Legislative Assembly of Ontario

MINISTRY OF HEALTH

CONTENTS

Tuesday 2 June 1992

Ministry of Health

Hon Frances Lankin, minister

STANDING COMMITTEE ON ESTIMATES

*Chair / Président: Jackson, Cameron (Burlington South/-Sud PC)

*Vice-Chair / Vice-Présidente: Marland, Margaret (Mississauga South/-Sud PC)

Bisson, Gilles (Cochrane South/-Sud ND)

Carr, Gary (Oakville South/-Sud PC)

*Eddy, Ron (Brant-Haldimand L)

*Ferguson, Will, (Kitchener ND)

*Frankford, Robert (Scarborough East/-Est ND)

*Lessard, Wayne (Windsor-Walkerville ND)

*O'Connor, Larry (Durham-York ND)

*Perruzza, Anthony (Downsview ND)

Ramsay, David (Timiskaming L)

Sorbara, Gregory S. (York Centre L)

Substitutions / Membres remplaçants:

*Brown, Michael A. (Algoma-Manitoulin L) for Mr Sorbara

*Sullivan, Barbara (Halton Centre L) for Mr Ramsay

*Wessenger, Paul (Simcoe Centre ND) for Mr Bisson

*Wilson, Jim (Simcoe West/-Ouest PC) for Mr Carr

*In attendance / présents

Clerk: Greffier: Carrozza, Franco

The committee met at 1535 in committee room 2.

MINISTRY OF HEALTH

The Chair (Mr Cameron Jackson): We have convened today to begin the estimates of the Ministry of Health. The committee has allocated 10 hours for purposes of this review. It is my pleasure to welcome the minister, the Honourable Frances Lankin.

As our standing rules set out, the minister will be given up to half an hour to make any opening comments. She advises me that she has a text which she'd be willing to circulate, but there isn't one at the moment. That can be received before day's end. Then we will go in rotation with the official opposition and the third party responses and then the minister's wrapup following that.

If there are no questions, we will proceed. Minister, welcome and please proceed.

Hon Frances Lankin (Minister of Health): Thank you very much. I will just take a moment and introduce the Deputy Minister of the Ministry of Health, Michael Decter, and a member of my political staff, Rob Smalley, who is the legislative assistant. There are a number of other people here from the Ministry of Health who will be able to be of assistance if questions are raised that fall within their particular areas.

I will begin by saying that over the course of the remarks that the critics from both opposition parties will make, leading to any questions, I'd appreciate it if there were an opportunity for members of the committee to let me know the areas of questions in particular that they have an interest in and the order in which they may wish to receive that information so that I can try to ensure that, as I come to these sessions, I have the most up-to-date information with me. I do have staff in those program areas with me as well in order to facilitate answering your questions.

I'd like to take the opportunity of the opening remarks to stress what I think is the most important driving force in what we are trying to do within the Ministry of Health over the course of the next number of years. I think it's underlined by saying that there's a tremendous need for reform in the delivery of our health care system. There have been many studies, many reviews in other parts of the country, royal commissions, that have looked at the state of our health care system and definitions of health, and I think that one of the things we hope to achieve is to bring to the culture of all parts of government an understanding of a definition of health according to the World Health Organization, which is, as members here will know, much broader than perhaps traditional thinking may be around the issues of state of health as simply an absence of illness or infirmity. I think we are all looking much further than that these days.

It's important for us to say that we do have a health care system that is worthy of pride, and it is one that government after government has sought to protect and enhance. I think in this vein it's important to acknowledge that there have been steps taken in the past that start to lead us down the road of reform. Over the course of the last 10 to 20 years, extensive research has been accumulated that, I think, guides the directions we take now.

That research shows things like health being related to economic status of the citizens of our province. We know that mortality rates for poor Canadians are much higher than for rich Canadians, as an example. We know on a worldwide basis that research shows that people live longer in wealthier countries. We know that access to health care, as it's traditionally defined and delivered, has not in general narrowed the health inequalities between socioeconomic groups. We know there's a strong correlation between poor health and lack of social support mechanisms, networks and relationships. Things like self-esteem and coping skills and the ability to exert control over one's life are important. Early childhood experiences play a potentially critical role; the environment; there is a whole range of issues we know are critically important in establishing the health status of our population. Those things have more recently been defined and listed and referred to in documents as the determinants of health.

I think the debate around the determinants of health -- ie, understanding the importance of them in the establishment of the health status of our population -- brings with it a necessary response from government to try and look at matching the resources we invest in health with the issues we see out there as being the determinants of our population's health, and that I think is a major part of the reform that is necessary for us to take some greater strides to achieving. The necessity then to set ourselves some goals for the reform I think becomes clear.

We're perhaps lucky in Ontario that there have been other groups that have looked at this issue and attempted to identify health goals. We've been able to benefit from the work of the Premier's Council on Health Strategy under the previous government with respect to the health goals it established, which were the shift in emphasis from disease prevention to health promotion, fostering strong support of families and communities, ensuring a safe and high-quality physical environment, increasing the number of years of good health for the citizens in Ontario by reducing illness, disability and premature death, and providing accessible, affordable and appropriate health services for all.

I want to indicate to you that certainly the Ministry of Health is committed to all of those goals. We have adopted those goals and internalized them as part of our framework for assessing initiatives and decision-making within government, and I'm particularly pleased to indicate that the government as a whole has adopted those goals. As I indicated before, it will take some time to have the change in culture that's necessary in government for all parts of government to see these kinds of health goals as screens through which they should filter decision-making and program planning, but I think we're taking steps in that direction. That's important, and those factors will really set the stage for reform.

It is also very important for us right now to acknowledge that there is a fiscal context to the situation we find ourselves in and a fiscal context within which we are attempting to achieve reform. It would be remiss not to acknowledge that it places certain pressures, certain constraints and certain imperatives on the decision-making we are faced with. With respect to the fiscal context, there are three major areas we need to keep in mind that I'd like to address.

The first of course is the recession we have been experiencing in this province and this country. There is no doubt that people have reached an agreement that this is the worst recession since the last Depression. We know there are tremendous forces that are restructuring our economic base in this province and we know there are effects of that with respect to the fiscal revenues of government and the ability of government to maintain levels of delivery of service and the challenges they present.

Although we find fiscal resources are very constrained, in the budget this year the Treasurer made it very clear that the government had identified three priorities: saving jobs, retaining services and controlling the deficit. Those are our challenges that are set out for all of government, and I assure you that the ministry is seeking to restructure and realign the health care system with those goals in mind. We're seeking to minimize the human dislocation and job loss, and I'll talk in a bit about how we are doing that. We're seeking to retain the necessary existing services and to create new ones where that is indicated, and we're working to introduce management that is geared to deficit reduction, excellence in management through quality assurance and provider planning and collaboration.

The second issue we need to contend with in the fiscal context is the federal withdrawal from medicare. Members will know that provincial governments across this country suffer from the reduction in federal transfers with respect to both the Canada assistance plan and established programs financing. The federal share of Ontario's expenditures on health and higher education has fallen from a high of 52% a decade ago to 31% now. It's important for us to recognize that this is a force with respect to the fiscal context, and here I don't want to simply say we're pounding the table and saying that the federal government should provide more money. I think it is very important that the federal government remain as a partner in our national health care system. I think we need to see an adequate and stable level of financing from the federal government, particularly as we go through this period of transition and restructuring. The need for that stability is important to provinces and to provinces' health care partners -- the transfer payment agencies and our communities.

I can't leave this issue without commenting on perhaps the more serious threat with respect to the continued reduction in the federal share of health care dollars, and that has to do with the federal government's ability to enforce the principles within the Canada Health Act. The fiscal levers they currently have under health financing through EPF are slowly disappearing as we see the deterioration of the level of support from the federal government.

I think we need to put squarely on the table, as provincial legislators in this province and other provinces are doing, our continued support for medicare, for the principles in the Canada Health Act and our message to the federal government of our deep concern at its soon-to-be-realized inability to enforce the principles of the Canada Health Act if it loses these fiscal levers and if those enforcement mechanisms aren't replaced by other mechanisms such as enshrining a social charter in the Constitution.

It's a very important issue that is sometimes hidden behind the scenes and the technical debate around formulas of federal-provincial transfer payments and fiscal relations. I hope it is one that collectively, as provincial legislators, we can bring to the forefront of public understanding and knowledge, because I think it truly is a very dangerous threat to our national health care system. I assume that you, like me, believe our medicare system is worth saving and that the public of this province and this country value very highly our health care system. That is something Canadians and Ontarians hold dear and believe reflects our different values as Canadians and our national identity in many ways. I think that has come through many times in the constitutional discussions that have been taking place.

The third issue that makes up part of the fiscal context we need to be aware of is the record of the escalation in costs in our health care system over the last number of years. I think we have to put squarely on the table a question for all of us to answer: "Is the health care system, as we have known it and have been financing it, a sustainable one?" I doubt there's a person in this room who could argue that it was sustainable. Therefore, if we agree we have a problem, we must find solutions to that problem. I think we're fortunate in that one of the first places we can look in trying to resolve that problem is to much of the study, examination and research that has been done which points us in the direction of waste in the system -- waste in terms of inappropriate treatments; waste in terms of duplication of services. There are many areas that we believe we can effectively reduce expenditures by moving to quality assurance and high-quality management, excellence in management, which will in fact improve delivery of health care services, not jeopardize delivery of health care services. I think in some ways that's a good-news note in the difficult fiscal context we experience.

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I want to stress that growth -- if you've read the supplementary budget paper, you will know the kind of numbers we're talking about -- over the past decade was on an average annual rate increase of 11.2%. If you break it down into different components, hospitals are just under 10% a year, OHIP has been growing at about 13% a year and the drug benefit plan has been about 18% a year. Behind those numbers, however, are real programs affecting real people and we have to understand what the effect can be. When I say that, I think there are areas in which we can improve, where we know perhaps there's inappropriate treatment, even harmful treatment.

I can point to examples like statements from the association of hospital pharmacists, which, by its numbers, indicates it believes that 4,000 seniors in this country die every year because of overmedication and there are 200,000 illnesses caused by the same reason. That's why it is important to take action on the recommendations that flowed from the Lowy commission and other reports. The drug reform secretariat is initiating the drug utilization review, bringing pharmacists, seniors, medical practitioners and others to the table to try to change the pattern of prescribing and the pattern of prescription drug use among our seniors population. That can produce better quality care, as well as a more cost-efficient use of our resources.

I want to briefly give you an update on the progress of the components of our reform, as we have indicated in the document we released in January in terms of strategic directions. First of all, the reorganization of the ministry itself is designed to try to meet the priorities we have set out: the establishment of several major groups like the health systems management group, the health strategies group and population, health and community services. We hope we have built the bridges in the appropriate corporate structure to be able to deliver more in the way of effective management of the health care system and provide assistance to our health care partners out there, as opposed to perhaps how government has been seen and the role it has played in the past of a claims payment agency or a funding organization, rather than an interactive partner in terms of the management of health care.

In our estimates book that we've circulated to you -- I think it's on page 6 -- you'll see the organizational chart that sets out that reorganization. You may want to take a look at it.

In the area of hospitals, you will know we have taken major steps with respect to our goal of program reform. The major parties have come around the table to develop the framework for a new funding formula and the priorities and the important areas they believe need to be addressed in the reform of the funding formula for hospitals. That is ongoing.

We have established, I believe, a new and dynamic relationship between community health planners in the district health councils and hospitals, to look more closely at regional needs and ensuring that health decisions that are being made within institutions are no longer centred in individual institutions, that they cut across the delivery of services to the community and that those decisions are guided by good health planning and good needs analysis to ensure the delivery of services is reflective of the community health needs that are identified.

I think the kind of support we are trying to give to the restructuring process, both with the active committees, with the hospital association and other partners that are developing operational plans, and the requirements for how hospitals develop those plans and work with their workers and communities and others to develop the plans, as well as a more proactive process of parties coming around the table and trying to look at the major issues of restructuring over a longer period of time, are all indications of major changes in the hospital sector and an attempt to involve the greatest number of people we can in these discussions and in these decisions.

You will know that there is major restructuring resulting from the transfer payment announcement. But I want to assure you that in addition to the 1%, the additional allocations that have been made have, I think, met with great approval in the hospital sector with respect to things like the $49 million for essential services, expansion of dialysis and bone marrow transplants, chemotherapy and cardiac surgery. Another $46 million helps accelerate the shift from institution-based to outpatient and community care, support high growth areas and reduce historical funding inequities. All of these additional dollars that are very targeted, very specific, I think have been welcomed by the hospital community.

As you know, we also have an established labour adjustment fund attempting to minimize the impact of changes in the hospital sector on individual workers. At this point I should indicate to you -- and although I don't have hard figures for you this week, I hope to have in the near future -- that despite the kinds of predictions we heard about the thousands and thousands of people who were going to lose their jobs as a result of the transfer payment announcement, hospitals and unions and communities have worked very hard to be innovative and creative and to find areas to reduce deficits by other measures. Their efforts are praiseworthy, and a tremendous credit goes to hospitals on this.

I can tell you that when we provide you with the numbers, you will see that it is only a fraction of what had been predicted that has actually resulted out there in the communities. Still, we would rather be in a situation where there wasn't any, but we will be working with those people to help them make a transition to new jobs in the community through retraining and other adjustment measures.

The Ontario drug benefit program reform: Essentially, most of the updates that I can give you with respect to that are contained in the health supplementary budget paper, and I would refer you to that information or answer any questions you have around it. It is moving and moving quickly, and over the course of the next year I think the drug utilization review and other initiatives will see a much more effective management and better product being delivered to the clients of that program.

For the first time, I think, in the history of this program, you will see that this year there is a decrease in the dollars being spent on OHIP in terms of the percentage of the overall health budget. We've gone from 32% of the overall health budget last year to 29% of the overall health budget this year. There are increases in areas of community health, long-term care and other areas that I think are steps towards the beginning of the shift, as well as an investment in other determinants of health and other parts of the government, whether that be job strategy, provincial training programs, the sorts of things that are very important for us to invest in in terms of upfront investment in health.

You know about the agreement with the Ontario Medical Association. There are other negotiations ongoing, and we are certainly prepared to answer questions that we can about that.

The area of mental health reform is next. We have a number of serious problems in our mental health system. We are facing increasing demands on the system which include demands for services and service access issues. There are inefficiencies in services; there are very poor linkages between research, policy development, funding and service delivery; there are labour relations concerns, and there is a lack of a long-term strategy for prevention and early intervention. We are talking about a problem that affects about 1.5 million residents in this province.

We think we need to take steps consistent with recommendations of the Graham report. We have identified mental health reform as a strategic priority. There is a steering committee of the relevant Ministry of Health branches that has begun to develop a work plan to try to link the recommendations that we saw in Graham and other areas, to try to build linkages between the facilities part of our system, whether those be our psychiatric hospitals or psych units in general hospitals, and our community delivery of the services. It is looking at ways to integrate those and looking at ways to truly direct the services to where they are most needed.

In this respect, we have again adopted goals from the Premier's Council on Health, Wellbeing and Social Justice looking at reduction in suicide, increased employment for people with schizophrenia, and reducing the disability from schizophrenia, Alzheimer's and other dementias. We are in the process of developing a multi-year plan for mental health services which will include mental health promotion and prevention of mental illness.

Mr Chair, can I just check on how much time I've got?

The Chair: You've got nine more minutes.

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Hon Ms Lankin: Okay, thank you.

With respect to long-term care redirection, you'll know that we have just completed the consultation on this major reform in government, and here I'm really thrilled to tell you about what I think is a success story in terms of consultation and reaching people. Over 70,000 people participated in over 3,000 organized sessions in this consultation. Seniors and members of their families came out, and persons with disabilities. It really was a tremendous success in actually being able to reach the consumers of this service and hear from them directly about what their needs were, as well as the organized voices of providers and others. It was a tremendous initiative. Almost 2,000 written submissions have been received on this. Well over 2,000 phone calls came into the government's phone line for more information. There were about 80,000 discussion documents distributed in various forms -- audiocassettes, other languages. It really is tremendous.

We heard a lot. I have to tell you that there were some important criticisms that we heard during the process of this consultation. We're in the process right now of reviewing the results of that consultation and giving policy consideration to some of the areas that the communities out there have said must be changed from the program suggested by government.

Again, I'll commit to you that this is a major priority and that the government has allocated $647 million over the next five years; $100 million of that will be flowing in this year. We will be moving to make those final decisions with respect to those dollars very soon, in keeping with the policy decisions that are being made.

The management of health human resources: This is a major challenge and, we believe, a very crucial necessity. A large part of our health care expenditures are invested in people delivering services to other people. There are just under 300,000 workers involved in health care in Ontario, and payments to providers of care, such as physicians, nurses and rehabilitation workers, comprise about 75% to 80% of our health spending. About $13 billion in 1992-93 will be directly related to the provision of direct services. That's not buildings, not technology, not the other things that are also costs in the system. Despite this -- not just in this province; this is right across Canada -- we do not have a history of effectively managing and planning health human resources. We've not looked at what the future projection of population health needs will be and tried to match our resources planning in terms of training and development of health care providers.

This is a tremendous challenge. We're undertaking a number of initiatives, both provincially and nationally, to address a number of key issues. You will know that one of those key issues is physician resource planning.

At the same time, we're also looking at trying to increase space for non-medical health professionals to assume full scopes of practice. The recent changes to the health professions legislation certainly allow for that evolving scope of practice. It's an important change, one that other provinces have looked at and are looking to copy in fact.

It is certainly necessary for us to be able to move to a mix or variety of health care providers in the delivery of primary care and other health services. In order to match the training and supply, there needs to be very active work in developing that kind of strategy.

We are working on the development of a community health framework. Here again I want to say that these are not new, radical ideas. What we have are some experiments that have taken place over the last decade that we think we can learn from and build on and for which we can try to develop a framework. We had the experiment of community health centres as one type of community delivery of primary health care. There are health service organizations. There has been discussion of comprehensive health organizations. All of these are various organizations of funding and individuals, and they vary in terms of their structure and goals, but they are essentially primary care delivery at the community level and different experiments in that.

We think we can move to develop a framework of comprehensive community health and public health strategy for delivery and funding of primary care, including more delivery sites and an expansion of what is on the ground now.

The plan we are working on, and we are working on it in conjunction with people from the community, is looking at determining the role of the primary care and health care delivery system, especially regarding accessibility and equity issues; developing a policy and planning framework that complements the role of institutions. As you know, we've moved and been able to establish a planning guideline framework for institutions so that district health councils and hospitals and communities have something to judge their planning by and to guide them. We are looking, with our partners out there, to develop a similar kind of planning framework for primary care and community delivery of that service.

We are hoping to be able to evaluate the effectiveness of existing models, including CHOs and independent health facilities and other sorts of experiments that are out there. We've never done much evaluation of what we do in the health care system, and as we become more rigorous about that, it needs to be applied to the community sector, not just the institutional sector.

We are looking in our plan to ensure that we're developing culturally sensitive services to meet the needs of specific communities and the changing needs of the communities that need to be served, and to develop mechanisms to ensure accountability and to have informed choice.

Let me conclude by briefly saying that the kind of restructuring and reform we are embarking on in this province collectively out in the communities and in government is not easy; it will not be easy. I don't bring a Pollyanna approach to this, but I do believe it is crucial to our ability to create a truly sustainable health care system. I come back to the premise I put to you, that everyone I have talked to in the system, irrespective of the sector he or she comes from, irrespective of political background, agrees that the system we have is not sustainable as it is, that there needs to be a change.

Therefore, I think the question of reform is a redundant question. Reform must take place. The nature of the reform, perhaps, becomes more debatable among various parts of the community, and various members of the Legislature even, but there have been almost two decades of research in Ontario and across this country and in the United States and internationally that I think really provides us with a great basis to be sure we're actually taking the right steps in terms of the reform we're trying to achieve.

I don't claim that we're pioneering this reform. I believe other governments started down this road. I can point to examples under the Conservative government. I can point to even more examples under the Liberal government, and I can point to many examples under this government. It is a period of acceleration of reform for many reasons, in many situations. The time is right. There is a historic window of opportunity. I hope the ministry, with myself in the role of minister, will be stepping through that window of opportunity, along with our health care partners, to truly achieve the kind of reform that will allow us to have continuation of a very valued resource and national heritage, our health care system into the future.

I think that gives you an overview of my feelings with respect to reform. We hope that in reforming the system, we'll be putting the issues of enhanced quality of care and reform to a new vision in the driver's seat, as opposed to the fiscal context within which we are doing it, being in the driver's seat. In this way, I think we can implement the kind of policies that we need to bring to life the consensus of directions in health care that have been held by all governments for some time.

I think we also allow ourselves to deal with the fiscal situation through enhancing the kind of quality in care that we provide, which will achieve objectives that are both fiscally and socially responsible, and those are the goals we have set for ourselves in the Ministry of Health. I thank you for the time to make the introductory comments.

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The Chair: Thank you very much, Minister. I'd like to proceed with the comments from the critic for the official opposition, Mrs Sullivan.

Mrs Barbara Sullivan (Halton Centre): I won't take the entire time, because I hope my colleagues who represent different areas of the province will also be able to contribute to the discussion of some of the changes as they see them occurring in the health care system from a geographical point of view, which I think is important in the discussion of the balance and equitable delivery of health services. Because the three of us represent very different areas in terms of geography and in terms of the demographics of our communities, I think the words they have to say are important to have on the table.

Where I'd like to start is really where you concluded, that the changes we're seeing in the health care system are in fact an evolutionary change that started during the Conservative government, continued through the Liberal government and will continue with your government and whatever government replaces your government in the future, that the goals of change are similar and that the data and the way people have seen health care move since the introduction of medicare are influencing decisions in terms of policy and political choices of all political parties, not only in Ontario but elsewhere as well.

There's no question that we see changes in the system as necessary, sometimes based on new technology, new technical approaches to the delivery of health care, sometimes brought about by pressures of burgeoning budgets, which is clearly a matter of emphasis for this government at this time; and very frequently, and in fact in a healthy way, changes are brought about by consumer demand, where people say they want to make different priorities the essential decision-making point in the delivery of what is a matter of national pride and a matter of the way we identify ourselves.

It's very interesting to compare, in my view, what's occurred in Quebec in terms of its approach to changed pressures in health care and the way we have approached them in Ontario. The first question people in Quebec asked was, what proportion of their provincial resources did they want to commit to the health care system? What specific surround of the GPP should people make judgements about as being the appropriate requirement and ongoing demand in terms of health care delivery, no matter what change in demographics or what change in technologies?

I thought that was a very interesting place to start, because what it means is that, given that surround and given the acceptance of the principles of medicare, which clearly are a matter of importance to us here, that particular context and decision means there can be a thrust in terms of change that has a base to it, that yes, by George, we're going to commit a third of our budget in perpetuity, but that's all we're going to commit so let's make these areas work. Maybe we're doing the same thing in Ontario without the words and without that physical description, but I think it's very interesting that that starts the Quebec documentation. It's led them to decisions that I think are inappropriate in terms particularly of their recent budget, but I think it's an interesting place to start.

One of the things we are most concerned about in our party is that while changes are made in health care, there is a balance and integration in the system; that in, by example, a shift from an institutional base to a community base, hospitals aren't left in a position where they can no longer deliver the appropriate level of quality services in the communities.

In my own community, my constituents are served by three hospitals. One of them, as you know, because that came before you just recently, is at a perilous point because it's so far below even the goal of number of patient beds per thousand population -- or patient days. I get these little formulas mixed up depending on what context we're in. That hospital is in a perilous situation and the people in the community therefore are in that situation. We don't have the long-term care services and we don't have the community-based services to alleviate that. I am sure that is not a situation unique to that part of Ontario.

I think the balance we're looking for is to ensure that not only is there care being taken in decisions, that the quality of care is not diminished in any way, but second, that useful tools which have been found to be beneficial in the community and in the health care system aren't rejected simply because they're old.

In the fiscal context in which you placed many of your remarks and in which I've to a certain extent opened mine, another area of concern we have is that while we acknowledge that decisions must be made within the fiscal context, we believe decision-making must be made not only on cost containment alone, but on the cost-effectiveness and quality of care.

Some of our reactions in question period and in other forums are concerning the decisions that appear to us to have been made in a cost containment mode rather than in a cost-effectiveness mode. I can give you the example of some of the drugs that became available only in a certain way: the AIDS drugs. It appeared to be an afterthought that in fact those drugs were also extremely important in the treatment of shingles for senior citizens. What appeared to us to have happened, and in fact I am convinced what occurred, was that a decision about cost containment had been made without looking at the entire parameters of that decision.

I think a similar situation is now being faced with respect to the item you have put forward in your health care supplementary budget document relating to the curtailment of fees for laboratory tests, when in fact the commercial laboratories themselves are prepared to come forward with proposals which they believe -- and I certainly find interesting -- would meet your fiscal containment needs, and they do not believe the method you have chosen will in fact do that for you because they have no control over which tests are ordered and who orders the tests. You've talked about partnerships; I think what they're saying is that if they were at the table with you and were in fact full and meaningful partners -- and other of the so-called partners in the health care system have indicated that same negative response -- that indeed there could be a greater consultative framework and in fact more positive decisions made.

I would like to hear more information from you and from people in your ministry in relationship to remarks you made about the Canada Health Act. We are naturally all concerned about the impact of federal decisions on transfers on the Ontario health care system, not only this year but in the future. None the less, we would like to have more specific and direct information on what the actual transfers from the federal government were this year. This year, we understand the increase was in the range of 3% to 4%, although the cap was 5%, in comparison to the transfers of 1% which were made by the government to our transfer agencies.

If that debate is going to go anywhere, I think there has to be fairness in terms of not only the way the issues are put but in the way the accuracy of the information is presented and put on the table.

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In the changes which have been made as a result of budgetary decisions and, following later, on the transfers, we know there have been numerous people laid off from hospitals and other agencies as a result of the change in transfer levels. To our mind, what was a positive step was that there was $30 million of transitional funding provided to the institutions to assist them with the employees in making changes.

One of the things that has concerned us, however, is that funding is not available to some of those institutions, facilities or agencies that in fact could most directly utilize the services of the people being laid off from the hospitals, by example. I think of the Victorian Order of Nurses, a major deliverer of home care services, not able to access transition funds to train people who have been used to working in an institutional setting in how to deliver care in a community-based setting. There are differences, and the people who are delivering care, whether it's in the institution or the community, all say this is not the same training, not the same approach, not the same skills that have to be applied.

None the less, we see the concentration of funding put into the human resources training, in how to prepare résumés and how to find out where opportunities exist, but little placed in the areas where in fact those services could be expanded and, in a community like mine, are desperately needed. Similarly, agencies in which we all hope some of those people would find new places don't have the money to hire them in the first place, let alone train them.

If you would like to address that as we go through the vote-by-vote materials, I think that's something on people's minds. It's certainly on the minds of people in agencies.

I've recently met with people from the mental health and addictions area on several occasions and followed up meetings, which we all have as members in our own constituencies. One of the things I'm hearing from those groups -- and you've talked about the goals in terms of changing mental health programs and approaches -- is that they have no idea what's on your mind. They don't know if you support the Graham report. They don't know where the district health council reports fit. There are no signals. They don't know anything about the multi-year plans and they don't seem to have access to find that information.

I think that's regrettable. District health councils, to a greater extent of quality in some cases and a lesser extent of quality in others, have worked diligently to put together reports on services which could be delivered and coordinated in their community, and many of them haven't had a response since they were first submitted. In one case -- I believe it's Durham -- the report has rested in the ministry, I'm told, for well over a year. Certainly in my area a report has not been in that long but it hasn't even been acknowledged that the report has been received.

If the simple acknowledgements aren't occurring, I think it's a legitimate criticism to ask, how are people expected to know what else is going to occur in that particular area, where they fit, what lies ahead for them in terms of managing an appropriate level of service and how that service will be funded?

I want to move on to long-term care consultation. As you know, this area is one that Bob Nixon, our Treasurer at the time, and Elinor Caplan, our Minister of Health at the time, felt would be the introduction of the first consultative paper, the most important change in the approach to medicare since the introduction of medicare itself. I think that was broadly felt through our government.

At the time of the introduction of the consultative paper, as you know, the consultations really didn't proceed because there was a change in government at the time. One of the things we found disappointing when a year and a half elapsed before the next government's paper came out was that it was basically the same paper, even though during that intervening year and a half there had been all sorts of issues and areas that had been determined through processes to have not been adequately addressed, or questions not raised in the first consultation paper; things from chronic care, to transportation, to respite care, to the training of workers, to community access agencies and whether indeed an appropriate body that already exists should be used, to how and if, by example, the Alberta patient classification system should be adjusted for an Ontario-specific approach to the question of housing. All those issues we had hoped would be there in the next document. A year and a half after the first one came out we just thought was a year and a half lost because in fact nothing much had changed.

If there's one regret about the whole consultative process -- and I agree that it's been an extensive one. My God, sifting through the issues is of course going to concern all parties and all people, whether seniors or others who require long-term care, but those issues I think will be on our tongues as we proceed through the discussion of long-term care.

We also want to know far more about how you see funds flowing, where they're going to be taken from, where the chronic care institutions, which have no place for people to go, are going to fit into that system. As we go through the votes we will want far more specific information in those areas.

How am I doing on time, Mr Chairman?

The Chair: You're doing fine; 13 minutes.

Mrs Sullivan: A couple of other areas we would like more information on as we proceed through the votes: You've mentioned human resources planning, which is a priority of the ministry, particularly the physician resources planning. We see a conundrum here, because we know you have announced in the supplementary budget that you will be looking to save $80 million this year in terms of reallocation of physician resources in the province. We have not seen and we don't believe there's adequate information or consultations that have taken place, by example, with the universities themselves, with the physicians themselves, although we know the JMC is working on this issue, and we wonder how the prediction of an $80-million saving could have been made for this year when the McMaster study -- what's that thing called?

Interjections.

Mrs Sullivan: No, the new centre at McMaster.

The Chair: Sounds like?

Hon Ms Lankin: Are you talking about the ICES, with Dr Naylor?

Interjection.

Hon Ms Lankin: Oh, the data centre.

Mrs Sullivan: Exactly, the data centre. What we don't understand is how the projections of an $80-million saving can be made when the work hasn't been done. CHEPA, the centre for health economics and policy analysis, right. People are so used to using the short forms. It's easier when you use the long ones; people understand what you're saying. When that work hasn't been completed -- we're talking not only about work in terms of physician resources planning but in terms of demographic projection, looking at emerging disease, illness prevention, patterns of care and so on -- how can that $80-million projection be made for this year, let alone for years in the future?

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The other thing in that area that we are concerned about relates to an issue that's been put forward by women physicians themselves, and an area that I think is very interesting to bring to the table as a woman -- not a woman who has practised at all in any of the health care professions, but many women who have tell me that women who are practising now in physician services are practising in a different way and making different choices about how to practise.

Once again, they are saying that as an impression but without the documentation, they tell me, that supports that kind of conclusion. If that kind of conclusion is not available from a database, how can this projection be made in terms of savings, and indeed what other necessary choices will be made? I think some of the work the OMA has done in its original paper, which was submitted to its own membership, is very interesting, and there are other issues to be raised, but we think that $80 million is questionable and would like to pursue that with you.

You talked in part, in relationship to alternative delivery of care, about the HSOs and the CHOs and the CHCs.

Mrs Margaret Marland (Mississauga South): Is that French or English?

Mrs Sullivan: What these organizations tell me -- each kind of organization, the health service organizations and the CHOs -- is that they don't know where they stand with the government either. They feel there has been inadequate direction, approach, communication with them; that decisions which were made in terms of their own billing methods, the method of data transfer between the ministry and the organizations themselves; in fact the questions regarding their viability and the ongoing commitment of the minister and the ministry to their continuance, are very much on their minds.

The question in terms of the indication you have given today, by example, of a multidisciplinary approach to health care delivery, is very much on their minds in that what they are saying is, if you don't see a commitment to the multidisciplinary approach in, by example, an HSO, where is that multidisciplinary approach in other areas?

In my community, some of my constituents are served by the Caroline Medical Group, one of the first HSOs in Ontario. It happens to be physically situated in Mr Jackson's riding. The people who deliver care there are in fact highly committed to the concept of a capitated system where the patient can be followed and treated in a multidisciplinary environment at what they believe is a cost saving to the province as a whole. We know that in a different form of capitated service the Toronto Hospital was held up for a long time in being able to move ahead on its own proposal for a community-based multidisciplinary care service.

All of these organizations are saying: "Where is the ministry, where is the minister, on these issues? Where is the funding? What do we have to do to convince them that we need to have support and an indication of what the policy base is?"

I'm going to conclude now by asking Mr Brown first and then Mr Eddy to add their comments -- in four minutes, two each -- on some of the geographical issues that are coming before us. I know we'll be able to pursue some of these issues in vote-by-vote discussion.

The Chair: Mr Brown, that's your entrée.

Mr Michael A. Brown (Algoma-Manitoulin): As someone who represents both a northern and a rural constituency, we obviously have some concerns about health care that may be slightly different from what the Metropolitan Toronto people or other urban dwellers may have. I'm concerned, for example, with the northern health travel grants. I'm concerned with the way they're flowing. We know there's quite a backlog at the ministry and the people are not receiving the dollars in a timely way to reimburse themselves. To be clear, a lot of my constituents drive 200 or 250 kilometres to get to a health care facility.

I would note, though, that I appreciate Dr MacMillan from OHIP writing to the northern MPPs asking them for their input on northern health travel grants and asking us how we saw that particular issue. I haven't replied; the difficulty is that I had no idea what he was asking me. Was this Santa Claus saying, "I'll give you whatever you want, Mike," or were there some parameters around the discussion, of, are we trying to spend the dollars we have better? Are we going to get more dollars? Are we going to get fewer dollars? It made that letter impossible for me to answer, because if I wanted to do the wish list thing I could easily do it, as could any member, but I was wondering what parameters are around that.

We have other concerns also. I have three hospitals in my riding -- I wouldn't be unlike a lot of other northern MPPs -- that are spread out and have very diverse needs. We see two of the hospitals laying off staff. One of the other hospitals is in the midst of a major reorganization as demographics of the particular community have totally flipped, from a community with people under 35 years of age with many children being the norm to a community of senior citizens, and the demands on the health care sector having changed radically in a short time.

We have concerns about closing down the seniors' lodge in Elliot Lake, for example, which is a real possibility, because we haven't got on with long-term care, and there's kind of a ping-pong ball between Comsoc and Health.

I'd better quit; Mr Eddy is looking quite nervous.

Mr Ron Eddy (Brant-Haldimand): I'm nervous about whether I'm going to get to speak or not.

The Chair: You're going to get to speak, Mr Eddy. Don't worry. We're patient here. You're in your concluding remarks. There's some latitude here from the Chair, as there was with the minister. So everybody just get comfortable.

Mr Brown: I'm actually very concerned about this particular issue. In Elliot Lake we have a large retirement community that has developed because of a proactive government-sponsored program. We do not have the health facilities there to take care of them. What is there is Huron Lodge, which is a Comsoc-supported facility. It is presently being denied funding by the Algoma District Social and Family Services board, meaning that the community of Elliot Lake itself, a city hard hit by the economic ramifications of what's going on there -- we don't know what the future is.

The community has been lobbying for a long time, not just since this government has been in power but before that, for a seniors' campus, for something to address this. We are getting somewhat frustrated in that area, in trying to integrate this retirement living program with a lack of services and actually what appears to be withdrawal of service. That's causing the people in the city of Elliot Lake a great deal of concern.

So we do have some different concerns, I think, than other parts of the province, but in many ways I could echo my colleague's thoughts about the budgetary difficulties and how we cope with those.

The Chair: Mr Eddy.

Mr Eddy: Thank you. I could always write a letter, you know.

When we think of health care, it's mainly concern with the hospitals, four smaller-sized community hospitals and two larger ones, but it's mainly the closing of beds and the number. When you close over 100 beds, most of which are chronic beds, it certainly creates a backlog. It creates a backlog in the homes for the aged in the extended care beds; there's a waiting list there. Some of those people should go to chronic care beds, but they're being closed. It also creates a backlog in active treatment beds, because active treatment beds are used up for chronic patients, resulting in overcrowding, using hallways and, in my opinion, in some cases, maybe too early departure from hospital.

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The chronic care costs, of course, in the homes for the aged result in increased property taxes because they are not funded the way hospitals are. There is funding through Comsoc, but certainly the funding does not -- and this is a matter I understand is being looked at -- match what it should be.

Local hospitals are community hospitals, and they were the once proud health care providers in our communities. In my opinion, they've become demoralized and scared. They're scared because the future looks like closure in many cases. Certainly they're constantly constrained through lack of provincial funds. I think what has happened is that they've changed from proud leaders of health care in our communities to, as I say, demoralized and scared citizens, hospital boards, administrators, staff and indeed patients. That's very common, I find. The closure of beds results in unemployment, of course, and there are not jobs out there to be found.

I find too in some cases that the hospitals, although they're operating downsized, don't have the funds to carry out even the most basic and necessary repairs; in some cases hazardous situations. It's very serious and I think it has to be faced, so I'll be asking about that.

The Chair: To complete the rotation of opening statements, I'd like to recognize Mr Wilson.

Mr Jim Wilson (Simcoe West): Minister and colleagues, I hope you'll bear with me. I have a number of concerns I'd like to put on the record, a number of comments dealing with various issues relating to our health care system. I'm going to plow through my notes here.

I want to tell you, as I begin, that my notes are derived from the hundreds, if not thousands, of letters I have on file now from people across the province who have written opposition members with concerns, and also the numerous meetings I've had during the past year in which I've had the privilege of being the Health critic. So while all these comments are not necessarily my own, they are concerns and I'm pleased to have this opportunity to participate in the estimates process, where hopefully we can find some answers and solutions to a number of the concerns.

Minister, you'll have an opportunity of course to straighten us out where we need to be straightened out. Perhaps we will bring some things to your attention that you and your colleagues and staff may not have thought of, so I appreciate this opportunity.

On the critical side -- much of it is critical and I apologize for that from the beginning, but I think it's important we get these concerns on the record -- I really do have to conclude, after reviewing the case loads I have, that after thousands of job losses and bed closures and persistent waiting lists for treatment the administration does not appear to have a comprehensive health care management plan. Repeated attempts to get the ministry to clarify its stance in the direction of health care have failed. We've tried that in the Legislature, as has the other opposition party. This is the case, I would say, in spite of an abundance of rhetoric to the contrary.

Minister, I know you had a number of general areas you had to cover today in your opening remarks. But if I'm critical of one thing, it's that the answers we get in the House have almost been too general. I note that the same applies to the goals and strategic priorities paper that was released by the Ministry of Health this year and the budget supplement paper. It's very general, and it's difficult for health care providers, hospitals and all those involved in the delivery of health care services to really get a handle on the direction the ministry is going.

In the area of hospital reform, I think one of the great comforts of living in Ontario is -- or, some would argue, used to be -- knowing that if illness or injury strikes, you would get immediate attention when you went to a hospital. I think lack of government direction has crippled Ontario's hospitals by limiting their resources and increasing their costs to the point where hospitals are having difficulty meeting demands and ensuring the availability of quality care.

Layoffs and bed closures are adversely affecting access to hospital services, as we heard the Liberal Party also mention, and putting a considerable dent in the local economies of communities across the province. While the 1992-93 budget has limited funding increases to hospitals to 1% this year and 2% in each of the following two years, I'd argue that this helps to solve the government's cash flow problem but it leaves hospitals on the hook. The Ontario Hospital Association has estimated that 4,000 staff will be laid off and 2,300 beds closed this year. In 1990-91, we did see 1,228 beds closed and 1,124 staff laid off. In 1991-92, 1,570 beds were closed and 2,738 staff were laid off. While the 4,000 projected layoff is exactly that, a projection by the OHA, I will be interested in comparing the OHA's predictions with your ministry's own figures.

Hon Ms Lankin: In fact their projections are much higher than what you've stated there, but we can refer to that too.

Mr Jim Wilson: Thank you. I'll look forward to further clarification on that and exactly where a number of the people are, because I'd agree with you that a number of the people who are being laid off in the hospital sector are being absorbed in terms of employment. I'm happy to hear the ministry is tracking that, and we'll have a discussion on it.

But I think we are running the risk of being turned away at the door when it comes to hospitals, particularly when specialized treatment is needed. This could be exacerbated when you think that the OHA is now negotiating contracts with 60,000 unionized workers; it could exacerbate the problem if those workers are persistent in high wage demands and job security demands. The reason we have to be concerned about that is that 75% of hospitals' operating costs are in terms of wages, and while the government has limited the amount of money a hospital can receive, it's done nothing to limit the single biggest expense, and that is wages.

I've raised the matter of hospital management and funding in the Legislature on several occasions. I've asked the NDP administration to provide desperately needed planning direction for health care facilities and hospital boards. I've asked the government to provide a prescription that enables hospitals to plan for the future. I want to say that the PC Party of Ontario believes it is time the NDP showed some real leadership in terms of saving jobs and improving the state of our economy. Implementing wage controls would be an important first step towards preventing bed closures and staff layoffs.

In the area of long-term care, I think the responsibility of government is not only to handle immediate problems but to plan for the future as well. A case in point is certainly long-term care. It's no secret that Ontario's population is aging and the demand for long-term care will increase dramatically in the next decade. The government's long-term care policy or, rather, lack of policy at this point, is a disappointment to individuals who have waited more than three years for government direction.

The former Liberal administration released its consultation blueprint for long-term care reform, Strategies for Change, in May 1990. After more then two years of study, it then announced that it planned to spend an additional $600 million annually by 1996. Under the Liberal plan, two thirds would go to community services, enabling individuals to stay in their own homes, and the remaining $200 million was to go to long-term care facilities.

In June 1991, the current government announced $647 million for long-term care and support services by 1996-97. As I gather, of the $647 million, approximately $200 million is to be spent in nursing homes and homes for the aged and the remainder, of almost $440 million, is to be used to expand services in the community and in people's homes. We will be questioning the figure itself of $647 million, because I'm not sure on what base that is premised, whether it's really additional money or the total dollar amount to be spent on long-term care over the next five years.

As everyone knows, on October 31, 1991, the government released its long-term consultation paper, Redirection of Long-Term Care and Support Services in Ontario. I would agree with Mrs Sullivan when she said it really is a replica of the Liberal plan with a few minor differences. I won't go into those differences because everybody's seen them, but I would say in this area that one thing I learned in attending a number of the consultation sessions is that not everyone, as you obviously know, Minister, is generally pleased with the thrust.

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One thing I really wanted to bring to your attention is that Simcoe Manor is in an area of my riding, down in the village of Beeton. It's a well-respected institution. Many of my relatives live there and several are on staff. That's probably how I won the election; half my riding's related to me. I was surprised at the end of the consultation evening. A couple of residents came up to me, and I guess I and the ministry bureaucrats who were there scared the living daylights out of them because they really felt that the message they were hearing from government was that they would have to move out of Simcoe Manor and go back to their farms. One lady said to me: "I've peeled enough damn potatoes. I've never had it so good. I don't want to have to go back to the farm and neither do any of my friends." It was a lesson to me that we have to be careful and that we cannot sell long-term care reform as a cure-all for our health care system.

I think it's obvious that reform is long overdue in the area of mental health. The ministry's goals and strategic priorities document indicated that the ministry plans to reform the mental health system. I have to tell you, Minister, I was alarmed at the omission of any mention of children's mental health services. The minister should be aware of the crisis in children's mental health services; I think you did mention that in your opening remarks. More than 10,000 children are on waiting lists for mental health treatment in the province, and the sad reality is that this has been the case since 1989.

I want to point out that the Premier, Bob Rae, in a letter to a Kitchener psychiatrist dated May 21, 1990, called the crisis in children's mental health services "shameful" and assured the psychiatrist that the New Democrats would fight to make the crisis a priority.

In the spring of 1991 the standing committee on social development, of which I am a member, released a report dealing with children's mental health treatment. That report was supported by all three parties. All witnesses presenting before the committee agreed that children's mental health services are in need of drastic restructuring. It's a shame that none of the report's recommendations has been acted upon to date. We will be pursuing this during the estimates process to see what plans the government may have.

In the area of ambulance services it will undoubtedly come as no surprise to you, Minister, that we are extremely concerned about the future of ambulance services in this province and your upcoming response to the Swimmer report. Private ambulance operators are concerned about their futures, and they have every reason to be concerned, I argue. They've witnessed NDP attacks on private child care, and to be perfectly frank, the private sector is frightened to death over what the NDP will do next.

The Ontario Ambulance Operators' Association has been an active and willing contributor to the restructuring of the emergency health services system. Within the province the association has encouraged the government to move forward with plans to make the emergency health system more responsive to the consumers and has pressed for a greater emphasis on training, safety and standards of service.

My colleagues and I share the concerns of the Ontario Ambulance Operators' Association regarding the Swimmer report. The commission approach recommended in the report will result in further bureaucratization and does not allow for an independent monitoring body which would ensure high-quality emergency health services. We are particularly concerned with the recommendation giving all ambulance employees the right to strike. This recommendation, if implemented, has the potential to be extremely disruptive to our health care system.

We're also concerned with the recommendation that private operators be bought out. The reality is that the compensation plan will never provide adequate recompense for private operators who are being forced out of the system. This has been proven time after time in the child care sector. Finally, the cost of implementing such a system would undoubtedly be yet another unwelcome burden on the Ontario taxpayer.

Again, my caucus colleagues and I are extremely concerned with the Ministry of Health's treatment of commercial laboratories, and I note that Mrs Sullivan expressed similar concern on behalf of the Liberal Party. The ministry recently announced a new payment policy for commercial laboratories including a new utilization sharing formula designed to reduce payments to the laboratories by 50% when the number of tests grows by more than 2% per year.

I find it inconceivable that these decisions have been made without any consultation with commercial laboratories and that your administration has rejected offers of assistance in cutting costs from the association representing medical laboratories. The decision has created uncertainty in the business community and once again reveals the NDP's bias against the private sector.

Minister, you've also indicated that you plan to promote the use of public hospital laboratories. I would argue this would be extremely costly, as commercial laboratories can do tests cheaper than hospital labs. I have evidence proving this very point and will bring it forward during these hearings.

Rather than penalizing the private sector for providing a necessary service, I think the government should look at the root causes of increased expenditures. There's absolutely no reason why the private laboratory sector should be penalized for providing a high level of service. The reality is that patients are demanding tests with limited value, and the demographics of the province are changing. Private medical laboratories do not generate unnecessary tests.

I recommend that the Ministry of Health establish a dialogue with the Ontario Association of Medical Laboratories and the Ontario Medical Association to control and reduce the rate of growth in laboratory expenditures through mechanisms such as education and professional development, development of guidelines for testing protocols and a review of compensation models for lab services.

The Ontario drug benefit program and the changes to date in that program: Minister, I thought you'd maybe spend a little more time in your opening remarks on that, so I'll make some comments now and perhaps later in the process you'll be able to expand on the very vague remarks in your opening statement.

It's no secret that the expenditures of the ODB plan are out of control. We believe the billion-dollar program is in need of reform but disagree with the manner in which the government is going about making changes. The budget supplement paper dealing with health care announced the intention of the NDP to improve prescriber education, contain costs of drug programs and review legislation.

I think the reality is that most of these initiatives were announced more than a year ago. I really have to wonder what Ralph Sutherland and others of that political stripe consulting your ministry have been doing for the past year and a half. I agree that it's time for an overhaul of the ODB program. What I do not support is another study of the program which will only end up collecting dust in government libraries. I realize the NDP does not want to be seen as acting on the Lowy report because it's a Liberal document, but the Lowy report is the most recent of a series of government reports evaluating and assessing the ODB program.

What is now needed is consultation. Any changes to the plan must be done through consultation with both stakeholders and consumers. We know for a fact that you have not been consulting with innovative drug companies. I've met with several who have expressed their disappointment in this regard. We also know that you have not consulted with generic drug companies. This became evident through the comments of the president of a major generic company whose highly publicized comments made it clear that Manitoba is a more desirable place to do business than Ontario.

I'm also extremely dismayed to hear that the Ontario Pharmacists' Association is being ignored. Pharmacists are the profession who have to communicate changes to the Ontario drug benefit plan to their customers. All the government brochures and buttons announcing changes simply do not cut it. It's the pharmacists who are the front-line workers.

Both the budget and the health supplement paper give the impression that the government has been consulting with ODB stakeholders, but it's certainly a great mystery who precisely is being consulted when pharmacists, innovative drug manufacturers and generic drug manufacturers have been ignored by the administration. Again, I can't overstress the importance of meaningful consultation. Ontario is the largest drug purchaser in North America, and other provinces follow Ontario's lead and insurance companies use Ontario as a standard.

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The budget health supplement paper again contains a reference to a 6.6% annual growth in the dispensing fee paid to pharmacists. In fact there has been no 6.6% annual growth in the dispensing fee paid to pharmacists. The Ontario Pharmacists' Association has been without a fee increase since December 1990 and, as members will recall, the Pharmaceutical Inquiry of Ontario pointed out that the impact of pharmacists' fees on the ODB program are minimal. The reason why the total payout for professional fees paid to pharmacists has increased is because the number of claimants and utilization have increased, not because the fee for the pharmacist has gone up by 6.6%, which I think is the public's impression.

I share the disappointment of the Ontario Pharmacists' Association that the Ministry of Health has not dealt with these larger systemic issues. The association has rightly asserted that the NDP response has consisted of "simplistic, perceived easy targets, such as freezing the fees for pharmacists"; that's a quote from a piece of correspondence from the association.

I'd also like to reiterate the position of the OPA that on larger-quantity prescribing and changes to over-the-counter drugs, it is absolutely essential that the Ministry of Health consult to ensure that changes are rational and truly cost-effective and in the public interest. You yourself, Minister, mentioned some of the horrendous statistics about the overprescribing of seniors, and it leads us to the question that if you're going to give them more drugs per visit to the pharmacist, I don't know how that will help serve to stem the problem of overprescribing and the real dangers of seniors not only mixing up medication but also taking too many pills at once. When I was an assistant at the federal level -- and I have summoned the studies -- we did extensive studies on this and began the process of putting together a program for the nation in encouraging seniors to clean out their drug cabinets and better education in terms of taking drugs.

We've come to the conclusion, Minister, that you'd like to move towards the Saskatchewan drug plan model of universality. Any government would wrestle over user fees or, the more politically correct expression, copayments. Copayments are seen as contrary to the NDP position on accessibility to health care, yet without copayments universality will be extremely expensive.

We believe the cost-benefit models to evaluate the effectiveness of pharmaceutical products are long overdue, and we also believe pharmaceutical manufacturers could provide valuable data on prescribing for older patients if they were consulted.

It is our hope that the newly formed drug programs reform secretariat will be an effective and fair manager of drug programs. It's no secret that the drug benefit program is under review; Minister, you've made this clear, and I'd appreciate your assurances today that this reform will not take place behind closed doors. That's something I cannot overemphasize because, as I said at the beginning of my remarks, there is a real suspicion that a lot of decisions are being made in health care in which the public is not being included properly in the consultation and decision-making process.

In the area of insured health services, a number of insured health services are currently under review by the Ontario Medical Association and the Ministry of Health. I know my colleague Mrs Marland has a couple of comments to make and questions in that regard.

I think it's important that we reiterate, because both the government has and the Liberal opposition have, that we very much are supportive of the principles contained in the Canada Health Act and the principles of medicare. I will be questioning some of the statistics and numbers you've presented, Minister, with regard to federal transfer payments and tax points. I don't believe that in this day and age any of us should get away with pointing fingers at other levels of government, particularly when -- and I'll be interested in the ministry's defence of its position -- I do not believe the federal government has been an absconding debtor in terms of education and health care transfers. I'm certainly aware that the figures do not form an accurate basis for the NDP government's position on this.

Mr Anthony Perruzza (Downsview): I can't believe you're a member of the Ontario Legislature.

Mr Jim Wilson: One of the members interjects, but I think it's important that the public be given all of the facts all of the time, regardless of who the federal government is. It's an old political game to point fingers. If I'm wrong, I guess we'll find out during the estimates process.

In areas of legislation, during four weeks of public hearings numerous groups and individuals identified serious deficiencies in the consent to treatment legislation. I think their testimony convinced my caucus colleagues and I that the bills as written could not be implemented and would require substantial and substantive amendment.

To ensure that all interested parties would have ample opportunity to review and comment on the amendments, my colleague Norm Sterling moved a motion, opposed by the NDP in committee, to reconvene hearings two months following the date on which the government tabled and circulated its amendments. The government's amendments were released May 4, and because these amendments will, in our opinion, dramatically alter the legislation, Mr Sterling once again asked that a comprehensive new round of consultations be held. I am very pleased that the government has agreed to another round of public hearings in this area, and I commend the minister for that.

We will undoubtedly be tabling amendments in the upcoming weeks, and I guess we can say right now that we are pleased with many of the government's amendments to Bill 109 -- it's no secret -- but we continue to have a great number of concerns with Bill 74, the Advocacy Act.

Under the Public Hospitals Act, I'm extremely disturbed with Jack Layton's appointment as a consultant or a political assistant or whatever you want to call him for public hearings into a new Public Hospitals Act. My experience of Mr Layton and what I know of him is that he does tend to have a fairly anti-management political stripe, and I think his presence could be --

Mr Perruzza: Have you ever met him?

Mr Jim Wilson: -- extremely damaging to the consultation process.

Interjection.

Mr Jim Wilson: What? Well, I'm not here to make you feel good.

The Acting Chair (Mr Larry O'Connor): Order. Interjections are out of order. I'd ask the speaker to direct his comments through the Chair.

Mr Jim Wilson: I do not believe Mr Layton's appointment is a signal that the NDP intends to work amicably with the hospital sector, and this worries me because of a number of the other concerns I've expressed.

It's my hope that a draft of the public hospitals legislation will be circulated before it's introduced in the Legislature. I'd like to avoid a repeat of the legislative mess we came up against when we were dealing with the advocacy, consent to treatment and substitute decision-making bills. I want to make it clear to the government that committee is not the time to hold major public consultations. Rightly or wrongly, I came to the conclusion very early on in the committee process with regard to the advocacy bills and the consent to treatment etc that a number of groups hadn't been truly consulted.

It would have been better, I think, for all legislators if the legislation had been circulated in draft form prior to an actual formal meeting of the committee, because what happens is that we really waste a great deal of our time and witnesses' time when witness after witness continue to make the same point and when the parliamentary assistant or any other representative of the government tells us: "Yes, we're concerned about that. Yes, we're going to change that."

My suggestion would be that if the draft legislation were put out first, before the committee was convened, a number of the problems that would be cited during the committee hearings could be cleared up and we could actually work in a more constructive manner during the actual committee hearings. The tradition of Parliament is that committee hearings are, yes, to hear from witnesses, but they're not to be part of drafting of the legislation. They are actually to fine-tune the legislation. When you see 199 amendments come in, I think it supports our contention that more work should have been done prior to the introduction of those bills.

Because the Public Hospitals Act is indeed an historic opportunity and an historic moment in the history of health care in Ontario, it will be contentious and there will be a number of groups and individuals who want to comment on it. Circulating it in draft form would be very useful.

Members will take note that we will be tabling questions likely tomorrow. So that the ministry has ample opportunity to respond to the questions, we'll try to give you as many of those in writing during this process and give you as much notice as possible. How much time did I leave for my colleague?

The Chair (Mr Cameron Jackson): About four and a half minutes.

Mr Jim Wilson: I'm sorry, Margaret, but the floor is yours.

Mrs Marland: Thank you, Jim. You are the critic.

Mr Jim Wilson: If I live long enough.

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Mrs Marland: I'd just like to discuss a couple of my concerns as the spokesperson for people with disabilities. Obviously, in that particular responsibility I have a lot of concern about the long-term care reforms that are proposed by this government. I'm hoping the minister will be able to answer some of those concerns.

One of the major areas that we feel the minister has to look at very closely is that the proposals in the long-term care reform white paper would in fact end up putting seriously disabled people together with seniors who are frail and elderly. Although in a physical sense they may have some of the same needs, really they are two totally different groups. The disabled community, Madam Minister, wants to be treated with regard to its specific needs and to have its own specific needs addressed. In fact, quoting Barbara Thornber, the executive director of the Ontario Association for Community Living, she says, "Our major concern is the obvious exclusion of people with developmental handicaps in the stated definitions of disabilities." Further in the same area of comment is the concern of putting seniors and people with disabilities together in any of the plans for the long-term health reform.

I would also like to draw to the minister's attention an excellent response to her long-term care reform paper which was sent to her in March by the residents' council of the Mississauga Hospital. This is a particularly significant response that I hope your staff will review closely, because the response comes from a group of approximately 75 citizens who are each individually knowledgeable in the existing health care services for the elderly disabled, and they focused together on this combined response. In particular, I want to mention that the leadership for this residents' council at Mississauga Hospital was given by Kathy Harvey, who is a registered nurse and the multiple sclerosis society citizen of the year, 1991. This Sir Joseph Flavelle award is actually a national award, and she's been recognized provincially. Kathy is a very unusual person because she's been a quadriplegic since she was about 34 and she has a tremendously long list of community involvement. Her approach to the subject has been really unbiased and very objective. When you read some of the recommendations from this group, I think you'll agree that it's very valuable comment and feedback to your white paper.

I think also it's important for you to hear what the Alzheimer people are saying very loudly and clearly. Particularly in Peel, the situation is critical. There are 1,184 legislated nursing home beds, no chronic care hospital and over 1,300 people on the waiting list for beds. In Peel, we currently have 40,000 seniors, and within 10 years we'll have over 90,000 seniors. At the moment, the minimum waiting period for a nursing home bed ranges from six to 18 months.

I think the important area you have to really look at -- and we would like to know the answer to this -- in your plans for the reform of hospitals to community-based care, where is that care going to be when there are no nursing home beds planned, and how are you going to handle the need for those services, again between the seniors and the disabled?

I can't help but ask you the question, which is very critical to the people in Ontario, about just how far you're going to go as the Minister of Health in playing God as to which services you will make available as fully accessible to anyone in Ontario, not only people who are rich and can afford something but also people who don't have the money and can't afford something. As far as we're concerned, some of the services we are told that you are looking at delisting mean we will have an even more visible two-tier health system than we have today. We know we have a two-tier health system today. We know that if you've got the money you can go elsewhere, out of this province, out of this country, and access some health services that you can't get quickly enough still today in Ontario.

Regarding the statement by your deputy minister, Mr Decter, about perhaps curtailing bypass surgery after age 70, I have to ask how you're going to make these decisions about what services will be available and who will get them. Will you sit back like God and decide that 60 is the latest for a kidney transplant and 65 for a bypass or whatever? I wouldn't want to begin to play that role and have that responsibility. While you're looking at some of the programs that you're considering delisting -- and we can only go by what we've been told and that's why we'd like to ask you these questions and have these answers -- I would like to know how you can consider funding abortion clinics on the one hand and look at delisting some other reproductive technologies on the other.

When you're looking at questions we need answers to, we need to be able to tell our constituents and your constituents in Ontario where it is we're going to be with full access to services that are equitable for everybody and not a matter that if you've got the money you can go and buy that service, either within the province or without. A platform that has been in the ideology of your party for ever is that the reason we prohibited extra-billing of physicians was because of the thrust in this province to have equal access to health care. We don't have it today. We have a two-tier system today and I hope you're committed to removing that rather than enlarging it.

The Chair: Thank you, Mrs Marland. I know I was delighted to have my vasectomy done a few weeks ago before I read your announcement in the paper, Madam Minister, but I'm sure that issue might be raised as well.

Interjections.

The Chair: Oh, is that a procedure? It sure didn't feel like a procedure; it sure didn't hurt like a process either.

We have completed the opening statements. Madam Minister, we're now in your hands and you have up to half an hour to respond, and that will take us very close to the point at which we'll be ready to adjourn, hopefully.

Hon Ms Lankin: Let me start by saying that I appreciate the thoughtful comments that were made, and even though some of the comments, I would suggest, are perhaps overly provocative and unfounded I'll respond to those. I think by and large much thought has been put into the comments members made, and the concerns you've raised are legitimate concerns about which we need to be always vigilant that we are addressing and keeping in the forefront of our approach to reforming the health care system and meeting the needs of the population. I appreciate your opening comments and will be interested in following up with you on many of the points you raised in detail when I receive your more detailed questions.

A couple of things: If I could just start where we were finishing off and correct the record yet again, although people don't seem to want to absorb the correction of this record, I would say to the Chair that I never made an announcement that vasectomies would not be paid for. so reference to an announcement made is not correct.

May I say to Mrs Marland that the deputy minister in fact has never, ever made a comment that we would not pay for bypass surgery for elderly citizens of our community? I know there have been many press reports speculating and stating that it has been said, but it was never said. I think what happens sometimes in our system is that when questions are raised people extrapolate answers from that and run with it and create concerns where concerns shouldn't be. We have never said that we are thinking of not paying for bypass surgery, and it's not even something that I would suggest is the approach to take.

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What we have said, and this would apply to all sorts of issues within our health care system, is that it is important that in our health care system we start evaluating the health outcomes of the resources we expend. So, for example, we have invested, along with the Ontario Medical Association, in the establishment of the Institute for Clinical Evaluative Sciences for us to try and get some very good epidemiological results to support decision-making with respect to expansion of programs or shrinking of programs we have.

What are the health outcomes of the moneys we expend? I think we can always find exceptions and we can always find even emotive arguments to put forward as figures to say: "Don't even look. Don't touch, don't think, don't question." I don't believe in our health care system today we can continue on saying, "Don't think, don't look, don't question." I believe we do have to have some very concrete data to be able to help us make decisions in the future.

I hope to be able to assure you today and as we go through further questions you may have that I am not on the verge of making, as you accused -- this was not a question; you accused -- God-like decisions. That's not the approach I would take to delivery of health care services.

What I think we do have to do, though, is reform our decision-making so we do needs-based analysis, we try and deliver services to meet those needs, we evaluate the services we are delivering to see whether they're meeting the needs, see what the health outcomes are and apply that kind of rigour in planning.

That's going to take us a while to get to. I don't think we should be making precipitous decisions along the way, and I hope to assure you of that, but as I've said on a number of occasions, I don't want to be deterred from being able to ask questions about what we're doing in our health care system, about the appropriateness of some of the things we do, and allowing us, with the medical professions, other health care providers and consumers, to discuss appropriate health care services and the priorities we have. Those discussions will unfold over a much longer period of time than short-term decision-making.

I take your point that there's much concern about the speculation that has been out there in the community and the press, and I don't underestimate that concern. I think it is a very valid point for you to raise and I hope to assure you that my approach will not be to precipitously make decisions around delisting of massive numbers of services or around age cutoff for accessing services. That's not the approach we will be taking. Decisions that we will talk to people about or recommendations we will talk to people about will be based on good health epidemiological data which will, I think, provoke debate among people.

To give you an example, the work that was done around guidelines for cholesterol testing: That wasn't a situation of delisting anything, but it was a suggestion to the medical profession that the kind of cholesterol testing numbers and volumes we had been seeing in Ontario and the escalation of that had much more to do with the marketing of this kind of testing and the fad of a preventive health notion that went along with that when in fact it didn't deliver with respect to a preventive health care initiative and there were very good epidemiological guidelines that could be developed which we hoped would sway provider patterns of practice with respect to ordering these kinds of tests, helping people avoid going through unnecessary tests, educating them about ways to remain healthy and to be able to avoid cholesterol problems, telling them when they would be appropriate candidates for screening of cholesterol problems and having a cost-effective delivery of service as opposed to a wide-open, "My gosh, I've got to get my cholesterol tested; let's go in there," and we see all of a sudden a huge increase in volume of tests for which we don't get good health outcomes back as a result. That kind of questioning I think is really important for us to be able to undertake.

Margaret, to continue on with the issues you raised around long-term care and particularly your comments around persons with disabilities in that community, I agree with you completely. We heard in spades during the consultation that the community felt the document and felt government policies were missing the boat with respect to understanding the unique situation and needs of persons with disabilities. The access to a long-term continuum-of-care system for persons with disabilities needed to be thought of in a different framework from our seniors. There would be parts where there would be similar services accessed, but particularly the issue of individual control and self-direction of access to services by persons with disabilities was very strongly articulated. We've heard that, and in our consideration of the recommendations coming out of the consultation we're looking at what we can do to try and address that through policy development. I agree with you. I did hear that and the other ministers heard that. We are trying to address it.

You also mentioned the issue of persons with mental disabilities and particularly the spokesperson from the Ontario Association for Community Living. Their voice was heard during the consultation and in fact long-term care redirection doesn't address their needs. That's right; the direction wasn't designed to. It was designed to look at seniors and persons with disabilities, but not the broader group currently under the Comsoc umbrella in terms of the association for community living establishments, residences and persons with mental disabilities. The other group this doesn't address is medically fragile children. Those are policy problem areas for the government.

Mrs Marland: But they do require long-term care, don't they?

Hon Ms Lankin: Yes, and I think that as we envisioned long-term care both in government generically -- I'm saying in the previous government and in this government -- and as we've talked about it in society we have focused on the two groups that have been the most readily identified users of long-term care services and the ones we can start to build a system for. I think it's important for us to acknowledge that the plan we have been working on and the moneys set aside do not address these other two groups, and government will have to find a way to develop public policy around this.

The issue of medically fragile children in particular -- the demand to bring children home from institutions; to keep them at home; to have the in-home nursing support; the strain on public resources that you could envision if we met the demand in terms of the numbers; the very real policy issues of keeping families together and of trying to deal with these situations to allow families to provide for family members, children in particular, and their other children; also to try and deal with the real issues around the quality of life in an institution versus a home, palliative care in some circumstances -- there are a lot of issues that have not been addressed in government policy.

I am not in a position to immediately move to address those, but I think they've been brought home very clearly in this consultation and in the events of the last number of months around some experiences with individual families that we have seen. I think it's a troubling area of public policy that government needs to find a way to address, and we need to be talking about how to do that.

If I could respond to some of the comments the critic for the third party raised -- Jim, let me say I found it hard to follow some of your comments because --

Mr Perruzza: That's an understatement.

The Chair: Excuse me, Mr Perruzza, please. You weren't even in the room for most of it. I'd like you to please cooperate with this committee.

Mr Perruzza: For most of what?

The Chair: For Mr Wilson's comments.

Mr Perruzza: Mr Chairman --

The Chair: I'm not asking you to comment.

Mr Perruzza: On a point of order, Mr Chair --

The Chair: You have a point of order? What is it?

Mr Perruzza: My point of order is that you're levelling what I think is an unfair accusation. I was in the room for Mr Wilson's full discourse.

The Chair: That is not a point of order. Mr Perruzza, please. It's constant with you. I'd appreciate your cooperation.

Mr Perruzza: I'd appreciate yours, quite frankly, and I think it's a little unfair for you to say stuff like that. You weren't in the room.

The Chair: Mr Perruzza. Thank you. Please proceed, Minister.

Hon Ms Lankin: I mean this genuinely in that I think there are contradictions in some of the things you have said. Perhaps as we go through the questions we'll be able to work through some of this.

Mr Jim Wilson: My correspondence doesn't always come in in logical order.

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Hon Ms Lankin: I'm sorry. In fact, you did indicate that your comments reflected a large range of views you have heard and that they were not necessarily your own. I'm glad you reminded me of that because I think that's fair. Let me say, then, not your criticisms but I think some of the comments we hear in terms of people's concerns, some of which you've reflected, contradict each other. If they come from a wide range of sources, that's to be understood.

Perhaps I'll just go through and point out some of those contradictions. They would therefore present to me issues that we need to try to resolve and determine ways of going, but for example, I think you did indicate that the Progressive Conservative caucus felt very strongly about saving jobs in the hospital sector, and you tied that concern to what I found to be an amazing statement about your concern that if workers in the hospital sector continued with -- I'm not sure if you used "excessively" or "outrageously high," or there was some adjective therein describing the wage demands as high.

I wonder where you're getting your information. In fact I have a fairly good idea where you may be getting that information, and suggest to you that you dig behind and find out what has actually been happening in negotiations in this province. If you followed debate in this, you'd see that the workers, represented by their unions, have been voicing publicly their desire to find negotiated settlements in which they're willing to settle for very low wage levels, and they're looking for movement from their employers on issues of job security and trying to address some of those real concerns.

Those are the sort of tradeoffs that I think are very constructive in the kind of leadership government has tried to provide, both in its own negotiations and in its suggestions to public sector partners in restructuring dollars being available to try to address that. It takes two to tango, and we haven't seen much dancing happening at this point unfortunately.

I find it interesting also that you go from there to say immediately, therefore, that the Progressive Conservative caucus suggests that what needs to happen is imposition of wage controls. Presumably you didn't suggest that we should go out and consult with the workers about doing this, but you lambasted in your comments again -- I think you said from the Progressive Conservative Party as opposed to the other concerns that people may have written to you about -- what you call lack of consultation with commercial labs; what you call lack of consultation with pharmacists.

You're concerned that we froze fees for pharmacists, yet you're willing to simply suggest: Go out and legislate wage controls. You're concerned that we have restructured the way in which we're making payments to commercial labs, and yet again, it's fine for us to go out and legislate wage controls. I would suggest that there are contradictions in your position.

Now let me deal with the concerns that are behind --

Mr Jim Wilson: No, it's wage controls versus do you want your job or do you want more money.

Hon Ms Lankin: Mr Wilson, at this point in time I do think that I have the opportunity to respond to the comments that you made.

The Chair: Mr Wilson, through the Chair, please.

Hon Ms Lankin: Just let me pick up on the point that you made. I think government has said very many times that what would be desirable is a balanced result in collective bargaining which produces low wages but which gives workers some sense of job security. We've attempted to facilitate that with the worker adjustment fund. It has to be a negotiated settlement in which parties are willing to negotiate.

I think, Mr Wilson, that if you're suggesting a legislated solution, the solution needs to be to the problem. If workers are suggesting that they're willing to settle for low wages, then wages aren't the problem. Perhaps you need to look at what is the barrier to getting an agreement if it's on job security. Maybe your caucus would like to suggest that we have a legislated job security package that might resolve situations out there. I don't hear you saying that.

The Chair: We will be doing Labour estimates some time in the future, Minister. We should stay with the Health estimates.

Hon Ms Lankin: That's a helpful suggestion, Mr Chair, and I will follow your lead on that.

With respect to commercial labs and pharmacists and your comment about consultation, I want to assure you that there are processes going on in both areas in which those parties are involved. We have initiated a review of the laboratory sector and the commercial labs. Last year we had suggested a certain revision to the fee structure. They came with alternative suggestions. We implemented their alternative suggestions, so it's incorrect to say that there haven't been discussions.

What we have now is a situation where we believe there is room for restructuring of the kinds of payments to the commercial laboratory sector to allow for discounting where there is high volume, where there are lower unit costs as a result of consolidation, new technology, other sorts of things in the commercial sector. We think there should be a share for the taxpayer in that it's not just a move for profit generation, and that's the move that we've taken, but we do hope that in our discussions with the commercial laboratory sector and the hospital laboratory sector through the lab sector review that in fact we will find many other useful suggestions from the sector that we will be able to work with it on implementing.

With respect to the Ontario drug benefit program and pharmacists, I indicated in my remarks that the drug utilization review is being initiated with a task force round table group that will be representative of the generic drug industry, the brand name drug industry, pharmacists, the medical profession, consumers, seniors, nurses. We have a broad range of people who are coming around that table who are part of that, so that consultation is there.

You suggested that we didn't want to be seen to be acting on Lowy because it was a Liberal report. Quite the opposite. I think there are many very important recommendations in Lowy, many of which we've already started to implement, we've implemented last year and we're in the process of implementing and will continue, and also from the process of discussion and consultation with our partners further recommendations, I'm sure, will come forward that we will include in that. I don't see any benefit to the people of this province to take some kind of a macho approach that we don't build on good ideas of former governments. It's not the way I operate in this position, and I think I have made that clear with respect in particular to the Lowy report on a number of occasions.

You also commented that not everyone was pleased with the thrust in terms of long-term care. I'm surprised to hear that, because in fact what we heard when we went out on the consultation was a tremendously high agreement with the philosophical thrust of what was being suggested in the general principles. There are criticisms with respect to certain aspects of the proposal, and I acknowledge that, particularly the structure of service access agencies, service coordination agencies, what role they play, whether or not they duplicate other structures that are already delivering service, whether they become a barrier, how do you coordinate single access points but without taking away from the role that's already been established in communities -- there are tremendous concerns about that.

There are other areas that as we do some of our policy work I'll be able to inform members of the Legislature with respect to the concerns we heard. We'll be releasing a document we're working on now to send back out to people of what we heard them saying in the consultation to combine the results from across the province, so you will see those criticisms outlined. I do agree that there are criticisms, but I think it is important for us to realize that the basic thrust of the proposals in fact has met with very wide approval.

Also you made some statements that we now run the risk of being turned away at the doors of our hospitals, especially for specialty services. I think as we get into the vote-by-vote considerations you'll need to be much more specific about what your concerns are. In fact I detailed in my opening comments a $49-million enhancement to many important specialty services, the creation of new registries to try and have in-province referrals to better utilize our services and the way in which we have managed waiting lists for many specialty services.

In fact the exact opposite is the truth of the situation, yet it's very easy to perpetuate this myth that somehow, because acute care hospital beds that are no longer needed in our communities are being phased out, there is lack of access to services or there are huge waiting lists. The data don't support that, so I think it's very important for us to be specific. I'm referring to your comment that in communities there is a risk of being turned away at the door of the hospital, especially for special services, which I've written down directly from your comments.

With respect to ambulance services, I appreciate the comments you've made and the concerns you've raised. As you know, the Swimmer report is currently out being responded to by communities at this very time. I expect a final report from Professor Swimmer with any changes to his recommendations in about a month's time and I'll be in a position to respond at that point in time with respect to government intent on the recommendations.

Children's mental health services: I agree with you completely that it is a major area of policy in delivery of service that needs to be addressed. I remind you that perhaps you should be addressing it under the Community and Social Services estimates, that the majority of the services are delivered in Comsoc, not in the Ministry of Health.

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I see one of your political aides shaking her head, but in fact children's mental health services are delivered through Comsoc. You might want to check that out. Psychiatric services are delivered through the Ministry of Health and we have a problem in the delivery of those services. I think from our experience with the out-of-country referrals -- this will be interesting for people; I'm not sure that we had a general awareness of this -- as we see the requests for prior approval to go to out-of-country services, the issue of children's psychiatric services becomes clear, the gap that exists in the Ontario delivery service network. It's an area we need to move on and to act in a much more coordinated way with Comsoc.

I am pleased to tell you that the Minister of Community and Social Services, the Minister of Education and myself are developing a coordinated approach towards the delivery of these services because they do cover three portfolio areas, although right now the major responsibility is within Comsoc.

In response to the critic for the official opposition, could I just, before I start into this, check on how much time I have?

The Chair: You have five minutes.

Hon Ms Lankin: Then I'll have to give most of my responses to the remarks from the official opposition as we get into the specifics of the questions and the vote-by-vote.

I want to say to both critics that on your request for more information on federal transfers in relationship to the Canada Health Act, we'll be pleased to provide it. I would ask you to look at the actual transfer to hospitals this year. You've both referred to the 1%. One per cent was the economic adjustment to the global budget, so the transfers this year have increased by 3.4%, and those are to address growth pressures, to address program pressures, and those are important transfer dollars as well that become targeted dollars as opposed to just general global budget adjustments. I think we will need to look at that.

I appreciate the comments of the critic of the official opposition with respect to labour adjustment in relation to services in the community, training for community jobs, new jobs in the community. You expressed a concern that the fund wasn't flexible enough perhaps to address that. We think we can address those very issues working with the stakeholders around the table, identifying the kinds of job growth in the community sector and funding appropriate retraining. That training could be provided through the Victorian Order of Nurses or through those other agencies.

As new jobs are being created in the community and new organizations are being established for delivery of care, we've also been looking at the issue of our ability in those communities to assist the transfer of people from institutional jobs to fill those new jobs that are being created. We think that's a responsibility and a challenge that we should be attempting to undertake and we are currently in discussions about that.

Your comments about various health system reviews and how long it takes to get responses from the ministry is a true echo of what I hear when I go around the province and deal with people's concerns. I would just comment that their concerns for this haven't just begun in the last couple of years; this has been a chronic problem with respect to asking communities to jump through hoops of planning and then not having the ability or the capacity to be able to respond to it.

I think that through our attempt to reorganize the ministry in terms of bringing together the major groups that can deal with health planning and strategic planning and being able to revamp the way in which our institutional planning is working to relate to the health systems planning group, we are hopefully going to start to address that and be able to respond to communities in a much more expeditious fashion. I think that concern is a very valid one and it's one I share.

There are a number of other things we can get into in detail with respect to the database study for physicians. You talked about CHEPA. There was work that had been done at the University of Toronto before that that we've looked at. We can answer some of those questions.

I want to particularly comment, however, on your remarks about health service organizations, and I understand. If you listened to the comments raised by the Caroline group, a group practice, I understand the nature of your concerns. I think there are many very good group practice HSOs, which we've tried to address through the course of the discussions about renegotiation of the HSO contract, but you yourself talked about the importance of a multidisciplinary approach being delivered through HSOs.

In fact, what we found out when we examined the program was that outside of the few group practice and community-based practice HSOs that were there, that were innovative and were delivering programs through a multidisciplinary mix, the majority of the growth in the HSO sector were solo practitioner practices that didn't meet the goals of the program, even the way in which your government had designed that. In fact, they were costing us, on average, more than a fee-for-service physician. We were seeing that incentives under the ambulatory care incentive program were being paid out to those physicians for people who were being prevented from going into the other system by virtue of the case load that they were carrying.

We have renegotiated the contract with the HSOs. I hope that when it's ratified and you see the results of that, you will agree that there is a tremendous support indicated by that agreement for the concept of alternative payment and delivery of community-based services with a multidisciplinary approach. I'm hopeful that by the middle of this month, following ratification, we'll be able to share the results of that with the House.

Mr Chair, with a five-minute bell running, I'll close my remarks at that and indicate that as we receive questions and notice of questions from the members, and their order of preference, we'll do our best to have staff available to respond to those questions over the course of the remaining hours in this estimates review.

The Chair: Before everybody races away I have one short announcement, and that is that it would helpful if we were able to start on time tomorrow. I ask all members if they could please be here. Second, we need to give consideration to ordering up the process of how we'll proceed, whether it'll be by time allocation or open questions. Would the members consider that and advise me before the committee hearing starts?

This meeting is now adjourned to reconvene at 3:30 of the clock tomorrow.

The committee adjourned at 1746.