Legislative Assembly of Ontario

MINISTRY OF HEALTH

CONTENTS

Wednesday 28 July 1993

Ministry of Health

Hon Ruth Grier, Minister

Jessica Hill, director, community mental health branch

Margaret Mottershead, assistant deputy minister, health system management

Patricia Malcolmson, assistant deputy minister, corporate management and support

Dr Richard Schabas, director and chief medical officer of health, public health branch

Mary Catherine Lindberg, head, drug programs reform secretariat

Michael Ennis, assistant deputy minister, population health and community services

STANDING COMMITTEE ON ESTIMATES

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

*Acting Chair / Président suppléant: Villeneuve, Noble (S-D-G & East Grenville/S-D-G & Grenville-Est PC)

Vice-Chair / Vice-Présidente: Arnott, Ted (Wellington PC)

Abel, Donald (Wentworth North/-Nord ND

*Bisson, Gilles (Cochrane South/-Sud N)

Carr, Gary (Oakville South/-Sud PC)

Elston, Murray J. (Bruce L)

*Haeck, Christel (St Catharines-Brock ND)

Jamison, Norm (Norfolk ND)

Lessard, Wayne (Windsor-Walkerville ND)

Mahoney, Steven W. (Mississauga West/-Ouest L)

Ramsay, David (Timiskaming L)

Wiseman, Jim (Durham West/-Ouest ND)

*In attendance / présents

Substitutions present/ Membres remplaçants présents:

O'Connor, Larry (Durham-York ND) for Mr Lessard

Sullivan, Barbara (Halton Centre L) for Mr Mahoney

Wessenger, Paul (Simcoe Centre ND) for Mr Wiseman

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

Also taking part / Autres participants et participantes:

Morin, Gilles E. (Carleton East/-Est L)

Villeneuve, Noble (S-D-G & East Grenville/S-D-G & Grenville-Est PC)

Clerk / Greffier: Decker, Todd

Clerk pro tem / Greffière par intérim: Grannum, Tonia

The committee met at 1534 in room 151.

MINISTRY OF HEALTH

The Chair (Mr Cameron Jackson): I'd like to call to order the standing committee on estimates. We've reconvened to continue the estimates of the Ministry of Health. We have approximately five hours and a bit remaining. Although our rotation will cause us to recognize the governing party in a moment, it's our custom to ask if the minister and/or her staff have any responses which they can share with us, either in print form or verbally, before we commence today's session.

Hon Ruth Grier (Minister of Health): I have answers to some of the questions, I think most of which came from Mrs Sullivan, which I can give you today, and then I'd be happy to give you the script so that the clerk can make copies for everyone.

Mrs Sullivan had asked about the regulations under the Consent to Treatment Act, the consultation on that and who might be involved in that consultation. I'm pleased to be able to tell her that once those regulations have been drafted, they will be distributed widely for consultation.

In addition to various associations, health practitioners and others, they will go to all of the colleges of regulated health professionals, all of the associations of health practitioners, the Ontario Nursing Home Association, the Advocacy Centre for the Elderly, the Advocacy Resource Centre for the Handicapped, Justice for Children, Ontario Friends of Schizophrenics, the Canadian Bar Association, the Canadian Civil Liberties Association, the Patients' Rights Association, the Alzheimer Association of Ontario and Dying with Dignity.

Of course, for any other association or individual who might be interested, we'd be more than happy to add to that list. There will then be ongoing discussions with respect to the draft regulations themselves.

Mrs Barbara Sullivan (Halton Centre): Mr Chairman, on a point of order: If it will save the time of the committee, we're prepared to accept the written response rather than having it necessarily read into the record.

Hon Mrs Grier: I had thought they might provoke supplementaries or that the committee would generally engage in --

The Chair: I had advised the minister that she briefly comment on the material while the clerk was preparing it. That was a point of assistance to the committee and it's duly noted. We will get that photocopied and distributed. Were there other items, Minister?

Hon Mrs Grier: Yes. There was a question with respect to the Ontario Research and Development Council of Ontario: just to confirm that no decision has been made on the funds, but I have something here with respect to the nature of the review that's being undertaken.

The other one we have available is with respect to the elimination of the clinical clerkship stipends. The question had been about the status of that. We have some data with respect to the cost of that program and an indication that in April 1993 all of the hospitals, the faculties of medicine, the student organizations and stakeholders were informed about the change in the stipends. I need to make a change in one of these answers, and then when we get that done, I can give them to the clerk for copying.

The Chair: Thank you very much, Minister and staff. That was helpful. Perhaps I then might move to Ms Haeck.

Ms Christel Haeck (St Catharines-Brock): I know the minister is somewhat aware of my comments because of issues that we've raised in our own caucus meetings, which obviously are confidential, but she knows my views on these issues. I find it enlightening that some of these views are shared beyond myself with members within the opposition parties. Mr Conway and Mr Runciman actually made reference to them last evening.

I guess for me personally I found it an illuminating exercise, the process of going through the regulated health professions hearings, because we had so many different health practitioners come before us and talk about their specialties, making it very clear how they all fit together in servicing our constituents and obviously ourselves.

Mr Runciman last night or during yesterday's debate made mention of what he called a physician's assistant. I know Mr Conway and others, even within our own caucus, people like Dr Bob Frankford, have long advocated nurse practitioners, addressing whether it's underserviced areas or just generally assisting in offices. I am personally concerned, because I think Niagara really does many times qualify as an underserviced area.

I'm just wondering what headway we're making in looking at alternative ways of delivery. It's not just doctors or nurses, but I'm also looking at the case of, say, speech-language pathologists. We have a real shortage of those in the province.

Have we been negotiating with the colleges and the profession to see how those fields can be opened up in a way that those deliveries can be achieved? I know in Niagara we need speech-language pathologists. We need physiotherapists. I'm quite sure that's true not only for the doctor side of the equation, but for a range of other specialties as well.

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Hon Mrs Grier: Yes. I think the member raises two issues in that question. One is the whole issue of underserviced areas and how we try to provide the appropriate resources to deal with areas of the province where, quite frankly, the fee-for-service free market system has not worked in attracting physicians to those areas. The other question the member touches on was one on which we had an interesting debate in the Legislature last night around Bill 50, where the member for Leeds-Grenville talked at some length about physician's assistants.

Let me deal with that one in the context of other professionals first, because in my response to Mr Runciman's comments last night, I indicated my broad support for nurse practitioners as a professional within the health system that I believe is underutilized. Mr Runciman corrected me and said that physician's assistants had a much broader scope of practice than did nurse practitioners and that they were not one and the same. So I stand corrected on that.

On the general issue of the more appropriate use of other professionals within the system, I see the Regulated Health Professions Act as being a critical component of enabling us to both make more appropriate use of the skills, the talents, the experience of other professionals as they become self-regulating professions, and also to try to get broad support for the fact that there are many health problems where the doctor is not necessarily the only game in town, or even the most appropriate one.

I always make much of the fact that as the client of a community health centre myself for many years, and as somebody who is at this point healthy -- touch wood -- when I need to make an appointment, I seek an appointment with a nurse practitioner. Should the nurse practitioner find there is anything that needs to be done, she then refers me to the doctor. That's an entirely appropriate use of a hierarchy of professionals that may well lead both to doctors having more time to concentrate on serious illnesses and also a better use within the financial structure by the professionals. So I see that happening. I see it happening through the RHPA. I see it happening through the expansion of alternative payments plans, of which community health centres are one, where the whole philosophy is that you work as a team and your remuneration is based not on how many people you see in a day, but how you work to meet the needs of those people who are there. I see that as beginning to happen.

With respect to underserviced areas, as the member knows, governments for decades have been struggling with that. I think the work we have initiated as part of the joint management committee with the OMA, and through that the creation of the task force headed by Dr John Evans and the subgroup of that headed by Dean McMurtry from Western, is going to, I hope, give us some help not just in a quick fix or a monetary solution to the problem, but in looking at the structures and making some fundamental changes.

I have confidence in that because the people who've been looking at the issue under the auspices of those committees have for the first time been more than the ministry and the OMA. The district health councils, the academic health science centres, the interns and residents themselves have been brought into the discussion.

Doing that, and at the same time putting more emphasis on district health councils to do the health care planning in a region will, I think, lead to solutions that are more than merely counting the number of doctors and then identifying whether there are too many or too few, but may in fact begin to identify what does this area, this district, this community actually need to meet their specific health care requirements? How then do we get those professionals into our community? How do we provide those professionals with the backup, the resources and assistance that will make them feel comfortable in that kind of a practice and stay there?

Ms Haeck: I must admit that I think Niagara's health council has actually done a commendable job in most areas that it's addressed. I have to say that when I moved to St Catharines in 1977, fairly shortly thereafter the district health council, along with the hospitals, managed to put parochial wars aside and do an awful lot of coordination locally of a range of services. So the Hotel Dieu is no longer doing obstetrics, it's actually being done at the St Catharines General, and life support is being handled in various hospitals, but it's been very strategic. In the case of the Hotel Dieu, it's doing cancer, dialysis and a number of other things.

The kinds of discussions, and they are sometimes very heated and sometimes even -- to use a pun, but it's not meant in any nasty way -- a bloody war between hospitals is not exactly what one likes to see, but one is aware that they do exist. Our local health council has actually done, I think, a commendable job in making sure that we are doing a number of things, and I think we've done them well for some time. But the issue of the underserviced areas still somehow eludes them, as it has eluded other people.

I want to address an issue that is close to my heart, partly because the St Catharines General Hospital is within about a block of my office and the psychiatric wing is part of that hospital. We see a number of ex-psychiatric patients who are clients, as well as seeing them on the street.

Around some of the mental health strategies that are coming forward, I'm wondering how we're going to be able to deal with some these folks a little more readily. I understand that this is all jelling at this present time, but I know there is a great need in all our communities, and I would appreciate your comments, because I know there is that need.

Hon Mrs Grier: I'm glad to have some discussion about that, because I know it's certainly a priority, and we mentioned it briefly on the first day. As members will know, we've released our mental health reform paper, and I may ask Jessica Hill from the ministry to speak in more detail.

Let me just say that I think what we have begun to do for the first time is to create a framework so that everybody knows what the ministry's approach is. That approach is that we have to deal first with the most severely mentally ill, that we have to look at the whole spectrum of services and that we have to set ourselves some definite targets with respect to number of beds per population and some time lines at which we can reach those targets.

To repeat my own very personal commitment, having lived through the closure of a psychiatric hospital in my neighbourhood without a buildup of community-based services being in place to deal with that, before there is any dramatic shift or closure, we have to work on developing the community-based services. But Ms Hill is here, and perhaps if I could ask her to come forward and identify herself, she might be able to expand on the mental health strategy and give you some sense as to where the general hospitals and their role fit in the planning that's now happening and to the framework.

The Chair: Ms Hill, please identify your position with the ministry and proceed.

Ms Jessica Hill: I'm Jessica Hill. I'm the director of the community mental health branch. Can you phrase the question in terms of the hospital issue for me?

Ms Haeck: We are seeing, let's say, the number of psychiatrists working in hospitals decrease. There's definitely a regular threat of fewer psychiatrists working within the hospital environment. I know there are a number in private practice, but they are not necessarily working in the hospital setting.

The number of follow-up programs that are available locally really don't tend to meet the needs of someone, at least from the user's point of view, when he's left either Hamilton Psychiatric Hospital or Hamilton General Hospital. There are a range of services that they really could make use of, but they're not necessarily available locally. Anything that you can provide from your experience that does work in a community like St Catharines, which has a population of 130,000, would be appreciated.

Ms Hill: Okay. I think there are several aspects to your question. The first is that we have identified what we're calling key services that need to be available in the community that make a difference in terms of providing essential supports to those living with a severe mental illness. Those are case management services, housing support services -- housing itself and support services to housing -- crisis intervention and support to consumer survivors through self-help and economic development, as well as support to families.

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We've identified these largely from looking at other jurisdictions that have implemented mental health reform, and the theory essentially is that you turn off the tap of admissions to the provincial psychiatric hospitals through the provision of these key services in the community. Now, to do that, given that we're in an environment of reallocation, we're going to be working through a planning process with district health councils, the provincial psychiatric hospital in your region, for instance, the general hospitals in your region and the community mental health agencies that exist, to look at ways in which these services can be further developed. Often there is a little bit of one service or one well-developed service but you don't have the full configuration.

All the provincial psychiatric hospitals have undertaken strategic planning and have been in a process of moving programs into the community. What the framework does is it provides a focus for where the services need to move and, through a planning process, both the programs will be enhanced and the workers will move from the provincial psychiatric hospitals into providing more community service, which has already started.

Ms Haeck: I know Mr Wessenger has got a couple of questions, but I just want one follow-up question, if I may. Hamilton Psychiatric: We basically fall into its catchment area, and I understand we make up about 30% of its workload and yet we get about 11% back.

Ms Hill: Right.

Ms Haeck: One of the concerns has been that if you live close to the hospital, basically you're going to get the service, and if you live, as my constituents do, at least 45 miles -- I'm sorry, I don't know what it is in kilometres -- away from that hospital, you're just not getting the same sort of follow-up programs. Are those actual programs going to be housed in St Catharines as opposed to someone occasionally coming from HPH?

Ms Hill: Yes. The answer is that there would be actual programs moving into the region. I think there are a number of planning challenges. One is that we hope to move to a point where the provincial psychiatric hospital catchment areas are better aligned with district health council regions, and there are six planning regions. The whole period of reform is 10 years, so we don't expect these things to be accomplished in the short run.

However, I think the provincial psychiatric hospitals recognize themselves that historically what has happened is that the buildup of programs has been in the centre, where the hospital is, and that the challenge now is to move the programs much further into their own catchment areas, and that has been done. Brockville has a program in Ottawa, for instance, and we'd like to see more of that development take place, based on the local planning needs.

Hon Mrs Grier: Let me just add to that. Thank you, Ms Hill. The provincial psychiatric hospitals have all, over the last year, year and a half, done strategic plans for their own futures and so have the district health councils. A first step in implementation of mental health reform has been a request that those plans be integrated based on the regions within the Ministry of Health.

In everything you do, you get into, what's the catchment area? Is it the district health council area? Is it the regional municipality? Is it the catchment area of a psychiatric hospital? The decision was made that it be the six Ministry of Health planning areas where the mental health planning would be done, as opposed to long-term care, which is on the district health council basis. The integration of those plans, I see, will begin to identify precisely the kinds of gaps that you've mentioned, whereby the services may be clustered around the institution and the rest of the catchment area left fairly empty.

The Chair: Mrs Sullivan, please.

Mrs Sullivan: Before I begin, I'd like to have Mr Morin present a question.

Mr Gilles E. Morin (Carleton East): Minister, I have a question on Bill 44. It's a bill that I introduced in June and it's An Act to amend the Health Insurance Act. I wished to debate that bill tomorrow, but for other reasons it was postponed. I hope to have the opportunity to debate it some time in September.

Bill 44 recommends a new health card, complete with photo and expiry date. It would also contain the cardholder's sex and date of birth. This bill specifically addresses the concerns that were raised by the Provincial Auditor. Its aim is to provide the ministry with accurate registration information and to weed out ineligible cardholders. The expiry date and proposed four-year cycle would assist the ministry by providing regular updates of information.

Mr Decter recognized before the public accounts committee last February that the highest inaccuracy in the database is on addresses, and that is a real problem. Mr Peter Burgess also referred to the need to clean up the existing address data.

It is clear that the health card I propose would greatly contribute to the control of fraud and misuse of the OHIP system. By requiring registration on a regular basis, it toughens the process leading to the issuance of a health card. You will agree that we need more rigorous identification guidelines, not to exclude the citizens entitled to health care in this province but to make it more difficult to defraud or misuse our health care system. The whole process of providing a photograph and proof of identity is part of the solution.

I have heard that the officials in your ministry support Bill 44 in its intent and thrust. I met with the OMA. I met with the College of Physicians and Surgeons. By the way, it's the first time ever that they have come out publicly and supported a bill. I also have the full cooperation of the Ontario Hospital Association. I have written to all of them and the responses are coming in every day supporting the bill.

So will you also express your support for this legislation, for its objectives, and are you prepared to implement Bill 44 as a measure to control misuse, cut losses in the long term and improve the administration of the OHIP system? If you do not support Bill 44, what do you intend to do instead?

I must point out I had a lot of experience with another bill, which is still waiting in third reading, and God knows how long it will take before it proceeds.

The Chair: We'll raise that during the appropriate estimates. Thank you, Mr Morin.

Mr Morin: Yes, I know. I'm just saying that a bill is never perfect, but the intent is to make sure that we present it and that we fine-tune it afterwards and that debates take place. That's where the real action takes place. My bill is not perfect. Nothing is ever perfect, and you know that. So where do you stand? What do you plan to do? Do you agree with my bill? Can I count on your support?

Hon Mrs Grier: Well, let me start, and I think there are some officials here from the ministry. I don't know whether there's anyone here from OHIP today, but I know Ms Malcolmson is here, who might be able to comment on it as well.

I don't need any convincing that we have to look at the existing health card, but I'm sure that Mr Morin, as a member of the government that brought in the current card, will recognize that to bring in such a system is difficult, not cheap, and complex. The decisions that were made three and a half years ago to bring in a very simple card -- I mean, people were asked their name, age, address and citizenship and that's all_were based on the fact that they didn't want to exclude anybody.

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I think now we recognize that we have to have a much more rigorous identification process before a card is issued and we have to make the card more secure. A decision was made that this was the most cost-effective card to bring in, and I think it was perhaps a case of being penny wise and pound foolish and it's now time to look at what form we could do.

I certainly support the intent of Bill 44 and I have already asked the ministry to develop some comprehensive proposals that I can review and that cabinet wishes to review with respect to health cards and to identify those areas where in fact legislative support is required in order to establish a new card. Many of the ideas in your legislation are indeed under consideration by the ministry.

Our support for your bill categorically today gives me some difficulty and I'm not prepared to say, "Yes, I support your bill." I appreciate very much the fact that you understand that as a bill goes through there's room for changes. The primary difficulty that ministry officials have identified with Bill 44 is the lack of flexibility, the fact that you're putting into legislation things like dates by which the card has got to be issued and the fact that people have to sign when they receive the card.

We believe it might be much better to do it as a credit card: you sign your card so that there's a signature on the card that can be matched with another piece of identification. But I think those are administrative details that we would need to work out, where perhaps they might more appropriately be placed in regulations as opposed to being put in legislation.

There are also a number of things that we think we might want to look at on the card such as a date, or an expiry date, which your legislation doesn't provide for. I make that point that if we in fact describe in legislation the nature of the card and we find that there is something that we ought to then add to the card like the version codes that we've now brought in on the existing card, it would require a change in legislation to do that and I'm not sure that's the best approach to take.

There are a number of operational details that we should look at and with new technology, which is changing all the time, I want to be sure that if we are going to change the card, we put in place a card that will last longer than the three years it has taken to prove that the card your government brought in isn't in fact the right one to do the job because it's going to be very expensive.

I guess one further difficulty with your legislation is that it prescribes a specific date on which new cards have to be issued, and I think probably what would have to happen, if you are going to do a changeover, is a gradual changeover, that perhaps you identified that as new cards were issued you began with the new card or then you did it with all seniors. But to have sort of a moment in time when a current card no longer operated and a new one would only be accepted would be an administratively very difficult thing to do as well as perhaps making even greater risk that some people might find on a particular day they didn't have the card.

Mr Morin: What you're saying, of course, is -- you're confirming what I've just said -- no bill is ever perfect. My concern is that we have a population in Ontario of 10 million people, we have 10.5 million cards floating around. I'm told that for every 700 cards, it costs the government over $1 million. Divided by 500,000, you come to a figure which is astronomical.

I believe that in the context of today it's not a question of blaming who has done whatever was done. Ms Lankin herself said that had she been in that same position she would have accepted the system. The important thing is that we're facing a problem right now, we cannot delay. Sure it's going to be costly, everything is costly, but at the same time if we invest an amount of $70 million to $80 million in order to save $1 billion, I think it's a very good investment.

All you have to do on a bill such as the one I'm introducing is to add a regulation to it, as simple as that, but to bring it forward and discuss it. I wish I could discuss it further, but I don't want to intrude on the time of my colleague.

Hon Mrs Grier: I think it's a really important issue because I know that the public accounts committee has been dealing with it and it was one that was raised by your colleague in opening remarks to this committee, and if we're talking about the expenditures of the Ministry of Health, it's critical that we look at that passport to that system, that we all are very concerned about if it's being misused.

I didn't work out what the formula for misuse that you identified would produce, but I certainly accept the estimates by the ministry that we're looking at about a $20-million expenditure that is inappropriate. That is far too much, but I think we have to recognize that if we took your bill and said from a certain day we would do it today, we would then be spending double or triple that on a certain day.

The other difficulty I have with passing the legislation first and then designing the card is that we may come up with a system that requires additional legislation. When the bill comes forward for second reading is of course up to you and the private members' rotation, but I think it would be preferable for the work to continue on the nature of the card and how we can best protect the system and assure the people of the province, who pay $17 billion through their tax dollars, that the only people taking advantage of that system through the insurance scheme are the people who are entitled to it.

The best way to go is to do our research, identify the most appropriate kind of card, discuss with the stakeholders what is easy for the professions and the hospitals to work with and how we can provide the backup to that, and then, if legislation is required to enable us to put that card in place or to add security to that card, to design the legislation that ensures we have the appropriate safeguards on the card that comes in.

But I hope we can have second reading of your bill as soon as you can get the time in private members' hour and give us an opportunity --

Mr Morin: As long as it doesn't end up in committee of the whole; that's my concern. If it goes before a committee, I'm agreeable to that.

Mrs Sullivan: I'd like to move on to an area which also relates to some of the information technology and introduction of new services, and that is the drug network. The first question I have is, was the contract for some $21 million with respect to a drug network tendered or was it awarded on the basis of a request for proposal?

Hon Mrs Grier: I don't think there's anybody here today from the drug reform secretariat. I regret that. I can answer fairly generally, or I can ask Mrs Mottershead to, or you might wish to stand it down and I can see if somebody can --

Mrs Sullivan: A written response is fine, because I have a number of other questions on that area.

Hon Mrs Grier: Perhaps we can answer so everybody in the committee is aware of its status at this point.

Mrs Margaret Mottershead: An RFP was issued for that system, and the proposals were all evaluated and the best bid, according to the criteria, a number of criteria used, has been --

Mrs Sullivan: How many proposals did you receive?

Mrs Mottershead: I believe there were about four. Patricia Malcolmson was on the committee that actually reviewed some of the bids.

Hon Mrs Grier: Perhaps I can ask Ms Malcolmson to come forward, and we could answer the question. I'm sorry, Patricia, I didn't realize your expertise extends to this one too.

The Chair: Welcome, Ms Malcolmson. Please introduce yourself, with your title.

Ms Patricia Malcolmson: I'm Patricia Malcolmson. I'm the assistant deputy minister of corporate management and support, and I've been a member of the steering committee on the drug process.

Hon Mrs Grier: Could you perhaps describe the process for us?

Ms Malcolmson: The process was a fairly complex and I think a very well-balanced one, whereby a significant range of criteria was developed to assess the proposals. We had, first of all, a call for an RFI, a request for information, which resulted in, I'm not sure, seven or eight replies from companies or consortia who thought they could in fact address the issues we were looking at. We had a process to evaluate those to see if they basically came up to the mark in terms of a broad capacity to achieve the objectives of the project, so we did not ask for very detailed financial responses, but we did ask for a capacity in terms of the members of the consortia to support a project of this size.

We then sifted through those responses and issued a formal request for proposal and there were four responses to that request. We finally selected one. The process that was used was quite a detailed and formal one which actually used a fairly complicated statistical weighting system in order to evaluate those requests as they came in. There was unanimity in the end about the winner of that proposal, and it was also the lowest bid. We are at this point fairly far into the implementation of the network and are expecting the core of the network to be implemented in the early autumn.

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Mrs Sullivan: I know the work Greenshields has done in the federal project for the Department of Veterans Affairs, in a pilot that was undertaken. I'm interested that much of the work they did as a background on that project will probably be utilized, or much of their experience will be utilized, in this one.

There are other areas of concern I have, though, about the process with respect to the setup of the network. They relate to the involvement of those organizations and individuals that will be required, it appears, to use the network, one of those being the pharmacists' association -- I mentioned this in my introductory remarks -- and the other being the physicians' association, which we're told in background documentation will be linked to pharmacists through the system.

I have information from the OMA that -- I'd just like to read a paragraph of this letter. This may not be this system; it may be the fault of the drafter of the news release, but I think something should be cleared up here. The OMA writes:

"The news release clearly implies that doctors will be on the network and therefore will be better able to communicate with pharmacists. Doctors will not be on this network. Repeated inquiries to both you" -- this letter was written to the minister -- "and your staff have revealed only the most vague plans. We have received no commitment that doctors will either be consulted in the development of this network or included in its final program. It is unconscionable for the ministry to continue to refer to inappropriate prescribing when your government has refused to include doctors in your plans to provide a major new information network."

That's one complaint. The second complaint of course is one I placed in the introduction to the consideration of the estimates: that the Ontario Pharmacists' Association, which is the bargaining agent for every pharmacist in the province, was not consulted in the design. While a pharmacist is represented on the secretariat, the OPA is not. The OPA is the body that considers a number of issues, not the least of which is the kind of linkups and proposals for linkups that it has suggested over a period of years, but as well assesses on behalf of the individual pharmacists the liability of members of the association with respect to the utilization of the system. I think that is singularly problematic.

In the meantime, the ministry has issued to the pharmacists a proposed contract which clearly means that those pharmacists who are not signed up on the network will no longer be participants in the drug benefit program. That was certainly not a part of their analysis originally, and they have not been able to contribute in terms of the design and the requirements with respect to that program.

The last hinge on this, as it were, is that I understand the results of the smart card pilot are available; indeed, for a number of reasons, the smart card project indicated that a smart card probably will not work as an information linkage in the health care system. While this program doesn't go as far as a smart card, it is a step that does integrate information from one provider to another, and with OHIP.

Having put those issues on the table, which go beyond the questions of the tender and so on, and I think you have probably a good provider here, how do you respond to the other issues with respect to the network being designed without an appropriate consultative framework and at some jeopardy, in the end, to the expectations for the system and the value of it?

Hon Mrs Grier: Let me say that I certainly will find out, and we will get, before the end of the afternoon, if Ms Malcolmson can't do it, the consultation that went on, but it is certainly my understanding that there was consultation. As I say so often, we do more consultation than one can believe, so I'd be very surprised if there weren't.

With respect to the OMA and its position on this, I have made it very clear from the beginning, and certainly in my questions when I was first told about this network shortly after becoming Minister of Health, that the network had the capacity at some future time to allow doctors to be part of the network. But I certainly was quite aware and never intimated in the unveiling of the network, and neither did the representatives of the company who are going to put it on line, that it was the intent initially to link with doctors' offices. In fact, the first stage has always been clearly identified as pharmacist linking.

On the question of those pharmacists who are not now able to link and are part of the ODB, again Ms Malcolmson may have some details, but it's certainly my understanding that there are relatively few pharmacists who don't have some electronic capacity. And yes, as 40% of their business comes from the Ontario drug benefit plan, I think, as the purchaser of that service, when we set up this kind of system, to say to the people who wish to have agreements with us to supply under that system, "We want you to be linked up so we can make the system more effective," is a reasonable expectation of the customer, ie, the ministry.

I don't know how many of them, as I say, are unable to link in as soon as the program is up and running, but perhaps Ms Malcolmson can add to my comments.

Ms Malcolmson: I don't have information exactly on how many pharmacists are indeed automated, but I believe the majority of them are. I also know there is a fairly detailed plan in place on the part of the project team to assist pharmacists in becoming linked to the network, and at this point in time we expect that network linkage to occur as planned by the early autumn.

I could only reiterate the minister's comments that it was not the intention of the project to include at the first level a linkage to providers' offices. I think it's part of the broader conceptual framework that, yes indeed, in the longer term it will be desirable to link prescribers as well as dispensers to the ministry. That, in the longer term, is the best way to do things, but this particular project is, at its first stage, confined to pharmacists.

You also, I think, addressed the issue of smart cards. I don't think smart cards are directly relevant, at this point, to the project. We have completed a smart card pilot in northern Ontario, as probably most members of this committee recognize. The government has not formally evaluated or assessed that particular report. However, we do have, based on internal evidence, two levels of evaluation of the project as it was undertaken. One was an independent evaluation by an Ottawa firm, Curry Adams, on the actual smart card pilot itself, and the other one of course is the internal one by the project team. I could perhaps give you some general information on that if you wish to have a little more information there.

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Mrs Sullivan: I think the interest in the smart card project was clearly a linkup to the OHIP cards. What I understand were some of the findings of the smart card project were that in fact getting the information into the system was the stumbling block, rather than utilization of the information after. Over a period of a long time, as we've identified a problem with, say, overdrugging of seniors and so on, some of which could be identified through that kind a system and some of which will be identified through the network, the information linkup, which is the key -- I was very interested to see that the plugging in of the information was the bottleneck, rather than issues associated with privacy, which have now become issues more of ensuring that care is taken with the information rather than the privacy issue itself.

As we look, by example, at a change of a card system that becomes both an identification tool, an information tool and a billing tool, and we see the minister considering methods of changing the cards, this drug network becomes, I think, in the scheme of things in the ministry, more and more important. That's one of the reasons I am very concerned that background documentation -- and indeed I have a piece of documentation that went to pharmacists as a draft that included a draft contract. It says right here, "The Ontario drug programs health network is a province-wide computer system that will link the Ministry of Health with Ontario pharmacists, dispensing physicians, dispensing nursing homes and hospital dispensaries."

If that's not the case, then the information should not have been sent, whether it came from the Ministry of Health or whether it came from the company that was contracted for the services, because it's created a lot of ill will. This is where many of the issues that I raised the other day, where I indicated my concern with respect to the consultative process and the information delivery process, are again underlined, because you've had a formal letter of protest from two organizations, both of which have to be on board in association with this network.

I don't know if I can get another question in now or not, but I did want to get this issue on the table.

The Chair: If the minister would like to give a brief response to that, then I'd like to move to Mr Wilson.

Hon Mrs Grier: Let me say that I regret if the impression that has been left was that it was immediately going to move to others than pharmacists, but as I said initially, I think it's very important that we have the capacity to do that, and certainly over time I would like to see us move in that direction. But we have not made any final decisions on that and I can't give anybody a time line as to when it will occur.

But the downside also of saying that this is only going to be for pharmacists is that if then you are able to expand to physicians and hospitals and nursing homes, they say, "You should have told us when you did it that in fact this was where you were going." I think it's very clear that the long-range objective would be to have everybody linked by the network, and the timing and the pace at which we can do that remains to be seen.

I notice some other representatives. Mary Catherine Lindberg, who's the ADM in charge of the Ontario drug reform secretariat, has joined us, so if Mrs Sullivan had felt there were any more specifics that she needed, we could expand on that.

The Chair: That will occur in her rotation. It's noted that the staff member is present.

Hon Mrs Grier: We asked them to come over after Mrs Sullivan's question.

The Chair: I know, and we still have until 6 o'clock.

Mr Jim Wilson (Simcoe West): In April 1992, your government announced that it would finally honour a $108-million commitment made by the Liberal government in 1987 to redevelop hospitals in Simcoe county. That's the General and Marine Hospital in Collingwood, Stevenson Memorial Hospital in Alliston, or what's now called New Tecumseth, Soldiers' Memorial in Orillia and the Royal Victoria Hospital in Barrie.

As you know, this announcement has been recycled on three occasions by at least two different governments over the past six years, and while there's been no shortage of announcements, we've still yet to turn the sod -- although I will note that Elinor Caplan at one point did go up and turn the sod twice at RVH.

Mrs Sullivan: It was heavy soil.

Hon Mrs Grier: They did have two elections in five years.

Mr Jim Wilson: Yes. The gist of the question, of course, is, will we see the construction on these projects begin this fiscal year?

Hon Mrs Grier: I certainly hope so, and I can assure you that so does my colleague and parliamentary assistant. I was warned when I visited Barrie that I wasn't even to think of turning the sod until it was going to be followed by bulldozers, bricklayers and construction. I know the assistant deputy minister is much more familiar with the details and the timing of this at this point, and I'll let Mrs Mottershead respond.

Mrs Mottershead: I actually think the members present in this room have probably the latest and most up-to-date information on this. Certainly, the intent is there. I think it has been communicated. I think it has been in the papers, and the district health council is really pushing to get the final pieces sorted out. There's one or two issues related to functional programs that we have had discussions on, and staff have been going up on a very frequent basis to try and expedite.

There is a letter that has been made available to say that we have explicit commitment to move as quickly as possible on this. That's been made public. We are certainly working very hard to do that.

Mr Jim Wilson: I appreciate the response, but I hope, and I'm sure you do, you understand the frustration. We have Hansards from last year where essentially the same thing was said, and bureaucrats recently went up and told them to redo their functional plans. I went over, with the administrators, some of the stuff the ministry was asking for, and it was pretty trivial. I'll say that publicly. It certainly left the impression with myself, administrators, fund-raising chairs, mayors and reeves, that the government's simply dragging its feet on this because it doesn't want to flow the dollars.

What is the holdup? What you asked for in the redevelopment of those functional plans was trivial. Some of the stuff that was asked for could have been done by conference call. In fact, at the end of the meeting with administrators, they were very discouraged and felt that they're being asked to spin their wheels. You understand that the problem also is that there's been a great deal of money committed by those communities, a tremendous amount of money, for some relatively small communities like Collingwood and Alliston. Those fund-raising commitments are based on the premise that you'll move ahead this year with construction.

Hon Mrs Grier: Before Mrs Mottershead gives the details, let me just say categorically to the member and to Mr Wessenger that there is no intent by the ministry to make this take any longer than it needs to. The direction has been very clear that this is something we want to see proceed. We want to see it proceed as quickly as we can. Having said that, there are always in such projects and ones of this magnitude details that need to be ironed out. I don't fault staff for making sure that the documentation, the planning, the functional plans and all of that are done correctly.

My last understanding, and I think I talked about this as recently as the end of last week, was that there had been a meeting, that there were some additional changes that were required, but that it was in fact proceeding. I have no reason to believe that the end of the year is not a target we can meet.

Mrs Mottershead: I want to clarify in terms of ministry and minister. It has been staff that has been working on this in terms of the functional program, and the minister's commitment and the government's commitment have been consistent in terms of moving ahead as quickly as possible.

We've had some concerns directly related to the operating cost as a result of some of that functional program design. As you know, in the kind of world we're all living in right now with zero increases, it's really impossible to make those kinds of accommodations.

I will certainly commit to follow up and review the outcome of the June 16 meeting of staff to see whether or not there were trivial suggestions made or whether they were substantive. I can commit that we are going to be moving very quickly on this. I want to make sure my staff isn't --

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Mr Jim Wilson: I guess the definition of "trivial" depends on what side of the fence you're sitting on with respect to this issue. You know that the faith those communities hold in governments is not too great these days, and that's part of the problem, because of previous commitments that were made and broken.

A specific date would be very helpful, or some sort of written response back to me narrowing down when we might be able to start construction, because some of the stuff that was asked for, I say with respect, I fail to see, as did experts in the field, why we couldn't go ahead with breaking ground while some of the fine-tuning and functional programs go ahead, because you've pretty well made it clear what the objective and the operating cost side is. Most of the stuff that I asked for didn't have any effect on the actual buildings, because you've already downsized all of those communities, and you can't downsize any more unless you're intending to not build hospitals at all. So I'd like your comments on that, and I would like a written response back also.

Mrs Mottershead: I believe we can oblige the member with a written response in the next couple of days. I just want to let people know that in the first iteration and looking at the architectural drawings, using the Royal Vic as an example, with ministry going over and over the design program, we were actually able to get a compromise in some of the structural design work that had been done, both from the architects the hospital engaged and between our architects in the ministry, which saved $10 million to $12 million. Some of the work that the ministry is engaged in, in terms of advising and reviewing these things, does actually produce efficiencies to the taxpayer's benefit. So I will follow up, and you will get a letter.

Hon Mrs Grier: I'd be happy, as part of that follow-up, to see if it would be possible to commit to some kind of a timetable, because I know only too well that when hospital boards and communities have engaged in fund-raising and communities have made a contribution -- I was in the Woodstock community, hearing the same thing just last week, where the money there has been in escrow for a number of years. There was a six-year fund-raising campaign that's come to an end, and there's another fund-raising campaign for an arena going on. People are saying: "We gave to the hospital. We haven't seen that built yet. We're not going to give to the arena until we see that in fact what we gave to the hospital results in a building."

I am, as a volunteer, very conscious of that and certainly wouldn't want to do anything to inhibit community contributions. So we will see if we can be more specific in my next response. I know I did send a fairly general response back to the chair of the board just last week, I think.

Mr Jim Wilson: Thank you, Minister, and I want to thank Mrs Mottershead also for her response. I look forward to the written response.

Minister, I want to turn to a topic that was brought to my attention by Mr Peter Campbell, who's president and chief operating officer for Connaught Laboratories. Last month, he expressed his concern to me regarding the Ministry of Health's decision to award its 1993 influenza vaccine contract to a Quebec-based firm. I feel it's important that several facts be put on the record here regarding the awarding of this vaccine tender to IAF Biovac of Quebec.

The background is that Connaught employs 750 highly skilled people, including 150 scientists. They have an annual payroll of $35 million, which resulted in $9 million in employee-paid taxes in 1992 alone. They returned 14.5% of their profits to Ontario as corporate tax revenue and invest 15% of every dollar into research. Connaught did revise its offer on the vaccine to provide the Ministry of Health with $270,000 in savings. I hope you have a ministry official here who's familiar with the wording of that.

IAF Biovac is a company that is subsidized by the Quebec government, both in terms of funding and annual vaccine purchase guarantees. I really have three questions for your consideration. What consideration did your ministry give to Connaught's value added component when you made your decision to award this tender to a Quebec firm? Are you reviewing your ministry's purchasing policy that will recognize the contributions being made by Ontario firms? Does the ministry require 300,000 doses of subvirion (split) influenza vaccine, and if so, will this portion of the influenza vaccine requirement be awarded to Connaught?

Hon Mrs Grier: I certainly know that questions from Connaught Laboratories have been asked, and I have been made aware of them. Dr Richard Schabas, who is the provincial medical officer of health, is here, and I think he's the one who could perhaps answer it in the kind of detail that the member wishes.

The Chair: Please proceed. You've been introduced.

Dr Richard Schabas: I've been introduced, and very nicely too. Thank you. I can answer some of your questions; I'm not sure I can answer all of them at the moment.

The process for purchasing influenza vaccine for the last number of years, as with some other vaccines, has been through a national tender process which we enter into with most of the other provinces and which is administered by Health and Welfare Canada. As a result of that national tendering process, which obviously allows for a much greater volume of vaccine purchase, we have achieved substantially lower prices for these vaccines, particularly for influenza vaccine, where I'm very pleased to be able to tell you that our vaccination costs have come down substantially. In fact, we've been able to greatly increase the volume of influenza vaccine, which has gone up by about 25%, that we've distributed for the elderly and other high-risk groups in the province at essentially no increase in cost because we've achieved these lower costs.

The tendering process is a competitive one. In effect, over the last few years there have been two competitors. In most previous years Connaught Laboratories has come in with the low bid and has won our contract. This year, Institut Armand Frappier, or Institut Biovac, which is the company in question, came in with a bid with its wholesale vaccine which was substantially lower than the Connaught bid, resulting in a savings for our vaccine purchase in the area of about $600,000.

I should point out that the vaccine which Armand Frappier produces is in fact manufactured in Canada, manufactured in Montreal. It has some Ontario content: Influenza vaccine is made in chicken eggs, and the chicken eggs are actually purchased in eastern Ontario, so we do have some economic interest in that. Connaught Laboratories produces its influenza vaccine in Swiftwater, Pennsylvania, and it really has no Canadian content. Whereas in other areas we have shown a preference for Ontario-produced vaccines, we didn't regard that as an issue in this case and went, as we have done in previous years, with the low bid, and in the process saved the Ontario taxpayers a great deal of money.

Mr Jim Wilson: I appreciate your response, doctor. I'm sure the eastern Ontario egg producers are quite happy.

Dr Schabas: In fact, we've received letters from that group that I'd be happy to share with you.

Mr Jim Wilson: It's interesting to point that out, but knowing the price of eggs these days, it's a very small component in the price of vaccine. It's none the less an Ontario component, I suppose.

The third question was, Connaught understands that the ministry will be maintaining a requirement of 300,000 doses of subvirion (split) influenza vaccine this year. Are they in the running to receive any of that contract?

Dr Schabas: I can't answer that question off the cuff. I would have to check and confirm that. I'm not sure where we are with the purchase. That is a part of the national tender. We will be purchasing smaller quantities of the split virus vaccine because there are certain groups which require that as opposed to the wholesale product. I could certainly get you a response for that.

Mr Jim Wilson: I'd appreciate a written response to that, if that's possible, Mr Chair.

Hon Mrs Grier: Let me just say before we leave that subject that certainly we have been doing some work and we now have within the ministry a health economic development branch, which I think I mentioned yesterday when we were talking. They have been looking at whether it is possible to develop criteria that evaluate the value added economic benefit. It's not that easy, depending on what assumptions you make and what factors you add, and one does have to look at, where do you get the cheapest products that will do the job that you want to? As we look at interprovincial trade and other considerations, I'm not sure we will come to an answer that will make every company in Ontario happy, but we are examining that.

The Chair: Thank you very much, Minister. Do you have further questions, Mr Wilson?

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Mr Jim Wilson: Very quickly, Minister, I think you might be familiar with a relatively new drug that's called Mycobutin. It's used to prevent microbacterium avarium complex, or MAC, which is a secondary opportunistic infection in patients with advanced HIV or AIDS. That drug, as I understand, is currently being reviewed by the Drug Quality and Therapeutics Committee, the DQTC. I wanted to know if you could tell me or find out for me what the status is of that particular drug. It's my understanding also that the drug has been on the market in Canada since March; I think the feds approved it in March. There are a number of people in the AIDS community who want that particular drug approved, and they're asking me why there's a holdup. I was wondering if you could check into that.

Hon Mrs Grier: Do you want to discuss that one first or have you another similar one?

Mr Jim Wilson: Sure.

Hon Mrs Grier: Mary Catherine Lindberg, who is here from the drug programs reform secretariat, can speak to that. My understanding is that it is still under consideration by the DQTC, but if Mary Catherine would like to come forward, perhaps she can speak in some detail about what the drug is, what it achieves and how much it costs.

Mr Jim Wilson: I don't need some detail; I need a quick response, please.

Hon Mrs Grier: But you need to identify yourself first.

Ms Mary Catherine Lindberg: The DQTC is still reviewing it. The submission that was put forward by the company was not complete, so we had to go back and get some additional information. But even if the DQTC decides that it should be paid for, it will only be available to those AIDS patients who are on ODB, and that doesn't answer the concerns we have about whether that will be available to the AIDS patients through a wider program, and we're addressing that as part of the reform.

Mr Jim Wilson: Can I just ask, currently physicians are accessing the drug through section 8s?

Ms Lindberg: Yes, for ODB patients.

Mr Jim Wilson: How frequent is that?

Ms Lindberg: I'm signing a lot of them, so there's nobody being turned down at the present time when they have a good justification on a section 8.

Mr Jim Wilson: So your intention is to put it on the ODB, not in the catastrophic drug program?

Ms Lindberg: Probably not, no. Septra still is the drug of choice at this point. This is an additional drug, but Septra, which is a lot cheaper, is still the drug of choice.

Mr Jim Wilson: Do I have a commitment that it will go on the ODB?

Ms Lindberg: No, not until the DQTC has had a full opportunity to review it. I'm not a clinician; I can't make those kinds of clinical decisions. They're still reviewing it, and the submission was not complete.

Mr Jim Wilson: Do you know what the time frame would be when the review would end?

Ms Lindberg: It will probably be the next month or so before they're completed.

Hon Mrs Grier: As I'm sure the member is aware, that report then comes to the ministry and is reviewed and regulation change has to occur if it's to be added to the formulary. But I want to make the point that as we look at reform of the Ontario drug benefit plan, the ability to extend special and very expensive drugs such as this to a broader population than is now eligible for the Ontario drug benefit plan is precisely part of our what our reform is all about, because even if it is approved --

The Chair: Minister, I think Mr Wilson has a specific question and you're dealing in a more general policy area, if I can go back to Mr Wilson, who had the floor.

Mr Jim Wilson: The response worries me, because if it's going the ODB route and you've essentially frozen the ODB -- I mean, are you intending to add new drugs to the ODB? I've a feeling that will be the next roadblock.

Ms Lindberg: What we've said is that no new product can come in without a cost-neutral or a cost-benefit towards additional. So the program cannot grow, but if we added a new drug or were thinking about it, we could then look at something else that would be cost-neutral or a cheaper alternative in another way.

Mr Jim Wilson: Do you have a plan in place if it gets approval at DQTC?

Ms Lindberg: No, because we don't pre-empt the DQTC. We really have to wait to see what they're going to say about that drug.

Mr Jim Wilson: But you'll wait a month for that. Given that there's an outcry for this drug, why can't you plan ahead?

Ms Lindberg: I guess we could. We'll be looking at what we're going to do. We're currently looking at new additions to the formulary and what we can do to make them cost-neutral to the program.

Hon Mrs Grier: I think Ms Lindberg identified that under section 8 of the legislation it is possible for somebody whose doctor feels they need this drug to have it made available to them, and we are not imposing any restrictions or turning down those particular applications at this point.

Mr Jim Wilson: I appreciate the response. Quickly, to you, Minister: It's my understanding that this drug is supposed to be selling to consumers and pharmacies at about $225 for a monthly dose -- I'm not sure, but I think it is a monthly dose -- but some pharmacies are selling it to people living with AIDS at about $500 to $600. Apparently it's getting a 200% to 300% markup. Is there anything that can be done about that? Is your ministry aware of that?

Hon Mrs Grier: I'll ask Mary Catherine to come back. I find it just appalling that the markup on these drugs is so enormous and the costs are so tremendous. How we can relate them to the cost of the development of the drug seems impossible to do.

Mr Jim Wilson: The $225 is the manufacturer's suggested price, including a markup. Frankly, I think people living with AIDS are being ripped off. They also are not necessarily having access through section 8s, from some of the stories I've heard, but you assure me that you're signing them furiously.

Ms Lindberg: I'm signing them.

Mr Jim Wilson: First of all, an answer to the markups; secondly, just while I think about it, the problem with the section 8s. As I've been told by physicians here in Toronto, they hesitate filling out section 8s because they don't want to tick off your ministry.

Hon Mrs Grier: I haven't noticed anybody hesitating to tick off my ministry, but if there is somebody out there, thank you very much.

Mr Jim Wilson: That's the language from a meeting of two hours ago. They're afraid, with the reforms going on -- there's some sort of rumour, and I didn't really get the entire gist of it, but there's some sort of rumour going on that a whole pile of section 8s going in on it may in fact impede the approval of this thing eventually getting into the ODB. I couldn't understand the reasoning for that, but I'll tell you, it's out there and it came from a very respectable source.

Ms Lindberg: From a staff point of view, to have the drug not on section 8 is a much better situation, because we have to do a lot of paperwork: Section 8s administratively are not easy to handle, because you have to get them to the Drug Quality and Therapeutics Committee and you have to have them reviewed. The staff would sooner not have a section 8, so they will not hold up any review by having a number of section 8s come in.

As to the markup on drugs, particularly drugs that aren't listed in our formulary, the pharmacists can mark up a drug in any particular way they wish. Most of the time we pay the listed cost of the drug, 10% and a dispensing fee. We will pay more than one dispensing fee if the cost is very high, but usually we don't. But when it's not in the formulary and it's sort of in the open market, the pharmacists can then decide what markup they would like to charge themselves. Some of them are charging 20% to 25% markup, we know, but there are no real rules around that if it's not listed in the formulary, then they can charge whatever dispensing fee they wish; it should be no more than their usual and customary fee, which is posted, but quite often when they get an expensive drug, they do increase that to two or three times.

Mr Jim Wilson: The question was more for the minister, in terms of what you intend to do about this. If you get reports of markups that large, which I think are unconscionable, do you talk to the Ontario Pharmacists' Association?

Ms Lindberg: No, we talk to the Ontario College of Pharmacists. We send a letter, document it and indicate that we think this should be investigated, and then quite often get a response back.

Mr Jim Wilson: So if I get those complaints, it should be in letter form to the ministry.

Ms Lindberg: Or it can go right to the college.

Hon Mrs Grier: I think you'll have to go to the college, because it is a self-regulating profession. If pharmacists are in fact gouging people who are vulnerable and who need a particular drug, then I think, as a self-regulating profession, the college would want to know about it and has the power to take some action.

Mr Jim Wilson: Okay. Thank you.

The Chair: You have five more minutes, Mr Wilson.

Mr Jim Wilson: Minister, last month I wrote you a letter concerning a local physician shortage in the area of the province I represent, Alliston or New Tecumseth. The letter is dated June 15. I can give you another copy of it if you like. It's talking about the shortage of physicians in the Alliston area, or New Tecumseth, as it's now called. In my letter, I request that this portion of my riding be designated as underserviced.

The numbers in the Alliston area -- the ratio points to it clearly being underserviced. The catchment area for Stevenson Memorial Hospital contains a population base of about 40,000 people. The local medical society informed me when I met with it in May that there are only 14 full-time physicians practising in the area, which translates into only one physician for every 2,857 residents. The local medical society also told me that three additional physicians may be leaving the area because of Bill 50. Those are their words, not mine.

What progress have you made in this matter? Have you had a chance to have anyone review the letter I wrote on June 15, and will you agree to grant an "underserviced area" designation to the Alliston, New Tecumseth, area? I can hand you that letter if you like.

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Hon Mrs Grier: No, I certainly am aware of your letter. I have to say to you that as we discuss this issue and negotiate with the Ontario Medical Association how we can handle physician resource management, certainly we have not been designating new underserviced areas until we come to some conclusion on those discussions, which I hope will be by August 1, which is looming.

As I have said on a number of occasions, I don't think the current system of identifying underserviced areas has necessarily resulted in new physicians in those areas. I'm becoming more and more aware that just saying something is underserviced doesn't mean a doctor is going to want to go and practise there, because for 24 years we've had areas in the north that haven't been able to get a doctor.

Mr Jim Wilson: Minister, I think you understand that the physicians throw that out as a solution, given that it's the only program out there.

Hon Mrs Grier: Exactly.

Mr Jim Wilson: So how do you intend to correct the problem?

Hon Mrs Grier: That was what I was coming to, looking, as have provincial ministers all across the country, at better management of human resources within the health care system, particularly physician resource management. We have been working with the OMA. It was for that reason that the committee that has been chaired by Dr John Evans has been looking at the question of resource management. Within that, the task force that is chaired by Dean McMurtry from Western has as its first priority looking at underserviced areas and trying hard to find a better way of dealing with this issue than merely identifying an area as underserviced, putting some financial incentives in place and hoping that somebody moves there.

We had a bit of this discussion yesterday but it's becoming obvious, as I hear more of the history of this program, that money isn't the only thing that gets people to move to an area, and particularly a rural area. It's the mode of practice, it's the peer support, it's the specialists or lack thereof, and in some degree it's their training. They are working in a rural area, in a more isolated practice. They may have to do more procedures that in an urban area they would pass to a surgeon or somebody else down the road. I'm not sure that we have effectively enough prepared people for rural practice or for northern practice.

I think also we tend to say, "Oh, `underserviced' is all northern Ontario," and to look for some solutions to the north, whereas I hear from my members in rural areas, as in yours, that are in fact not that far from the greater Toronto area. Yesterday, the member for Durham-York talked about Georgina township as being underserviced within the greater Toronto area.

We have to find better ways of doing it. I think the better way is going to be by working with the academic health sciences centres, the professions and the district health councils to find both a better way of identifying what we mean by "underserviced" as well as a better way of providing support and encouragement to physicians to move to those areas, recognizing at the same time that by every objective analysis there are more physicians in Ontario than are justified by all of those objective analyses and based on our population.

Just saying, "Yes, we will import new doctors from overseas or from other jurisdictions," as we have been doing this summer in order to provide locums, is not the answer, because that then increases the overall pool of physicians and thereby increases our overall costs.

Mr Jim Wilson: Let me just quickly respond.

The Chair: Then I wish to move to Mr Wessenger.

Mr Jim Wilson: I appreciate your comments, Minister, and I think you're right with most of what you've said. I think the current approach is not working. One reason is strictly this numerical doc-pop ratio stuff, particularly if you live where I live, in the hangover of the greater Toronto area.

Hon Mrs Grier: Urban shadow.

Mr Jim Wilson: Yes. When I look at the stats your ministry uses to determine how many physicians are needed in my area, I suffer greatly, as do my constituents, from that. I know the district health council is always fighting that.

Secondly, I'll say that in the village of Beeton, just down the road from Alliston but still in the town of New Tecumseth, the caps on GP billings are forcing people to go into larger groupings of physicians in order to cover the overhead cost of medical clinics.

I have a situation that arose this week where of the three remaining physicians in the village of Beeton, one is leaving for ever and the two remaining -- because there were four originally -- can't, because of their caps, carry the overhead costs of the medical centre in Beeton, so they're going to Tottenham to join with three or four other physicians. That means I'm going to have another large gap in services in my riding. Compounding the problem, the local hospital is the Alliston hospital. Now I don't have any services in Beeton and I might have too many physicians in Tottenham.

I throw all that out, and I sincerely say I don't envy the job you have in trying to come up with a solution on this. I agree with what Mr Conway said in the House last night, and that is that, really, past governments haven't been able to come up with very good solutions. It's been a patchwork approach to date. I wish you all the best in coming up with a solution and I hope you do it quickly because something has to be done. The old ways, I agree with you, are not working.

Mr Paul Wessenger (Simcoe Centre): My question really is going back to an issue that was raised by my friend the member for Simcoe West. First of all, I'd just like to put on the record that I appreciate very much the efforts of the ministry staff with respect to the Simcoe county hospital. I know they're doing their utmost to expedite that process. I'm very impressed with the work that's being done there, but arising out of that aspect of the pure issue alone of the capital projects, I think a more interesting aspect has arisen. I know that in Simcoe county a health system review has been ordered with respect to the whole question of planning future service delivery and rationalizing the system of delivery of service within the county.

I know we've been very successful with respect to restructuring hospitals to date and keeping costs down and rationalizing services, and I'd like to know the planning model we're working on with respect to this whole question of restructuring the hospital system. One of the interesting comments that has been made to me by several hospital administrators I've been talking to is the fact there are a great deal of efficiencies they feel can be obtained in the future in the delivery of services without any loss of service to the patients. So I'd like to know the planning process in that way.

Also, there's a secondary question of that planning process. How are we doing that planning process in view of the fact that we seem to be moving very quickly with respect to targets, for instance, for beds and hospital reducing? For instance, when I started out in Simcoe county we were looking at 1,000 beds per 1,000 patient referrals. It went to 850. Most recently in looking at the planning for Simcoe county, it was at 750, and it has been suggested that 650 perhaps is an attainable goal in the future.

It's a very large question and I know, Minister, that you probably need your assistant deputy minister to perhaps outline this, but maybe some preliminary remarks from yourself and then some comments from the assistant deputy minister.

Hon Mrs Grier: I'd be very glad to comment because something that is of great interest to everyone in the province is as hospitals all around the province struggle with restructuring initiated for different reasons in different areas, and that's what interests me.

I was talking to a physician in an area where there is restructuring going on. He pointed out to me that he now had privileges in three hospitals and in one day could have to make rounds in all three of them. That wasn't particularly efficient use of his time and it would make more sense to restructure.

We're looking at it from, how can we provide better service and contain costs? For a number of reasons, it's an issue whose time has come. What has happened is that because it has been begun, I think, over the last five or six years, hospitals have come to look at how they operate and how they can more efficiently operate, hospital restructuring had begun, and then it was recognized by communities that they had to look more broadly than just at hospitals and look at health system planning and restructuring. That is the task we have asked the district health councils to undertake. I know that in Simcoe county the district health council has embraced that, has embarked upon it and is doing a really excellent job.

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The area where this is going to come to fruition earliest is Windsor, which has four general hospitals and which began the exercise of hospital restructuring or examination and over the past two years has moved into a very comprehensive examination of all the health care needs of that community.

The way in which the steering committee of the district health council has worked has been an extremely open and inclusive way, with a labour advisory committee looking at the impact of any restructuring on employees, how any shifts are to occur and how those people can be involved in the discussions.

With the community-based services side beginning to recognize that and as hospitals look at changing patterns of operation -- I think in my first day here I talked about the increase in the number of day surgeries, ambulatory care and the reduction in the number of hospital days per 1,000 of population -- if that trend continues, as it will, then it follows that you must look at what services are available to those people if they return earlier to their homes and to their communities, to make sure they get the health care they need.

It's not good enough to just look at your hospitals and say, "Okay, we can shave some beds, we can restructure the hospitals," without at the same time involving in that plan what is the whole range of services that are needed for the health of the community. That then leads to the public health units and the preventive side.

We have now, I think, happening in almost every district health council a much more comprehensive exercise in health planning than was started when hospital restructuring was put on the agenda. I believe from that will come a system that is more of a system, is more responsive to local needs and diversity and the special needs of different communications, and that more adequately reflects the differences in distance, in travel times in the north and south and rural and urban, as well as a system that makes a better use of all the components and identifies where there are gaps and where new services are required.

The studies that are now being done or planned that I am most aware of and that I think will lead to the greatest change are, as I say, Windsor-Essex, but also Thunder Bay, Sudbury, Guelph, Belleville, Trenton and Picton, that's one, and Perth-Smiths Falls, Brockville, Durham region, Sault Ste Marie, Haliburton county, York region, and in Metropolitan Toronto, where at this point it's merely a look at the hospital structure.

Along with that are the operating guidelines, and that's having an effect on that planning too. Perhaps Mrs Mottershead would like to address that briefly.

Mrs Mottershead: I think the member knows that the ministry did release a health planning framework in 1992. He's absolutely correct in saying that the system is moving along very quickly in terms of restructuring. It is going to prompt us to have a review yet again in terms of the planning parameters, the number of beds per 1,000 population, because with the number we had put in as a benchmark number of 850, we know right now that we are provincially well below that. There are still some problem areas in terms of still having a lot of capacity in the system, particularly in northern Ontario and in eastern Ontario; however, in other parts, that utilization capacity is shrinking and we're probably going to have to revise that number.

We have a number of activities in terms of reviewing that. Some relate specifically to restructuring that has been accomplished already, where a standard has been set. I'll mention the Orangeville-Shelburne area, which is well below the 850. They're closer to 750, and that's in terms of actual implementation. In the Windsor area, for example, that number is being questioned and the district health council is asking whether or not it should use 750 as we plan for the new facilities.

There is a committee that is looking at that, through the joint policy and planning committee, as we review some of these guidelines. We're also looking at utilization of a number of clinical areas, and in that utilization, we're discovering that there are great variances in terms of the hospital performance in a number of areas, where we really need to do more benchmarking and have more standards out there and more information-sharing between hospitals so they can learn from each other and their experiences. You're right, and we will be pursuing that in the next couple of months.

Mr Wessenger: For a change of area, this is perhaps more a specific concern that has been raised to me in meetings I've had with public health units; that is, the question of the role of the public health unit, what is foreseen as the role of the public health unit in the whole system in the future. There seems to be a great deal of uncertainty out there in public health units with respect to this aspect, and I'm wondering if I could have some clarification to the committee of where we're going in that direction, what the planning process is.

Hon Mrs Grier: I'd like to ask Dr Schabas if he could come back and address that, because it is a question that is being asked consistently, and it's one that I don't think we're yet ready to give a clear answer to. I know that Dr Schabas, who has been the person most involved with them, would want to expand.

Dr Schabas: I think there are really two answers to that. The first relates to the role of the boards of health in providing public health services, and I think we have a very clear direction for that through the mandatory health programs and services guidelines, which set a very clear course, with a focus on primary prevention and particularly community-based and community-wide kinds of initiatives for primary prevention. But I think the question is really alluding to the other roles of boards of health. Of course, traditionally boards of health have been very flexible and have been community leaders in providing a whole range of primary care kinds of services, including things like home care service, providing dental care programs, community mental health programs and a whole range of things.

I'll certainly take up the minister's invitation not to give a clear answer, because I'm not sure we know exactly what the future role will be. I think it will likely be different. There are 42 boards of health, and I think you'll likely find that each board will play a somewhat different role, but I know that many boards are keenly interested in a continuing involvement in the long-term care sector. There's a great interest in providing community mental health programs, and this likely will evolve in a different way in each of the boards; there's certainly not one blueprint at the moment, although the project, which is called the community health framework, is looking at this as well.

Mr Wessenger: If I might follow that up -- and perhaps you don't want to answer this question; maybe the minister should answer this question. You're talking about perhaps different roles in different areas. In line with the planning, using the district health council, do you then see roles being defined more through the local planning process?

Dr Schabas: Well, there certainly are close relationships between many of the boards of health and the district health councils, and I think they work very well together in planning community health services and also in giving an epidemiological framework to the planning of the district health councils.

Again, there's not one set formula, though. I think that if you went to the 42 boards of health and the 30-odd district health councils, you would find a slightly different relationship and I think a somewhat different vision of where the future roles would lie. I don't think that's necessarily a bad thing. I think one of the great strengths of our public health system has always been its devolved and decentralized basis, with a great deal of autonomy in the local boards. That's an aspect of our system that I hope we can retain.

Mr Wessenger: Fine, thank you.

Hon Mrs Grier: Let me add my two cents' worth to that. It's an area with which I haven't become as familiar as perhaps some other parts of the ministry, but I did serve on a board of health for many years before coming to this place. I think there's a real difference between urban and rural boards of health, certainly in Metropolitan Toronto, as I look at the role of the boards of health, compared to, for example, northwestern Ontario when I was there. I think that integration into the planning process varies depending on where you are.

One of the areas in which I think we can everywhere make better use of the boards of health is in the collection of data, because they are essentially the repositories of the data. As we look at streamlining and doing things more effectively, I think we have to find a way of making sure that these data are transmitted to the district health council so that as it does its planning it is informed by the data collection systems of the public health units; that this in itself will work to make that planning more integrated than it has been in the past.

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The Acting Chair (Mr Noble Villeneuve): Does this complete your questions, Mr Wessenger?

Mr Wessenger: Yes, it does.

The Acting Chair: Mr. Bisson, you will have about four minutes, at which time we will move on to the official opposition.

Mr Gilles Bisson (Cochrane South): I'm going to share the four minutes with my counterpart, for two minutes apiece.

I won't put this in the form of a question but actually a request, because the time doesn't permit. Like most hospitals in the province of Ontario, a couple of years ago our hospital, the Timmins District Hospital, had to go through a process by which it tried to balance out its budget in the deficit recovery plans that were in place about two years ago.

The comment I would like to make is this: One of the things that happened through that process was that it forced employers, being the hospital administrators and boards, to sit down with employees from various bargaining units across that operation to take a look at their budgets in trying to find ways of trimming them so they were able to keep within their allocated envelopes of the amount of money they should have to run their hospitals.

The one frustration I found with that process was that although the process worked, with a lot of work and a lot of give and take on both sides, and, I'll tell you, a lot of sleepless nights on the part of a lot of people through that whole process, including many people from your ministry whom we dealt with, they did come to a resolution of that problem.

The one thing we learned through it, however, is that there's a weakness in the system, the weakness being that there isn't a strong link between people who run hospitals and people who work in them. There was some talk a while back about taking a look at whether there's a way of putting people on the hospital boards -- I know this is a sensitive issue for some people -- from within the organizations of the hospitals to deal with helping to strike budgets, to take a look at cost efficiencies, but more important, to try to build the kind of atmosphere I think you need in a public institution, which is a better understanding of what the goal of the operation is and what's needed in order to operate. I'm just wondering if anything is being contemplated there. I think I probably ran out of my two minutes.

Hon Mrs Grier: Let me respond very quickly to say I absolutely agree with you, and yes, it has been contemplated and it's very much part of the social contract negotiations that are ongoing, I hope, as we speak and that will culminate at the end of this week. I certainly hope the Ontario Hospital Association will change its mind and sign the social contract, because that will then give us an opportunity to follow through on the kind of suggestions you're making.

Mr Larry O'Connor (Durham-York): To start off with, I'd like to agree with one of my colleagues, the member for Renfrew North, who in debate the other day said how difficult a time we are going to have in making some of the decisions in the future around health care and that the decisions can't be just left up to the government; that we need to go out to a more local level. My colleague stated this in the House in debate, and I agree with him.

I'd like to ask this: There was a recent announcement of the mental health reform and the expenditure for the redevelopment of the Whitby Psychiatric Hospital, which I'm pleased about. The difficulty I have is that with the whole mental health reform and trying to develop a role for district health councils in this, and knowing that a local group that covers part of my riding, called CO/AD from York region, was very pleased about the mental health reform announcement, how do they fit into the picture in planning for reform and for the future? What role does a district health council have in the reform of mental health care? For example, in my area you've got Durham region, York region, you go up into Victoria-Haliburton; it's a huge catchment area. What role would a district health council play in that sort of reform?

As my colleague from Renfrew North stated, we need to go to the local level. At the same time, as we take a look at hospitals and rationalizing some of that, district health councils obviously do have an important role to play locally.

Hon Mrs Grier: Mr Chair, just before I answer that question or ask Jessica Hill to come forward and give us some help on that question, I wanted to be very clear in my response to Mr Bisson's suggestion, when I suggested that we wanted, through the social contract, to have more involvement of the employees in a hospital in the management of the hospital. In case I set off a raft of correspondence about, "Are you opening up the Public Hospitals Act in dealing with the board question again?" let me be very clear that in fact I was talking about joint workplace committees and involvement in the operation.

With respect to mental health and the role of district health councils, I think you're absolutely right, and I very much appreciated the constructive contribution of the member for Renfrew North to what was a very good discussion last night of the reform agenda and the need for one, despite the fact that the item on the House calendar was Bill 50. But it was all within context.

Jessica Hill, who is the director of the community mental health services branch, can perhaps speak more specifically about how we're going to integrate the planning of district health councils, particularly in areas where we have the psychiatric hospital in two districts converging, as we do in York-Durham.

Ms Hill: Specifically, we're in the process right now of developing implementation planning guidelines for mental health reform. In the reform document, the district health councils are identified as the lead in planning. The guidelines will address both membership and process issues because of the need to both address local planning, which obviously they're very experienced with in terms of the Graham report planning, but also how that will roll up into regional planning. That process is taking place right now and we're working with a group of district health council staff and council members.

As well, there are a number of stakeholders who are very interested in participating in planning. Again, they've had experience with Graham. But I think now, more than ever, as we see with our mental health advisory committee, everyone wants to be involved and at the table in terms of mental health planning: consumer-survivors, family organizations, physicians, workers in both facilities and community agencies and so on. The participation issues are very important.

Specifically with respect to CO/AD, there has been a very interesting process that CO/AD and the district health council went through in terms of developing a memorandum of understanding about CO/AD's role in planning and coordination and how it would feed its work into the district health council. It's a bit of a model in terms of the memorandum of understanding.

The coordinating bodies currently are meeting together to determine how they can work most effectively in addressing mental health reform planning with the district health council, and I understand those have been very productive meetings.

The Acting Chair: I believe this completes, for now, the time allotted to the government. We now move to Ms Sullivan from the official opposition.

Mrs Sullivan: I'm going to ask the minister if she'll bring in her quick-response team on two or three questions I have. First of all, under the drug benefit --

Mr Jim Wilson: Did you see the budget for that?

Mrs Sullivan: Under the changes to the drug benefit plan, I have two very quick questions. One of them relates to changing the format of the formulary itself to include detailed information about products that are included on the formulary. I'm wondering if the ministry is seeking assistance from pharmaceutical companies to participate in the production costs of a revised formulary.

Hon Mrs Grier: I'll ask Mary Catherine Lindberg, who can perhaps talk about the work of the drug programs reform secretariat, as well as the advisory committee and working groups, which have representatives from industry and pharmacists and consumers and seniors.

Mrs Sullivan: I know all about that. All I want to know is, are the pharmaceutical companies going to participate in paying for what will be an extensive listing of their products for use within the system?

Hon Mrs Grier: Oh, I don't know; interesting idea.

Ms Lindberg: An interesting idea. We haven't looked at that, but we certainly are including the pharmaceutical manufacturers in the development of how we're going to move to prescribing guidelines and away from a list of benefits. We want to look at diagnosis and the drug of choice and the first-line therapy. We'll use pharmaceutical manufacturers, physicians, clinicians, pharmacologists, pharmacy, all the way through.

Hon Mrs Grier: I don't understand, really, what's implied in your question. It would be helpful, because if it's an opportunity for revenue, we would want to look at it. But I would be very reluctant to get into anything that was like paying for being on the formulary. You're not suggesting that, I'm sure.

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Mrs Sullivan: No, I'm not suggesting that. I'm suggesting that there be a participation in the cost of production of the book.

Ms Lindberg: Like they do with the Compendium of Pharmaceuticals and Specialties, where they put an ad in each one?

Mrs Sullivan: No, I'm not talking about advertisements. I don't think advertisements are appropriate.

Ms Lindberg: We have not addressed that, but it's something we could look at.

Mrs Sullivan: Okay. A second question with respect to changes to the drug benefit plan: Are you considering the inclusion or a requirement for the use of mail-order drugs for those conditions which are chronic or require long-term drug therapy?

Ms Lindberg: I don't think we'd look at that as the only solution because it would be too broad; I mean, unique areas and unique kinds of things. What we're doing right now is looking at mail order as any other pharmacy, as any other distribution point of drugs, where if you wish to have a contract with them -- and some employers are looking at that for some of their employees -- we're not discouraging that because it is a cheaper dispensing fee than we're currently paying and it's a lot cheaper than what the employers are currently paying.

But I don't think we would look at a universal plan across the province to offer those chronic drugs through mail order because I think it would be too difficult to get to some areas. So I think you might look in special areas like nursing homes or something like that, but we haven't really looked at that. We're just investigating some ideas on it.

Hon Mrs Grier: Let me just say that I think it's something that we do have to look at seriously. As I understand it, certainly in the Metro area, one of the mail order companies is delivering prescriptions sort of overnight for $5 per prescription.

When we hear, as the member for Simcoe West was talking about prescription fees -- and I'm not talking about ODB prescription fees, but prescription fees of $12, $13, up to $20 for some drugs -- we have to question, if the market is to work, and this is a program that involves the marketplace, how do we in fact justify $6.47 as our prescription fee for every prescription when there are now those people who can provide a service for some elements of our clientele for $5 per prescription? That's something that has to be examined as we try to expand the program as well as contain the costs.

Mrs Sullivan: If you were considering mail order drugs for chronic use, what kind of surround would you be able to put on the distributors with respect to educational requirements associated with the drugs in terms of instructions to patients about safe use of the drugs and so on? And how is the drug reform secretariat approaching the issues of product safety and security of the product as it's moving through the mail and other areas?

Hon Mrs Grier: I'll let Mary Catherine answer the more general question, but let me say that I think it's premature to be definitive about any of this. We've just put out a drug reform consultation paper. The secretariat has been working and looking at a number of different aspects.

We know that particularly in the US, a number of health providers are using the mail order system quite effectively and finding that having the 800 line or whatever where there's always somebody there to give advice and counselling in fact is an improvement for some clients over what service they now get.

But I don't want the tone of the member's question to suggest that we see this as a panacea or necessarily meeting all of our criteria or that we've even progressed in our work on this to the point where we can be specific or definitive about the conditions. But Mary Catherine, I know, has looked into it.

Mrs Sullivan: I'm going to move to another area now, if I can.

The Chair: Mrs Sullivan has the floor, so if Mrs Sullivan wants to hear a response in part by both members, she can, but if not, she still has the floor.

Mrs Sullivan: I'd like to move on to another area. The area that I'd like to move on to now requires only a one-word answer, frankly. When will an announcement be made with respect to a compensation plan for those who have contracted HIV or AIDS through a tainted blood supply and blood products?

Hon Mrs Grier: Before the end of this year.

Mrs Sullivan: Before the end of this year? Has that been conveyed to the groups?

The Chair: I'm sorry, Mrs Sullivan. Is that the fiscal year or the calendar year? Because we deal in fiscal years here.

Hon Mrs Grier: I'm sorry. Well, then, well before the end of this year.

The Chair: So you're referring to the calendar year. Thank you.

Mrs Sullivan: Has that been conveyed to the associations which have made representation on behalf of their members?

Hon Mrs Grier: No, Mr Chair. That's certainly been the position I have said publicly, and I think everyone is aware of my commitment to this issue. But given that the question has been raised, let me talk in a little bit more detail about what is happening.

We have indicated --

The Chair: I'm sorry, Minister. In fairness, Mrs Sullivan notified the Chair that she has a series of questions and she had requested specifically short answers. If she wishes to have the fuller explanation of your consultation process to date, fine, but I'm really guided by Mrs Sullivan in this matter.

Mrs Sullivan: I think I'm familiar with the consultation process. What I'm eager for, and what I know the organizations are eager for, is a specific time line with respect to this issue, because as you know, Hemophilia Ontario, by example, has underlined extensively that two people die a week. So the issue is one of time. That is extremely important to them.

I want to move to HTAP --

Hon Mrs Grier: Mr Chair, I would like the opportunity to give some time lines and benchmarks in response to the question that was posed, which was for a definite date. I said the end of the year, but I think --

The Chair: Fine, Minister. However, in fairness, Mrs Sullivan has about 12 minutes left, at which point we will not have an opportunity to reconvene until some time in October to complete these estimates.

I think it's helpful to the process, as I indicated at the beginning, that she would like to get a series of questions on the record so that your staff can provide responses and then we can proceed again in October. It is helpful if the response can be brief and to the point. I'm just simply trying to assist those members to get those questions on the record.

Hon Mrs Grier: I'll make it as brief as possible, but as you know, Mr Chair, the committee has decided to have this meeting in public and there are many people watching who I know want some reassurance that it's not going to be merely an internal process between now and a date that I've generally said will be before the end of the calendar year.

As I have said, I think it's important that we be consistent across the country in our response to this tragedy. The meeting of federal and provincial ministers of health that is scheduled for September will be addressing this issue, but it will be addressing it on the basis of detailed work that is being done by each province.

In Ontario that is being done in discussions with Hemophilia Ontario and the people who have contracted AIDS through transfusions, so that we go to that meeting informed by what we know are their desires for the shape that an assistance package should take. I think that is a better way of doing it than for me to say, "We will make an announcement, this is it."

If it is to meet the very desperate needs and frustrations that those people have felt for five years when they've been seeking a resolution of this issue, then I think we owe it to them to have some consultations before we come to a conclusion. That is occurring over the next couple of months.

Mrs Sullivan: Could I move on to the Hospital Training and Adjustment Panel, which, under the social contract negotiations, will have a new face and a new responsibility? From the old face I'd like some written responses.

I'd like to know how much money was spent under the HTAP program, what the breakdown of that spending was, how employees accessed the funds, how many received job retraining -- my understanding is that the retraining component was close to zero -- and how many people who accessed HTAP actually found new jobs.

I would also like to know publicly now if, as a result of the document that came from the social contract discussions around midnight last night, the organizations -- say, the Association of Ontario Health Centres, district health councils, community support associations, community mental health centres, addiction programs, VON -- will now be included in the new form of HTAP.

The last thing that I want to know is, what additional cost will be placed on hospitals and other organizations as a result of the HTAP restructuring?

Hon Mrs Grier: As I suspect all members are aware, the Hospital Training and Adjustment Panel was created over a year ago with a fund of $30 million in order to assist employees in hospitals who might be facing layoffs as a result of the hospital restructuring.

In fact, the rather dire predictions of thousands of layoffs and great dislocation that had been made by people who were not supporters of the restructuring and who saw some benefit in placing worst-case scenarios before the public were not realized and the number of layoffs was much less than had been feared, thank goodness.

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There have been, I think, at this point about 2,000 laid-off workers in hospitals who have had access to HTAP, but I will get specific figures and data and provide those in writing to Mrs Sullivan, as she has requested.

What we have discovered is that to just look at hospital training and adjustment in isolation of the reform agenda and what is happening across the system has not been particularly fruitful. For example, we were talking earlier about the possibilities of workers in psychiatric hospitals being trained to follow their patients into the community. So as we look at retraining, we find that it's not possible to sort of segregate off hospitals and just do training and adjustment.

It is important that the entire health sector be part of that. So even without the initiatives taken under the social contract, I think we would have looked at whether it was possible to broaden the base of HTAP and in fact make it a Health Sector Training and Adjustment Panel. So the member is quite correct when she says that, as part of the social contract, that is being looked at.

While we have not yet completed those discussions and negotiations and will not have until August 1, I can tell her that what is emerging is the proposal that there be three subsector panels under the Health Sector Training and Adjustment Panel, one of them to deal with hospitals, one to deal with other institutional health care and one to deal with community services.

In response to her question as to whether the Association of Community Health, Resource and Service Centres or the other community-based services would, under the sectoral agreement as part of the social contract, have access to the HSTAP funding, the answer is yes. How much that funding will be in addition to the $30 million and whether it will be an add-on to the $30 million or how that will work I'm not yet able to respond to, but once the social contract discussions are concluded, I will be happy to do that with her. I think we will have a clearer picture of that by the end of this week.

Mrs Sullivan: In fact there will be an additional cost to all of the employers to participate in the new HTAP and it will be a substantial one. There are many other costs associated with some of the recent changes from the Ministry of Health to various institutions. I think of a new cost to hospitals, by example, being the loss of technical fees. I know that there has been an increase in the late filing fees with respect to the operating plans and so on. There are a lot of costs that are being transferred from the ministry to institutions and to other groups and organizations that are participating in the social contract.

I'm not convinced that HTAP was successful in the first place. Imposing additional costs on those who have to participate in it through what will probably be, to my mind, an imposed agreement isn't necessarily appropriate.

However, I'd like to move on to --

Hon Mrs Grier: Can we talk about some of those extra costs? Do you want some explanation of those, Mrs Sullivan?

Mrs Sullivan: Not at this point. I want to move on to another issue.

Hon Mrs Grier: Let me then make one comment about what I think the member is --

The Chair: If it's brief, Minister, but my obligation is to the committee and you have graciously offered to assist with fuller written explanations, and that has been afforded you. So very briefly, and then I would like to get the floor back to Mrs Sullivan.

Hon Mrs Grier: I just wanted to point out to Mrs Sullivan that I think she's making a rather arcane if not artificial distinction between the ministry and institutions which the ministry funds 100%.

The Chair: That wasn't meant to be inflammatory, was it? Please proceed.

Mrs Sullivan: I'm still proceeding to a different area in any case. I think that people would be very interested in understanding and knowing precisely the policy direction that the government is taking with respect to commercial laboratories. We know the estimates for this year include a $43-million reduction in payments. We know from the social contract documents, and I can just quote, "The government is committed to the objective of developing an integrated and cost-effective provincial laboratory service system and is requiring the laboratory services review to make recommendations by December 1993."

Behind that, however, we want to know and I believe the public wants to know what the public policy is of the government with respect to the operation of commercial laboratories. Is it your intention to put them in the situation you have placed home care in or child care in, and move them to a lower and lower portion of the market in the provision of laboratory services, or do you intend to maintain the same ratios and seek a cooperative approach to reducing the total cost of the services that are provided?

Hon Mrs Grier: We're certainly looking at how we can reduce the costs, and I think Mrs Mottershead can respond on how that is progressing.

Mrs Mottershead: I'd like to answer the question by referring to the laboratory review we have going right now.

Mrs Sullivan: Mr Chairman, I think it's unfair to put Mrs Mottershead in this position. I was asking specifically for the political decision with respect to the ratio of commercial laboratories that the government intends to maintain in the system. That is not a question I feel it is fair for the bureaucracy to have to respond to.

The Chair: The Chair has been rather flexible in the free flowing of conversation here. But to be fair and within the standing orders, when the minister responds directly she may, and through the Chair, ask if the member wishes a further clarification from another person, a member of your staff, and I have sort of been doing that in a more flexible way. Mrs Sullivan has the right to say that response is sufficient from you or insufficient, but if she really wishes to hear from Mrs Mottershead she has that right, and she's indicating she doesn't wish to hear the response in that sense.

Mrs Sullivan: Mr Chairman, Mrs Mottershead in her responsibility, in her capacity as an employee of the Ministry of Health, responds to the policy direction that comes from cabinet and government. That was the question I was placing: What is the cabinet's policy and what is its direction on this issue?

The Chair: That is to the minister?

Mrs Sullivan: That is to the minister.

The Chair: If the minister wishes a further clarification, fine, and then we'll proceed.

Hon Mrs Grier: The cabinet policy is that we have to find a way of reducing our costs in this area. There have been no further policy decisions taken with respect to as we review the services provided to us by laboratories, whether in fact we plan to change the system so there will be any difference in the way we now do it.

We believe there are considerable savings to be found by way of this review, and we certainly have made a commitment to all of the players in the system that they will continue to play a part and that the lab services review will be the vehicle by which recommendations for changes are received by us.

We have not yet completed that review, and it was the details of that review and the facts which I thought this exercise was designed to elicit and that I thought Mrs Mottershead could comment upon.

Let me assure the member that from a policy point of view, there have not been any changes in direction taken at this point, nor will there be until we receive the recommendations of that review. If she would like some details as to what that will cover, then I think Mrs Mottershead would be the more appropriate person to give them to her.

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The Chair: The time in this sequence has come to a conclusion and perhaps additional information can be provided to the committee. I'd like to move to the third party, and I understand Mr Villeneuve has a question.

Mr Noble Villeneuve (S-D-G & East Grenville): Thank you very much, Mr Chair and Minister. I'll be talking about a situation that happened last week. It's something that was very annoying to me and to the people it happened to.

First of all, we have three small hospitals in the riding that I represent, Alexandria, Winchester and Kemptville, and there are some great concerns about funding because they are convalescent hospitals by and large. There are services provided in the Brockville General Hospital, the Kingston Hospital, the Ottawa hospitals and of course the two Cornwall hospitals. Certainly, the constituents in Stormont, Dundas, Glengarry and East Grenville have a wide variety of places to go to, and by and large service has been quite good.

What I have here is a letter that was faxed to me, and I'll read parts of it into the record because I think it's important:

"On Monday, June 19, at approximately 11 am, a fellow coworker was discovered unconscious on the floor of the TV lounge." We're speaking of a truck stop along Highway 401 at Cardinal. "We revived him and helped him to a chair, while an ambulance was called. The gentleman was in considerable pain, was barely audible, while holding his head. Upon arrival of the ambulance attendants, he disclosed that prior to passing out he had a dizzy sensation followed by what he said felt like his head exploded. His consciousness was in and out while en route to Brockville General Hospital.

"Upon arrival at the hospital, he underwent preliminary testing. The attending physician, Dr Comeau, suggested he should be airlifted to Ottawa Hospital for further testing by a neurosurgeon, as they suspected a blood vessel had erupted in his head.

"At approximately 4 pm, he was airlifted to Ottawa as recommended. He underwent testing as prescribed, then he was airlifted back to Brockville." That is the first little different thing. "The reason being he was admitted to Brockville and therefore had to be discharged from Brockville before he could be readmitted to Ottawa."

That's strange. The author of the letter, in bold, black letters, says: "Tell me where this makes sense? This gentleman's wife was called at home at 1 am and told that she had to pick up her husband at the Brockville General Hospital and take him home to wait for admittance to Ottawa hospital. Upon her arrival at 2:15 am at the Brockville General Hospital she found her poor husband lying alone in the emergency ward. Brockville General Hospital stated the patient had to leave due to bed shortage. The patient was the only person in the emergency ward at that time."

The question here is: Could they not at least have kept him till morning? It goes on. I checked with Brockville General Hospital. They had some sketchy information. They were not able to tell me why the patient was airlifted back to the Brockville Hospital. I understand that as of tomorrow -- he resides in Kemptville -- he will be admitted to the Ottawa General Hospital.

I understand he is convalescing well. The worst of his problem, whatever it was, is over, but to me this does not make sense. I won't read into the record what this lady has to say about the way this patient was treated at both hospitals, but she has, I believe, a very legitimate complaint. Could you comment on that?

Hon Mrs Grier: I can certainly comment and say that the facts as the member has portrayed them really concern me. If that's a letter to me, I would certainly like to --

Mr Villeneuve: We'll make it available to you, Minister.

Hon Mrs Grier: I'd like to have it made available, but also to make the point to him that hospitals are fairly autonomous bodies and they and the physicians make the decisions in an emergency, not the ministry, so the letter also has to go to both hospitals to get some explanation as to how the patient was dealt with. Perhaps, if the member would agree, and with the Chair's permission, I could ask Mrs Mottershead if there were some process in place that would ensure there was a factual response and some investigation, because I'm not sure how either of those hospitals would handle it. I think that in this case the patient profoundly deserves the greatest possible explanation.

Mr Villeneuve: As a follow-up, and this is presently being done with freedom of information and the patient-doctor relationship etc, I have had some difficulty, and I understand that and I appreciate that. As Minister of Health for the province, in monitoring the cost of air ambulance or ambulance or the ambulatory system, would you be doing audits? To have flown this patient back from Ottawa to Brockville seems rather bizarre. Is a check done by your ministry as to the cost of these things?

Hon Mrs Grier: I can't answer that --

The Chair: Is there someone here who could be helpful?

Hon Mrs Grier: -- but I think with respect to ambulance services, Mr Ennis can respond as to how we monitor the contracts and the ambulances that we have. I don't know whether it was a hospital ambulance or a private sector ambulance.

The Chair: Welcome back, Mr Ennis. You've been introduced once before. The question is about how the ministry checks the flight logs, and accountability with respect to air ambulance billings to your ministry or the service.

Mr Michael Ennis: I can respond more generally to the question very quickly. All the calls are placed and monitored through the central dispatch, which is government-run. The dispatcher will respond according to the level or the state of urgency of the call itself. So on the directions that are received from the hospital in terms of the critical nature of the patient, they will then proceed to dispatch either land or air, depending on the specific request.

In terms of the actual cost itself, an individual vehicle call averages about $250 across the province. That's an average. In terms of an airplane, in terms of responding by air, the average is in the range of about $2,000.

Again, the dispatch is done on the basis of the urgency, and the central dispatch has to rely on the hospital and the doctor to declare the level of concern and emergency. There are records kept of all these calls.

Mr Villeneuve: Would it be normal to fly a patient back from whence he came that because he was admitted to a certain hospital, he has to be released from that hospital? Is that a normal sequence of events?

Mr Ennis: From the way it has been described by yourself, I haven't heard of a similar situation like that, but again it's not necessarily totally up to the government or central dispatch. They have to respond to the hospital and the doctor's concern as to how the patient should be transported. We could look into that. As the minister has indicated, in terms of following up the actual situation with the individual, we will look at what happened around the call, what the level of urgency was and why the person was flown back again.

Mr Villeneuve: I would appreciate certainly a written response.

Just further, when auditing the cost of ambulatory service, be it air or by road or whatever, is it simply a matter of the ministry saying, "A flight was logged in and therefore it's an automatic payment," or do you have secondary follow-ups to monitor this?

Mr Ennis: In this case, there are a couple of ways of approaching it. First of all, in this case, it may have been a dedicated air ambulance, which is actually run by the government itself, so the costs are built into that service as it is. In terms of any other air transport, there's a contract. It's laid out ahead of time as to how much that would cost and the average costings are known. So there's a process of evaluating how much the cost would be, both in the government-run and in the purchase of service, the contract.

Mr Villeneuve: I appreciate that the ministry will be looking into it. I felt I had to bring this before this committee, particularly the timeliness of it. It happened very recently, and certainly, I had no explanation at all. This letter is well documented and you'll be getting a copy.

The Chair: I appreciate your willingness to look into the specifics of the case. Mr Villeneuve will share that letter with the deputy and they can proceed.

Mr Jim Wilson: Mr Ennis, you may want to stay put for a minute and talk about the area of home care.

The Chair: Welcome back.

1750

Mr Jim Wilson: Minister, on June 25, you announced that commercial agencies would be restricted to a maximum of 10% of the home health care market. Many believe this announcement will not help to improve the system of home care and that this decision was based solely on the NDP's ideology. I will say that no previous government has ever restricted the private sector to 10% of the market. I will also say that previous governments, contrary to the spin your government keeps putting on this issue, attempted to have a balance between private sector and public involvement in the delivery of home health care services. You've tilted that balance.

Following your announcement, the Ontario Chamber of Commerce wrote to the Premier. I want to quote this letter very quickly. It says:

"We are therefore disappointed by your government's recently announced plans to restructure long-term home health care in a fashion which seriously discriminates against commercial home health care providers in Ontario. Frankly, this decision seems to be driven by pure ideology rather than by legitimate concern for those who are in need of long-term home health care or based on valid economic considerations.

"The Ontario Chamber of Commerce believes home health care in Ontario will be more expensive, less efficient, less responsive to the needs of its clients, as well as be subject to lower-quality standards which the industry currently enjoys if the commercial providers are eliminated as planned.

"We fear that the taxpayers of this province will be the big losers in the end when they are faced with higher cost, lower tax revenues and lower levels of service."

Minister, other than ideology, what factors fuelled your decision to starve the private sector from the delivery of home care services?

Hon Mrs Grier: Let me say that if it's a competition as to who's ideological, I don't wish to compete with the Ontario Chamber of Commerce.

No other government, let me say to the member, has embarked upon the kind of consultation that went into the preparation of the long-term care reform. That was begun by the previous government. I guess they embarked upon it. What we did was carry it on and then listen to what we heard, and what we heard, loud and clear, across the province was, aside from an ideological few, the vast majority wishing that this be a non-profit system and that the services that need to be provided to the elderly in their homes or in an institution, as far as possible, be on a non-profit basis.

When we looked at how we should best spend and get the best value from the resources that were available, and knowing that we wanted to maintain our commitment to provide new resources but at the same time were having to find those new resources by reallocation within our budget, we made a very clear decision that it was the best use of taxpayer dollars to pay for salaries and services, not to go into profit.

We have then, as the member has said, outlined a basis by which over a three-year period there will be a shift in those areas where the majority of services are provided by for-profit agencies to not-for-profit, and any new services to be provided and paid for by the taxpayers will be provided on a not-for-profit basis.

Mr Jim Wilson: Minister, I would disagree that the public consultations resulted in overwhelming support for the not-for-profit sector. That's not what I heard during the consultations. I had people lined up in my office telling me the exact opposite. You put the cart before the horse; your government did. It said, "We have a preference," and kept stating it in document after document, went out on that premise, looked for that response and interpreted the results from the public in that way. You had preconceived notions based on your ideology.

Will the taxpayers be paying more to get less with the shift and the driving out of the private sector, will they be paying more to get the same level of service or will they be paying more to get more services? What studies do you have to show that taxpayers are going to benefit because of your driving the private sector out of the delivery of home care services? I want to know what studies and I want them tabled.

Hon Mrs Grier: Mr Chair, the --

The Chair: That was a request, I think.

Hon Mrs Grier: That was a request. Okay, we will take that request under advisement.

Mr Jim Wilson: Minister, do you have any studies?

Hon Mrs Grier: I don't know whether there are studies available in the ministry. This has been an issue that has been debated, that has been looked at for a long time. I certainly am completely comfortable with the direction that emerged from the consultation and from the work that was done and I firmly believe that the taxpayers will (a) get better value for their dollars and (b) under this reform have, for the first time in this province, a holistic system, a coordinated system, a system that provides them with the services they need --

Mr Jim Wilson: Minister, I simply asked you whether you had any cost-benefit studies.

Hon Mrs Grier: -- wherever they happen to live.

Mr Jim Wilson: Chair, that's not my question. I'll ask Mr Ennis. Are there any studies that the government prepared to back up the decision to drive the private sector out of the delivery of home-care services, any cost-benefit analysis or anything that resembles that? If so, I want those studies.

The Chair: Mr Ennis has been asked a direct question. Please proceed, Mr Ennis.

Mr Ennis: I'm not aware of any studies that have been developed to show a cost-benefit analysis of profit or not-for-profit sectors.

Mr Jim Wilson: Then how can you say that the citizens of this province are getting a better deal under your scheme? On what basis do you justify that?

Hon Mrs Grier: On the fact that you're spending a dollar. What do you spend it on? You spend it on services and you spend it on the employees and there isn't anything left over to be skimmed for profit. We know that the level of service that has been provided by the profit-making agencies has been good. There is no question about that and I'm not suggesting that they provide in all cases an inferior service, but I certainly believe that as we expand that service, and as we expend more taxpayer dollars, that it is more cost-effective to do it on a non-profit basis.

Mr Jim Wilson: Do you have any understanding of the fact that if the private sector is involved -- one of the reasons that services have been good, what services there are in the province, is because the private sector is there driving down costs, and that both the not-for-profit sector, which is the government sector, and the private sector have worked pretty much in harmony over the past several years to deliver services to the public? It's my understanding that the government sector competes alongside with the private sector and because there is that balance there, we've been able to keep costs down.

I would simply once again ask, on what basis other than ideology do you base this decision? This is a significant decision. You are driving thousands of people out of their jobs, who currently work in the commercial agencies, and you have no basis whatsoever for doing that in terms of cost-benefit analysis, quality of care -- you've admitted yourself that the quality is very good in the commercial sector.

The Chair: Mr Wilson, I'd like to give the minister a moment to respond in the time remaining, if I may.

Mr Jim Wilson: Yes, I would like a response to that. I can't believe --

Hon Mrs Grier: Let me respond to the allegation that jobs will be lost and remind the member that in fact new jobs will be created in this program and that there may well be people who shift from the private sector to the non-profit sector, but this is a growth area. When the member says that having the private sector there has driven costs down, I don't know what studies he has on which to base that assertion. We've had an exchange here today, for example, about pharmacies' prescribing fees and we're in a contract that says we pay $6.47 for every prescription. The market is at $5.

Mr Jim Wilson: It's not the same thing.

Hon Mrs Grier: We are talking about contracts from the public sector to pay for services, and I certainly have not had any evidence that the existence of the private sector in the home support area has made it any less expensive than it has been for government. As I say, we have made a policy decision and I stand by and defend that policy decision.

Mr Jim Wilson: You defend it on no grounds whatsoever.

Secondly --

The Chair: Mr Wilson, I --

Mr Jim Wilson: Mr Chairman, just one sentence.

The Chair: If you have a question, perhaps.

Mr Jim Wilson: She just used a private sector example of $5 to justify a non-profit thing.

The Chair: That's fine, but --

Mr Jim Wilson: The $5 dispensing fee is coming from the private sector.

The Chair: -- this is not a debate; this is the estimates and unless you have a question --

Hon Mrs Grier: The point is, the structure doesn't permit the kind of open-ended competition you're suggesting.

The Chair: Minister, Mr Wilson, please. With it now being 6 of the clock, I wish to advise the committee that we have approximately two hours and 52 minutes remaining to complete our estimates review for the Ministry of Health. Since I'm advised by the House leaders that the intersessional will begin next week, this committee will stand adjourned to reconvene for Health estimates at the call of the Chair.

Hon Mrs Grier: Don't bang the gavel for one second. I have some additional information in response to questions that I will leave with the clerk.

The committee adjourned at 1759.