for funding to create the Montreux centre for eating disorders. I just want to touch very briefly on what I see as an opportunity to expand on the treatment options currently available. For the record, in terms of comparison with other treatment models, the Montreaux counselling treatment summary to date: the number of patients they've seen is over 300; as for age
[ Page 6026 ]
groups, the youngest eating-disordered person was two years of age, and the eldest was 63 years old; condition to onset -- by the time this particular resource is called into place, and particularly.... Peggy receives her patients from the acute care setting when it is determined that they are not going to improve in that particular setting, so they are moderate to very severe patients. Her total recovery looks at 90 percent, and the length of treatment is two to 18 months. If we need to discuss the economics of the question, we are looking at the comparison between the cost of hospitalization over the cost of a counselling program that is very effective.
In a local hospital facility the term of treatment is three to 120 months at a cost of $600 to $1,000 a day, and the success rate is known to be 50 percent or less. At a specialty clinic the term of treatment is three to 48 months at a cost of $900 a day, and the treatment outcome is considered to be 50 percent or less. The model that Peggy Claude-Pierre is advocating is looking at a three-month intervention with a cost of $350 per day. Based on the 300 patients she has seen, this has put her success rate at over 90 percent.
If there is a model that's working particularly well, we need to spend some time exploring that in more detail. Because we are in Health estimates, at the end of the day we are discussing dollars in terms of how much these treatments cost. If we are getting a better return on the dollar -- a 90 percent success rate, and the research certainly backs that up, at a third of the cost -- it makes sense to explore that option.
Regarding the minister's press release of April 15, "B.C. Community to Benefit From Innovative New Nursing Centre," that speaks to me, perhaps, of a nursing centre for eating disordered patients. It seems that the funding is in place under this Health estimates process, and I understand that a B.C. community is going to be chosen to put that in place. I think it's a glorious idea. Why not combine it with an opportunity to expand on options for treating eating disordered patients? I personally would love to see the Montreux counselling model in place in a centre for evaluation and support.
If someone has created a model that apparently works extremely well, why not support it in the community? Why not have this Ministry of Health come forward and say: "Yes, for whatever reason, success is achievable in the treatment of eating disorders, and success at twice the rate of current models. Let's explore that; let's get behind it; let's see if there's some ways we can allow it to go forward in the system." It certainly fits in very nicely with the New Directions in health care. The innovative new nursing centre could be the home to a program that is incredibly successful and incredibly cost-efficient. I would ask the minister to comment.
Hon. E. Cull: I've had the pleasure of meeting with Peggy and talking to her about what she's been doing. And she has been doing some incredibly marvellous work in terms of dealing with young people who have not been able to get anywhere in other parts of the system.
Going back to what we were just saying a few minutes ago, we need to have different kinds of approaches, because the same model isn't going to work for everyone. There are other people who are also active in this area. I'm sure you're aware of Sandy Friedman in Vancouver, who has another approach -- a non-medical approach -- to eating disorders that I think is worthy of support as well.
I received the proposal for the Montreux centre for eating disorders, and we have been reviewing it. But when I last met with Peggy, I encouraged her to start to work with the group of people that we are putting together here in Victoria to deal with eating disorders. While we want to have different types of treatment available, we also don't want to have the system so fragmented that the pieces don't work together. I think that her valuable skills and ideas can be brought into the work that is going on right now, and that some of the money available might in fact be directed to support the program that she wants to put in place. So I've been encouraging her to meet with our staff and also to meet with the other people who are looking at eating disorders, so that we can learn from what she's doing and build that into our planning.
L. Reid: I would ask the minister to perhaps comment on the innovative new nursing centre, because I am hoping there is some way to incorporate a treatment centre for eating disorders within this concept. I await your comments.
Hon. E. Cull: I think it's an interesting idea. The concept of the innovative nursing centre is being worked out between staff and the RNABC right now. I think that this is an idea that we should put to the people who are looking at it. They haven't yet selected a community. I think we have something like 28 communities that have written in and said "pick me." So it's going to be a bit of a challenge. I think we should be looking not only at the communities where this might work but also at the real needs of that community. If we can find a community and some issues that will come together, that a nursing centre would allow us to really test as to what the role of nurses can be, then we should not preclude this from the series of options that we'll be looking at.
L. Reid: I applaud the minister's interest in pursuing this idea, because I believe very strongly that if someone is achieving such a tremendous success rate, as is Peggy Claude-Pierre, then we need to take a look at that. Certainly we can encourage her to become involved in the community, but at the end of the day she has an extensive caseload. Somebody doing that work, where she is achieving remarkable success, would certainly receive my full support. So I thank the minister for her comments.
J. Weisgerber: I'd like to spend a few minutes this morning talking about some of the problems people experience in travelling long distances for health care, and perhaps look at some of the ways we could start to deal with that. Just to set the stage for the kind of
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difficulties that people around British Columbia face, I recently received a letter from a constituent who had arranged a time at one of the hospitals in Vancouver for surgery for her son. She drove 14 hours from Tumbler Ridge in order to be there, had the x-rays taken and then was advised that there were no beds available and that the surgery would be rescheduled for six weeks later. Obviously she then had to drive back to Tumbler Ridge with her son.
[12:30]
I think that points out a number of problems that, if we have time today, I'd like to talk about. First of all, I think it's essential for administrators in hospitals in urban areas to understand the time, expense and difficulty for some people in getting to hospitals for surgery. I think it's important for specialists in communities like Vancouver and Victoria and other centres around the province to understand the incredible difficulty that some people face simply to get there for an appointment. It speaks also to the costs of getting there.
I'd like to start by asking the minister whether she has any plans to make health care givers more aware. I understand that these people have all kinds of issues facing them, and I'm not being overly critical of hospital administrators or others, but there needs to be something in the system that sends up an alert. In major hospitals, like the one this lady travelled to, there always must be a bed. Somebody has to sit down and evaluate the issue and decide. Either that, or a very firm arrangement should be made before people are asked to travel that far for surgery or for an appointment.
I wonder if the minister would have any thoughts.
Hon. E. Cull: The member raises an excellent point. I've heard those stories too, and my sympathies are with the patient. I think it is deplorable when somebody travels that far to be told: "Sorry, we've changed our plan. Something else has come up." It's particularly a problem with elective surgery. It's not a big problem if it's cancelled for me, since I'm 20 minutes from the hospital; but obviously for people going from Tumbler Ridge to Vancouver it is a major problem.
We have been working with hospitals. I think hospitals are not unaware of this issue. Certainly they need to be made perhaps more sensitive to it, and perhaps physicians individually -- those who are making decisions about bookings, etc. -- need to be made more aware of it as well. No doubt we could do more in terms of sensitizing the hospitals and the physicians about these issues. But we have been working with hospitals over the last year to try to address some of the related issues, particularly the need for hostel units or accommodation at the hospital so that patients and family members who are travelling from a great distance can be there.
There's one problem you haven't raised, though I'm sure you're fully aware of it, with people travelling a long distance -- whether they're going to Vancouver or going into Prince Rupert Regional Hospital from a long distance upcountry. When they're discharged the next day at eleven o'clock, it may not be easy for them to get back to their home community. They may be waiting for their family to come in from up the coast or to come a long way over a very poor road. Sometimes physicians don't want their patients that far away immediately after discharge, but it's not a good use of our resources to keep them in the hospital simply for observation. So we have been working with hospitals, encouraging them to look at more flexible arrangements -- a hostel ward in the hospital, for example, which would have a lower level of nursing care but still have the patient there and accessible to the physicians. I know Vancouver General, for example, has arrangements with motel operators in the Vancouver area for family members to come and be able to stay at reduced rates.
So there is a recognition, but I agree with you that more could be done in this area. As you've raised it, I will make sure that we raise it with the B.C. Health Association.
J. Weisgerber: That leads us rather obviously to the next issue, which is the incredible cost that some people face in travelling for health care. Anyone who spends as much time in airports and on airplanes as I do knows that there are people travelling regularly. I get to know people who bring their children down regularly for treatment. There is some assistance available through charitable groups and I want to take the opportunity now to commend Canadian Airlines for their program which allows travel points to be donated to charitable organizations who, in turn, use them for travel.
I think there should be a directive from government that anyone accumulating air points be required to donate them to Canadian Airlines. I think we should put some pressure on Air Canada and Air B.C. to adopt a similar mechanism for their travel points and I believe we should require politicians and government employees to turn their travel points over for the particular purpose of health care travel.
I'll go one step further. I think we should also require that of organizations where the province essentially picks up the cost of travel. I'm thinking about school boards, colleges, universities and health care students. People whose travel is paid for by the taxpayers and who are accumulating travel points, I think, should put them into a pot that we can use to help people with their travel. That would be a start and it wouldn't cost us any money. Canadian has in place a mechanism that will allow that to happen with their travel points and I think that perhaps with some encouragement from the province, Air Canada might be willing to consider the same kind of mechanism.
I don't think that's going to solve all of the problems, but I think it's going to be a big start. Both the minister's party and my own, during the last campaign, campaigned that we would bring in travel assistance for people living in remote communities. I'm curious to know what kind of progress the minister has been able to make on that issue. Obviously our opportunity to deliver was rendered somewhat ineffective in October of 1991, so the ball has kind of gone to your court.
There are some good models that I looked at. Quite honestly, I don't believe that we should pick up all of the costs or the costs for the most expensive way to get
[ Page 6028 ]
there. But we have to recognize that if we're going to have a universal health care system, we can't say to someone: "We have a universal health care system, but the problem is that you live too far away." It's universal for people who live where the services are available; it's anything but universal for people who have to drive or fly to get to them. I'm curious to know what kind of progress the minister has made in dealing with this critical issue.
Hon. E. Cull: As the hon. member said, the ball is in our court, and indeed, we have caught the ball. We are working on ideas. Certainly your suggestion in terms of travel points is, I think, a very worthwhile idea to pursue. We have been pursuing a number of different strategies, such as looking at what has been done in other provinces and talking to some of the people in the private sector who provide travel services, to see what we can do. I think that with some patience, you will find that we will be able to deliver on our campaign commitment with respect to travel assistance. I daresay that given the comments you made just now, you will find that it will be something that you can support.
J. Weisgerber: I'm encouraged. Unfortunately, because of budgetary pressures, these things have a way of not being developed. I will be watching closely to see that we get some concrete commitments and plans in place for people to receive travel support.
D. Lovick: Trust us.
J. Weisgerber: The minister for Nanaimo says: "Trust us."
Hon. E. Cull: Soon.
J. Weisgerber: I want to say that this issue has been promised and talked about; it's time to deliver on it.
I want to take this debate on changes to the health care system one step further. I recognize -- as I think most people do -- that we have to rationalize the way we deliver health care in this province and in this country. I suspect that the rationalization and reorganization of our health care delivery -- particularly in the minds of people who study models -- will, at least in part, look toward centralization and toward efficiencies by perhaps taking services out of community hospitals and putting them into regional centres. That's nothing remarkably new.
I believe -- and I have believed it for some time -- that what happens when this modelling is done is that nobody calculates the transportation costs. So they say that it is easier to close these hospitals or facilities in rural areas and put them all in one central area, and that it will be more cost-effective. And truly it will be, for them. What they've done is put a burden on all the people who have to travel for the service. It's not calculated into the decision, and it's a mistake.
So if you follow through -- as I trust you will -- on a program to assist people with travel, it will immediately be of assistance and comfort to those people. It will also then force your economists to calculate the cost of travel into the decisions around centralization. It's a very real cost. If you have to drive from Dawson Creek to Prince George, or if you have to fly from Dawson Creek to Prince George, that is a very real cost. If it was a cost, for example, that we were to impose on someone in another way -- if we were to suggest we were going to impose that cost in the form of a user fee -- the minister and her party would be outraged. They would find it totally unacceptable. But we still impose that kind of cost.
So I want to see a comprehensive program brought in for travel assistance. I believe it will relieve hardships for the people who travel, and I believe it will affect some of the decisions that your ministry is considering. If they have to pay the cost to travel to centres, they will find that some of these centralizations are not as economically attractive as they first appeared. I'd like the minister's commitment, I suppose, or perhaps I'd ask her to at least acknowledge, as part of her commitment to bringing in a package, the importance of that calculation. It is a very real and substantial cost to people who have the misfortune to have an illness in their family, to someone who can't travel by themselves. It often involves flying with two people or, as the lady from Tumbler Ridge did, driving about 700 miles over 14 hours in order to get there for surgery.
Hon. E. Cull: You have my acknowledgment of that as an issue, as a cost, as something that has to be factored into the decisions that we're making. Our priority is to try to bring the health care services closer to where the people are. The first initiative is to try to bring the health care services closer to home. However, we recognize that there will always be health care services that can't be provided closer to home. They will have to be in Vancouver; they will have to be in regional centres.
As we deal with these two competing forces that are at work in health care right now: the need to try to get some services back into communities and out there where they should be -- repatriating them, if you like, to the local community hospitals.... We have other cases where better health care will be provided if we start to centralize some of the services so that there is a critical mass of physicians that are providing that service -- that there are enough patients being seen.
[12:45]
I think you are absolutely right. There are the obvious costs that are very easy to add up in a hospital budget or in a Medical Services Plan budget, but we cannot make decisions that will be good decisions if we don't recognize the hidden costs that are borne individually by patients and families. I think that applies in other cases. As we look at moving services closer to home -- out of institutions into the communities -- we're going to have to recognize that in some cases there are expenses that families have at home that they don't have if their family member is in an institution, and we have done that through some programs. In fact, your government brought in some programs that recognized that additional cost factor for families.
You've made good points. We're aware of them, and we're trying to sort them into our costing.
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Mr. Chair, it's Friday afternoon, and some people have travel arrangements that they would like to make to return to their constituencies. I would like to move that the committee rise and report progress and ask leave to sit again.
Motion approved.
The House resumed; the Deputy Speaker in the chair.
Committee of Supply B, having reported progress, was granted leave to sit again.
Hon. M. Sihota: It's been an enjoyable week. I wish all members a good long weekend, a restful one at that. With that said, I move adjournment.
Motion approved.
Deputy Speaker: The Chair would like to offer its good wishes to all the members as well over the weekend and announce that the House is adjourned until Monday at 2 p.m.
The House adjourned at 12:47 p.m.
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