PROCEEDINGS IN THE
BIRCH ROOM

Committee of Supply

ESTIMATES: MINISTRY OF HEALTH

(continued)

The House in Committee of Supply (Section C); S. Chandra Herbert in the chair.

The committee met at 2:45 p.m.

On Vote 31: ministry operations, $20,698,339,000 (continued).

Hon. A. Dix: Is this birthday rumour true?

The Chair: I’m told it is indeed true. I don’t remember the day itself, but my mother assures me it did happen.

Hon. A. Dix: Well, happy birthday. Really, it’s a week-long celebration. That’s good news.

N. Letnick: Thank you to the minister and his staff. Also, thank you for yesterday, for the first day of estimates with the minister. The answers were clear. My colleagues were very happy. We got through all my colleagues’ questions but one. The one member will be back tomorrow to ask one or two questions, and then the critic for seniors and the critic for Mental Health and Addictions will also be in attendance.

We have set aside some time in the afternoon — the first hour — for the Third Party to ask their questions. Then, I understand…. Well, we’ll be at the mercy of the House Leaders as to whether or not there’s room for anything else.

I would assume that the only opportunity for us to have a discussion, minister to critic, is this afternoon. For that purpose and because of the number of items that I’ve been collecting over the last year on behalf of stakeholders and other interested parties, I met with the minister’s staff to give them a pretty clear brief as to what the areas are going to be — in many cases, what the questions are going to be. That way, hopefully, we can get through all of these in an expedited manner. Without any further ado, if it’s okay with the minister and the Chair, we’ll begin.

So $20 billion is a lot of money. Could the minister please describe what the planned Health budget growth is over the next three years?

Hon. A. Dix: Much thanks to the member for Kelowna–Lake Country, the critic, for having organized the estimates so well. I think it really helps to get through material, and we’re going to try and meet the test today and get through the issues that he wants to present before us on behalf of people he’s met and on behalf of the opposition.

The Ministry of Health budget, of course, for 2019-20, is, as you say, $20.846 billion. It represents an increase from the prior year of $1.091 billion, or 5.5 percent. Over the three years in the fiscal plan, the Health budget increases by $1.3 billion, which is 12.2 percent overall in that period.

I know the member will have follow-up, but I’ll just give you a sense of what’s driving some of the increases, some of the items that were given particular focus in this year’s budget. Many are for the B.C. Cancer Agency — over the next years, $105 million; the B.C. Children’s and Women’s Hospital, $24 million; the B.C. emergency health services, $51 million. Global funding increase for ’21-22 — as the member knows, these are put out in advance — is $639 million.

We also received resources for new drugs in the PharmaCare program, which we’ll get to later, which is $42 million over the three years — so $14 million a year, in addition to the inflation increases.

[2:50 p.m.]

We received resources to support transition on the employer health tax — obviously, compensation increases — the overdose emergency response and the mental health strategy, all of which are part of the incremental dollars.

That’s what the budget looks like over the next three years.

N. Letnick: Would the minister agree, then, based on those numbers…? If I can just go back a few years — five years, for instance. The budget was just under $17 billion. Then it went to $17.4 billion, which was a 3.1 percent increase. Then it went to $17.9 billion, which was a 2.9 percent increase. And then in ’17-18, it went up to just under $19 billion, $18.9 billion. In ’17-18, it went up by 5.4 percent, quite a considerable jump. Last year it went up to $19.7 billion, which is 4.5 percent, another considerable jump, and then this year, as the minister stated, 5.5 percent.

Then it goes down, back to the previous first years that I just mentioned. It goes back down to a 3.2 percent increase, and then in ’21-22, at $22 billion, it’s a 3 percent increase.

This almost looks like a bell curve, where you have 3 percent, 3 percent, 3 percent, 5.4 percent, 4.5, 5.5 and then back down to 3.2 and 3. I just want to confirm that I have my math correct.

Hon. A. Dix: The member is correct. I’d be happy to share. I’ve got a document, which he may well have, that deals with three questions, estimate actuals, and by health function within government. They show, roughly, what the member talks about.

The member will know in the period essentially between 2012 and 2017, those increases in those years were just under or at 3 percent, in that range. To a degree, that reflected, as well, reductions and increases in the Canada health transfer. For a long period in the ’04 to ’14 agreement, federal increases in the health transfer were higher than provincial lifts, and then they came together in the last number of years. Again, provincial lifts have been higher than the federal lift in the Canada health transfer net and other federal initiatives that have come forward.

He’s right that in 2017-18, both in the budget that was tabled in February and then in increases in the budget, which were largely devoted to mental health and addictions but were within the Ministry of Health envelope, that amount moved up to 5.4 and this year to 4.4, of course. And these are, of course, cumulative…. So 3 percent includes all of the others, so that has to be kept in mind. When we have these increases, that’s the case.

In future years, these are the base levels set for future year budgets, for future increases — what the ministry can expect. The member, as a former minister, is aware of the Treasury Board process — that should we wish more or require more or have other initiatives, we would have to seek that in that process. Today we’re obviously debating the budget for this year, which is the increase of 5.5 percent. That’s reflected, obviously, in the motion we put forward at the beginning. But that’s the situation.

In the next two years, that’s the base lift increase that has been established in the three-year plan. Should the ministry wish or require more or make the case for more, it would be more than that, and that would be determined, of course, by the Minister of Finance on budget day.

N. Letnick: Thank you to the minister for that. I’m going to move now to 1(b). For those of you who are watching, the minister and his staff actually have a list of all the topic areas in advance. So 1(b) talks about….

Interjection.

N. Letnick: So the planned budget growth for the regional health authorities…. Given that the minister and I have agreed on the increases being approximately 3 percent for a few years and then approximately 4½ to 5½ percent for three fiscal years and then down to 3.2 and 3 percent in years 2 and 3, I was very curious to see the source of the same numbers described for the health authorities. In this fiscal year, the year we’re dealing with, the increase is 3.9 percent for the health authorities.

[2:55 p.m.]

But in year 2, while for the ministry it’s a 3.2 percent projected lift — if he needs more, he goes to Treasury Board; we know that argument — for health authorities, it goes down to a 2.4 percent lift. Then in year 3 of the plan, it goes down to a 1.6 percent lift. Given that — in my little knowledge of health inflation — there usually is somewhere around 4 to 6 percent a year annual health inflation, it really exceeds the standard CPI.

How does the minister plan to make sure that the health authorities have the money they need to deliver improved services, let alone expanded services, when they’re actually going to be realizing a net increase of only 2.4 percent in year 2 and then 1.6 percent in year 3. As I said, health inflation’s probably 4.6. I’m not going to suggest there be any cutbacks. There might be efficiencies or something else the minister has in mind that can support these lower numbers than inflation. I look forward to hearing the answer.

Hon. A. Dix: Thanks to the member for his question. I think it’s possible we’re operating under different numbers, so I’ll just read in the numbers that we have for this year and subsequent years. Then, if the member wants, I’ll also be happy to share with him the back numbers. I don’t want to take too much time and go through all of those.

The numbers for regional health authorities this year are 6.1 percent. That number in Fraser Health is 5.8 percent; Interior Health, 6.4 percent; Vancouver Coastal Health, 5.2 percent — this is based on funding letters; Vancouver Island Health, 5.1 percent; Provincial Health Services Authority, 8.5 percent. That 8.5 percent reflects the cancer agency increases that we’ve talked about. That’s why it is higher.

The expected increase based on the three-year plan for next year is 3.4 percent and 3 percent in the third year. That is similarly divided amongst the health authorities. But I’ll just give one year, and then I’ll actually be happy to share the note with the hon. member: 3.5 percent, Fraser Health; 3.1 percent, Interior Health; 2.8 percent, Northern Health; 3.1 percent, Vancouver Coastal Health; 2.6 percent, Vancouver Island Health; 4.5 percent, Provincial Health Services Authority; which add up, collectively, to the 3.4 percent. So 6.1, 3.4 and 3 percent for a cumulative increase over the three years of 12.9 percent.

N. Letnick: Thank you to the minister. I’m realizing right away, given all we have to talk about in about four hours, that I’m going to have to apply self-discipline to myself for not going down the rabbit hole on all these different issues.

Just to put on the record. Using the same sources, which is the budget, that the minister and I have been talking about so far, the numbers I got for health authorities, for this fiscal year, is $16.292 billion, $16.681 billion in the second year, $16.953 billion in the third year. So I will go back and review my numbers against the numbers the minister has said, and maybe staff can also do the same. Tomorrow we’ll come back and discuss this because I don’t get 6.1, 3.4 and 3 percent from the numbers provided by government. I get 3.9, 2.4 and 1.6 percent, which are definitely — I would imagine the minister would agree — troublesome.

I’ll just leave that there and move on to….

Interjection.

N. Letnick: I’m sure it’s myself that has miscalculated or has taken the wrong number off the wrong ledger. But that did shock me when I saw that.

The issue 1(c), actual versus forecasted change in MSP beneficiaries by age group. The minister, in the past, has talked about British Columbia — and, actually, I’ve talked about it as well with the minister — being very attractive for people coming here to retire. I think some people peg it as approximately 35 percent of their health care costs, once they come here to retire, that are actually paid for by them through their contribution in taxes and other things, which leaves 65 percent on the table that taxpayers, generally, in British Columbia are covering for them. We believe in mobility as a country, so that’s great.

This begs a question. Over the last couple of years, given the current government’s policy decisions, has there been any change in the in-migration of people from outside of British Columbia on the rolls for MSP, in particular. The reason why I ask by age group, and the minister doesn’t have to go through all the young age group, is I’m really looking for retirees.

[3:00 p.m.]

Have the retirees started to taper off coming to British Columbia and applying for being a beneficiary under MSP?

[The bells were rung.]

The Chair: Division has been called in the main House. I would like to propose that we call this recessed.

The committee recessed from 3:01 p.m. to 3:12 p.m.

[S. Chandra Herbert in the chair.]

Hon. A. Dix: There are some detailed questions that the member asked for that we’re retrieving — that we’ll get for him with respect to expectations and interprovincial transfers. One document that I received about community residential care…. It shows that our estimates, which include, obviously, an assessment of those changes, were that we didn’t go over, in ’17-18, what we expected for people in the 85-plus bracket or the 80-to-84 bracket. That said, those expectations were set based on an understanding of interprovincial transfers. I think we’ll have an opportunity, in the next session, perhaps, to talk about the Canada health transfer and what it means.

On the specific question the member asked, we’ll get that information for him and read it into the record shortly.

N. Letnick: Thank you to the minister. Are we saying that the number of MSP beneficiaries is not available at this point? The minister will get back to me on that, whether it’s changed up or down over the last few years?

Hon. A. Dix: We’re hoping to get that, I think, before we close today. We’ll have that information if questions flow from that. It’s there. There was just some misunderstanding about the information required.

N. Letnick: May I ask a question on the federal health transfer? I can. Okay. So we have those numbers.

I know that the government agrees with the opposition, because when the opposition was in government, we fought for the same thing. I think all British Columbians would agree that doing the health transfer based on a per-capita basis is putting B.C. at a disadvantage, especially when we have people from across the country moving here in their peak health-use years. Somehow, we need to reflect that in our transfers.

Obviously, this is a federal transfer, made by federal politicians, but it would be nice to know what the analysis of the gaps is — if it was based on a different model, a preferred model, by the minister and the ministry. I would assume that work was done with the previous minister and the current deputy minister. I would assume that information is still current. I don’t think that would have changed very much over the years.

Can the minister please provide some insight as to how much we’re losing in health transfers because it’s on a per-capita basis versus some kind of weighted basis?

[3:15 p.m.]

Hon. A. Dix: Some historical information in there, again. I apologize to the member. We’re searching for some of the historical information from Finance, from the previous government, because there was a debate at that time, in 2014, and again in 2017. There was a reduction in the annual growth rate in 2017 that had, obviously, a significant impact; $142 million was the one-year impact in 2017-18.

There was a significant debate between British Columbia — the then Health Minister and the then Premier — and the federal government in those discussions, particularly in 2014 and again in 2016, around that. And clearly, British Columbia is penalized by the lack of reflection of the demographic changes of the province — who moves here, the qualitative questions.

There is a document that’s available — I’ll make it available to the hon. member — that comes from the time of the previous government. It has been archived, but it is available, and we’ll share that. Happy to share that with the hon. member.

N. Letnick: Thank you to the minister. Being the former Minister of Agriculture for four years, I wasn’t involved. That’s why I didn’t know there was a document. That’s great to know. I’ll look forward to seeing it.

I’m going to take a one-question tangent on this, if I may. What can we do, as the official opposition, to assist the minister and Premier so that we can get our fair share?

Hon. A. Dix: I think it’s, really, very much a British Columbia debate. The member will know…. This is a question when I go, for example, to federal-provincial conferences and so on: to what extent do you complain, and to what extent do you get on with it?

This current structure is going to be in place for the next five years and will have significant impact, obviously, in that time on British Columbians. So part of what we have to do in British Columbia is consistently make the case, particularly as we get closer to renewal — that would be past the next general election — that British Columbia has not been well served. British Columbia citizens, and Canadian citizens, ultimately, who move to British Columbia, have not been well served by the current arrangement.

It should be said, of course, that unless the federal government was to lift the overall amount to reflect that, this is a zero-sum game. There were winners in the last round of the process. I won’t want to reflect too much on who they probably were, but I have a sense of who they probably were. They include the province of Alberta, I believe, the province of Quebec and others. That’s the way it goes.

I think that we have to make the case for this. We have to make the case in agreements that happen subsequently — agreements such as some of the agreements we’ve done on mental health and addictions, where, clearly, the problems are more significantly felt in B.C. and therefore the expenditures should be disproportionately applied in B.C. But I think this is a case that we have to consistently make over time. One of the things that I try not to do, obviously…. Establishing and saying the case consistently over time so that that message is received.

But we have to also get on with it. This is the amount of money that we’re going to receive from the federal government. I may not like that, I may not like the decisions they’ve made, but I think in this period, we have to continue to make the case that this is what’s happening in British Columbia. These are the demographic increases we’re seeing in the coming decade, and we have to make the case that the federal government, federal tax dollars, which of course come from British Columbia, should flow appropriately.

[3:20 p.m.]

We have equalization in this country, and that’s the appropriate place for us to make decisions as between provinces and ensure that all provinces can provide equal services. In the federal health budget, surely, it should reflect the needs of the population.

N. Letnick: Thanks to the minister. Seeing as the minister is responsible for la francophonie in the province de Colombie-Britannique, and seeing as I’m the previous representative for that portfolio, I’d be very, very happy to be good cop, bad cop. He can be the good cop; I’ll be the bad cop. We can go after our Quebec colleagues and let them know that it’s time to share the wealth of this country equally, equitably, with those of us in British Columbia.

On a little bit of a tangent…. I promise this is the only question, I think, that’s this kind of question. The constituency office expenses — is it correct that the minister has an executive assistant, paid for from the ministry budget, based in his constituency office?

Hon. A. Dix: Yes.

N. Letnick: Thank you to the minister. Three more of these. I’ll actually just ask them all. What is the total cost for creating workspace for EAs in the constit office that was paid out of the ministry budget? Are any of these costs coming out of the ministry budget? If so, how much? And the last one is: were there any expenses charged to the ministry for these five things — renovations, phones or computers, furniture, supplies and, lastly, travel?

Hon. A. Dix: My executive assistant works out of the constituency office. There were no changes, no renovations to make that possible. She has a desk in the office. We did add to my constituency office a phone set-up, which cost $386. This allows me to do conference calls, from my constituency office, that are ministerial calls. I’m a Vancouver MLA, so I’m there frequently and do those calls frequently. We also spent an additional $806 for furniture. As the member will know when the public accounts come out, we underspent our ministerial budget this year, and I expect that we’ll do that next year.

I feel that having an executive assistant based in Vancouver is of value to my office and is the right thing to do, but we’ve done it in such a way that the costs to the taxpayers are minimal. We use the existing space. I think we use it well, and one of my excellent staff members works out of it. In terms of travel for staff, staff do travel with me, but that’s not really affected by the executive assistant being in Vancouver. Probably those costs are reduced, since my executive assistant in Vancouver is able to staff me at a number of events and not have staff come over from Victoria.

N. Letnick: Thank you to the minister. This is on behalf of the member for Skeena, who could not participate yesterday. He would like to know, for the Mills Memorial Hospital, if there is any money in the ten-year capital plan.

Hon. A. Dix: The answer is yes. I had this discussion yesterday. The member, because he was a member of the executive council, knows this. You know that there’s money in the ten-year capital plan for a project when a concept plan is approved. That’s the key moment in the approval of any project. There’s some debate — and I think the member for Skeena has been engaging in this debate a little bit in his constituency — because there is a budget list of projects that go into that budget list when business plans are approved.

When the project at Mills Memorial was announced, it was a wonderful day in February of 2018. We usually take 12 to 18 months for the business plan. We’ve received the business plan from the Northern Health Authority, and we’re, of course, planning to move that project forward. It’s an excellent, needed project. It will add beds. It will add services. It will be a regional centre.

[3:25 p.m.]

I think that people in Terrace and the whole surrounding area have been waiting for the Mills Memorial Hospital project for a long, long time. I’m very happy that the government was able to follow through on the Premier’s commitment and deliver on that.

N. Letnick: Thank you to the minister. We move on to item No. 2, human resource management and primary care. I just made some notes as to what I think the previous governments have done regarding medical school spaces. It might be — probably is — a part of the Advanced Education Ministry, but hopefully, the Health Minister can shed some light on these questions as well. The places for medical students went from 128 to 288 over the last few years, at distributed campuses across the province. We discussed this yesterday. The minister, I think, is very keen on making sure that we educate people in their home areas. That way, they tend to stay there.

We’ve seen over 8,900 new health and medical program spaces, including more than twice the number of spaces for nurses; over twice the number of new spaces for midwives; over twice the number of resident spaces, from 134 to 346. In 2005, the nurse practitioner program was created. I think the minister has said somewhere around just over 400 nurse practitioners in B.C. as of 2017 — with, of course, the great announcement of moving that up by 30 per year, so that in addition to the 45, it’s 75 new ones per year, as of 2018.

Obviously, part of our primary care initiative is to increase the number of people working in the sector — in this case, doctors, nurses, midwives and nurse practitioners, etc. I was just wanting to know: does the minister and his government have any plans underway — any studies, any business cases, anything — that would indicate that there might be, in the near future, some expansion of any of these programs?

Hon. A. Dix: I think it’s fair to say that our priority, what we’re looking at, other than the increases in some of the health sciences professions…. We’ve talked about increases in nursing, increases in care aides, which we’ve discussed in previous days, and as the member notes, the large increase in nurse practitioners because of, certainly, the anticipated need and the growing need and the use, in the health care system, of nurse practitioners.

One area we are looking at expanding is, clearly, residency spaces. I think it’s 346 right now, divided between the 288, if I’m not mistaken, for Canadian graduates and the remainder for international medical graduates. The focus will be to expand out in areas where there’s particular need. This is sometimes a struggle for international medical graduates, who graduate in areas that are not of particular need, or where we don’t have a lot of need for expansion. But looking at the health care system, looking at medical specialties, there are going to be some areas where I would expect that in the next few years there’s going to be greater need. Those are the areas where we’re looking at an expansion of residency spaces in this fiscal year.

N. Letnick: I’d like to thank the minister. I especially want to thank the minister for his concise answers. This is great.

Hon. A. Dix: Unusual.

N. Letnick: I wouldn’t want to say that.

Whenever the minister’s ready to do it, he does it. I’m very thankful for that, so that we can get through this long list this afternoon, which does allow me to go to just one tangent, the 346 spaces. The minister is correct — the residency spaces.

[3:30 p.m.]

If we’re looking at expansion on that, do we have, as a province, the latitude to do any return of service for those B.C.-educated new residency spaces, or are we limited by some federal legislation, as far as mobility is concerned, human rights or anything else, that would say residency spaces must be open to anywhere that they choose?

Hon. A. Dix: I think the short answer to the member’s question is no. But, just to be precise, obviously we have return of service for IMGs. We’re doing a pilot project this year for two dermatology positions, which is an area of significant needs in some parts of the province, that are B.C.-based that will have a return-of-service component, which I think will be very useful.

We’re very focused on this issue, though, of ensuring that the people we train in B.C. at significant cost, obviously, to the new doctors or the residents themselves but also to all of us and to the taxpayers — to get the maximum uses…. It’s part of why, when we were hiring our 200 new doctors in the primary care plan, we focused on making those positions salary positions in response to requests by resident doctors, who overwhelmingly have said they’re interested in alternate payment provisions, especially when they start out. It allows people to build up patient panels, for example.

This is a real focus of ours. In terms of those areas of health care that are of particular interest in B.C., I think the member would be able to guess what they might be. They would include areas such as dermatology, which we’ve mentioned, but anaesthesiology, which is always a challenge, and really the principal challenge in practical terms of meeting some of our surgical goals. We don’t have a shortage of surgeons, but we often have challenges with anaesthesiology in areas such as geriatric medicine, which, obviously, given the changing demographics of the province, will have ongoing and significant importance.

N. Letnick: Thank you to the minister. If I can clarify, with the IMGs, international medical grads, we could have return of service, but for residency spaces we are limited, basically, to putting the spaces where we want them, hopefully, to stay afterwards. We can’t tell them that they must work in a certain area, but we can actually put them in certain areas, and they would have to apply and get accepted for those residency spots in the locations and for the fields that we would prefer they do. Correct?

Hon. A. Dix: I think when I said no, I meant this. We’re piloting two…. A pilot project this year in dermatology that would involve — for B.C., essentially B.C. — the Canadian doctors from B.C. that have return of service. So that pilot…. We’ll see how that works. But that’s in a particular area.

We don’t feel limited, if you will, by, as the member says…. That’s what I think I was saying no to in the previous answer. So there may have been some confusion there. But that pilot project, I think, will be of interest to the member and certainly is of interest to us. It’s part of a focus on particular areas where we clearly need to find ways, in particular specialties, to ensure that people have access around the province.

N. Letnick: Thank you for the clarification of the “no,” much appreciated.

Speaking of residency spaces, I’ve been approached by the group representing residents. They are asking the government to address the shortage of residency positions to provide all medical grads from UBC with the opportunity to complete their training in full, so they can address the health care needs of British Columbians, specifically increasing the ratio of medical grads to residency positions from the current 1 to 1.01, to 1 to 1.10, given that 1 to 1.10 has historically ensured all medical students are able to practice medicine in a residency program.

The number of current-year graduates and prior-year unmatched applicants exceeds the number of residency positions in B.C., meaning that, at its current rate, it’s impossible for all medical students to successfully graduate from UBC to secure residency. They estimate this is a cost of $3.6 million.

Or they are offering to ask to provide additional residency positions specifically for unmatched medical grads from UBC, given this reduces the loss of investment represented by each unmatched graduate by allowing them to continue training and eventually practice medicine in B.C.

[3:35 p.m.]

Medical grads who complete both their undergrad and postgrad training in B.C. are more likely to remain in B.C. long term.

Now, from what I heard from the minister, actually, he’s looking very favourably on doing one or both of these. Could the minister comment as to which one he is leaning towards?

Hon. A. Dix: It’s a real tribute to our students at UBC, first of all — 96 percent matched in the first round. There are subsequent rounds. The 96 percent were matched to residency, which I believe in this year is going to be the best record in Canada, so that’s a real achievement.

I did meet with the group, and we did talk about unmatched residencies, which is a pretty small number when you consider the number I just expressed. That can change in different years. But the quality of education that our students receive, and their work, is going to, I think, continue to earn us very high matching in the first round of matching. There are subsequent rounds, as the member would know.

We are looking, though, at increasing the number of residency spaces. We did have a discussion with the group about just the issue the member raised before, which is: what, if anything, might be considered with respect to return of service for those physicians if one were to create positions? I would say that the group was not yet ready to commit on that question, but that was a good discussion we had. I know they had a similar discussion with the hon. member and his colleagues.

I would say that we just negotiated an agreement with the Resident Doctors of B.C., and I think it was ratified at 86 percent, which is less than the Doctors of B.C. You can’t get 98 percent every time. But it reflected the work that resident doctors are doing and their increased engagement in the medical system. I think the Resident Doctors of B.C. are doing a very good job at that and at making the case — I think an important case — for us to ensure that when people are trained here, we give them every opportunity to work here. We’re looking at all those options.

N. Letnick: Thank you to the minister. That would have been a good segue to my next question. But before I do that, international medical grads. If the number of residency spots is very close to the number of graduates from UBC, it doesn’t leave much opportunity, even in the second rounds, for our children who go abroad to get a qualified — and I say “qualified” — education somewhere else and then want to come back to British Columbia. So basically, they’ve paid the shot, whether it’s $100,000, $200,000 or $300,000 not covered by taxpayers, to become doctors but still require residency to become fully accredited doctors.

Is there any thought at all as to how we can better accommodate the international medical grads that are coming back to British Columbia?

[3:40 p.m.]

Hon. A. Dix: Like the member, I’ve had meetings with families and international medical graduates as well. As he expressed, people are very, to say the least, invested in the process and want to come back and want to work here.

[The bells were rung.]

Hon. A. Dix: I’ll continue this answer after we vote.

The Chair: It’s a vote in the Douglas Fir Room, not in the main chamber. So there’s no requirement, unless you are a sitting member of that chamber, to vote. We can continue in this chamber, once the bells are done.

Hon. A. Dix: There are 58 residency spots for IMGs. There have been human rights rulings that say that all IMGs are treated equally. In other words, there’s no preference for Canadian IMGs against other IMGs in that competitive process.

We do have the 58 positions, and that’s, of course, part of the policy question that might be decided. Would one expand that number of positions, or not, to increase the number of IMGs against the number of Canadian medical graduates? That’s one of the decisions that would be facing us. Would we expand the number of residency spaces?

It should be said, of course, that the quality of residency education has to be maintained. It’s not an unlimited question. You might say: “Well, why don’t you go from 346 to 400 or whatever?” It also involves enormous effort by existing doctors and nurses and others to ensure that the residency process goes well. It’s expensive, obviously, to the health system, although very valuable to it. Those are the choices that we have to make.

The one consideration…. Would we consider expanding the number of spaces for international medical graduates? That’s something that, obviously, is before us to consider as we look at increasing, somewhat, the number of residency spaces in B.C.

N. Letnick: Thank you to the minister. It’s really unfortunate we don’t have two weeks to do this. That question…. We could have gone for two days, just by itself, on that one.

The Resident Doctors of B.C. did, as the minister said, come and speak with us and, on March 12, sent a letter to the minister basically outlining the challenges that they face in terms of workload and salary. Shortly after, resident doctors ratified an agreement with the minister. See how quickly the minister has responded to their needs? Notwithstanding the 2 percent increase per year in wages, which…. I don’t know, actually, if I asked them if that’s enough. It’s never enough, obviously.

My concern is the same one, I think, that politicians and citizens have had for generations, which is: is it sustainable, the work that we put these resident doctors under and the hours that they have to work? Under the — I don’t want to say the words, so I won’t say it; I’m learning — paradigm of, “It was okay for a different generation, and therefore it should be okay for this generation,” which is: “If you have to work around the clock, that’s just the way it goes. We did it, so you should be able to do it.”

As the minister knows, a lot of problems that end up in hospital are because of medical errors. We’ve seen the studies all across the world. Again, I don’t know what the current number is, but 20 or 25 percent of admittance to hospitals is because of some kind of error.

Is there any work that’s being done by the ministry to review this particular situation of the workload and what we’re asking for from the current set of doctors that are in residency and whether or not that’s going to have a negative impact on British Columbians and their health care?

[3:45 p.m.]

Hon. A. Dix: As the health critic will understand, this was a significant issue in the discussions that we had with resident doctors for an agreement. We’ve made progress in that regard. We now have a tripartite working group involving UBC — HEABC, on our side, and the Resident Doctors of B.C. are all signatories — that is tasked with developing a system to gather data on issues of resident scheduling, identifying systemic challenges and barriers pertaining to call workload and scheduling, and making recommendations to the parties by April 1, 2020. So there’s a process to deal with that, which was of great importance to resident doctors.

Since 2013, as the member may know, residents have been required to purchase insurance. So there was funding for that. That was a part of the agreement. We also have designated some funding for resident engagement so that we do a better job of engaging residents with the health care system in B.C., which is important.

Of course, other parts of our primary care plan involve resident doctors, much more so than before. There is, I think it’s fair to say, a difference of views. The member referred to people looking back and making sure that educational systems and residency systems were like the past. Maybe it wasn’t what should have happened in the past. So that’s the first part of the discussion.

Also, resident doctors, as I mentioned, have consistently said to us that…. They have a different view of their role, especially in primary care, once they start practising — after they stop being resident doctors and become doctors. So some of the changes we are making reflect that, because we have to ensure that the people we’re training become part of our health care system in B.C. We’ve got to do a better job of connecting not just our graduates with residencies but our residents with positions in British Columbia that are supporting health care here.

N. Letnick: Thank you to the minister. I’m very happy to hear about the work that’s being done between the resident doctors and the ministry to look at this issue and look forward to the decisions or recommendations that come out of that process. I know the minister is fair-minded and will do what’s in the best interest of British Columbians on that to make sure we can reduce any potential opportunities for medical errors.

The next question, topic area, is about physician supply. I’m talking about the interprovincial mobility and foreign immigrants. Obviously, we have physicians that live or train in British Columbia that move to other provinces and other countries. Some years, some decades, the numbers are higher than others. We also import people who trained and practised in other countries into British Columbia.

My first question would be: does the minister have any numbers to indicate whether or not this is getting bigger or smaller in these areas?

Hon. A. Dix: We have some specific numbers which I’ll share with the member before the end of today. The member will know that we have 112 physicians currently, in 44 communities, in the practice readiness assessment program. Thirty come in per year. Essentially, obviously, there are 30 rotating out of the program.

[3:50 p.m.]

We have now…. What we can say is that we’re clearly net beneficiaries in B.C., and have consistently been, in terms of people coming into the province to practise as opposed to people leaving the province to practise, by a significant margin.

The staff is committed to getting the details of that information before the end of business today.

N. Letnick: Thank you to the minister and staff for doing that work.

If I understood correctly, we have 30 international medical doctors — not grads, but medical doctors — from other countries that come to British Columbia each year to work. They’re coming from countries all over the world. Do we have any guidelines as to which countries we will not accept doctors from? And I don’t mean in the case that they’re not qualified; I mean in the case of the moral hazard of taking poor countries’ physicians, who they’ve taken the time to train, and stealing them and bringing them here. I think that’s, ethically, a very poor practice.

Do we have any guidelines that will dictate which countries we will accept potential British Columbians from and which countries we will not?

Hon. A. Dix: The short answer to the question is no. The opportunity is available to all to come who qualify, obviously, and who meet standards to come. One could look at that two ways, I suppose, in terms of moral hazard, in terms of who has opportunity to come and to take part in the practice-ready assessment program and who doesn’t. Then the reverse part of it, which the member rightly points out, is that people have been trained elsewhere, and then those countries lose the benefit of that.

The member will know that there are some countries in the world where we’ve had a significant number of doctors come to British Columbia, particularly the British Columbia interior. In the last number of years, many people will know, we’ve had many doctors over the last several decades from South Africa, for example, and other jurisdictions such as that.

The specific answer to the member’s question is no. There’s no such restriction other than all of the medical standards that we apply in these cases.

N. Letnick: I appreciate the minister’s answer. The answer does trouble me. It’s not a political thing. This goes probably since time immemorial in British Columbia that we’ve haven’t had it.

Is the minister aware of any other provinces in our Confederation that does have some kind of standard or criteria as to which countries they will or will not accept qualified medical doctors from?

Hon. A. Dix: I think the answer is no again, but I want to make this clear. I’ll explain what I mean by no, which is that we have a national system of designated, accredited medical schools which accept people to this program, and all provinces are part of that. So I think the answer is no to the question. No province has something that, maybe, the member is suggesting, which are limits on receiving doctors from particular countries for the reasons that he explained.

There are some countries that do not allow or do not participate in international accreditation in order to protect doctors in their jurisdiction. Or they would see that…. That’s not necessarily a limit on those doctors in arriving at the Canadian program, but it might be a domestic limitation on those doctors in those circumstances.

N. Letnick: I’ll switch now to a different topic, but with the minister’s indulgence, I will follow up on this conversation with the United Nations and other bodies to see if this is something that is frowned upon. I believe, in my studies over the years, it is quite an interesting moral dilemma. But I’ll take that off line and do some research.

[3:55 p.m.]

The next one has to do with violence against nurses. I assume that the minister signed a pledge to help combat violence against nurses. I’m not holding up a prop, Mr. Chair. I’m just reading from this pledge that we had, I think, all signed.

One of the items on the pledge was to ask the federal government to modify the Criminal Code of Canada to make violence against a nurse an aggravating circumstance for sentencing purposes, as it is already for transit operators. So my first question is: what has the minister done, if anything, to see this happen?

Hon. A. Dix: At my first opportunity, meeting the federal Minister of Health, it was the one issue I raised — at the first federal-provincial conference I attended with Ms. Petitpas Taylor. I believe it was in November of 2017. It was the one issue we raised. I brought the letter to her attention and asked for some action.

The federal government has not yet moved forward with action, but nonetheless, I think that there is a consensus in British Columbia. I believe that members of the opposition have also indicated their support for such legislation, which would parallel the legislation for transit drivers.

I also believe that the legislation should apply to other people in health care who provide nursing and other services. So it’s not just talking about registered nurses but all categories of nurses and care aides as well.

We’re supporters of that action, and we’re hopeful that the federal government will listen. I understand that there’s a private member’s bill in the federal House of Commons now, in support of that, put forward by Don Davies, who’s a Member of Parliament from British Columbia. That’s, again, a little bit of progress. There will be an opportunity, I’m sure, during the federal election, for British Columbians, for people active in politics and for nurses and everyone in the community who supports them to press federal politicians to go forward with this change.

N. Letnick: Thank you to the minister, and thank you to the minister and his government for those actions. Quite exemplary. This, of course, is something close to heart to all members of the House, in particular to the Leader of the Official Opposition and also to the member for Prince George–Valemount, who wanted to be sure that she got another chance to tell the minister how passionate she is about nurses. So there we go.

I’d like to congratulate the government on getting an agreement with the Nurses Union. The minister can tell us what percentage support he got for that one. I’ll let the minister put that on the record in a minute.

In the summary of the agreement, it does identify commitment to workplace safety that allows nurses to provide the highest level of professional care without fear of injury of violence. In particular, contract provisions are considered to be in addition to those found in the Workers Compensation Act. Violence prevention training will be offered to all employees on an annual basis, as well as to employees in new positions. OH-and-S supervisory training will also be offered to those in supervisory roles.

There will be six new EDMP representatives added to the system, bringing the total number of reps to 17, and a new working group will be established to make recommendations for a provincial OH-and-S framework and continue existing projects such as the implementation of the CSA national standards for psychological health and safety in the workplace.

These are all good things. But when I went to visit my mom at Peace Arch Hospital back in the fall before she passed away, I did notice that the security person, at night, was there. My question to the minister is: are there any plans to make sure that security personnel in our hospitals and other sensitive health care facilities are of the highest qualified standard and not just parking lot attendants with a uniform?

[4:00 p.m.]

Hon. A. Dix: First of all, I’ll draw this to the member’s attention and certainly share it with him. There was a series of incidents at the Forensic Psychiatric Hospital over the last number of years that were, at least to me, unacceptable. So we put in place there, in particular, an action plan working with all of the unions that work there. In that case, it’s principally the B.C. Government Employees Union because of that particular site, and the B.C. Nurses Union in others. We’ve put together an extensive plan to address issues at that site, which is a particularly challenging site in the health care system.

Secondly, I note that all of the collective agreements that we sign…. Because, well, the violence issue is a significant issue for nurses. It’s a significant issue across the health professions and amongst skilled health care workers. All of the agreements that we sign reflect a commitment to support, protect and reduce violence and the threat of violence and injury in the workplace. Those are agreements with the HSA, with the HEU, with the BCNU — the broader community agreement. What you’re seeing in the nurses’ agreement, you’re seeing elsewhere. The nurses’ agreement, by the way, passed with 54 percent.

The third point I’d make is I wasn’t…. While I think that collective bargaining is an important place to engage in this discussion, there’s a broader responsibility for the employer, in my view. I’ve asked Michael Marchbank, who the member will know. I have asked the former president of the Fraser Health Authority, who is an outstanding leader in health care, to do a report about how we address system-wide violence in addition to those steps that have been taken in collective agreements — those steps that have already been worked on, or we’re working on, through the system. I have now received that report and will be responding to that in the near future.

Finally, I’d say this, with respect to security. This is one of the issues that we, of course, have to look at, with respect to how we contract certain services in the health care system. What’s essential and what’s not? There has obviously been a significant contracting out of security services, particularly in Metro Vancouver and southern Vancouver Island, but everywhere in the last number of years. The expectation of those agreements sometimes has been to reduce costs for the health care system, which is always a legitimate goal. It has to be balanced against the effectiveness of that.

Obviously, we’re looking at those contracts, particularly in the wake of the passage of Bill 47. We’re looking at those contracts in the public system to see what would be appropriate. What might be appropriate — I think what the answer to that is — is some combination of a return for some classes of security, in order to ensure — or to have a higher qualification of people, in addition to the work done by people in the health care system.

I think that people who do security in health care work very hard, and they’re very committed and are qualified people. But it may be that there are things we could do to increase their training and their consistency, because sometimes, when you contract out, depending on what the circumstances are of the contract, you have fewer long-term employees. That’s in terms of the system — in terms of knowing the work and knowing the institution. Knowing the job is a challenge sometimes.

Those are some of the things that we’re working on in terms of violence, which is a significant issue to me. I signed the pledge. The member signed the pledge. We’re working to fulfil the pledge that really, I believe, almost every member of the Legislature signed, including the Leader of the Opposition, just recently.

N. Letnick: Thank you to the minister. I appreciate his concern for the safety of all health care workers. I’m sure of that.

I’m agnostic, quite frankly, as to whether or not these are done through contracts or done by in-house employees — whatever can give us the level of security that’s required for all these staff at the minimum cost to taxpayers, so we can invest that money in drugs and other things that the minister has to deal with on a day-to-day basis. I’m quite sure, as we’ll see later on this afternoon, that it’s not easy making those hard decisions as to: “Do I fund this and not fund something else?”

I’ll just repeat it. Whether it’s through contract or in-house, we’re looking for the best bang for the buck that will give our hardworking employees the safety they require. On that, whether it’s contracted or in-house employees, what is the minimum standard of qualifications that is required for our security personnel?

[4:05 p.m.]

Hon. A. Dix: The process, in general, is that there’s assessment at each site of the security needs of that particular site. Then what’s happened in the last number of years, really in the last couple of decades, is that the health authority goes to the market and asks vendors to provide those services on site. There are, in some health authorities and in some positions, people who do that work directly for the health authority, but for the most part, that work is currently contracted out.

So there is work with vendors who do this work in the area and who, obviously, have a background and competency in the area. They, in effect, bid for those contracts. The health authorities do the assessments of the needs. They go out to the market, they get proposals, and then they respond to those proposals and select the vendor. That’s really been the pattern over the last number of years.

N. Letnick: Again, another area of discussion we can go down for a couple of hours, but I need to move on.

The nursing policy secretariat prepared a report by David Byres, who I see is in the room. Thank you to David and all the staff that are here, obviously. In particular, I just want to refer to some of the questions regarding licensed practical nurses, or LPNs, which is item 2(e) on the agenda. I’m going to go to page 9 of the report. On page 9, it talks about scope of practice. What the LPNs are looking for is a consistent, larger scope of practice so that they can do things that they were trained to do in school and practise outside of school.

In particular, the recommendations from the Byres report….

[The bells were rung.]

The Chair: Thank you, Members. Just wait until the bells are complete, and then we’ll continue.

Just to be clear for everyone, this is a division that’s been called in Committee of the Whole, Business Corporations Amendment Act. If you have to vote, please proceed. But otherwise, we can continue.

N. Letnick: So in case that was missed from the bells, I just want to do that again, because it sounded so good. In the Byres report, recommendation No. 15, “The nursing policy secretariat will examine certified practice as a concept for consideration with RPNs and LPNs,” and 16: “The nursing policy secretariat would conduct a fulsome needs assessment to articulate the roles required across nursing,” and it lists all the different nursing categories, “to enable an optimized practice within primary, community, acute and residential settings, with careful use of clinical examples and clinical decision-making tools to support desired practice.”

I’ll just stop there for a second and ask the minister what he thinks of those recommendations from — I know it’s the Byres report — January 24, 2018.

[4:10 p.m.]

Hon. A. Dix: Well, we were saying back here that it’s always good to get your advice on what you think of the recommendations from the Byres report from Byres himself. That’s how it worked out, which I know the member will appreciate.

The scope-of-practice needs assessment was completed, in fact, yesterday. I think the first meeting is tomorrow, of the working group on these issues, around scope of practice for LPNs. There is both a provincial nursing network and a practice assessment working group, and that’s part of the work done by both of these groups. It includes the BCNU and, of course, the colleges.

One of the significant benefits in all areas of nursing is the coming together into one college of nursing professionals, which has allowed us, rather than have competing colleges with different views, to have people working together in the same direction. I think that reflects a lot of the work done by Mr. Byres and everyone else in the area.

N. Letnick: Thank you to the minister, and thank you to the author of the Byres report. There are other parts of the report which I found quite interesting and supportive of the ask by the LPNs — under the surgical model, for example, under primary care.

One thing I’ll just touch on, if I may. When this is all done, when the work of the committee is done, are we going to see a single standard for all health authorities regarding scope of practice — so that an LPN in Fraser Health is an LPN in Interior Health and an LPN in Northern Health? So if there still is some issue between different professionals and questions as to whether or not an LPN can do what an LPN is able to do, it’ll be consistent across the province. If you’re an LPN in surgery in Vancouver Coastal and you can do these things, there shouldn’t be any reason why you could not do the same things in Northern Health.

Hon. A. Dix: Yes. That’s exactly what the college is working towards.

N. Letnick: Excellent. Thank you to the minister. We’ll move on to 2(f), which is chiropractor scope of practice. Let me just read an introductory paragraph from a chiropractor. This is not representative of all the chiropractors. This is just one chiropractor, but I think it hits the message home. This is from Dr. Dale Forsythe. He says, as part of his letter to you, cc’d to me:

“I would like to bring your attention to the issue of MSP providing coverage for necessary X-rays requested by their chiropractor. Currently if I wish to have X-rays taken on one of my patients at a lab, I have to first write out a requisition slip for the patient to take to their medical doctor, who in turn rewrites the requisition for the patient to take to the lab or hospital diagnostic imaging lab. The lab then charges the patient $50 to make a copy onto a disk for the patient to bring to me. The medical doctor’s visit fee is then added to the MSP costs for that extra service — both a waste of time and money for the patient.”

Could the minister comment on whether or not we’re going to get to the day when chiropractors can requisition these lab tests?

[4:15 p.m.]

Hon. A. Dix: I thank the member, and Dr. Forsythe, for the question. I don’t know if the member was there. I believe I recall that the Leader of the Opposition was there. Lots of members from both sides were there when the association presented to us about a month ago, largely on this question. It’s not just chiropractors who are looking for an expansion of their scope of practice here. It’s also true of other regulated professions in B.C. For example, I’ve seen, recently, similar requests from practitioners of traditional Chinese medicine and other groups that are regulated professions in the province.

In making a decision about that kind of question, the member has laid out a particular scenario, but there are a number of practitioners who can make such requisitions. Any decision to expand the numbers — even, in this case, significantly expand the numbers — would have to meet a financial analysis, as far as the ministry is concerned. In the circumstance described by the member, there are obvious challenges there and, potentially, costs to the health care system that could be saved.

On the other hand, you do have to make a decision with all professions. We’re soon going to have, I think, a similar discussion around pharmacists and others who want to expand their billing opportunity, shall we say, or their billing space but not necessarily just their billing space. In some cases, people are seeking the right to requisition, which they don’t have now, but not under MSP. They’re just seeking that right.

These are challenging questions. They’ve got to meet a financial analysis. We look at them one by one. We know that this is something that chiropractors have advocated for and that other professions are advocating for: to expand their ability to have access to tests, paid for by MSP or not paid for by MSP. We have to assess those both financially and in terms of reasonableness. It’s not that we’re saying, “No, that won’t happen,” but the case has to be made, and the decision would have to be made based on a broad analysis of value to the system.

N. Letnick: Thank you to the minister for that. One of those interesting things, as we’ve worked together for almost two years now, is there’s a tell the minister has when he’s about to sit down, when he’s finished his question. That’s why I’m able to pop up so quickly; I know he’s done. That’s because you twist your body just slightly this way. Don’t play poker.

This leads me to an obvious question. If it’s a business case analysis that needs to be done, is there any credential or clinical reason why the chiropractors would not be able to get what they want in this case?

Hon. A. Dix: I think the short answer is both. You have to meet the test clinically. One would expect that. This would be true of any profession looking for an increase in scope of practice — what would happen post such a test, and whether it’s an appropriate path to take or not. We have a professional regulation oversight branch in the ministry that does work in that area, as do the colleges themselves.

With respect to the issue of MSP billing, that’s obviously an issue for the commission to assess. Those decisions are made by the commission on a fairly regular basis, although in this case, as in others, the tests would be both financial and clinical.

N. Letnick: Thank you to the minister. Is the minister saying that chiropractors today are judged capable, of ordering these tests in the province, by whatever approving authorities would decide that? I’m not too sure who would actually decide if, clinically, they have these things.

[4:20 p.m.]

Obviously, I — as a politician, grandfather, father, businessman, teacher — am not qualified to order a test of this kind, an X-ray, a CT or anything else, for that matter. Chiropractors are a professional group. I was just wondering if they are deemed to be qualified in British Columbia to do so, should the ministry or should the MSP group decide that there is a business case that they would want to prove? In other words, before you go and do all the work to calculate the numbers, it’d be nice to know whether or not they’re actually qualified to do the tests.

Hon. A. Dix: First of all, I’ll just take a step back. Chiropractors, as the member knows — because it’s something that we’re working on a bit together — are overseen by the College of Chiropractors of B.C. They’re authorized now to requisition — including X-rays, CTs and MRIs — as part of the regulated scope of practice in their practice standards. In that respect, that’s a partial answer to the question.

Chiropractors can also interpret X-rays and provide a report further to their interpretation. Where chiropractors requisition CTs and MRIs, they must have the results interpreted by a radiologist, who provides a written report documenting the interpretation. Radiologists can, of course, interpret the full range of diagnostic imaging.

Then there’s a separate question of MSP and so on. We haven’t looked at that question. I know the chiropractors have brought this idea forward, as have other health professions, because this issue of being able to requisition and scope of practice is of interest to all of them.

Again, there would be an ongoing clinical assessment, although the question for chiropractors is different than for some other professions in that their issue is that they would like it to be paid for by MSP. And at present, as the member will know, diagnostic imaging requisitioned by a physician, dentist, podiatrist, nurse practitioner and certain certified registered nurses will have their services paid for through MSP. Obviously, the chiropractors would want that.

It’s a double process. It’s assessing the value of that and what would be paid for. Because of course, when you’re talking about the interpretation of diagnostic imaging, you’re also talking about paying for other services as well. The decision about who can and can’t initiate for payments and services is, obviously, a decision for the commission, and there’s a role for the ministry as well.

N. Letnick: Thank you to the minister for clarifying that for me. I appreciate that.

Are there any other provinces in our Confederation that do allow chiropractors to order these tests directly, covered by their provincial taxpayers?

Hon. A. Dix: I don’t know the answer to whether there are any. But the note I have — which I’d be happy to share as well — says rightly that typically, chiropractors are regulated in all provinces and territories in Canada, with the exception of the Northwest Territories and Nunavut. Authorizing the application of and interpreting X-rays, with the exception of CTs, is a core component of the chiropractic scope of practice, where regulated in Canada. Typically, publicly funded health care reimbursement programs in Canada only insure a limited number of chiropractic treatments — this is certainly the case in British Columbia, as the member is aware — and do not include reimbursement for diagnostic imaging.

Whether there are exceptions to that, I don’t know. Although I would…. Well, I don’t know the answer to that. But typically, no.

N. Letnick: Thank you to the minister. I’m sure that if any of the chiropractors watch or read this, they will let us know in due course.

The idea of doing a business case analysis. Would that include the potential…? Well, there’s a stupid question. Would that include the potential of a pilot project? Of course it could. Let me ask it a different way.

As part of doing a business case analysis for these different groups that want to have expanded scope, and paid for by taxpayers, would the ministry typically say that they would like to see a pilot done first before making it available to everybody else?

[4:25 p.m.]

For example, if chiropractors can make their case and the numbers show that, actually, it’s potentially a benefit to patients, of course, and to the treasury that they do move forward with being able to order these tests, would that then automatically go through the whole province? Or could they say, “Well, let’s try it in Northern Health,” for example, or try it in one section on Vancouver Island, that kind of thing, versus making it available to the whole province?

Hon. A. Dix: I think that, in the sense that anything is possible, I suppose the answer to that question is yes. I mean, I think it would be challenging to determine a pilot project here. Because what would one do if, say, the profession couldn’t order X-rays now? The issue here is principally billing and the value of that service — to the positive and to the negative — to the net incremental cost of what they’re trying to do.

Trying to figure out a way to do a pilot project would be somewhat difficult — to realize the savings. What are we trying to achieve here? Is it a savings to the system? Is it an improved service? How to measure that within a pilot project would be difficult.

There’s nothing stopping that from happening, I don’t think, but it would be challenging. Often, when you add into the system a particular service, it usually involves people being trained — being trained in the delivery of, I don’t know, injections, for example. In pharmacy, at one point, the scope of practice changed, and then you had to meet certain tests to be able to perform that. If you were a pharmacist, you met the tests on top of that.

In this case, this is, in many respects, a billing question. So you’re opening up the system to more billing and who could bill to the system. Measuring the benefit of that would be, I think, challenging, but that doesn’t mean it couldn’t be proposed or suggested.

N. Letnick: Thank you to the minister. The reason I ask about the pilot is that Dr. Forsythe’s letter — the chiropractor, Dr. Forsythe — basically says that he could save the system money by being able to requisition directly rather than having to go through a whole bunch of different avenues. I’m thinking that if that’s the case, if he can actually save the system money, make the system more responsive and, therefore, provide better health care to patients, it’s a win-win-win.

I’d find it probably a challenging thing for any government to just say, “We’re going to open this up to the whole jurisdiction of the province,” without making sure that we’ve had an opportunity to do a test somewhere. So I’ll just leave that there.

It’s a good segue, actually, into the next item, which is urgent care centres, primary care networks and medical homes. Why I say it’s a segue is that the chiropractors that came and spoke to us, in part of the conversation, wanted to know if they would be included in the primary care network system so that they can also be part of this great direction our province is moving towards.

[4:30 p.m.]

Hon. A. Dix: Potentially, you could envision expanding primary care networks to include lots of health professions. Right now, the early focus in terms of the organization has been on, obviously, the health authorities themselves and First Nations, as well as communities, doctors — divisions of family practice, principally — local communities, nurse practitioners, registered nurses. We have, obviously, a significant role being played by clinical pharmacists in that system, and others. The one that we just announced in the Okanagan-Similkameen envisions dietitians, and so on.

We can envision building out from there, and depending on the communities…. In Fraser northwest, which was the first one announced, there is a role for a local non-profit agency to support clinical counselling, for example — mental health and addiction workers and professionals, and so on. So there’s the possibility for that. Certainly, it doesn’t exclude other health professions, from chiropractors to massage therapists. This is kind of where we’re starting, and we would expand out from there.

N. Letnick: Thank you to the minister. I’m quite sure that everyone in this room and within the health care field is familiar with medical homes and primary care networks, now, and urgent care centres. The minister has done a very good job of promoting them, one by one by one…

Interjection.

N. Letnick: …around the province. Never find some good news you can’t repeat in different parts of the province. It’s good politics. I congratulate the minister for being a good politician.

Having said that, and this might be debatable…. I think most of this came out of the work by the person to the minister’s right, in his research paper starting in 2015, and then the conversation continued and actually started to get implemented, and then the minister really put it on steroids and continued to grow it. Again, the minister should be congratulated for continuing with those initiatives.

Having said that, I did receive some correspondence that troubled me, by a physician — actually, two physicians who are being impacted by the cost of doing business.

[The bells were rung.]

The Chair: Thank you, Member.

Division has been called in the main chambers.

This committee is now in recess.

The committee recessed from 4:33 p.m. to 4:44 p.m.

[R. Kahlon in the chair.]

The Chair: I recognize the member for Kelowna–Lake Country.

N. Letnick: Thank you, Chair, and welcome back to the big job. Keeping me in line is a big job. The minister is easy.

This gets a little more prickly than the questions up to now. I think that’s an appropriate word.

These are comments coming from two community GPs in a letter that I got. I actually had a phone conversation with them as well. It’s different issues, so I’m going to split them up. I’ll just read the issues one at a time.

[4:45 p.m.]

The comment is about the PCN process so far.

“The current offerings at the PCN table — restricted funding options for new family practitioners to set up practices, health authorities, managed RNs and allied health, high attachment expectations for RNs, no new funding models for existing family practitioners — do nothing to repair the damaged and failing business model for the vast majority of primary care physicians in community practice in B.C.

“Many of us involved in the PCN planning process are increasingly frustrated by it. We are being asked, by the ministry, to provide solutions. We spend time and money to provide practical solutions, being the experts in primary care for decades, and then we are ignored repeatedly. This is breeding disengagement.”

I understand that — what percentage? — 98 percent of the doctors approved of the new contract, but obviously, there are some doctors that are still not happy. I asked them for their input. Quite frankly, this goes past the minister’s time in office. This is before the minister and before that minister and probably before that government. This has been going on for a long time.

The minister is the minister now, and this is the place. Together, I always firmly believe…. I told this to the minister last year. Whatever I can do to support the government in making sure we provide the best services possible to British Columbians, I will do. This feedback is important to hear, even if it might be difficult to hear.

Before I go on to the next comment, does the minister have any comment on this?

Hon. A. Dix: Believe me. Occasionally I receive emails that are critical. That’s as it goes.

What we’re trying to do with the primary care network transformation is one of the most significant transformations of primary care that has been done since the system was, really, first established. That presents challenges. There are challenges of existing interests. It’s not that you can just start reforming the system. You have to continue to provide services while making improvements.

Philosophically, we made the decision to do exactly what we’ve done, which is to work community by community to establish the first primary care networks in areas and in communities where the doctors were most favourable and most interested in doing that work so we could have some successes and show the kinds of changes we wanted to bring to team-based care.

The reason we announced first in Fraser northwest was because they went through the process first. They came forward with proposals first, and they signed the agreement first, which will add, in that community, 65 new health care professionals in the next three years. That is an extraordinary achievement. And 95 percent of the health care clinics in that area, which includes Coquitlam and Port Coquitlam and Port Moody and New Westminster, agreed to it.

As the member says, doctors are a community with diverse opinions and views. That’s an extraordinary level of commitment. We had an agreement, of course, with the Doctors of B.C., which addressed a lot of these issues, that had 98 percent approval. We had an agreement with the resident doctors that had 86 percent approval. What that shows is the kind of working relationship we’ve developed on these very questions. That doesn’t mean that every one or every question can be solved at once.

[4:50 p.m.]

One of the interesting changes in this round of discussions with the Doctors of B.C. on the master agreement…. Historically, a lot of our focus has been: how do we address the need for doctors in rural B.C. and in remote communities? How do we, in some cases, incent doctors to go to those communities and be sustained in those communities? How do we ensure that that happens?

Previous governments have done lots of different things — Liberal and NDP and Social Credit — to ensure that that happens. I think what was unusual in this round of negotiations, and it may be reflected in the letters here, are the struggles that individuals have, that the community of doctors is having in many urban areas, with increased costs and increased challenges.

It’s an increased acuity of a population in some areas — for example, north of where we’re living here, in Sidney and Saanich — with very large and significant percentages of seniors, with doctors with practices disproportionately with people over 80 — the challenges that they face, the challenges that people face in terms of lease arrangements in the business side of health care.

It’s why we made the decision to add resources here and add 200 doctors and to do that largely on direct contracts, on salary or on alternate payment arrangements — 200 nurse practitioners and 50 pharmacists. At that time, some existing doctors said: “Well, how do we get in on this? How does that happen?” It’s a very challenging situation.

There was a situation a number of years ago where the health system made a mistake, in terms of how they valued hospitalists in Fraser Health, that caused a lot of disruption in Fraser Health at the time. It was a mistake. People didn’t make it intentionally, but it had consequences. You always have to be aware of the possible other effects and other consequences of decisions that are made.

That’s certainly the case in this instance. We did say, at the time…. We’re working with the doctors of B.C. on this every step of the way, which is the representative organization — and local divisions of family practice are the representative organizations — to see that these issues are worked through.

We’ve done an assessment now of how we might transfer, from the fee-for-service system, existing doctors as well. That analysis is being done now. It’s a complicated question, but one that we’re going to be working now, with the doctors of B.C., with the GPSC and other organizations, to come to some conclusions on. So I think we’re making progress.

I would say — and the member is in politics as well; he’ll understand this — that I would like us to be making progress quicker. That’s always the imperative, of course — to bring out reform more quickly. We’ve determined to go this route, which is to engage in primary campaign with nurses, with doctors and with communities, even if it takes less time and even if it’s more challenging to meet the goals that are set out in my service plan and so on. I think we’re going to create resilient networks of health care providers and teams and communities all over B.C. that are going to be able to last a long time — that it’s not an issue of checking off things on my service plan, although that’s important and my responsibility.

We’ve gone in this route of deep negotiations, in some cases, with divisions of family practice. We’ve gone on for months to address these questions, because we want people on board. We don’t want a situation where we’re adding resources but then losing resources. That’s the reason we’ve gone on this approach.

I understand that not everyone will be happy about the conclusions. Ultimately, you come to agreements. In Fraser northwest, 95 percent are part of it, but 5 percent are not. I don’t know if that’s just inevitably the case when you go forward with things, but I think that’s a remarkable level of support.

Again, in other communities such as Sooke — other communities where we’re adding resources; we’re working with local family doctors — I think it’s been successful as well. The reaction of doctors, everywhere I go, to it…. We went to Prince George, and I believe the response in Prince George was that 100 percent of the local division of family practice supported our primary care network and supported our urgent primary care centre.

The final thing is it’s reflected in the kinds of institutions you’re doing, which reflect local conditions. We do have an urgent primary care centre in Vancouver that is essentially run by Seymour Medical Clinic — public paid. But Seymour Medical Clinic has been a provider of primary care there for a long time. On Vancouver Island, on the West Shore, it’s directly health authority–owned and –operated.

What we’re trying to do is work this through with our partners so that we have resilient local institutions that address the very significant attachment and health issues in primary care in the province.

N. Letnick: I’ve said this before: we could probably spend two days just on this question alone, but we can’t.

[4:55 p.m.]

Let me skip to another issue that these two doctors bring up, the issue of nurse practitioners. I wouldn’t call nurse practitioners an issue. Nurse practitioners as primary care providers, they feel, can be part of the solution. The U.S. has been studying cost effectiveness of nurse practitioners in their health care systems for ten years, and the data is about to be published. Now, this letter goes back to May 6. I’m not too sure if the data has been published since May 6.

They suspect that:

“As many of their colleagues, however, the nurse practitioners would prove to be far more expensive than general practitioners. They rate highly with patients, because they are paid by salary and do not have to be” — I’m reading; these are not my words — “efficient to cover their costs. Therefore, they have more time with patients.

“More family physicians dream of being paid for their time, not for the number of visits. Many NPs generate much higher health care system costs due to overinvestigation and overreferral due to their lack of experience and different training than physicians. The fee-for-service system gets a lot of people seen quickly but disincents quality care.

“Alberta family physicians can bill an additional fee when a visit exceeds 15 minutes, in 15-minute increments thereafter. We desperately need this in B.C. Our patients are becoming increasingly complex and deserve careful assessment and treatment. This takes more time.

“Our primary care models, evaluated worldwide, show that a blended payment model is best.”

That’s where the ministry is going. We’ve been talking about that for ten years — since I’ve been elected. Ten years ago this Sunday, by the way, was my anniversary. Thank you, because I know the minister will say happy anniversary. He’s keen on these kinds of things.

“Pure salary slows everything down, which is generally neither affordable nor in the population’s best interests.” That’s why these two physicians are advocating for blended payment.

They obviously have their opinion on nurse practitioners. I wasn’t part of the government at the time, but our government brought in nurse practitioners. The minister has expanded places for nurse practitioners.

Obviously, we have a case to be made to the public that nurse practitioners are cost-effective. These would not be the first physicians that I’ve heard question the cost-effectiveness of nurse practitioners versus family docs, to be honest. I’m not trying to take a swipe at nurse practitioners. That’s just what I’ve heard in my travels. If the minister could provide some comment that would take care of these doctors’ concerns, I would love to hear what they are.

Hon. A. Dix: Listen. It’s always an interesting debate amongst doctors. That’s why — I don’t know if I’ve mentioned this before — I find it so extraordinary that 98 percent of the doctors approved our new master agreement with doctors. I don’t know if I’ve mentioned that before, but if I did, I just did again.

On the issue of nurse practitioners, I think there’s significant peer-reviewed evidence in this and many other jurisdictions about their value and quality. In the previous government, George Abbott was the Minister of Health when the nurse practitioners were recognized and brought into the health care system in B.C. They recognized that in 2006.

My predecessor, Terry Lake, established, I think, the first-ever nurse practitioner–led clinic in the north of Kamloops in 2016, I’m thinking — maybe early 2017. I can tell the hon. member that the response in there, both from a financial perspective but also from a patient perspective, has been enthusiastic. Nurse practitioners do this work across the country, and there has, of course, been a resistance to their role. There always is resistance to change. Here in British Columbia, as I’ve mentioned before, we’re pretty much last in the country in the utilization of nurse practitioners. That’s going to change.

[5:00 p.m.]

When I meet doctors…. Overwhelming, one of the things that changed from the time I was a Health critic, which ended in 2011, and the time that I became Health Minister was the transformation amongst many, many doctors, especially young doctors, of how they value nurse practitioners and how people working together in teams, doctors and nurse practitioners, can do even more for the health care system. Nurse practitioners themselves have enormous not just potential but proven results — over, now, at least a couple of decades in multiple jurisdictions — of the value of their work.

I understand some people don’t agree with that and don’t think that’s the right approach, but we believe it is. I think the evidence suggests that we’re going in the right direction. In that question, I think there’s been a line of direction. I’m very proud. The member talked about this earlier — about it being connected to work done in the past, work done by deputy minister Steve Brown and others. The decision 13 years ago to bring in nurse practitioners has put us in the position today to dramatically expand their role in primary care to the betterment of patients everywhere in B.C.

We recognize that. What we have to do now is ensure that patients get that care, that this works for them and this works successfully. I think it has been up until now. All the evidence shows it has been up until now. I think we have to continue on that path.

Not everyone’s always going to agree with that. We just had a discussion of…. You can have a debate with people in the medical community about chiropractors, about many other things as well. You’ll get different views as well. But nurse practitioners have shown and that path has shown itself to be the right path. I think the evidence — really, the bipartisan evidence — shows that to be the right path.

N. Letnick: Thank you to the minister for that.

If the minister, through the ministry, has any current evidence on the cost-effectiveness of nurse practitioners that he’s willing to share with me, that would be greatly appreciated. Since I said, as I travel the province and discuss things with people and listen to them, this comes up, it would be nice to pull out: “Here’s the evidence. Now what do you think?” Right? That would be great.

There are more issues that are brought up, but in the interest of getting to other issues, I’m just going to bring up one more.

Urgent primary care centres — the letter says they’re an extremely expensive model. “Communities and their physicians could have continued to provide this type of service for a fraction of the cost but we were shut out of the process, and our suggestions on how to build up and support existing providers of urgent care were ignored.”

The key part in this is the next line, for me: “How will they be evaluated? Will they be evaluated? By whom?” And when will the public be able — and I’m adding this last piece — to see the evaluation of the urgent primary care centres?

Hon. A. Dix: Thank you very much, hon. Chair. And as I say happy birthday to you, I say happy anniversary to the member. Ten years. It’s hard to believe. It seems like only yesterday that we first met here in the Legislature. So congratulations to the member. Actually, for those of us who are members of the Legislature, it’s an incredibly moving thing to do.

I think we’ve had an extremely good start with urgent primary care centres. Again, we have delivered in communities that needed improved access to care. We started in Kamloops, not just with the urgent primary care centre but the family practice learning centre there, which will build and support the next generation of family practice doctors in Kamloops. The data to May 1 shows 31,258 patient visits already. It’s the implementation in communities in every health authority of team-based care.

[5:05 p.m.]

Urgent primary care centres are not stand-alone. Their intent is to connect to patient care networks, to PCNs. They’re an important part of that discussion. But a far bigger budget part of that proposal will be primary care networks, it should be said. Urgent primacy care centres will play a role in all of those.

I believe, if you look across…. I’ll just break down the numbers so far. So 9,603 on the West Shore. Many of these have built out, so they started small and then they built up to full capacity — almost 10,000 patients on the West Shore here in Victoria. So 7,500 patient visits in Surrey. About 4,000 in Vancouver. The two combined in Kamloops, which have been around the longest, around 9,000.

I think they’re going to be valuable. I just want to say that the goals, the intent, everywhere is the same — team-based care with a focus on attaching to permanent primary care. In Vancouver, the Seymour urgent primary care clinic now has new family practice doctors with the Seymour medical clinic on top so that, as people who are unattached come to the urgent primary care centre, they can be attached. So that’s a very significant improvement.

It’s about attachment. It’s about addressing and reducing some pressures on emergency rooms. It’s about extra-hours and after-hours health care for people across the province. I think more and more communities have been talking to me and wanting urgent primary care centres to come to their communities. You know that one of the next sites will be in the member’s area. I think there, like everywhere else, while the principles are the same, the structures can be different.

We have, in some cases, health authority–owned and operated urgent primary care centres connecting to the system. In other cases, such as Burnaby, such as Vancouver, we have what are essentially existing networks of family doctors who are operating the urgent primary centre for the health authority.

We’re being, I think, entrepreneurial and flexible in our approach. It’s not one-size-fits-all. We’re meeting the needs of communities. We’re working with local divisions of family practice, and I think they’ve been a success. Absolutely they’re going to be evaluated on a regular basis.

I believe one of the challenges for health care and for every part of public services is that we have a difficult time learning and, occasionally, a difficult time admitting we were wrong in one thing and making changes in direction. We have to be prepared to look at what we’re doing, because this is new in many communities, and make an assessment about its value against other alternatives and its value for the costs that are put forward.

That’s absolutely an assessment that will take place, absolutely will be made public. I receive, obviously — and I’m very interested — regular reports. We’re hoping, as we develop out urgent primary care centres — I expect a couple more to be announced within the next few weeks, and then another group to be announced in each health authority in the fall — that they’re going to continue to prove their worth.

But some of them will be more successful than others, so we’ll have to assess that as time passes. I think you continue to learn. I think they’ve proven their worth, and I think the results already show that thousands and thousands and thousands of people are getting care that wouldn’t have got care if we hadn’t proceeded with this initiative.

N. Letnick: Thank you to the minister. The minister is right. We have to be entrepreneurial in these things. We have to celebrate our successes and repeat the successes and also be prepared to identify when things go off the rails or are not as successful as they should be.

Sometimes government, political parties, tend to accentuate the positives and try to be very quiet on the negatives. So I made that offer to the minister a year ago — working together to make things better. He took me up on the offer by inviting the opposition critics to join him on a particular file. I think that’s the right approach, especially when some things can be politically difficult, as the health colleges issue is.

On this one, it would be, I think, advantageous that when there is some kind of internal report as to the effectiveness of the different urgent primary care centres, the minister take the opportunity to share the good news with the bad news so that we can all learn from this new direction for our province, which, as the minister states, started a few years ago, but is really ramping up now.

I will not ask the minister when Kelowna is going to get theirs. I know he said soon, and I’m sure that’s when it’ll be.

[5:10 p.m.]

Just one last question directly on urgent primary care centres and then one as a segue, ministerial order questions.

To my knowledge, the Westshore Urgent Primary Care Centre is the only care centre that has been designated a health facility under section 49 of the Hospital District Act. Why is this? Are there plans to designate other urgent primary care centres the same?

Hon. A. Dix: I’ll get a specific answer about other institutions. It involved the range of services being provided on the West Shore. In some other cases, it won’t be necessary. For example, the urgent primary care centre in Quesnel is on the site of the hospital, so I wouldn’t expect that it would be required there — to designate an existing hospital site in that way. We’ll have information in the next little while. I recall that it involved the specific services, so the answer is that it may happen with other urgent primary care centres, but there were specific services being offered there.

N. Letnick: Thank you to the minister. The next item is attachment of patients, which is a good segue from urgent primary care centres.

By some accounts, there are approximately 700,000 to 800,000 people in British Columbia that are unattached. Some of them don’t want to be attached. They have no desire, and that’s fair enough. It’s personal choice. But there are a number of people who would like to be attached that have been having trouble finding family practice practitioners or practice teams to get attached with.

This is partly a political question. My concern, from the political side, is with the good work that we were doing on primary care centres, with networks, with medical homes — with all these things that we are working on to provide more access to health care. The ministry, or whoever calculates attachment, will say that a patient who, before, was unattached — now that they are connected to or have visited an urgent primary care centre, for example, two or three times — now is attached, all of a sudden, when they’re really not attached. They might be attached, in a way, to the primary care centre, but they’re not attached to a full-service family physician or a medical home.

I want to forestall that by asking the minister now: who decides how many people are attached or unattached in the province of B.C.? What is the definition, specifically, of that attachment? So that we are comparing apples to apples as we go forward over the next, I don’t know, maybe two and a half years, and we get to announce how great the ministry has done in attaching so many patients.

Hon. A. Dix: First of all, just to say that the Westshore was designated because of RHD funding. That’s why it was designated — on the urgent primary care centre.

On the issue of attachment. First of all, I think we have to reflect on — I think the member will know this — why attachment is important. We know, when there is attachment between a person and a nurse practitioner or family practice doctor or a group of family practice doctors, that they get better care.

That connection is important. Every single person in this room and every single person outside this room can tell of an example of that relationship being helpful in navigating the health care system, but also, that knowledge is very important. I’ve said many times — I have type 1 diabetes, so I walk into a primary care doctor with that problem and whatever problem I’m going in with on that day. Having that depth of experience with a family practice doctor, which, by the way, I don’t have right now…

Interjection.

Hon. A. Dix: …is very important. It’s very important.

That’s the way it goes. We all know how we can reduce that by one.

The Ministry of Health is reliant on two measures, historically — something called the Ministry of Health’s attachment algorithm, which is where we use the significant data that’s provided to the Ministry of Health through the Medical Services Plan, and also the Canadian community health survey data, which is a Statistics Canada measure, so it’s not our measure. It’s their measure.

[5:15 p.m.]

Just to give you a sense, the algorithm is derived from MSP data on patterns of primary care use. A patient is categorized as “attached” if the majority of a minimum of five primary care visits in up to the last ten years were made to the same primary care provider — this allows us to be not valuing attachment qualitatively but through data — or a patient does not have five visits but has three visits to the same practice.

A patient is categorized as “unattached” if the patient has the minimum of five visits in up to ten years but does not have a majority with a primary care provider.

A patient is categorized as “unknown” if the patient does not have the minimum five visits in up to ten years and does not have three visits to the same practice.

That is how the algorithm works, essentially. It’s using MSP data to define the attachment of a patient to a primary care provider. Equally, the Canadian community health survey, the Statistics Canada survey, goes another route, which is to survey the population broadly and provide similar information. We use both of those. What we want to do…. Something that’s, obviously, very important to me to know is how we’re doing. Sometimes it’s complicated.

I’ve said this, and the member has heard me say this before about GP for Me. There’s a political discussion about GP for Me. There was a political debate, and there was a promise that everyone would be attached to a family practice doctor. That didn’t happen. They abandoned the program, and the numbers of people went up. It doesn’t mean that everything about the program was bad. Indeed, significant efforts were made under GP for Me. Part of the problem, in the case of that program, was, let’s say, the overselling of what the program could do.

It is a challenge to measure it. The member will know this. In his own community of Kelowna and here in the capital regional district and Vancouver, there are doctors who are retiring. Sometimes what happens as a result of that is several thousand people may be sent out to find new attachments to family practice doctors. Those are challenges. We not only have to meet the challenge of the unattached but to reattach people whose family practice doctor or nurse practitioner…. Or they themselves have moved.

These are real challenges in the system. But that’s how we try and measure, apples to apples, what we’re doing. We have a federal government measure, which is important. It’s not just us. Then we have a much more technical and, in a way, much more detailed measure to do it so that we can tell ourselves how we’re doing from period to period.

N. Letnick: Thank you to the minister for that. I’m glad there are two sets of metrics that are working on this. I’m sure the minister would agree…. All members of the House would like all unattached patients who wish to be attached to be attached. That’s the goal. We’re here to serve. I don’t think there’s a better thing to do than make sure everyone has an attachment.

Over the last few years, the GP for Me program…. As the minister knows, I was not involved with the GP for Me program. But from what I understand, the money invested in the GP for Me program was able to find attachments for 178,000 unattached patients. His ministry, through the program and through the help of divisions of family practice and other allied professionals, was able to find 178,000 homes for unattached patients, which were attached.

The minister has already mentioned…. That’s not including the people who lost their doctors because of retirements. According to the statistics that I’ve received, that was another 130,000 patients because of loss of their primary care provider through retirement or relocating docs.

That’s over 300,000 people that were assisted by the GP for Me program. I understand that they didn’t achieve the goal of everybody getting attached. As the minister said, maybe the goal was very high. I always believe in shooting high. Better that way and not making the goal than shooting low and then exceeding the goal, but you didn’t really go very far because your first goal was too low. It’s always that compromise.

I’ll just put that aside so that we can move on to other questions.

Hon. A. Dix: We could debate GP for Me for ten minutes.

[5:20 p.m.]

N. Letnick: We could debate $1.5 billion in GPSC to improve access, and all that.

Here’s the question again, to the minister. If I’m an unattached person and I go to an urgent care centre and I see different doctors at the urgent care centre…. In one year, let’s say I get six visits, which is more than the minimum five. Am I now considered attached by the ministry? Or am I not considered attached because I didn’t go see one particular doctor? For another example, if I go to a walk-in clinic and I see six different doctors on six different occasions, am I considered attached to that walk-in clinic?

Hon. A. Dix: These are always interesting discussions about attachment. One learns things all the time.

It is possible now, if you go for the first time to see a doctor, to use a fee code to attach yourself — for example, if I was to seek out a new person who was going to become my family practice doctor, to do that through the fee code. In general, what they’re talking about with respect to urgent primary care system centres doesn’t happen today. The goal of the urgent primary care system is attached to the network of doctors and to the doctors accepting patients in the community, and there’s a real effort to do that.

The value, though, of attachment is what you call longitudinal care, which is to ensure that people have a consistent level of care. In the previous group of doctors that I was involved with, I had a primary doctor, but there were occasions when that doctor was not there, where you’d go and see another doctor. I’d still be attached to that doctor and to that clinic. But in general, the effort is to attach to a primary care provider or to a nurse practitioner.

There will be some UPCCs that have their own attachment, but their principle goal is to both treat and engage with the patient and deal with their needs and then ensure that they’re attached and they have continuing care. If someone is coming back six or seven times — it’s certainly possible, and that will happen — that’s not the attachment we’re necessarily looking for. The attachment we’re looking for is to have the patient treated and then connected to someone who will know them the next time they come and the time after that.

N. Letnick: Thank you to the minister. That answer gives me comfort that we’ll be comparing apples to apples for the foreseeable future.

That’s the challenge, right? A lot of young people might not want to get a primary care nurse practitioner or a physician. They might want to just go to the urgent care centre. We would consider them as unattached, because they go in, they get their treatment, and they’re gone. They don’t have that comprehensive care the minister is talking about that we all want for everybody.

[5:25 p.m.]

That’s fair enough, but I wouldn’t want them to be a statistic that favours the government, when they come out with their messaging saying, “Look how good we are; we’ve attached 200,000 or 300,000 people now,” kind of thing. Unless, of course, we actually do attach 200,000, 300,000 or 400,000. Then kudos would be to the minister and his team for doing that.

I look at the time, and I look at how much we have to discuss. So I’m going to go into the short snappers, at least for me, and hopefully the minister will oblige me. I’m also going to skip some questions.

Non-surgical wait-lists for northern communities, particularly long-term care — could the minister please describe where that’s at right now?

And, if I may, to the staff: I’ll be skipping 2(k). So if you have someone coming for 2(k), they can turn around.

Hon. A. Dix: The member will tell me if he’d like more than this, but we have data, which is one of the standard data items in the ministry, about provincial wait time in Northern Health. This is the wait time for residential care, by health authority. This is the percentage of home and community care clients admitted to a residential care facility within 30 days of approval for services.

The member will know that Northern Health operates, in terms of residential care, at close to or at full capacity most of the time and that other areas of home and community care have a good record of service, including for adult day programs and others. With respect to that data, though, for Northern Health in 2013-14, the number was 27 percent within the 30 days. Just to put that in context, the provincial average at that time was 67 percent. So that’s, shall we say, not good.

It continues to trail the provincial average. Currently, in the 2017-18 year — the most recent year I have here — it’s 50 percent, which is better, obviously, than before but still significantly below the provincial average. If you’re looking at Northern Health on that basis of care, of wait-time care — percentage admitted to a residential care facility within 30 days of approval for those services — that number is 50 percent currently, which is, as I say, an improvement but still not as good as it should be.

N. Letnick: Thank you to the minister. As I said, we’ll skip 2(k). If I get time tomorrow, I’ll ask that.

Moving on to surgical wait times, I’ll lump (a) and (b) together to make it easier, I believe. The public is always interested to know how wait times are doing in the province. That’s one key barometer as to how well the ministry is doing. Is there a place that the public can get access to wait times, for their particular procedures and overall, for different health authorities, through the Internet?

Hon. A. Dix: This is the information for patients, and we can have the discussion about the surgical and diagnostic strategy, which I’m sure the member will be asking about.

To improve the communications with patients on surgical wait-lists, we’ve implemented what’s called a patient notification and point-of-contact initiative. This is not just helpful for patients; it’s helpful for us. It’s absolutely critical, when you’re booking people for surgery, that they be prepared for that surgery and, obviously, that they attend that surgery but that they also be prepared in the many steps that sometimes have to be taken to prepare for surgery.

[5:30 p.m.]

The notifications inform patients that they’ve been placed on a surgical wait-list and provide them with an estimation, in weeks, of how long they should expect to wait for their scheduled surgery. They also provide phone numbers where they call in case they have questions, and the phone line is the point of contact.

We did an early evaluation of how we’re doing in that initiative, because it was an important part of what we’re doing, with input from approximately 90 stakeholders, 70 of whom were patients. The evaluation found that the initiative has significant value for patients. They appreciated being informed initially and really liked being able to call the health authority with questions. To have a point of contact for something as important as surgery is a very important thing.

The second thing we’ve done is to do a refresh of the surgery wait-times website, which is available. This displays information with respect to surgical wait times, and new tools have been adopted that provide more information to patients waiting for surgery and, obviously, their families.

Finally, we’ll obviously be reporting publicly. We’ve already reported…. The member may have heard that we’ve reported publicly on how we’re doing with respect to MRIs. I would expect, in the coming days and weeks, we’ll report on how we’re doing with respect to surgeries, just in general. We’ve met the overall surgical target for the year, which is an enormous achievement.

It’s easy for a minister to say we’re going do 250,000 surgeries, or approximately that, but that requires enormous effort by a whole bunch of people in the health care system. I’d like to pay tribute to them here. I think these are really remarkable achievements. We obviously gave priority this year to reducing wait times for hip and knees, which was a quantitative question. There were long waits for hip and knees. And dental surgery — I think I’ve talked about that to the member before — which is a qualitative measure. We’ll be reporting out on those programs and those numbers, etc., in the coming days and weeks.

N. Letnick: Thank you for that answer, Minister.

We’ll now move to 3(c), DBS surgery. All I wanted to say was: thank you to the minister for expanding the amount of DBS surgery that will be available in British Columbia. That’s it. Given the time, I don’t want to canvass that too much.

Bariatric surgery. I’ve seen a lot of correspondence from different people, and different MLAs with constituents, who are really concerned. I don’t think the minister needs to hear the issue. Since he is a type 1 diabetic, I think he’s really familiar with some of the things involved here.

When can we see an increase in bariatric surgery in British Columbia?

[5:35 p.m.]

[D. Routley in the chair.]

Hon. A. Dix: I just want to acknowledge the Chair is the only Chair that we’ve had so far today who isn’t out celebrating a birthday today. So that’s pretty good. We were two for two.

The Chair: It was my birthday last week.

Hon. A. Dix: Last week? Happy birthday, belated. I don’t know if you know this, Chair, but we’re celebrating the tenth anniversary of the election of the member for Kelowna–Lake Country and a lot of other members of the Legislature.

We did, in 2018-19, 411 surgeries. That’s up from 363 in 2014-15. We’ve established a floor for those surgeries because there’s always pressure on different kinds of surgeries in the system. You will know…. There’s a Dr. Sharadh Sampath, who’s been advocating for more such surgeries, arguing that, really, we are both performing fewer such surgeries in other jurisdictions, and we’re not coming close to meeting what he would perceive to be the need.

What’s definitely in place is the protection of that ongoing funding, both for the surgery and the significant preconditioning required for the surgery. I believe, in the last year, the surgical target was 415 in 2018-19, and that target was met: 200 here on Vancouver Island and 215, I believe, at Richmond Hospital, where Dr. Sampath does his work. He’s a very effective advocate.

In addition, there’s been preconditioning last year for…. The target last year was 406. The target has been increased this year so far, as we assess our surgical plans, to 438.

So the member is right. There’s a considerable campaign going on in this regard, and there are very effective arguments being made that we need to advance these programs. There are also changes in the types of surgeries taking place, which may be of significant value to patients in future.

It’s one of the areas of surgery we’re clearly looking at, as compared to other jurisdictions in Canada, as compared to the people waiting for surgery that we may proceed with. We haven’t made that decision yet, but it’s something that we’re looking at. Obviously, Dr. Sampath and his patients are strong advocates for that.

N. Letnick: Thank you to the minister. The minister is right. In addition to all the patients, Dr. Sampath is quite the strong advocate. He actually took a strip off the minister in public in the Province newspaper, describing wait times by the ministry to be a little rosy compared to what is actually happening. I’m sure the minister is aware of the Province article, since his name was all over it. I’m sure the minister doesn’t want me to reread the letter here. I don’t have that time. I’ll just let the minister sit with that.

Interjection.

N. Letnick: January 7, 2019. Let the minister look it up and have a read. Okay.

One more question on this. This is more of a clinical question, which is totally out of my area of expertise. In researching this issue, I found a lot of alternatives to surgery — the pills people swallow to fill up their stomach, other medical devices that can be inserted through scopes that move up and down with digestion, all these kinds of things. Again, I know the minister is not a clinician, but are these realistic options for the long wait-list to get bariatric surgery?

Hon. A. Dix: I think it’s fair to say that bariatric surgery is, itself, a complex surgery, a challenging surgery. I am aware of the advocacy of Dr. Sampath. He’s not arguing…. I don’t take his words as critical of me. He’s advocating for his patients, as he should.

[5:40 p.m.]

Part of the discussion we had around…. A lot of people on the issue…. It’s one of the challenges we face on the issue of deep brain stimulation, which the member referred to. In that case, what we were spending a lot of time working out was actually building the actual capacity. It’s one thing to make announcements; it’s another thing to make sure you can respond and deliver on that. That took some time. In the interim period in that case, there was some criticism as well, which is just the way it goes.

There are other devices. Just to give the member a sense of that, several of them have been approved by the FDA, which offers some alternative, some opportunity and, I think, some potential, to do some of the same things that bariatric surgery does but in a less interventionist way. There’s some potential for that, which I think is very positive for the future.

In our case, the health technology assessment committee makes those decisions. It helps us make those evidence-informed recommendations to executives as to whether a technology should be publicly provided. While they haven’t yet recommended any alternatives to bariatric surgery, some of the things going on, both elsewhere in Canada and in North America and the world, show promise.

N. Letnick: Organ donation. Are we at a point where the government is seriously considering making organ donation automatic — in other words, assumed consent?

Hon. A. Dix: First of all, I think the member would agree with this: there’s nothing more moving than the relationship between, sometimes, donor families, if the donor is deceased, and the recipient of an organ donation. Certainly, the work done by B.C. Transplant in B.C. is extraordinary work.

I’m really proud that 1.35 million British Columbians have registered their wishes to be an organ donor. I’d like to acknowledge the excellent work of my colleague the minister responsible for ICBC, who has made this, at a delivery level, a significant effort on the part of the Insurance Corporation. You see that every day, if you’re renewing licences and so on — a real effort to increase both the number of organ donations and to engage with the public.

We’re the leader in Canada for both deceased and living organ donation. In 2018, our donor rate per million population was the highest in the country for the second straight year, and 502 lives were saved in British Columbia in 2018 through organ donations and, I think it’s fair to say, the work of B.C. Transplant and all of the clinicians involved in it. Also, the work of hospital staff, frequently, is extraordinary in facilitating this and then in making it happen.

We have tried to, I think, for a number of years, follow Spain, which is the world leader in deceased donations. They attribute their success primarily to the use of transplant coordinators — as we do in B.C. — donation physicians and a robust education program. The evidence suggests that the major reasons for differences in donor rates between countries are varying practices in the identification of potential donors, rather than different legislation governing organ donation and presumed consent.

The member will know that Nova Scotia is looking to proceed in this direction. Of course, we’ll take a look at what they’re doing. There’s also some movement in the United Kingdom. But I’m very impressed with how we’re doing now — not how the health system is doing or the Health Minister is doing, but how British Columbians are doing. As the rates of people registered to be organ donors continue to increase and as we improve our health care system and our transplant coordination system, following Spain, we can do the job we need to do, which is to get the organs to people who need them in as timely a manner as possible.

[5:45 p.m.]

I am interested in the debate. Of course, when I became Minister of Health, it was one of the questions I asked — that whole issue of consent. But every time, in my view, you can get someone to actually step up and agree and register is a success. We’re doing well, and I’d like to continue on that path for a while. I don’t reject out of hand the idea of a different approach to this, of having a presumption of consent, but I love the idea that millions of people in B.C. are giving consent — and the generosity that that shows.

N. Letnick: Thank you to the minister. I had quite a number of questions on MRIs, which would probably take us till ten o’clock tonight. I’m going to skip a whole bunch of opportunity for the minister to tell us how great the program is going. He’s already done that; he doesn’t have to repeat it.

I do have three short, I hope, answerability questions. One of them is: one of my colleagues has a constituent who had a scheduled MRI in 2018 that was cancelled by a technician who told her that he could not do the MRI due to her size, and he rescheduled the MRI for November 19. The constituent said that the technician had no empathy. Immediately after she went out of the MRI room, a larger person than her — who was characterized by her as looking like a football player — went into the room. There did not appear to be any apparent problem or issue with him getting the MRI. He was likely close to 350 pounds in weight.

She obviously was discouraged by this. She is only 190 pounds in weight. She is wondering why she would have been told that she was cancelled — to use the word — due to her size, and how rescheduling an MRI for her would make any difference. My question is: does the minister or staff have any idea why someone of 190 pounds would be considered too large for an MRI, versus someone of 350 pounds? Or is there something else involved here, like the shoulder width, the stomach width or something like that? In the interests of time, if there isn’t an easy answer, I’ll just pass this file to the minister and his staff to look into.

Hon. A. Dix: What I would suggest are two possible approaches. Obviously, there’s a complaints process through the patient care quality review board. Certainly, if there’s a complaint or a concern, that’s something that was set up in 2008 — the whole patient quality process. I was opposition Health critic at the time, as I recall. There’s an opportunity for people who have complaints about the system to see those and have those complaints reviewed independently. If the member would like the ministry to review that — I would imagine he would go through the consent process — we’d be happy to take a look at the case.

N. Letnick: Could the minister please tell the members how much it cost to buy the two private MRI clinics?

Hon. A. Dix: I think I’ll have to check on this question. One of the issues around a commercial acquisition like this is, potentially, of course — I’m not suggesting we’re going to do this — being prepared to do this again. There may be some commercial confidentiality questions. If there are not, I’ll be happy to get the information for the hon. member.

N. Letnick: When the minister is doing that, would he mind also looking at the budget to run them, if it’s any different than running them inside a hospital, like traditional MRIs? The minister hasn’t been musing in the media about possibly doing this again. It would be nice to know if this model is actually more cost-effective than just buying machines and putting them into public facilities that were built for that purpose.

[5:50 p.m.]

My last question related to this issue is, and it’s appropriate to see the Attorney General here: is the legal cost in the Cambie case coming out of the Health budget, or is it coming out of somebody else’s budget?

Hon. A. Dix: It’s actually coming out of the Ministry of Health’s budget, but of course, that is being led by the outstanding legal team at the Ministry of Attorney General. It comes out of our budget. It’s the Ministry of Health, effectively, that’s being sued or was sued or had the case brought against us, in part. There were others that were defendants but in January of 2009.

N. Letnick: I concur with the minister. This has being going on for some time, over successive governments now. Is it a public record as to how much this is costing, on an annual basis, the ministry for the legal fees to defend in the Cambie case?

Hon. A. Dix: We aren’t providing information about the costs. How the process works is we provide money to the Attorney General’s ministry that they draw down on to pay their legal costs — for example, the cost of expert witnesses, travel and issues such as that and, obviously, the cost of legal services, and so on. That’s how the payment process happens.

We haven’t made public the legal cost of defending against this lawsuit. Sometimes there’s confusion about this lawsuit in some places, that we’re somehow engaged with Dr. Day. The lawsuit is against the province of British Columbia, and we’re defending that lawsuit.

I don’t know whether, at the end of the lawsuit, that information will be provided, but it’s not being provided at present.

The Chair: Member — the father of the best teacher in British Columbia.

N. Letnick: Thank you. Her name is Melanie Letnick, by the way — just to get that on the record. I’ll make sure she sees that from you, Mr. Chair.

I’m not familiar with the FOI process. I’ve never had to do an FOI. That might be of comfort to the minister. Is this something that I could FOI? Would that be something that, under FOI, is available to the public — to find out how much it’s costing British Columbians to defend in the Cambie case?

Hon. A. Dix: I don’t want to make this distinction and sound like I’m being in any way glib. The member, of course, can do an FOI request to government. I think, in this case, that would be adjudicated at that point. This is, obviously, an ongoing proceeding that has been carried on for a long time. So the member could submit such an FOI. It actually wouldn’t take the member very long.

[5:55 p.m.]

Whether he would be successful in that is not really mine to say. My guess is, from my own experience of…. I’ve attempted to do that in the case of a number of Crown corporations that I was the critic for at some point, and I found myself singularly unsuccessful. I’m not giving you advice as a minister of the Crown in that case. I’m giving you advice as a fellow MLA.

In the meantime, I wanted to put on the record that we have MSP beneficiaries by five-year age groups. This is just a chart, which I’ll share with the member. The area that he would be most interested in, though, is that in general, for 2014 and below, we’re seeing an increase in beneficiaries, an expected increase in beneficiaries over the next five years. In the gap between 15 and 24, a decrease. Then between 25 and 44, an increase. It goes from 10.3 percent in the 25 to 29 category to 7.9 percent in the 40 to 44. Then a decrease of beneficiaries in their 50s and then very significant increases — 10 percent between 65 and 69, 22.4 percent between 70 and 74, 20.5 percent between 70 and 79.

Here’s the kicker: 30 percent, for 90 and above, in terms of MSP beneficiaries. So 90 and above, 43,398 in 2017-18, expected to be 56,000 by 2021-22. Those are obviously significant increases. That’s an annual percentage change of 6 percent a year in that category of 90 and above.

I’ll share this with you.

N. Letnick: Thank you to the minister. This reinforces the whole argument we were talking about before about fair compensation.

Pain management. Again, this is another one of those that received a lot of concern from constituents across the province — about the change.

We discussed this in estimates last year, with Dr. Etheridge saying that the qualifications for issuing pain management services outside of hospitals are being reviewed and are potentially going to change, whereby up to 80 percent of people will no longer be able to practise this service outside of public hospitals and other public institutions.

What I understand, however, from the visit from the College of Physicians and Surgeons last week, is that they are reviewing this. They’ve asked for more input, and they are potentially going to slow-walk this, moving forward, in light of all the public input that they’ve received. Is that the minister’s understanding as well?

[6:00 p.m.]

Hon. A. Dix: The member will know, because we had a discussion about this on Tuesday, May 15 of last year, 2018. At that time, we’d received information. I think the day before, or something, a review had in fact been announced. Because of considerable concerns…. A number of doctors put forward concerns. A concern that the member expressed at that time was that that new regulation would, for all intents and purposes, disqualify 80 percent of people, including him, in that case. That was the concern that was being expressed at the time.

A year later some progress has been made. First of all, it should be said that health authorities were directed in their mandate letters this year to improve chronic pain management services, in collaboration with PHSA. For people living with chronic pain, it’s obviously a central question.

The B.C. medical quality initiative, which is part of PHSA, is completing the last phases of what are called privileging dictionaries, related to procedural pain management, anaesthesia, diagnostic imaging and other areas. These have been developed with specialists practising in the areas, the B.C. medical quality initiative draft public facility privileging dictionaries, allowing grandfathering of physicians currently performing PPM, providing they meet current experience and quality requirements.

This is the part more interesting to the member. The B.C. College of Physicians and Surgeons is, of course, establishing…. He and I and other MLAs met with them last week for credentials and facility requirements for PPM in private settings. They’re currently posted for feedback until May 27, 2019. Then obviously the college will be dealing with issues around that feedback. The college believes — and I think they expressed this — that the majority of physicians currently offering PPM in private facilities will be able to continue to do so under the new facility accreditation standards.

So that’s the process going on. It’s an ongoing process with the college. Obviously, they did a lot of work in the interim years since we’ve last spoken on this question, which is a question of real import both to practitioners and to patients. The member can tell, in discussing these issues with Dr. Etheridge that they take them seriously and have responded to the concerns and are trying to find the right balance.

N. Letnick: Thank you to the minister. Based on his answer, and also based on the conversations I’ve had with the college, I guess I would say to those people that are suffering in pain out there that it’s different today than it was a year ago. I have much more hope in this than I did a year ago that it will not see 80 percent of physicians lose their ability to take care of this very, very serious chronic problem that people have.

I also heard some good news that there might be an announcement to be made in a particular riding that I’m familiar with, in the near future, concerning this. But I’ll let the minister make that announcement once he’s told what it is by his staff. I might actually, based on his body language, have heard something before he did. I’ll take it.

We’ll move now to binder 2 of two binders. We only have less than an hour left. We’re just having way too much fun. For those that are keeping score — and I don’t mean basketball — we are going to skip 6(b). We’re going to skip 6(c), 9(b), 9(d) and 9(e). Hopefully, the rest will be short snappers.

Evaluating performance of regional health authorities. The minister is responsible for the health care of all the province. However, a lot of the health care is delivered by health authorities, which the minister gets to appoint members to and trusts that the health authorities will act efficiently and effectively on behalf of all British Columbians. But how does he know that? How does he know, how does the government know and how do the people of B.C. know whether one particular health authority is actually working better than another health authority, or a third or a fourth?

[6:05 p.m.]

I happened to just be looking at different reports, trying to figure that out, and I came across this beautiful report, the Patient Care Quality Review Board report, that listed the number of complaints that different health authorities had received over the last four quarters.

When I was reading through it, I was kind of surprised to see a general increase in complaints over the last four quarters by 24 percent, which is not a good indicator of anything other than, maybe, more people reporting that they’re not happy. But I would suspect that these are all legitimate complaints or inquires that have been lodged.

Then I looked by health authority, and I saw 24 percent in general, but at Fraser Health, it was 18 percent increase; Interior Health, a 28 percent increase; Island Health had a 21 percent increase; Northern Health had a 45 percent increase; PHSA had a 59 percent increase; and Vancouver Coastal, the star of the gang, only had a 10 percent increase in complaints.

Now, I have no idea if this means that one particular health authority is doing better than another. It’s just one measure of how a health authority is doing — one important measure, obviously. But there must be other measures that the minister uses, and I was wondering if those other measures are public.

Is there a benchmarking tool, something, where the public can see that their health authority is actually doing really well and should be congratulated for doing really well in the different categories of whatever it is — wait times or complaints or whatever the ministry has come up with as the “hold them accountable, feet to the fire” kind of criteria? Is that available to the minister? And is that available to the public?

Hopefully it’s available to the minister. If it’s not available to the public, can it be available to the public so that the public can see how their health authorities are doing? Those that are doing well can be congratulated and those that are not can face the consequences of their skills and abilities.

Hon. A. Dix: First of all, I’m sorry, I’m going back to a question for a little while, just to provide some information to the member. In 2016, the most recent year for which interjurisdictional migration data is available, B.C. gained a net of 282 physicians from other provinces and 42 internationally. So that’s kind of interesting information.

With respect to the monitoring and valuation, as the member will know, that’s something that I’m interesting in. Those are questions that I ask all the time. We see this in specific initiatives.

How are we doing on primary care networks? How are we doing on urgent primary care centres? How are we doing on surgical procedures and wait times? Will the circumstances…? Sometimes circumstances will affect how a particular site does. If you have issues with anaesthesiologists on a particular site and, in that period, there are some cancellations of surgeries as a result of that, that’s not a systems problem. That’s a personal problem that you have to address over time. These things happen.

With respect to the patient quality review boards, that’s also affected by something that I’m very proud that we’re doing, which is giving more significant publicity to the right to complain. I think that’s important. It’s important we hear those complaints and that we assess them not just in quantity but in quality. What were the conclusions that were developed around those complaints? That’s important. That’s why the review boards play such an important role.

Again, in that case, that was an initiative of the previous government that I supported at the time. We’ve gone through both the quality council and the review board’s ten years of activity. I think one of the things that we want to do and what’s valuable about those complaint processes is they give people a place to go, with independent adjudication, a place to have their concerns felt. I think they’re very important.

How they measure and how measuring the quantity of complaints or, conceivably, the outcome of complaints one could do, how that is measured. I would say it’s one measure among many. If we were to publicize the complaint process even more, we might get more complaints, but that wouldn’t necessarily reflect on the performance of the system.

That said, we do a number of things to set expectations, and we’re proposing to do some additional things because — I think we had this discussion a little while ago — I share the member’s desire to have ways to measure — and measure and assessment.

The first is, obviously, mandate letters. We also provide each health authority with an annual bilateral agreement, which specifically details expectations and requirements for priority setting. The former, the mandate letter, is a public document. The latter is not.

[6:10 p.m.]

We obviously have health authorities developing annual service plans, as well, that identify how the health authorities intend to carry out the direction of the mandate letter. Internally, we have a leadership council, which is led by the deputy minister, Steve Brown.

Essentially, once a month, the health authority CEOs meet with the deputy minister, often for a full day, sometimes a day and a half. We go through — area by area, issue by issue — the issues facing the health care system. We’re all part of the same team. I think there’s a tendency when you create separate authorities — especially very large authorities like Fraser Health, which is, objectively, maybe the largest employer other than the provincial government in the whole province — they are focused on their own concerns. So we have a leadership council.

In addition, they produce an integrated report, prepared quarterly, that monitors a set of indicators. Health authorities themselves prepare annual service plan reports. Obviously, we’re periodically getting wait-times reports. I’m pushing to get more of those because those are of concern to me. I meet bimonthly with the chairs of the boards of the different health authorities.

I think, objectively, we have outstanding chairs of our health authority boards, who I meet with regularly. We discuss expectations and have an exchange. The member will know Dr. Penny Ballem, who is the new chair of Vancouver Coastal Health, a former deputy minister of health. Leah Hollins is the chair here on Vancouver Island, a former deputy minister of health and Order of Canada winner. Tim Manning, who the member will know from Kelowna, is just an outstanding board chair and chairs my committee of chairs. He is just excellent.

I won’t go through everybody, but you know the rest. We just have outstanding chairs in every authority, and I’m very proud of the work they do. Some of them date from prior to my becoming Minister of Health. Others are obviously new appointees, but all of them are excellent.

In the future…. We obviously work with the Canadian Institute for Health Information, so we get a series of indicators there. There are plans — this is being led by the deputy minister — to improve monitoring and evaluation. We’ve developed what’s called the health sector performance management framework to drive continuous improvement and innovation. We’re working on its implementation. That will include — in addition to these measures — trends in population, health needs and health services received, and performance and population patient and system outcomes across health authorities.

I think that there is an expectation, on the part of the public, to have accountability. What we’re doing today is part of that accountability, of course, as well. But we believe that we can do more to demonstrate the extraordinary efficiency and success, overall, of the public health care system in B.C.

N. Letnick: Thank you to the minister for that. He did mention that health authorities had service plans and annual service plans reports. It would be advantageous if we could actually see those. Would the minister comment if he can make those public?

The minister also mentioned wait-time reports. I was given a wait-time report for 2018-2019 — P-11. The report is interesting in that it talks about the number of surgeries as of March 7 that British Columbians are waiting for. Hips and knees were 10,467. Dental — 1,994. Other surgeries — 73,883. And that’s compared to the fiscal year 2016-2017. So two years ago, the number of people waiting was 80,702. Over the last two years, basically, has been an increase in people waiting for surgeries across all health authorities by 5,642.

Now, that’s one piece of data. For me, the more important piece of data, the telling data, was the distribution of these waits across different health authorities. You look at different health authorities as to whether or not they met their targets. For those quarters in B.C., the target for all health authorities was 16,712. We came up shy 773 in hips and knees.

[6:15 p.m.]

IHA came up shy. They were only able to do 3,414, and the target was 3,814. Fraser Health — their target was 3,811, and they only did 3,434. VCHA — their target was 4,098, and they achieved 3,955. VIHA, however, gets the green star. They achieved 4,021 when their target was 3,839. Northern Health came in very close. Their target was 1,154, and they were able to achieve 1,115.

Now, that’s just hips and knees. Then it goes into how much time people had to wait. We have 14.9 percent that were able to meet — if I’m reading this right — the 50th percentile, which means 50 percent of the surgeries. So 14.9 weeks for half on the wait-list who were able to get their procedure, and if I’m reading this right, again, for all of B.C. for hips and knees, the wait is actually getting longer for the 50th percentile. But B.C. is doing well on the 90th percentile, achieving 41.3.

That’s fine, again, on hips and knees for all of B.C., but then you can look at the individual health authorities, and you see that the one that stands out the most is the biggest one, which is Fraser Health, where it’s taking longer for hips and knees to occur. They are not meeting their targets, and their times to get to hips and knees are not improving. Actually, they’re getting worse on the 50th percentile as well as the 90th percentile. So they kind of stick out.

This is just one report — one report that I would imagine is not available in the public domain — that clearly shows that in the case of surgical wait times, the province is not meeting its targets, and that clearly shows that in the case of wait times, Fraser Health is not doing as well as the other health authorities. I think the people who live in the area of Fraser Health have the right to know that their health authority, according to this report, needs to up its game.

I’m not asking the minister to really look at and comment about every single stat in this report. I’m just asking if there’s any way that we can see, in the future, that the health authorities are given their marching orders — as the minister said, their service plans that are produced — and then the annual results of those service plans are made public so that the public has the ability to know whether or not Fraser Health is doing any better than it did the year before or the year before that, and the public can help improve the delivery of health care services that clearly, from a wait-list monitoring report that I received, shows that there are some challenges in some of the health authorities and, overall, in the case of hips and knees, in the province.

Hon. A. Dix: Well, I’ll be reporting in full on this question, and I will be delighted to.

The province set a target of a dramatic increase. People will remember that in ’16-17, there were 14,300 hip and knee procedures in British Columbia at that time. This year you’re going to see a massive one-year increase in that. We actually set a higher internal target than the public-part target we set for that and for surgeries, and I’m very pleased with the results that emerged from that.

I’ve already told the member, and we’ll be reporting on this in detail, about the surgeries to do. We met and exceeded our surgical targets for the year. The reason some health authorities have higher wait-lists than other health authorities is generally because that’s what we’ve inherited over time. In Fraser Health, the surgical capacity is less and the population growth has been the most. They’ve faced the most challenges over time, and everyone understands that.

In terms of meeting the targets for surgery, our surgeons have done an outstanding job this year. We’ll be reporting on these things in detail to the public, who, as the member says, have every right to know. We said what our targets would be. We set them out in a public press conference a year ago — what the target for overall surgeries would be. We laid out a number there. We’ve exceeded that number, so I’m going to look forward to that equally. In the case of diagnostic procedures, we’ve have that discussion. We’ve had that report already, and the results have been excellent.

[6:20 p.m.]

I’m satisfied with the performance, which is on hips and knees and on dental. It dramatically exceeds any reasonable expectation. I think from the last full year of Liberal government to the first full year of NDP government, that’s a 28 percent increase, which is pretty good. Could we have done better than that? Well, we could. There are limits to that, and there are challenges to that.

That achievement is not my achievement. That’s the achievement by doctors and nurses and health care workers and patients themselves who prepared for those surgeries, patients who have rehabilitated themselves. A big part of that is success in Fraser Health. I think they’re doing an excellent job on hips and knees. We’re moving and changing the procedures and have moved and changed the procedures. We’re moving in these areas to centralize wait-lists that will improve public responses.

I think there are dramatically fewer people now waiting on hips and knees wait-lists — by more than 1,000 — than there were when I became Minister of Health. One could say it should be 2,000, that it should be 4,000. But there are fewer people waiting, and they’re waiting for less time. We will be reporting on that soon.

N. Letnick: Thank you to the minister for that response. Again, I used the hips and knees and the wait times and targets not being met as just an example. The key question was: the service plans for health authorities and the annual service plan reports — are they public, and if they’re not public, could the minister consider, please, making them public so that the public can see what is going on in the different health authorities?

Hon. A. Dix: Yes, they are.

N. Letnick: Thank you to the minister. I love the “yes, they are” answer. That was perfect.

Hon. A. Dix: We got it down. Can I check one off there?

N. Letnick: Yes, now we’re moving on to No. 7, health information technology.

Hon. A. Dix: Well, that’s three hours.

N. Letnick: That’s three days in Toronto, actually, next week.

Hon. A. Dix: That’s right. Are you going to report out?

N. Letnick: I will absolutely report out. I’m happy to do so, maybe in a two-minute statement in the fall session.

Welcome, to the health IT experts behind you. This won’t take too long.

PrescribeIT and PharmaNet — there is some concern by some companies that the government is seriously considering and going to move towards a system whereby PrescribeIT or PharmaNet — I’m not sure how PharmaNet would do it, but the Minister can enlighten me — will become the only method by which physicians and other prescribing professionals could send prescriptions to pharmacies in the province of B.C., thereby interfering, I guess would be one way of putting it, with the relationship between doctors who choose to use other methods to send their prescriptions electronically to pharmacies.

This is, I believe, being done in some of the other provinces, being considered as also exclusive. I understand how PrescribeIT came about, so I don’t need an explanation on that. I might, please, given the time we have…. I know; you have ten pages of that.

Hon. A. Dix: It’s such a good explanation.

N. Letnick: It is. It is a great explanation. My only concern at this point is: are we moving in a direction that would see PrescribeIT having an exclusive corner on the market, so that would exclude people from sending their prescriptions directly to their pharmacy of choice?

[6:25 p.m.]

Hon. A. Dix: No.

N. Letnick: The gold star goes to the minister. He knows how much I appreciate that. Thank you.

Personal health records. I don’t know if the minister’s familiar with this particular issue. I’m in IHA. Therefore, I have my health portal, which tells me what my results are if I go to get labs from IHA facilities. I go to the private lab, and it’s not on my personal health record. I then end up in an accident. I’m brought into the hospital. They have what IH has, but maybe I’m in the hospital, let’s say, in VIHA. Do they have what IH has?

You know where I’m going with this, which is: when are going to get to the day…? Obviously, in the last two years of the minister’s leadership, I don’t expect that to be today, but it’s a progressive thing. We’ve been working towards getting there.

When are we going to get to the point where every British Columbian has a single source of all their medical records that they own, that they can see from all providers and that they can then distribute to whomever they wish to distribute to, so that if they want to deal with Babylon Health and tell the guy on the other end of their smartphone that they have access to all their records…? Then when that meeting is over and done, they end up in the hospital, and they have access to all the same.

Obviously, that’s the way we want to go. We have countries around the world that are way ahead of us on this. I know the minister is probably going to say: “We’re doing catch-up as fast as we can, given the last 16 years.” He’s shaking his head no, so I appreciate that.

Hon. A. Dix: Only ten.

N. Letnick: Only ten.

When are we going to get there — maybe in two or three years? It would be nice.

Hon. A. Dix: One day, I’ll be able to give my 30-minute speech on the history of this question, because I have a lot of interest in it. Of course, as the member will know, it has a fairly colourful history, both within the Ministry of Health and within the country.

I think we have a system of EMR, electronic medical records, in general, that has been disastrously managed by not just the previous government but just about every other provincial government and the federal government. It’s a system where Canada Health Infoway used, as its defining metric, getting money out the door rather than results. The original bidding was disastrous, and obviously, it had consequences as well for individuals.

All of that said, again, I think, it’s a constant learning thing for governments. I don’t know — and I don’t quite understand; and I’m glad the member’s going to the conference — why, on so many areas of procurement, we do fairly well, and on areas of IT procurement, as a country and as jurisdictions, we don’t do very well. My general view is that the tendency has been to want to give big contracts and make big announcements. Then we have to start to prove things can work. That’s the way our staff is going through this process.

We’re actively working on a provincial patient gateway to provide patients with a secure, single on-line point of access to health information, regardless of where it’s held. Through the gateway, patients will have secure access to on-line health tools, using their B.C. Services Card. Certainly, the advent of the services card has been helpful in this regard.

Patients and their health care providers will be able to communicate securely, such that patient privacy is protected. Patients will be able to see their lab test results, medication history, diagnostic imaging reports and immunization information — the latter is very important to me right now.

[6:30 p.m.]

Connections will be made to external systems, such as physician EMRs, using provincial technical and health information standards that will improve patients’ and providers’ access to health services and information.

As the member will know, if you look at the past EMR vendor statistics in B.C., there are essentially eight vendors with at least 2 percent of the market, six vendors with at least 8 percent of the market. That’s the nature of the EMR side of the market, but we feel we can do better. I think we’re going to proceed on the basis that I’ve described. Take steps. Show they work before we give anybody massive contracts in future.

N. Letnick: Thank you to the minister. If I’m understanding correctly, we’re going to move towards a system where we have interoperability so that we don’t have a one-size-fits-all for everybody, with a big system, that we set together the architecture how people will communicate to this, but they can use their EMR or somebody else’s platform. As long as they have the right interoperability capabilities, then that’ll be good.

I understand that. People are shaking their heads. So probably in the next two or three years, from what I understand, is roughly what it’s going to take to get there, based on my conversations before Doug Kingsford started to work directly with the ministry, when he was a PhD adviser for somebody in the room.

Okay, that’s great. I’ll just leave that there and move on to hospital pay parking.

Jon Buss, amongst others, has been a strong advocate to see hospital pay parking stop. The minister has said, and I quote from an article: “One action that we have taken is that pay parking is not being expanded to new sites. We are systematically reviewing issues around parking across the system.” My question is very simple, to the minister. How much revenue is coming in for pay parking? What are our costs for pay parking? In other words, what’s the net difference? And what are his plans?

Hon. A. Dix: It’s interesting. Obviously, the direction of the previous government was to dramatically increase revenues from pay parking. It went from $19.2 million in 2005-06 to $44.2 million in ’17-18, which is a significant increase — 130 percent in that period. In FHA, you saw the same thing, in Fraser Health: $6.7 million in 2005, $15.3 million in 2017-18.

If you look at the nets and the costs of pay parking, the estimated costs are about $13.5 million, so you sort of take that off the $40 million, and that’s the net, which is around $26 million, $27 million in net revenue. In some cases, in some hospitals, the net revenue actually goes directly to the foundation, but that’s the situation in general, with respect to pay parking — that this sort of pay-for-play for parking was dramatically increased as a means, in part, of funding public health care. It wasn’t done for any other reason, but it was also an increased tax on people.

I think the member will know this, as Health critic. There’s no other issue, I think, that provides…. I said no other issue, but it’s one of the issues that provides the most passion from people, the most frustration. Partly, that’s the case because we want people to go to public hospitals to support their family members, to be there, so when they feel like they’re being ripped off, they feel like they’re being overcharged…. They feel like they’ve paid for the hospital, and they’re there doing something that we are encouraging and wanting them to do. In some cases, they don’t have a choice to do it. They go when they’re going into an emergency room, for example. This is a subject of enormous frustration for people.

[6:35 p.m.]

Mr. Buss has been talking about that publicly, but it’s a subject that I get asked about just about everywhere I go, with respect to hospital pay parking.

What can we do about that? Well, we’ve asked the PHSA to undertake a review. Current contracts, the main contracts for pay parking, end March 31, 2020. The need for that review now is an important one. Some people have already implemented some changes. In Fraser Health, they’re looking at having the payment happen at the point of exit, because that’s a moment of frustration.

The final thing I would say is, in the meantime, as the member will know, some new health care facilities, such as those in Comox and Campbell River, do not have pay parking — as he’s noted in what he had to say.

We want to be advocates for patients. But we have to understand that if there’s a decline in revenue as a result…. It’s like everything else. It’s one thing to say the previous government increased it by 130 percent or doubled medical services premiums. We still have to, if this is a priority, find the money but also make changes that might make the system fairer.

I happen to think that the proposal made by Jim Sinclair, the chair of the Fraser Health board, to move towards paying on the way out is an excellent and appropriate thing to do.

The final thing I would say is — and I can get the member this information — in significant numbers of cases, people are offered relief if circumstances require. This is true in every single health authority.

The challenges of pay parking are real. The woman who is working on this file is one of the most outstanding administrators in public health care, Linda Lupini. She’s conducting the review of this question for me. She works at PHSA and is the executive vice-president at PHSA.

We’re going to review that and consider all of the options involved. I think we can make some improvements. And then we have to address…. If we want to make improvements that reduce the amount of revenue produced by hospital pay parking, then we’ll have to make those decisions that are also budget decisions.

N. Letnick: Thank you, Minister. Just for my two cents’ worth, if we get to a position where pay parking is basically to pay for the parking and not to pay for health care, then I think that would be a reasonable compromise. You have to pay for the structures. You have to pay for the cost of managing the parking. In some areas, if you didn’t put a pay system in or some other control system in, the parking spots would be all filled up by people in the surrounding areas going to other facilities or other businesses.

It’s a challenge. I don’t see the day when all parking is free and available in all parking places around the province. For that reason, you have to manage parking in a lot of places. I don’t think you’ll get any argument from me if there is some mix of different things in different parts of the province.

Moving on to pharmacy, to drugs. I’m just going to talk very briefly on dispensing fees. We have the pharmacy association that basically says that they’re not getting enough money for dispensing fees.

In particular, I have one letter that said: “My cost for dispensing a prescription, as last measured by my fiscal year-end, September 2018, was $12.72. My cost to dispensing in 2011 was $10.72. That represents a reasonable annual cost increase of 2.7 percent.” Of course, he’s not getting that. He’s only getting $10 for the dispensing fee.

Is there any talk underway to see that the dispensing fee for prescriptions is increased?

Hon. A. Dix: I wanted to, since we have five minutes left, minimize the delay here, so the member might get another question.

The amount overall paid to pharmacists from the PharmaCare program is about $289 million. It represents a significant portion, as you would expect, of the PharmaCare budget.

[6:40 p.m.]

That proportion, that amount has been going up roughly 3 percent, per year, over the last number of years, so it has continued to increase. There are some areas of payments made to pharmacists in B.C. where we pay significantly above other jurisdictions. There are some areas of payments made to pharmacists in B.C. where we pay significantly above other jurisdictions. There are some areas where we are below. Obviously, those fees are always subject to review.

I spoke to the B.C. Pharmacy Association last Friday about the contribution they can make. I think one of the extraordinary things that’s happened in B.C. since the H1N1 virus hit the province…. They were responding, in the way that we immunize people, in a much greater role for pharmacists. That’s the role they’ve played. You’ll see that as we report month after month on our immunization catch-up campaign. The pharmacists who are providing immunization services, which overwhelmingly had been flu up to this point, about 97 percent flu, are going to be significant providers of MMR and MMRV vaccines in the next little period.

We are taking steps to increase the role that pharmacists play. In addition, of course, clinical pharmacists are playing a central role in primary care networks and in our primary care strategy.

That’s the situation now, and obviously, those fees get reviewed regularly. I understand that pharmacists would like the fees to be larger. We sometimes have these interprovincial comparisons. Depending on what we’re talking about, sometimes we’re higher, and sometimes we’re lower.

N. Letnick: Thank you to the minister for that.

What I’m going to do now, in the five minutes I have left…. I’m actually going to read out all the questions that I have left so that tomorrow, when we meet again, we’ll just basically, if possible, go through the answers. This way, the staff have a chance to do some homework tonight and put together the answers for the minister.

The first question is: can the minister release the price agreements made with Pharma?

The next question will be: what’s the government’s plan on biosimilars? Are we moving to a situation where people will be switched for non-medical reasons?

The next question will be under spinal muscular atrophy. It’s, obviously, a very serious genetic issue, life-threatening, debilitating. There are people that are looking for improvements to the reimbursement for patients on drugs that deal with it.

The next one will be for atrial fibrillation. Sorry. I can’t pronounce all these medical terms. I didn’t go to medical school. I went to business school. Rivaroxaban, also known as some other name that I can’t pronounce, Xarelto. The question is…. For the atrial fibrillation group, it’s only covered through special authority. Can we please advise if it’s being considered for PharmaCare coverage?

I got a letter from the CARP group, Geoff Cowan, also from Beverly Baxter, looking for the minister’s comments on funding for seniors when it comes to the high-dose influenza vaccine and also for shingles. If we can understand what the government’s position on that would be.

A lot of work over the last year on Orkambi for cystic fibrosis. Obviously, the minister is fully aware of their ask. It’s such a heart-wrenching story.

I know the minister says frequently that if you support one thing somewhere, then you have to find what you’re not going to do somewhere else. I understand that, and I know the minister is up at night thinking about these things. No one is debating the compassion the minister has or how much this must tear at him and his predecessors. The struggles that these people face, especially when they see Orkambi working in other jurisdictions and it’s not approved here…. They have a legitimate question.

[6:45 p.m.]

Pacific Hep C is another area of concern that I’d like to get some assistance on. So the elimination of hep C in British Columbia. The Hep C Network is asking the minister to commit to the development and implementation of a hep C–specific plan to eliminate the virus by 2030 in British Columbia — and that the plan to eliminate hep C in B.C. include meaningful and robust community roles, both in development and implementation.

We have the ALS group that also came, I think, last week or the week before. A very sad story that we heard from one individual, just representative of many individuals…. Wendy Toyer, the executive director of the ALS Society, is asking for B.C. to participate in the clinical trials. That is something for tomorrow.

The B.C. Schizophrenia Society would basically like their work to be base funding, as opposed to one-time, year-end, maybe funding.

The Canadian Hemochromatosis Society is asking the government to look at this genetic condition. Early intervention would prevent future chronic illnesses. We’re looking at some issues around that. So if the minister can talk about them.

The Alzheimer Society, First Link, again, is looking for base funding.

The MEFM Society would like to understand where they fit in the funding plans for drugs in B.C.

Lastly, the one the minister knows, probably, the most about because he’s lived the longest with it is diabetes — drugs, devices and other topics. In particular, if someone is given a medical device, an infusion pump, should it not also come with the insulin being covered under Fair PharmaCare as well? I want to talk specifically about that.

If we get time in the time we have tomorrow, we’ll canvass B.C. emergency services, the Auditor General’s report and some of her recommendations.

With that, thank you for your indulgence.

Hon. A. Dix: Just for a head start on tomorrow, the answer to the first question is no.

I move that the committee rise and report progress and ask leave to sit again.

Motion approved.

The committee rose at 6:47 p.m.