Legislative Assembly of Ontario

MINISTRY OF HEALTH

CONTENTS

Tuesday 23 June 1998

Ministry of Health

Hon Elizabeth Witmer, minister

Ms Sandra Lang, deputy minister

Mr Ron Sapsford, assistant deputy minister, institutional health and community services

Ms Linda Tennant, director, drug programs branch

Ms Mary Catherine Lindberg, assistant deputy minister, health insurance and related programs

Mrs Louise Steele, director, fiscal strategies branch

STANDING COMMITTEE ON ESTIMATES

Chair / Président

Mr Gerard Kennedy (York South / -Sud L)

Vice-Chair / Vice-Président

Mr Rick Bartolucci (Sudbury L)

Mr Rick Bartolucci (Sudbury L)

Mr Gilles Bisson (Cochrane South / -Sud ND)

Mr John C. Cleary (Cornwall L)

Mr Ed Doyle (Wentworth East / -Est PC)

Mr Gerard Kennedy (York South / -Sud L)

Mr John L. Parker (York East / -Est PC)

Mr Trevor Pettit (Hamilton Mountain PC)

Mr Wayne Wettlaufer (Kitchener PC)

Mr Terence H. Young (Halton Centre / -Centre PC)

Substitutions / Membres remplaçants

Mrs Marion Boyd (London Centre / -Centre ND)

Mr John Gerretsen (Kingston and The Islands / Kingston et Les Îles L)

Also taking part / Autres participants et participantes

Mr Jean-Marc Lalonde (Prescott and Russell / Prescott et Russell L)

Mrs Lyn McLeod (Fort William L)

Clerk / Greffier

Mr Viktor Kaczkowski

Staff / Personnel

Mr David Rampersad, research officer, Legislative Research Service

The committee met at 1535 in committee room 2.

MINISTRY OF HEALTH

The Vice-Chair (Mr Rick Bartolucci): I apologize for being late. We will continue with our health estimates. I believe the NDP, the third party, has 10 minutes left in their statement.

Mrs Marion Boyd (London Centre): Before I begin, I understand there was a discussion about a lot of materials that were to be submitted to us and the minister had made a commitment to try and have those submitted to us by today. I don't see any materials at our desks. I wonder if someone can tell me what has happened.

Hon Elizabeth Witmer (Minister of Health): My deputy is not here yet, so I'm not in a position to respond to you, but as we had said last week, I can tell you that, further to the request by Mr Kennedy and the detailed analysis we are endeavouring to do based on the information that was presented to him, ministry staff are analysing very carefully his report and the supporting material. As soon as the results of the analysis are complete, we'll share them with you. I can give you some initial response, though. If that would be required later, I'd be prepared to do so.

The Vice-Chair: Minister, I think what Ms Boyd was referring to was the letter from Anne -- do we have a copy of that? -- asking the minister to compile a list of material that had been requested by different members of the committee. At the time, you had given your assurances that you would try to have something, either before the meeting or for the meeting.

Hon Mrs Witmer: I'm going to have the deputy respond to that -- apparently she does have some information -- but before I do, I would just indicate that I have written a letter to you, Mr Chair, indicating that due to circumstances beyond my control I will not be able to attend tomorrow afternoon. I think we have what, about an hour and a half left tomorrow?

The Vice-Chair: Yes.

Hon Mrs Witmer: Mr Newman has indicated he would be here on my behalf, if you wish, or if not, obviously we could reschedule. I guess that would take us into some time after the House is finished.

The Vice-Chair: I was going to deal with that at the end of the meeting, but since you've mentioned it, what's the pleasure of the committee: To delay the final health estimates until we resume in the fall or to have Mr Newman present before us to answer our questions? Any discussion?

Mr Terence H. Young (Halton Centre): There are lots of precedents actually where the parliamentary assistant has replaced a minister when it's necessary due to government or ministerial duties; and, as well, not just the parliamentary assistant but the deputy ministers. I would like to have Mr Newman appear tomorrow and I'd like to get to this matter tomorrow. I think it would be beneficial to the committee to complete the deliberation of the ministry's estimates rather than break it up and reconsider doing it at a later time. Mr Newman appeared before the estimates committee last year on behalf of Minister Wilson, the former health minister, and proved very capable of answering all questions.

The Vice-Chair: Do we have consensus that we'll have Mr Newman appear before the committee, replacing the minister? Agreed. Okay, that's taken care of. Now maybe we can go back to the list of material.

Ms Sandra Lang: I have just reviewed with my staff where we are on the completion of the information requested. We haven't compiled it all yet. They've assured me that we are working hard to get it pulled together, but we don't have it completed. Hopefully we will have it ready for tomorrow.

The Vice-Chair: If you don't have it all ready, would it be possible for you to share with the committee that material which you have ready, as opposed to giving it all in one package?

Ms Lang: Okay. We will certainly try to do that.

The Vice-Chair: Great. Any other questions or comments from the members of the committee? Then we'll go to Ms Boyd, 10 minutes.

Mrs Boyd: I would have preferred, obviously, to have the list since I wasn't able to be at the first two days of estimates. Apparently, according to the minutes of those meetings, you expect to be finished tomorrow. We were asking for the material and certainly for the list of materials so that we could ask questions. Just so you're aware, I'm not best pleased that we aren't at least able to have the list, if not the materials themselves that were requested.

Ms Lang: Excuse me, could I just clarify the list in terms of the questions?

Ms Boyd: The list of materials that you were to provide to us as a result of the first two days of estimates was to be provided by today. You were to compile that list and to present it to us for today. It certainly puts me at a disadvantage not to have that compiled list.

Ms Lang: We were in receipt of a note from the clerk the other day itemizing all the items that were to be completed, so I assume it's available.

The Vice-Chair: That's right. We'll have a copy of that letter for all the members of the committee. However, it's my understanding that some of it would be here today as well. I don't think any of us expected that all of it would be here, but at least some of it would be here. That could have formed the basis of some questions from the three parties, but the reality is, it's not. It will be tomorrow. Maybe we can continue on with the questions.

Mrs Boyd: Minister, in a number of different parts in terms of your answers to questions, you indicated that you were committed to dedicating more money to the prevention end. You were talking very confidently about the need to spend a lot of attention on health promotion and prevention.

I'd like to draw your attention to vote 1405, the program being population health and community services, and the activity being health promotion and program administration; operating expenditures. In 1997-98, your estimates were $20,948,200, but your estimates for this year are $18,258,600; in other words, a decrease of 12.8%, for a total of $2,689,600. In terms of transfer payments for health promotion programs, in 1997-98 your estimates were $13,967,900; in 1998-99, your estimates are $11,967,900; again a difference of $2 million and a reduction of 14.3%.

I understand the health promotion program to be one that provides financial support to community health promotion projects which are targeted to address four key issues: cancer, cardiovascular disease, alcohol and other drug abuse, and maternal and newborn health. The programs to address these health issues are based on known risk factors.

I'm really quite concerned to see, in total, a fairly severe reduction in the health promotion and program administration areas and in the health promotion program at a time when certainly all indications are -- and your own speech to the committee indicated -- that there are many diseases which we now know can be prevented; that there are expenditures we are now having to expend on people who have not had the benefit of those that we would not have to spend tomorrow. I'd like an explanation from you as to why there would be this kind of reduction in the population health estimates.

Hon Mrs Witmer: There were some changes made in the area of the promotion. Certainly you're right, Mrs Boyd. Health promotion, wellness promotion, disease and injury prevention are certainly key issues for the ministry. I have made reference to the fact that it is important that individuals within the province assume greater responsibility for their health and that we look at improving health outcomes and doing what we can to shift the focus from illness to wellness. I'm going to call on Mr Sapsford to deal with this issue, as to how this is being dealt with.

The Vice-Chair: Welcome back, Mr Sapsford.

Mr Ron Sapsford: The change from the preceding year in health promotion expenditures is really the result of a program review in the health promotion program. The result was a decision to focus most of the resources on four key health issues faced by the province: cancer, cardiovascular disease, alcohol and drug abuse, and maternal and newborn health. The reductions came at the conclusion of that program review, where decisions were made to consolidate the funding along those four program areas, and a number of programs were reduced. The bulk of the money was from administrative overhead savings, as opposed to direct program costs, and the program moneys aligned to these four target areas of health promotion. It was felt this was a better use of the funding, by focusing it on these key areas rather than spending it across dozens and dozens of very small and uncoordinated programs.

I would add as well that this line does not represent the only health promotion expenditures of the ministry. There are many other programs that have health promotion components attached to them. I'll give the example of the diabetic programming, where a significant portion of the program expenditures in that particular program are related to health promotion. As well, in the drug area there are significant expenditures on the development of drug-prescribing guidelines in the efforts to improve health.

Mrs Boyd: I don't have any quarrel with your addressing the four key health issues, but at least three of the four certainly have a lot to do with the tobacco rejection strategy. The minister claimed she was working on a tobacco rejection strategy for the province. It's quite clear from these estimates that the minister doesn't expect to introduce that this fiscal year. There's nothing there for a major investment in tobacco reduction strategy, even though the minister said that was a major focus. Minister, can you tell us when you expect this tobacco rejection strategy to be introduced and where the dollars are going to come from?

Hon Mrs Witmer: Yes, I'd be happy to. Mr Sapsford has indicated that the ministry has shifted the focus of recognizing all health promotion activities on the one line. Much of the promotion activity now is tied into other lines as well. I think a good case in point is dialysis and diabetes, where we're now focusing on education programs as well for the patients.

To talk about the tobacco strategy -- and this is an issue that we are personally most concerned about at the Ministry of Health -- we've had actually quite a bit of consultation with some of our stakeholders and we are about to set out the parameters for the initiative of reviewing the tobacco health strategy. We hope to have sufficient consultation that would allow us to start making changes, because we are certainly quite alarmed that the present strategy is not, in all cases, achieving its targets.

When the price of tobacco was reduced, it did have an impact on individuals and their ability to purchase cigarettes. We're seeing an increasing number of young people. Our focus, when we take a look at the tobacco strategy, is really to focus on how we prevent young people, in particular, from starting smoking and also, just as importantly, for those who have started, how we encourage them to quit smoking. We are just about to start, and I hope we can complete that task in very short time. But we need to consult with people in the province and then we need to move forward and make the changes to the strategy in order that it can have a significant impact on the individuals who unfortunately are taking up this habit.

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The Vice-Chair: We'll move to the government side.

Mr Trevor Pettit (Hamilton Mountain): I know the government is looking at different ways of providing health services to individuals. One of the recent initiatives that I have an interest in is the announcement you made a few weeks ago about primary care. In fact, we were honoured to have you make it in Hamilton. This, to me, is a very progressive partnership between the doctors and their various communities. I'd like it if you could explain how this is going to work in a little bit more detail, if you would, and also if you could give us your best estimate of when this program, assuming it will be successful, might be expanded to other centres in the province besides Hamilton. Is it four others or three others?

Hon Mrs Witmer: It's four others; a total of five.

Yes, the announcement was made in Hamilton and actually it was extremely well received by the community, as well as by the Hamilton Spectator. They indicated they appreciated the focus we were putting on upgrading front-line patient care for your population. It's one that's growing and aging.

We announced this new model of care in conjunction with the Ontario Medical Association. The pilot sites are in Wawa, Chatham, Paris, some municipalities around Kingston and of course Hamilton.

What we really want to ensure happens is that we can increase the accessibility to health services in Ontario. We also want to look at different, more innovative approaches to delivering services to people in the province. We want to make sure that this primary care reform that we undertake does comply with the Canada Health Act in every aspect. We want to then, of course -- if that's our objective -- ensure that it's accessible and universal.

Most importantly, what this initiative does is provide a comprehensive level of care that most people in this province are not receiving today. What I mean by that is that those people who become part of the pilot project and make an agreement with a physician to be part of the rostered list of patients will actually have access to 24-hour care. That means if the physician is not available to take the call and to take the patient, he or she would ensure that a colleague would be available to do so. If the physicians are not there and it's night-time, there will be a nurse available who will be in a position to provide advice and information as to how to deal with the medical concern and to give the appropriate directions. I think this is one of the real pluses of this initiative, the fact that you do have the continuity, the access to care 24 hours a day.

People participating in these pilot projects do so based on their volunteering to do so. It's not compulsory. If you live in Wawa, you don't have to sign an agreement. You don't have to roster with a physician. You can still continue to receive services as you presently do on a fee-for-service basis. People will not be compelled to be restricted to a provider. As I say, they have an opportunity to make the decision. They have an opportunity to choose their doctor and, if they're not satisfied with the physician, they also have a couple of times each year where they can evaluate that particular decision.

Also, your access to emergency services is not going to be impacted in any way. As I've just pointed out, you actually will be able to call the doctor and get a live person on the other end 24 hours a day. Obviously, if it's an emergency situation that warrants you going to a hospital, you would be directed to do that if you haven't already made that choice yourself.

We know there's a need for fundamental change. Doctors are indicating to us that they like this approach. I think they're anxious to see how this is going to work. Actually it'll give us an opportunity to look at different methods of payment for physicians. We can pay them according to the old fee-for-service, we'll have some reformed fee-for-service, and some of them will be paid according to a method called capitation where it's really a fee per patient. Based on the age and some of the other factors related to that individual, they'll be reimbursed a lump sum for providing services to that individual.

The other area where these physicians are going to focus their attention and be compensated is in the area of prevention. They'll actually have time to discuss with patients means for keeping them healthy. Nowadays most doctors don't have an opportunity to focus on prevention. There will be improved use of technology available on all of those five communities and there will be access to computerized patient records. We actually had a demonstration, if you remember, in Hamilton and the two physicians there were quite impressed.

We believe this is certainly a way of increasing the accessibility to services and also ensuring not only that physicians are part of this project, but also that nurse practitioners are going to be involved. As you know, in Hamilton, the individuals there, we're working with the pharmacists, the dentists. They had a mental health support worker, they had therapists. It really is bringing all the health care providers together and being able to respond to the needs of the individual patients in that type of setting.

We hope we're going to see some good results. We have an independent body that's going to be doing the valuations. As soon as we can see what's working well and what's not, we'll make the appropriate changes. We obviously, as interest indicated, would be prepared to expand it to other centres in the province. But as I say, it's voluntary.

Mr Ed Doyle (Wentworth East): One of the questions that was asked last week, and I'd like it to be expanded on, was the money the government saves as a result of copayments made on prescription drugs. However, I think we should get more information than that. I think we should also find out how much it's costing the system because of the new drugs that have been added to the formulary. Is it possible that we can get that kind of information as well?

Hon Mrs Witmer: The drug information?

Mr Doyle: Yes, that's right. The cost to the system because of the additional drugs that have been added to the formulary, and I believe there have been a few hundred added.

Hon Mrs Witmer: That's right.

Mr Doyle: In addition to that, it's also my understanding that many, many more people are eligible for the plan now.

Hon Mrs Witmer: That's right.

Mr Doyle: That would obviously have some financial effect.

Hon Mrs Witmer: I'm going to ask Linda Tennant to respond to some of those questions and then I'll provide some additional information as well.

Ms Linda Tennant: I'm Linda Tennant, director of drug programs branch. I'm sorry, I have to try and remember the question. The number of new drugs added in the last two years is just over 500, and that includes the full range of drugs, whatever becomes available within the pharmaceutical community.

In addition to that, I don't have the exact figures with me but the drug budget continues to rise. If you look within the budget, you'll see the growth that you would expect to see. We expect about a 2.5% to 3% increase in the number of people turning 65 each year. It nets out to about 4,000 to 7,000 per month. There was also an increase in the number of people who take drugs over a certain age, 70 to 75. Within the budget, in the last two years we've seen a major increase in the number of people on home care because the drug budget covers drugs while people are receiving care in their homes.

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The Vice-Chair: Ed, any other questions?

Mr Doyle: Yes, I do as a matter of fact. Minister, there are a lot of people wondering about the year 2000.

Hon Mrs Witmer: Before we go forward, I think it's important to remember, when we talk about the drugs, that actually that's one of the areas where we have seen the greatest increase as far as expenditures are concerned. We've actually seen an increase of 17.7% in one year. Obviously this is something that is due in large measure to the demographic growth as the population is aging. Certainly there are more people than ever before who are receiving coverage and obviously have access to these drugs that are being provided by the government.

Mr Doyle: In addition to that, there are more people now eligible for it who are under 65 because of their income.

Hon Mrs Witmer: Yes, there are. That's right, because of the changes we've made, and so really we have expanded eligibility, and also as the population ages. We've actually increased access to the drug program and there are more people than ever before who through Trillium or the ODB have access to these drugs.

Mr Doyle: I was asking about the year 2000. A lot of people I think are somewhat confused by the year 2000. What has 2000 got to do with computers and so on? It's my understanding that the computer can't tell the difference whether it's 1900 or the year 2000, so it will cause confusion with computers. I wonder if you could expand on that and tell us what actions are being taken and whether we're going to make it.

Hon Mrs Witmer: I think all ministries and the government as a whole are obviously very concerned about problems related to the year 2000, as is anybody in this province who has a computer. What we're doing, as you know, is we're ensuring that we can meet the year 2000 deadline. We are working as hard as we possibly can. This is obviously a new experience for all of us and we're making sure that the steps are taken.

We've actually allocated $300 million to deal with this issue in the 1998-99 budget. I will ask the deputy, who obviously has the responsibility for the health sector, what steps are taking place.

Ms Lang: We're actually dealing with this issue on at least two fronts, if not three. Inside government, Management Board has taken a major lead around information systems and all the ministries have been working extremely hard to identify mission-critical systems and how we're going to ensure our systems are in compliance with year 2000.

I'm quite pleased to say that the Ministry of Health is well advanced and certainly working quite hard to ensure that the systems are upgraded to be in compliance with year 2000.

In addition to that, we've been working very collaboratively with what's called the Ontario Health Providers Alliance, which is an organization of member agencies who have interest in the health care sector: the OMA, the hospital association, the labs, the drugs, the pharmacists, the home care providers, all of those folks who have an interest in health care.

We've been working very collaboratively with them around a process to review the state of readiness of the health care system and the health providers in terms of compliance, particularly as it relates to medical equipment and ensuring that the commitment for those providers to have their organizations ready to deal with the requirements of year 2000 are in place. We've put in place a major project and been able to recruit someone in from the health sector to work in a significant leadership role in making that happen with the various providers.

On the third front, we've been working with our colleagues across the country, because this is not a unique issue to Ontario, as I'm sure you appreciate. So we are working very collaboratively with our colleagues across the country to ensure that we're not replicating and duplicating effort, and focusing energy. We have, with the help of our colleagues in other provinces, set up a process now to look at an equipment-testing vehicle to ensure that the critical equipment for the health care system is able to meet the year 2000 requirements. We have a lot of activity under way. It won't be for want of trying that we aren't ready by the turn of the century. Certainly we have put in place and the resources are given to the ministry to make sure we can make the system compliant, in the information sense but also in the service sense.

Mr Doyle: It's quite a daunting problem, obviously. When you consider that when we get to the year 2000 and 2001, there will have been some people who are still alive who were born in 1899, so we'll be covering three different centuries.

Mr John L. Parker (York East): Are you one of them, Ed?

Mr Doyle: No, but I will be in 2002.

The Vice-Chair: Mr Wettlaufer.

Mr Wayne Wettlaufer (Kitchener): Thank you, Chair. How much time do I have?

The Vice-Chair: You have three minutes.

Mr Wettlaufer: Minister, when the Canada Health Act was signed in 1960 something or other, the federal government agreed to contribute 50% of health expenditures, to transfer that much to the provinces. Presently the federal government is contributing only eight cents, and does not fund home care or, I believe, long-term care. The provincial Liberals have chosen to say nothing.

The provincial Liberals indicated in their red book that they would have spent $17 billion per year on health care. The government is spending $18.5 billion or $18.6 billion in this year. The Saskatchewan government indicated not too long ago that the Saskatchewan Liberal Party has estimated it could find $1.3 billion in savings in health care, but of course they haven't come up with the figures. They haven't indicated to the government in Saskatchewan where those savings would be. I suspect the provincial Liberal Party in Ontario seems to think it could also find $1.3 billion or $1.6 billion in savings.

Mr Pouliot last week asked, "Is the federal government jeopardizing health care in this province?" Could we have an elaboration from you.

Hon Mrs Witmer: Our government has certainly recognized that health, health care, health services are a priority for people in this province. We had indicated that we would never subsidize health at less than $17.4 billion, but as we've taken a look at the needs of people in this province, it's become abundantly clear that not only would we not go below that number, we actually have invested more dollars because what's happening is there is a need for additional programs, as people are aging, the population is growing and people are simply living longer as well. As you know, we're spending more money today.

We have been very disappointed that the federal government has not responded to the needs of people. Across this country, citizens have made it abundantly clear that they want accessible, high quality health services, and certainly we're trying to provide those. Not only are we spending $1.2 billion in additional dollars today, since 1995, we've also had to absorb the almost $2 billion in cuts in transfer payments from the federal government. Obviously, if there are additional dollars that would be forthcoming from the federal government to support the services, they would be appreciated and money that could be well used.

The Vice-Chair: We'll go over to the official opposition. Mr Lalonde, welcome to the committee.

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Mr Jean-Marc Lalonde (Prescott and Russell): Thank you, Mr Chair.

I have a question. Minister, since your government has decided to, I call it, download the ambulance services to the municipalities, even though your ministry comes up with some figures, we know those figures go up all the time, because every time a section of the ambulance service has to purchase a new ambulance, it goes towards the budget of the counties or the municipalities. Do you have an idea at present what the saving to the province will be due to the fact that you have downloaded the ambulance services to the municipalities? What will be the provincial saving?

Hon Mrs Witmer: I'm going to ask Mr Sapsford to respond to that question.

Mr Lalonde: While he's doing some research on that, I'll say this: Three weeks ago I just happened to attend an accident on Highway 17. We're waiting for the report from the 911 services for the time it took for the ambulance to get there. I will see on my cellular phone bill the time I called and I will have the exact time before I come back with it.

With the fact that it is downloaded to municipalities, the rural areas, I would say, will be second-class citizens because they won't be able to afford the current ambulance services. We know there are areas that will not have the financial resources to continue supporting the ambulance services we are getting now. But currently, even though the management of the ambulance services is taken care of by the provincial government, we have noticed already the reduction of services we are getting.

Have you got those figures yet?

Mr Sapsford: At present, the estimates include the costs of ambulance services. The actual transfer of the funding will not occur until January 1, 2000. The estimates reflect the amounts and that will be billed to municipalities. As far as the net savings to the province is concerned, the transfer of services between the province and the municipality was meant to be revenue-neutral so that there's no direct savings to the health budget. We will be transferring exactly the cost of the services to the ministry as part of the calculation for the funding transfer to the municipalities.

Mr Lalonde: The whole cost is going to be taken care of by the municipalities. You are invoicing the municipalities for the cost of the ambulance, so definitely it is a savings to the province, but it is an additional cost to the local taxpayers, which is the municipalities, because this is something we did not have to pay in the past. So it won't be revenue-neutral. It can't be.

In my own county, for example, at present, even though we had received some figures, it's up to $2,916,000. That is the actual cost until they buy another ambulance. On top of that, they have to look after the insurance. This is the part that the municipalities haven't received from your ministry yet. How much is it going to cost for insurance, for example, the liabilities? Also, there were other additional costs that the municipalities didn't expect to have. It's good that at present you're keeping the management of it, but you are sending the invoices to the municipalities. They already received the approximate cost they will be paying by the end of 1998. But you don't have those costs?

Mr Sapsford: We are basing it on the actual cost to the ministry --

Mr Lalonde: Of 1996 or 1997?

Mr Sapsford: 1997-98.

Mr Lalonde: Is this available yet?

Mr Sapsford: The breakdown is not available here in terms of the total amounts. But the whole transfer of the ambulance services was based on the Who Does What exercise, so while some of these costs are moving to be funded by municipalities, other costs were taken from the local level into the provincial budget, not in the health area but in other areas of government expenditure.

Mr Lalonde: I have another question. I don't have the answer to that one, so I'll go to the next one. The health care funding for the five counties of eastern Ontario -- Glengarry, Stormont, Dundas, Prescott and Russell --is $23 million they get on a yearly basis. But when I look at the hospital restructuring commission report, in many places they refer to the county of Russell, including Cumberland, which amounts to about 90,000 in population. According to that report, the residents were using the Cornwall facilities to get their health services, which is absolutely false. Probably they don't know the area, and probably because the health care funding goes to the office in Cornwall your ministry was under the impression that all the people within that area were getting their services in Cornwall.

I received the breakdown from Champlain health council just lately: There's not a single person from Russell. Two persons from Rockland went to Hawkesbury, but it was a car accident in the Hawkesbury area. They don't even go to Hawkesbury. They always go to Ottawa. What I'm getting at is that when we fought to get the Montfort open, Montfort was the only hospital for the majority of residents of the county of Russell. They were going to Montfort, and that did not show up in the report.

Hon Mrs Witmer: The commission's report.

Mr Lalonde: That's right. I think it's something to look at. Looking at the article in the Ottawa Citizen this morning, they stated that to keep the Montfort Hospital open would cost the ministry $775,000 for the first year. But how much is it going to cost to transfer all the services to a central hospital in Ottawa?

Hon Mrs Witmer: Mr Sapsford, did you want to speak to that?

Mr Sapsford: Yes. I can't answer the specific question, but the method used by the commission would be based on hospital discharge information. Every patient discharged from an Ontario hospital is recorded. Part of the information that's included would be the residence of the person. In looking at a particular region of the province, the commission will look at all the discharges on an annual basis and the residence of the people who are in a specific hospital, so if there were a portion of Prescott residents who were discharged from a Cornwall hospital, that would be part of the information.

Mr Lalonde: You're saying Prescott. I'm not saying Prescott; it's Russell.

Mr Sapsford: Well, in Russell then. If there were any people who were resident in Russell in the Cornwall hospitals, that would be part of the information base that's recorded on a routine basis.

Mr Lalonde: Minister, we know that Hawkesbury is a very important hospital for the eastern part of that riding, right up and down the Quebec border. We were getting approximately 20%, up to 30%, of our clientele from Quebec, and the Argentia health council is trying to get all their patients back to la Chute because they want to justify their hospital over there. The director general, Michel Lalonde, no relation to me, is trying to get all the residents within the Prescott area to use the Hawkesbury hospital, but the problem is that they don't have the professional doctors in Hawkesbury to serve eastern Ontario. This is why even the doctors within the town of Hawkesbury are sending their patients to Ottawa at present. Do you foresee any budget that would allow the Hawkesbury hospital to attract additional doctors down there so they could justify -- they do justify the hospital, but to make sure that if we lose this clientele from Quebec, we are able to continue serving the people within the eastern Ontario part of our county?

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Hon Mrs Witmer: One of the problems we face in this province is the fact that we have sufficient doctors, but unfortunately they're not going to the areas where they are most needed. If we take a look at the numbers here in the city of Toronto and some of the other teaching centres, we see that in some situations we have too many.

As you know, we have introduced a program whereby doctors' billings are negatively impacted if they set up in an area that is overserviced. We've tried to use this negative means of encouraging people to go to underserviced areas. We're also paying additional money to physicians who set up in the underserviced areas; certainly there's additional remuneration. That works in some cases but doesn't work in others. We're now working with at least one university in the province to start working with students who are in medical school as early as we can so they have an opportunity to do some of their practical work in the urban-rural settings where they're going to be needed. We hope that by giving these people an opportunity to go into some of the small communities and the more isolated areas where we need the physicians, they may, as a result of this work experience, return and practise at a later date.

We also have a private member's resolution where we are looking at maybe providing reimbursement for physicians who go to underserviced areas. We are continuing to work with PAIRO, the OMA, the OHA, the universities, any stakeholder in this province, to ensure that communities like Hawkesbury, which I had the opportunity to visit on one occasion and spend a day or two, have access to physicians, because it's a very serious problem. We'll continue to do what we can to provide the incentives to encourage people to go to those communities.

Mr Lalonde: Next question: I don't know what the status of the Montfort Hospital is. As you know, the Montfort Hospital was the only French teaching hospital. When I'm talking of Hawkesbury, I'm talking of Cornwall and also Alexandria. In my riding alone, in that area, 30% of the population, especially the older generation, don't speak or understand English. What are the plans at present for the French teaching hospital of the Montfort?

Hon Mrs Witmer: Mr Sapsford, did you wish to provide additional information? Or maybe we can get some more information if we don't have all of it detailed enough for you, Mr Lalonde.

Mr Sapsford: We can provide more detailed information, but basically at the present time the commission has given directions that Montfort operate an outpatient ambulatory care facility. The hospital is continuing discussions with the university and the commission about the scope of the application of its services as a teaching centre in the French language. That's led to some discussion about some inpatient-based capacity and the scope of the emergency services that will be provided. That discussion is still going on and those final decisions have been taken, it is my understanding. But the Montfort certainly will be there as an operating hospital providing services to the community and will be developing its role as a teaching institution affiliated with the University of Ottawa.

Mr Rick Bartolucci (Sudbury): Minister, you're very familiar with the restructuring that's taking place in Sudbury. Could you tell the committee what the difference is between the original cost of restructuring in Sudbury and what it is today?

Hon Mrs Witmer: We'll need to get you that specific information.

Mr Bartolucci: Suffice it to say it has increased dramatically, as you are aware. You're right now in the process of negotiating, so you're familiar with the increases. Your government had once committed $59.2 million to the restructuring efforts in Sudbury. How much are you going to increase that by, given the new added costs of restructuring in Sudbury?

Hon Mrs Witmer: I'm not sure if we have that specific information.

Mr Sapsford: No, I'd have to find the specifics. But in general terms, the estimates originally provided by the commission -- this is the capital costs you're speaking of. In the process we use, based on the directions of the commission, the hospital will then work to create what we call a functional program, which describes in some detail the program and physical requirements of the building. Many of the issues that the hospitals are facing outside of the commission's recommendations have to do with what we call interdependent projects. In other words, if you're going to add to an existing building, there may be something you have to do to the existing building to make it compatible, and in all cases those costs have not been identified. The ministry is undertaking discussions with hospitals to work out the details of those interdependent costs to come to an agreement on the overall capital costs. Each case is different, depending upon the physical plant that exists and what might have to be done to it to bring it to an appropriate level.

Mr Bartolucci: I don't want to disagree or sound like I don't believe what you're saying, because I respect you too much to say that. The reality is, though, that you're in the final stages of negotiation with the Sudbury Regional Hospital Corp, so you are familiar with the numbers we are talking about. I say this not to get a commitment of an exact amount today, because I don't expect that you're going to announce it at the committee; I expect that you'll either come to Sudbury or send a letter or do something that will garner a little bit of attention to it. But what I want to ensure is that at this point in time, when the Sudbury Regional Hospital Corp is holding its first annual general meeting a week from today, and your ministry and I think the minister's staff -- I think very well-placed staff -- have assured the Sudbury Regional Hospital Corp that there will be an agreement, a letter, signifying the government's intent --

Interjection.

Mr Bartolucci: Then maybe I'll ask, what's your intention going to be?

Hon Mrs Witmer: I hope we can soon make that information available to you, real soon.

Mr Bartolucci: Real soon?

Hon Mrs Witmer: Real soon.

Mr Bartolucci: Well, if past history's any indication, "real soon" meant the very next day in Mr Cleary's case.

Hon Mrs Witmer: That's right.

Mr Bartolucci: Okay, great. That's very important. That's very good.

Hon Mrs Witmer: I don't know if it's that soon, but it's real soon.

Mr Bartolucci: In this real soon announcement -- I know we have to be a little coy here and a little cute, and that's fine. I believe you're familiar with the constraints on the community, our high unemployment rate and the lack of what we would consider economic growth. I think our community is probably going to be more than fair in trying to raise the appropriate capital that they see fit, given the economic environment.

Hon Mrs Witmer: When is their annual meeting?

Mr Bartolucci: A week from today. The reality is that the government is going to have to put in a lot more money than they originally thought they were going to have to put in. I don't want a commitment of dollars, but can I be assured, can my community be assured, that there has been an agreement as to what is an appropriate of money and that you've factored in the economy of the Sudbury region?

Hon Mrs Witmer: I'll let the deputy make one further comment on that.

Ms Lang: I was recently in Sudbury and I met with the board of the hospital and the CEO. They actually shared with me in quite significant detail the plans for the hospital. We committed at that time that we would have some news for them before their annual meeting next week, and I can assure you that the ministry is working very hard.

We also talked about the challenges facing the community in terms of fund-raising. We understood, but we also talked about the policies that guide government funding and financing for capital, and I think there was a mutual understanding of how we would proceed. But we do intend to be able to say something to them before their annual meeting.

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Mrs Boyd: I'd like to go back to the issue around tobacco cessation, because I understand that recently, in the fall of last year, your cabinet rejected a proposal from the Ontario College of Pharmacists to amend the regulations under the drug and pharmacies act to permit the sale of smoking cessation products in the self-selection area of retail pharmacies.

There's a lot of material which shows that making those products more available, not making people go through the prescription issue or even asking from behind the counter, makes a significant difference in terms of the ability of people to stop smoking. There's all sorts of research about the lack of abuse of these products, the lack of problems in terms of people having side effects from these products. We're the only area of Canada now that does not offer these products in a way that doesn't require prescription. Why, when you're trying to lower utilization rates in terms of physician services and when you're trying to encourage tobacco cessation, would your government have rejected that proposal from the Ontario College of Pharmacists?

Hon Mrs Witmer: In response to the question -- and actually I know that you had sponsored a press conference yesterday related to this -- I think I had told the media yesterday that we were reviewing that particular decision that had been made in light of the fact that the federal government did indicate on June 1 that it was no longer mandatory that the patches be used according to prescriptions filled out by physicians.

One of the concerns the government has always had is the level of nicotine in either the gum or the patch, and also the health and safety of people in this province, particularly children and their accessibility to these products. Obviously, as Minister of Health, that's something that we always need to keep uppermost in our minds: Who else is going to have access if you do make these products readily available on the shelf? As I say, we are currently reviewing the decision that was made, in light of the change in the federal position regarding the patch and making that patch available. We hope to make a statement soon on that particular issue.

Mrs Boyd: The federal department made it clear that decision was going to come forward; it was coming into effect on June 1, but they made the decision some time before. The one good thing about the bill that we're currently debating the time allocation motion on is that one of the effects will be to allow the college to make that regulation itself. I'm not sure why you're bothering to review it, because you can be sure, having brought that regulation forward, that they will go ahead and do it.

It's rather interesting that you appear to ignore the research that's been done that shows that in fact these products are not abused by kids. Certainly the gum tastes terrible and the patch is extremely expensive. Much as we like to raise bogeymen about some of this stuff, it's ridiculous compared to the danger of smoking.

I must say that I'm distressed that you didn't take that action, as I think it would have made a big difference. It strikes me that children in Ontario are no more likely to abuse these products than children in any other province or any other jurisdiction. It seems rather ridiculous that we're stuck with this regulation and certainly, to me, really calls into question the focus that you say you have on this issue.

You did not answer my question before around how you expect to persuade anyone that your focus is on prevention and promotion when you've taken, just in two parts of the prevention and promotion budget, more than $4 million out of it. These programs cost money. For your assistant deputy minister to make the comment, "We're consolidating the programs so they'll be more effective," yes, you're consolidating the programs so you can scoop $4 million out of them. That really belies your repeated concern about prevention and promotion.

Hon Mrs Witmer: I think perhaps it wasn't made clear, but obviously you can put all of your promotion dollars on the one line or you can incorporate the promotion activities within some of the other priority programs. Certainly that's what we're endeavouring to do. There are many things that are happening today that are components of prevention.

Let me get back to the gum and the nicotine. I think we can say there's no real danger, there's no real problem, but I'd just like to bring your focus to two quotes that I know were made. One was by Dr Jay Siwek in the Washington Post on February 28 of this year, when he said: "Some people pervert the whole purpose of nicotine substitutes by using them to maintain a smoking habit rather than helping to break it."

Also, we have Tamar Nordenberg, who said in the FDA Consumer in November-December 1997: "Chewing nicotine gum may not be the right choice for those with joint disease or for those with dentures or other vulnerable dental work." This person also says that these products do have potential side effects as well. For example, "a mild itching, burning or tingling at the site of the patch when first applied is normal, but should go away within about an hour. After removing the patch, the skin might be red for up to a day. If the skin develops a rash or becomes swollen or very red, a doctor should be consulted. The patch may not be a good choice for those with skin problems or allergies to adhesive tape."

We always have to be cognizant of all of the impacts of the use of these products, whether it is the patch or whether it is gum. As I say, at the Ministry of Health we have a responsibility to make sure that we have taken into consideration any of these negative consequences. We are reviewing our decision and we hope to be in a position where we can make some comments very soon.

I would just emphasize that promotion is extremely important for our government. That's why, when you take a look at the five primary care pilot projects in this province, we've actually, in working with the Ontario Medical Association, included an opportunity for them to be reimbursed for any consultation that they do with their patients when it comes to prevention and focusing on health promotion. Again, we talk about maybe the dollars aren't on that line, but we are now, for example, prepared to reimburse physicians for focusing on health promotion and prevention. We're trying to integrate some of these activities and not isolate them, but make them part of the whole. Certainly, there's a tremendous amount of diabetes education taking place. When we've made our announcements in recent months about the diabetes additional priority funding, it has included money for diabetes education. We're extremely focused on the need to promote and prevent health care problems.

Mrs Boyd: Let me suggest to you that there's almost no product that you can buy over the counter in a drugstore that might not cause some problems. You talk about the adhesive tape. Surely you're not going to say we shouldn't have adhesive tape over the counter. Aspirin: over the counter for years. Sure, it can cause internal bleeding, but the benefits outweigh the negatives. The same with all sorts of things. If you're looking for a reason not to allow this to happen, sure, you'd be able to find a few negative comments in all of the research. It strikes me that it is passing strange that you would continue to take this position when no other government in Canada does.

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You gave me a perfect segue, talking about physician services, because in doing the mathematics -- and I'm now on page 82 -- between the actuals spent on physician services in 1996-97 compared to what you're estimating for the coming year, I see an increase of $447,101,903. How much of that increase of $241,807,675 between 1996-97 and the interim actuals for 1997-98 and the $269,700,000 that you're increasing those payments for -- how much of that payment is for prevention and promotion in these new five primary care projects?

Hon Mrs Witmer: We would have to get that information for you.

Mrs Boyd: I'd certainly be interested in having it, because I must tell you, I think that's a shocking increase for physician services. I need to say to you very clearly that, having read the agreement that you signed with the OMA, which clearly said that you could not, for the three years of the agreement, transfer anything out of the fee-for-service pool into alternate payment plans, it's a really fine question to wonder how much of those additional dollars are additional dollars you're spending on those five primary care projects. It's very interesting that you've set these projects up when there's such a control over those dollars, particularly since, in discussions with Dr Thoburne of the OMA, he even takes the position that the $36.4 million that you had promised to pay for globally funded group practices, which hasn't been flowed, would have had to come out of that amount of money and wasn't in fact a discreet amount and therefore couldn't have been flowed anyway. I wonder if you'd comment on those issues.

Hon Mrs Witmer: You're looking at the $269 --

Mrs Boyd: Between 1996-97 and your estimated actuals for 1997-98, there's a $241,807,675 difference. Then we see in your estimates that you're adding another $269,700,000 for next year. That's almost a $450-million increase.

Hon Mrs Witmer: That increase in the OHIP transfer payment I guess is what you're referring to. That is due to increased population growth, demographic changes and utilization. Also, there is additional funding in there to meet the increased demand for medical and laboratory services. Also, I think we need to remember that as the population is aging we are seeing increased utilization, so certainly some of that addresses those issues. That is what is reflected here.

Mrs Boyd: None of this is an increase in the fees?

Hon Mrs Witmer: There is an increase of 1.5%, as you know, that was allocated in each year for the physicians --

Mrs Boyd: How far over that cap did they go?

Hon Mrs Witmer: They did go beyond the cap and, as you know, we are working with them in order to ensure that the increases remain at the 1.5%.

Mrs Boyd: I'm sorry. They went over cap last year. Are you meaning that you might scoop them back in this year? Because you're not allowed to do that under your agreement. You're not allowed to clawback. How do you plan to deal with the fact that they were over your cap, and how much were they over the cap?

Hon Mrs Witmer: I'd ask Mary Catherine Lindberg to address that issue. She has been working with the physicians and certainly has been working to ensure that we continue to deliver high-quality services to people in this province and stay within the negotiated terms of the agreement.

The Vice-Chair: Welcome, Mary Catherine. Could you please read your name into the record.

Ms Mary Catherine Lindberg: Mary Catherine Lindberg, assistant deputy minister, health insurance and related programs.

You want to know how much they were over their cap last year?

Mrs Boyd: Yes.

Ms Lindberg: They were 4% over their cap last year; 1.5% of that is what we would allow them. For the other portion, we have worked with the physician services committee with the OMA and we have developed a number of items, such as adding the technical fees into the thresholds. They currently have a threshold of $380,000 and when they reach that -- that's only on professional fees. We're now going to include their technical fees that we pay doctors on that, which will help us curb some of the utilization on technical fees.

We've put in about $50-million worth of modernization in the schedule advances, items such as making sure that they only get paid for the services they rendered, such as a second physician seen and some of those kinds of things. We've also looked at taking the threshold away from some of the exempted thresholds that we've had in place. Some of them were exempted from thresholds and we've taken that away.

Those are some of the ideas, and there are others that we could give. We're not clawing them back; we're not putting a hold-back in. We're actually reducing the number of things they can bill, so we've tightened down on the kinds of services they bill.

Mrs Boyd: Who suffers as a result?

Ms Lindberg: The patients certainly don't suffer, because they are not denied any services. The physician will not be able to bill for some services.

Mrs Boyd: Let's just look at the reality. What you've done is lower the percentage of billings from 50% to 20% for home visits at the same time that physicians are more needed for home visits because you're releasing people from the hospital sicker and quicker and you're encouraging all this home care. That's one of the changes that you've made. If a physician goes over 20% of billing, then they start to see a reduction in the fee for home visits. Don't you think that's going to discourage them from doing home visits and therefore make it very difficult for patients who are on home care?

Ms Lindberg: What we took away was the second patient seen on a special premium visit. Is that what you're talking about?

Mrs Boyd: No, I'm talking about the 20% at which -- if a physician bills more than 20% for home visits -- you used to start reducing the fee after 50% for home visits. You've now changed it to 20%. Isn't that directly counter to the whole issue of long-term care and home care?

Ms Lindberg: The actual visit to the home we haven't reduced. We've reduced some of the services at walk-in clinics, but not home visits. I think you're talking about the special premiums. I'll have to look that one up.

Mrs Boyd: I'd be happy to find the announcement, that was the joint announcement from the joint committee, that clearly said that was one of the things you were doing.

Ms Lindberg: We'll look at it, but it's not clear to me that that's what we are doing.

Mrs Boyd: I'm all in favour of doing whatever you can to reduce this nonsense about walk-in clinics. I think that's the biggest boondoggle in the world. In fact, it amounts to double-doctoring all the time because the only way these guys are able to practise is that they tell people that they have to see their own doctors, so it amounts to double visits all the time.

I think there are many of the things that you've cut into, many of the procedures that you won't pay doctors for, that will result in patients not getting services. One of the things you've taken off the exempted list is labour and delivery. Isn't that one of them?

Ms Lindberg: No. You must be in attendance at labour and delivery, not just at delivery.

Mrs Boyd: So if he doesn't get to the hospital, he doesn't get paid?

Ms Lindberg: No. If he gets to the hospital and the physician attending both labour and delivery -- if you deliver fast, you're still attending at labour and delivery. But if there's a doctor attending labour and a doctor attending delivery, then the doctor who's just attending, not delivering -- if you get there and deliver, you get paid for it. If you attend labour you get paid for it. But if you're the second physician coming in and watching the delivery and just attending, not delivering -- you have to be attendant at labour and delivery. By attendance it means you're the second doctor, not the first doctor.

Mrs Boyd: Do we have a problem --

The Vice-Chair: Thanks, Mrs Boyd, and thanks, Mary Catherine. We'll move to the government side now.

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Mr Parker: Minister, one of the areas of treatment enhancement that has received some profile in the last few years has been the availability of kidney dialysis services. It seems like every time I open my mail there's another announcement out of your ministry announcing some new dialysis service that's been made available somewhere in the province.

I haven't tracked it all and tried to piece together how it all fits and just what the total pattern is. I wonder if we could take this occasion to have you walk me through what the status of kidney dialysis service in this province was at some point in the past -- pick a point -- and then walk me through what's happened in the past few years and where we are now.

Hon Mrs Witmer: I'll go back to 1995. Since that time, our government has invested more than $73 million in dialysis services across the province. We've already spent $25 million to create 20 new dialysis centres across the province.

One of the areas, obviously, that was a priority for us was eastern Ontario. Last week we did announce that we're going to be providing dialysis services in eastern Ontario, one of them being in Mr Cleary's riding, Cornwall, one being in Ottawa, and one in the community of Brockville. We also approved in December 1997 the expansion of dialysis services at Renfrew's Victoria Hospital and also Kingston General Hospital's Belleville satellite unit. As you can see, much of the recent activity concerning the expansion of facilities and construction of new facilities is taking place in eastern Ontario.

There is growth as well in other areas, and I'm proud to say that today we have 22 regional dialysis centres and 34 satellite centres. Of course, with the satellite centres we're able to provide services closer to people's homes. That's obviously much less stressful for people, and as people are aging it means less driving. We're certainly proud of what we've done.

Another very exciting project is in Mrs Boyd's community. At the London Health Sciences Centre I actually made an announcement there that $3 million would be used for a project that would involve two innovative ways of treating dialysis patients within their own homes. One of the pilots is night dialysis; the other is day dialysis. Again, we hope that as a result of that initiative this is another means that will be available to people. It will mean no travel at all, and people obviously will be able to continue with their jobs and all of the other activities.

In 1997-98, we made an $18-million investment: $14.3 million was used to treat 450 more patients in the province, and $3 million went to the London Health Sciences Centre. As well, a $25-million expansion and relocation of services was announced in 1995.

Overall, what we are endeavouring to do is to bring the services as close to people's homes as we possibly can. We are working on reducing the incidence of diabetes in the province. We are particularly targeting people in the north, seniors and aboriginals. I'm very pleased to say -- we've talked about health promotion and illness prevention -- we have set aside $5.8 million over three years for diabetes education. I know people across the province are extremely grateful for the investments that are being made and the fact that today we have 22 regional centres and 34 satellites.

Mr Parker: May I ask a follow-up question?

The Vice-Chair: Yes, and then it's Mr Young's turn.

Mr Parker: Can you help me understand the difference between a regional centre and a satellite centre? I'd like to know more about the in-home dialysis as well.

Hon Mrs Witmer: The regional centres are the centre of activity, and the satellites are satellites of a regional centre. For example, I guess I can relate to my own community of Kitchener-Waterloo, where we have the Grand River hospital being the regional centre and we have a satellite in Guelph. People in that community would formerly have had to travel to Kitchener. Now, of course, they can receive the dialysis in their own community.

In the satellites there are those who are treated who obviously are receiving a different type of service than could be provided in the regional centre. They are the less serious cases. But I'm again going to ask again Mr Sapsford to respond specifically as to the opportunities in the regional centres.

Mr Sapsford: Basically, the regional centres provide full medical service for kidney treatment, including inpatient services. The satellite clinics are designed for people who are essentially living at home and can attend several days a week for dialysis directly in the satellite. As well, the satellites will provide monitoring for people who are receiving dialysis at home. Sometimes people have their dialysis at home while they sleep during the night, for instance. So there are a number of modalities for dialysis treatment, and depending upon the severity of the illness and the condition of the patient, they can move back and forth from the regional centre.

The regional centre provides the overall clinical direction, and when the patient has an onset of serious or acute illness, the referral back to the regional centre for acute care would take place.

Mr Young: I wanted to try and get a better understanding of long-term funding in relation to drug therapy and its relationship to other therapies. You said that the greatest increase in health spending in one year was in fact the drug budget at 17.7%. Is that correct?

Hon Mrs Witmer: Yes.

Mr Young: And that our government had introduced 500 new drugs on to the drug formulary for people who need them.

Hon Mrs Witmer: Yes.

Mr Young: In addition to that, I understand the previous minister in our government as well made available under the Trillium drug plan free drugs for those in need who are the working poor, to about 240,000 Ontarians. I assume that explains a lot in relation to the costs going up, as well as the fact that 4,000 to 7,000 more people a month turn 65 and more people are now in home care.

What I wanted to ask you about is the relationship between drug therapies and the fact that we use a silo funding model. If I could give you examples, that might be helpful.

For instance, if you have a hiatal hernia, you can have it repaired surgically and the operation would cost, I guess, between $5,000 and $10,000. But they don't do it very often any more because there are drugs like Zantac that you can take that get rid of the symptoms, so you don't have tremendous heartburn and you can sleep at night etc. So you have an expense on one side, and on the other side you save on hospital stay and surgery etc.

Another example might be some drugs that treat asthma. If you had a new drug come on the formulary that treated asthma, you would not have the hospital stay and you wouldn't have the hospital visit etc.

Another one that comes to mind is a drug that would support or help particularly elderly women who might suffer from osteoporosis. I don't know the name of it, but what it does is, if someone takes a fall, there are fewer broken bones, less surgery and pain, and less expense as well related to that.

Long term, is there a plan to have a way to demonstrate that with drug therapy, although that particular silo spending is going up, there are savings in the other silos, in the other budgets within your own ministry, so that we can make sure we're doing the absolute right thing for the patient?

Hon Mrs Witmer: I'm going to ask Linda Tennant to respond to that particular question, but you're right. Certainly drug therapy has really made a difference in the way health services are provided in this province. The additional access to new and enhanced drugs really is meaning shorter hospital stays. It's preventing people from being readmitted. It's had a very positive impact. There have been additional costs, and I guess we need to be sure that somehow, as costs increase in the drug envelope, we're able to achieve some savings on the other side.

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Mr Young: I don't think there are any easy decisions in health care, but I understand the previous government removed over 200 drugs from the formulary. With regard to any specific drug, I don't know if that was a mistake, but I think it's a mistake to look at each in a silo without relating it to where savings are elsewhere.

Ms Tennant: Linda Tennant, drug programs branch. The psychotropic drugs on the system are looked at by our expert advisory committee, the Drug Quality and Therapeutics Committee, through something called a pharmaco-economic assessment, which as of March 1996 became mandatory in all drug submissions.

In the pharmaco-economic assessment, the drug manufacturer is required to show the impact of the drug not just on the patient in terms of health outcome, but on the other parts of the health system. They have to be able to demonstrate in a cost-benefit analysis if there is a reduction in hospital days or if it enables faster discharge to home care or if it facilitates mental health reform in the case of the two new anti-psychotic drugs. The expert advisory committee takes that into consideration in assessing the product.

Ontario, in fact, is one of two jurisdictions in the world that is a world leader in the development of pharmaco-economics and their application in this particular field to prevent the silo thinking within the health care system.

Mr Young: I have another question related to a private member's bill I recently introduced, which is to address substance abuse among our youth. The bill was designed to address the most serious substance abuse, which is cannabis and LSD and speed. Sometimes they don't even have the money to buy that, so they'll take excess doses of Ritalin or Tylenol, whatever, depending on what kind of neighbourhood they live in and how much money they have.

In introducing the bill, the hardest decision I had to make was whether to include tobacco or not. I included tobacco because in many cases they go hand in hand. I'm not saying tobacco use leads to drug use or cannabis, but they do go hand in hand. For instance, our youth can put hash oil on the end of a cigarette and the parents drive by the school in the morning and they say, "There are some teens having their last puff before they head into class," and it's not actually just tobacco; it's a powerful joint.

Canada has the strongest marijuana in the world, the police tell me, because it's grown indoors hydroponically. But as well, that's where they hide drugs when they take them into school, in a cigarette pack, and it's difficult for the principals and vice-principals to say, "Hand them over."

In addition, 30,000 to 40,000 Canadians die a year.

I wanted to try and address the fact that that's how our young people begin an addictive lifestyle that leads down a path that sometimes leads to death by cancer or other respiratory diseases.

I wanted to ask you if there's any way that such an initiative might fit in with a drug strategy at the Ministry of Health or if it's supportive of your long-term intentions.

Hon Mrs Witmer: As I've said not only today but at other times, we certainly are most concerned about the young person, the pre-teen, the teenager, who obviously is experimenting and does start to use on a regular basis tobacco or other forms of drugs, and obviously we include in there alcohol as well.

We'd certainly be prepared to take a look at the bill that has been brought forward and be pleased to incorporate it in any strategy that we would develop. It personally does concern me to see the number of young people today who are starting to use drugs, whether it's tobacco or some of the others. We'll do what we can.

We have certainly indicated to the stakeholder community, particularly those who have a strong interest in eliminating tobacco use, that we want to work with them, we want to work with some of the experts in the province, in order to ensure that we can develop a strategy that is going to make a significant difference and will reduce the amount of usage in this province.

Mr Wettlaufer: Minister, last week the Liberal health critic, Gerard Kennedy, presented what he called a rather detailed analysis of hospital restructuring to this committee. I've noted over the course of the past year that some of Mr Kennedy's detailed analyses are not exactly detailed; they're quite often flawed, poor information. I wonder if the ministry has had an opportunity to review his analysis yet.

Hon Mrs Witmer: Yes, last week there was information that was presented and I had asked the ministry staff to very carefully analyse the information that had been presented. I think certainly one of the concerns we had is that we weren't quite sure what factual information was being used to come to some of the conclusions.

Although the complete analysis is not yet finalized, I do want to indicate that thus far there are certainly several entries on the report that are not factually correct. For example, he indicated that in 1996-97 the ministry reinvested only $200,000 in long-term care and community care funding. We did actually reinvest $20.9 million for those services, so that's certainly quite a significant difference.

Also, the claim was made that by the end of 1997-98 the ministry only put about $64.4 million in Metro Toronto, when in fact the correct number is $74.6 million. Also, taking a look at the GTA, the government did not spend, as was stated, $29,212 for new and long-term-care community funding for the GTA in 1996-97. We actually invested $11.1 million, which is quite a significant difference.

I want to point out too that we've already announced an investment for long-term care that exceeds the one that was recommended by the Health Services Restructuring Commission. In fact, our long-term-care announcement of $1.2 billion was one that was fully supported by the commission, and they have indicated their support.

The report also does not appear to fully reflect all of the investments that we made in 1996-97 and 1997-98 for long-term-care services. That includes our investment of about $130.6 million for close to 500 community-based programs. Really, the list goes on and on and on.

Many of the communities in this province were totally overlooked in the report. There was a focus on only seven cities, and yet the commission has made final recommendations in many other parts of the province. I think Pembroke is a very good example of a community which has benefited tremendously from hospital restructuring.

As I say, we're not sure where some of the information comes from. It may perhaps be based upon the commission's advice to the ministry about appropriate expenditure levels. I think we need to understand that the ministry considers that advice but we actually establish our own actual expenditures for hospitals and long-term-care services. So that's important.

Also, the report last week totally ignored the $675 million in capital investment that this ministry has already committed to ensure the development of modern, state-of-the-art hospitals to provide care into the next century.

It also doesn't consider the fact that we have directed people who provide health services to eliminate waste and duplication. We want to make sure that any money spent is spent on front-line care. We need to remember that absolute expenditure levels don't tell the whole story. We want to make sure we have a health care system that we can sustain and that the system can deal with the additional demands of the aging and growing population.

At this point in time it appears that many of the statements of last week are based on some very speculative long-term assumptions, so they are somewhat unreliable.

I want to emphasize categorically that our government is not transferring any money out of the health envelope. We are indeed increasing and have increased health spending in each and every year. We are today spending in excess of $18.5 million. So we'll continue to analyse.

Mr John Gerretsen (Kingston and The Islands): Million or billion?

Hon Mrs Witmer: Billion, sorry. That's right. Billion is difficult to comprehend when you're spending so much.

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The Vice-Chair: Thanks very much, Minister. We will go to the official opposition.

Mr Cleary: I want to thank you for the announcement last week on the dialysis. It gave a little bit of hope in our part of eastern Ontario since the last announcement on April 24, 1996. My question to you is, when will the licence be issued?

Hon Mrs Witmer: I'm going to ask ministry staff to maybe define more clearly when the licence may be issued.

Ms Lindberg: For a licence for an independent health facility, you have to give 60 days' notice to all the proponents prior to issuing the licence. Once we write a letter saying we have the intent to issue a licence, you have to give them 60 days to come back or make a reference to us, a referral to us if they don't agree. We give them that kind of notice. Then the licence is issued. It's just a notice period.

Mr Gerretsen: I'm sorry I wasn't here at the beginning of the meeting, but I was in Kingston listening to the minister announce through her health restructuring committee the closing of the latest hospital in Kingston, a hospital that has existed for 153 years.

I want to go over some of these figures with you since I'm sure you're fully familiar with this. I assume you got a copy of their report today, or your ministry did. There, it's coming right now. I knew it would be here. I'm sure you can fax something quicker to Kingston than you can drive from Kingston to here, so I'm sure you have these figures.

First of all, I want to be clear about this. The report says that the commission recommends a total of $108 million to upgrade and expand Kingston's hospitals to meet the health service needs of the 21st century. The first thing that I want to hear from you, categorically, unequivocally and clearly: Is that a commitment by you and your government right now to reinvest $108 million into Kingston hospital upgrading and expansion?

Hon Mrs Witmer: The commission made that recommendation today, and you're wondering if we're going to be making that investment?

Mr Gerretsen: Right.

Hon Mrs Witmer: Once the final directives have been issued, our ministry becomes responsible for the implementation. There will be further dialogue with the Frontenac, Lennox and Addington community, to determine what the actual figures will be. Then within a few months we hope to share with you the final number. Obviously, we need to take a look at some of the functional programs.

Mr Gerretsen: Your commission, which you set up and created, isn't saying that. Dr Rob Williams, commissioner, made the categorical statement that that would be the reinvestment amount -- minimum. Depending upon what else can be discussed, I can understand that these figures go up and down, particularly up, since I understand that in most municipalities, in most situations, the for -- capital improvements have gone up quite significantly from what the estimate was. He is telling people, in my community anyway, that that is going to be a commitment and that so far the ministry has delivered on every one of the commitments.

What I want from you, since you are the minister in charge of this $18.5-billion department of the government, is, are you making that commitment, that the minimum reinvestment will be the amount of money the commission has stated it will cost to upgrade the capital facilities? Yes or no?

Hon Mrs Witmer: I think it's important that we review the process. I think it would be premature for me to make a commitment, having just received the final directive from the commission ourselves today. As I say, now it is our responsibility to review the final directive, to work with the community and also then determine what the final dollars and cents figure will be. I'm going to ask Mr Sapsford to take us through the process as to what is going to happen as a result of us having received this report today, because it now becomes --

Mr Gerretsen: We can talk about the process later on, but your commissioners are out there saying that's the minimum amount that will be made by way of capital reinvestment. If they're saying something different from what you're willing to commit to, I think you should get that directive out to them that they shouldn't be telling communities that sort of information. That's what they're telling the Kingston people and the Kingston media today, that that would be the minimum amount of the reinvestment.

Hon Mrs Witmer: As I say --

Mr Gerretsen: If you're not willing to make that commitment, then you should get together with them. Rather than worrying about the process, how you deal with this -- I'm willing to do that; I just don't want to waste my time on that process right now because I have a couple of other questions. The fact sheet that they've handed out shows that the total annual saving is going to be $52 million per year -- I assume this is on the operating side of things -- and that the total investment, on the other hand, is going to be $1.3 million in home care, $7.3 million for long-term-care spaces -- that's about $8.2 million in total -- plus another $27 million in annual reinvestment in home care, subacute care, long-term care, rehab and mental health, which I total to be about $35.2 million.

We've got $35.2 million being new investments on an annual basis, and we've got savings of $52.1 million. What's happening to the other $19 million? From statements you've made, I've always gathered -- and I take you as a person who can be taken at her word -- that's going to be reinvested in the community in health care. From the figures that have been presented in this report, it would seem that we're $19 million short. There's $52 million annually coming off the operating side of things, and there's about $35 million going in new services on the operating side. What's happened to the extra -- I may be off a million -- either $17 million or $18 million? What are you doing with that.

Hon Mrs Witmer: I would need to get that information for you, Mr Gerretsen. I'd certainly be prepared to do so. We just received the report ourselves today. We haven't had an opportunity to thoroughly review it, but we'd be prepared to get some of those answers for you.

Mr Gerretsen: I know a significant amount of that has already come out. But as to the statement that's being made continually by you, that you're going to reinvest the same amount that you're taking out, the commission's figures released today indicate there is going to be at least a $17-million or $18-million discrepancy there. Is some of that money being used for the restructuring, the $108 million which will be needed for capital expenditures, of which I understand the local community has raised 30%? Is that what that money's being used for? In other words, are you going to use some of the no-longer-required operating funds for capital purposes?

Hon Mrs Witmer: This has been received by us today. We'd be prepared to respond to each and every question you have as quickly as we can.

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Mr Gerretsen: Let me ask you a general question, then. Are you taking the savings in different communities where the Health Services Restructuring Commission has come up with a savings amount -- I assume that in every community they've come up with a savings amount on the operating side of things -- and taking some of that money to actually do some of the capital upgrading that's required?

Hon Mrs Witmer: Mr Sapsford, do you want respond to that?

Mr Sapsford: The savings figures that the commission uses are a methodology to determine siting and to determine the consolidation of physical plant. They started in 1995-96 as the base year, so the first point I would make is these are not savings that are yet to come out of hospitals. Because of the fiscal plan of the government in the last two years, much of that savings has already been achieved.

Mr Gerretsen: I understand. About $26 million of that has already come out. What I am asking is, the government has made the statement over and over again that all the savings that have come out are going to be reinvested in health care in the different communities. What I want to know is, show me that is so in this particular case.

Mr Sapsford: In terms of the overall investment, certainly in terms of the capital investment, that money is going back many times over in most communities. As well, the additional investments in long-term care and mental health that are being announced are meant to close that gap as well. In some communities there will be significant investments well beyond savings levels, depending upon pressures of growth for service.

Mr Gerretsen: But by the same token there are also going to be communities where the amount of capital reinvestment is going to be quite a bit less than the amount that has been saved, if you're going to spend the same amount of money. You can't be giving some communities more money, from the same pot, without giving other communities less money.

Mr Sapsford: The total amount of savings that has been taken out is $800 million, today's, and the investments of the government are well beyond that in terms of the costs that have been absorbed. I think the point made earlier is that the overall expenditure for health is growing at a faster rate than the amount of savings that have been taken out.

Mr Gerretsen: When you say overall, are you talking about province-wide?

Mr Sapsford: Yes.

Mr Gerretsen: So then some areas of the province are getting more money because of population changes or whatever than other parts of the province. Is that correct?

Mr Sapsford: That's correct.

Mr Gerretsen: By the same token then, there are some communities that are going to have less health care dollars spent in their communities than other communities.

Mr Sapsford: That's also correct.

Mr Gerretsen: Right. So when they're talking about there being savings of $52 million per year projected and a reinvestment of $35 million per year, that community, whether it's my community or somebody else's community, in effect is losing $17 million to $18 million per year.

Mr Sapsford: On the overall operating base.

Mr Gerretsen: On the overall operating base.

Mr Sapsford: That is the calculation --

Mr Gerretsen: Well, sir, I have to congratulate you. You are the first person in the ministry, or the minister herself, who has at least given that much of an acknowledgement in the last three years that I've been here. If you're spending the same amount of money across the province and there are population shifts, you are going to be spending more money in some parts and that money's got to come out of other parts of the province. Anybody who denies that --

Mr Sapsford: That's the basis on which the commission has put together its reports and that's their advice to the government.

Hon Mrs Witmer: I guess what's important, Mr Gerretsen, is to remember that what we're trying to do is to ensure that people across this province, no matter where they live, hopefully will have the same access to high-quality services. If you take a look at the long-term care announcement we made, for example, and the fact that 20,000 new beds are going to be built, there are going to be communities now in rural and northern areas where people aren't going to have to travel to cities. They're going to have the long-term-care facilities constructed in their own communities.

Yes, there is going to be a redistribution of some of the health dollars, but that was the reason for setting up the commission, to ensure that people across this province would have equal access to health services.

Let's take a look at Renfrew, for example. Before our government took office, when you took a look at the long-term care, there wasn't equity funding. We've introduced equity funding to ensure that with community services, long-term-care services, you have equal access to those services no matter where you live. So yes, there will be redistribution, but hopefully --

Mr Gerretsen: How do you explain this, Minister? There are currently in the Kingston area 225 long-term mental health beds. As a result of a reconfiguration of the district -- some of it's being lost at the west end, in the Hastings area -- Mr Williams confirmed today there are 40 beds being lost, which would mean, if you went on the old bed numbering, there are 185 beds for the catchment area that will still exist.

How can that community possibly get along with only 74 long-term mental health beds in the same reconfigured catchment area when it goes from 185 to 74 beds? What is going to happen to the 115 people who occupy those beds, when there aren't any community care facilities or programs currently available for them?

These people are going to be walking the streets or living in flophouses or living, as a lot of them already were -- also as a result of a Conservative government's attempt about 15 to 20 years ago to put a whole bunch of these people out on the street under the guise of reintegrating them into society -- in deplorable conditions, three or four in rooms that anybody would be absolutely ashamed of to have people living in them. How can you, as Minister of Health, possibly justify that kind of situation where a community goes from 185 beds to 74 beds?

Hon Mrs Witmer: I'm not sure what figures you are looking at. My figures are --

Mr Gerretsen: I'm looking at the figures that were given today by the Health Services Restructuring Commission, not by anybody else's propaganda, by their figures.

Hon Mrs Witmer: There is no point assessing blame for the deinstitutionalization.

Mr Gerretsen: I'm not assessing blame.

Hon Mrs Witmer: That's right. Because the reality is, Mr Gerretsen, three different governments of three different colours have had an opportunity to deal with the issue of what we do with those who suffer from serious mental illness.

Certainly Marion Boyd is well aware of the fact that a strategy was developed about five years ago. We have just reviewed that strategy because it became apparent that again there was a need to take a look at the situation because people are not receiving the community services that are necessary.

Our government also put a moratorium on the deinstitutionalization and the closing of the psychiatric beds. In fact, very recently I made an announcement in Toronto that we were investing $60 million in additional dollars to help those with mental illness. We are putting in place community treatment teams in order that people who no longer need to be in the residential care setting are going to have support 24 hours a day. We have court diversion programs that we've set up.

Mr Gerretsen: It's not happening out there.

Hon Mrs Witmer: The money was announced a few weeks ago. I will tell you it was very well received, not only by those who suffer mental illness but by those who provide the services. They said we're on the right track. We are developing an integrated, comprehensive mental health strategy. We're building on what was started by the NDP and we're going to improve upon it. I can assure you that we're all concerned about helping these individuals and making sure there is 24-hour support.

Mrs Lyn McLeod (Fort William): Let me tell you, it's always a bit dicey when a northerner walks in to hear somebody talking about equal access to health care. But in three minutes I'm not going to get you into northern health travel grants, as much as I might have liked to.

I really came in because I wanted to follow up on the issue that Mr Gerretsen was just raising specifically in terms of mental health and to follow up on a question that I had an opportunity to ask in the House. That is about the planning for community care services to replace psychiatric beds that have been closed.

The recommendations, as you know, from the hospital restructuring commission were that mental health agencies be established. They've continued to stay with that recommendation in order to deal with whatever dollars are to be reinvested -- and we don't know that yet in our community -- and to do the planning for the community services that are needed.

There is a lot of question about why the mental health agency has not been appointed and whether or not the ministry is backing away from that and is not even going to do a pilot project mental health agency in Thunder Bay. I'd like to ask you for an explanation of what the planning process is going to be. Is the mental health agency going to be pursued? If it's being abandoned, what is the alternative?

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Hon Mrs Witmer: In light of the fact that Mr Newman, the parliamentary assistant, had done an analysis of the strategy that had been developed and of the need to make some changes to the strategy, we took a look at the status of the northwestern Ontario mental health agency, and we are working with them, as we were directed to do by the Health Services Restructuring Commission. We're reviewing the advice and we're reviewing as to whether indeed we will proceed in that direction. We want to be absolutely certain that when we do move forward with providing the community care for people in northwestern Ontario, it is the best system we can possibly put in place. As I say, discussions are under way. We're reviewing the commission's recommendations but we have not made any final decision.

Mrs McLeod: We haven't seen an alternative, though, so we have no way, as people in northwestern Ontario, of commenting on whatever alternative there would be. There's a very strong feeling that there needs to be an agency that is dedicated to mental health. One of the concerns is that the alternative you're considering might be tied into the regional district health councils and the concept of integrated care being provided through the health councils.

I see you shaking your head. I'm trusting that means that's not the alternative you're considering, because we really hope there will be a dedicated agency in mental health.

Hon Mrs Witmer: I appreciate that information.

Mrs Boyd: Just following up in terms of the mental health reform, we're very concerned in London, for example, that there continues to be a delay in the transfer of the two psychiatric hospitals to St Joseph's Health Centre, which was recommended and was supposed to happen in January, then was supposed to happen in April, and still hasn't happened. We're concerned about that because in the meantime we're not quite sure who's home and who's responsible. You've made a commitment that people aren't being released and beds aren't being closed, but beds are being transferred between those two hospitals --

Hon Mrs Witmer: Yes, they are.

Mrs Boyd: -- and people are losing services as a result. Who's in charge and why the delay? I want you to know that the longer the delay, the more the opposition to that grows among those who have been in opposition, and the more it becomes the rumour that passive aggression has overtaken the whole process and nothing's going to happen.

Hon Mrs Witmer: I've actually had an opportunity to meet with some of the employees of the two centres. I've also met with some of the union representatives, the professional staff, as well as the administration, because I know this has been an issue of concern.

First of all, let me confirm that we do support the advice that was given us by the HSRC that the governance and management would be transferred for both London and St Thomas psychiatric hospitals to St Joseph's Health Centre. I can assure you that programs and services are being maintained during that time period. Our staff are currently working with the St Joseph's Health Centre people to implement the recommendations of the commission.

I want to stress the fact that we want to be absolutely certain that before we close any beds we do have the appropriate community services in place. Again, the DHCs in southwestern Ontario are also working and helping in that respect to develop some plan as it relates to the eventual closure.

We have recently invested $4.869 million in community-based mental health services in southwestern Ontario. As a result of that initiative there is the capacity now for crisis intervention, case management, outreach, community treatment teams, peer support and family support. We believe we're getting closer to a point where we can move more rapidly on the recommendations as soon as we see the results of the reinvestment.

Mrs Boyd: You talk about the reinvestment that you've made as being community-based reinvestment but in fact it's a grant to the hospitals to set up community action teams. Is that not correct? Basically, they're still hospital-based. We're getting a very blurred line between what's community-based and what's hospital-based. Survivor advocates in the mental health community are very concerned that that $60 million went to further psychiatrize the problem rather than what was always meant by moving services into the community: taking them out of the medical model.

When you talk about that as community-based, it's rather disturbing to those who've been working in this field for a long time. While you may argue that it's community-based because people aren't actually living in the institution -- they're out in the community and the institution is coming to them instead of the other way around -- it certainly is not the philosophy of care that most survivor advocates have looked forward to as community-based services.

Hon Mrs Witmer: I will tell you, the review of the mental health strategy and the recommendations that were received were developed in consultation with hundreds of stakeholders in Ontario, and the recommendations that came forward by Mr Newman were extremely well received. There's been very strong support for the initiatives that have been recommended.

Mrs Boyd: I just need to comment to you that one of the major recommendations Mr Newman made, and one that was praised by survivor advocates, was the one recommendation you left out of your entire acknowledgement of his efforts, and that's the one that people need safe housing, they need income security, they need those kinds of supports in the community. That's just completely missing from --

Hon Mrs Witmer: Actually we are moving on the housing issue.

Mrs Boyd: Well, you're maintaining the supportive housing. We could talk about the $27 a day that homes for special care get. The only thing you need to know about that is, because it's such a low figure, it is becoming uneconomical for even the good ones -- and all of them aren't good -- to maintain those services. You need to be really aware that the communities out there, particularly communities like mine, are looking at a service delivery problem in the very near future that is by no means addressed by the kinds of actions you've taken. In fact, getting out of social housing, getting out of a lot of the programs, downloading housing to the municipalities, downloading the income maintenance to the municipalities is simply causing a great deal of difficulty in communities that may not have been particularly welcoming communities in the first place.

I think you need to be aware that there's real concern about what the long-term effect of this is going to be, however willing people are to even acknowledge that a lower level of deinstitutionalization may be appropriate if the appropriate services are there. But the money that you've flowed so far is frankly hard for anyone to translate into community services.

Hon Mrs Witmer: I know the deputy wanted to add something that may shed some further light on this situation.

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Ms Lang: I think it's important to clarify for you that the $60 million did not go to hospitals. The $60 million that the minister announced is in fact part of our community investment in a truly integrated long-term plan for dealing with mental health programs, and the fact that we now have supportive housing, part of the Ministry of Health, allows us to develop a truly integrated community response. We are working very much with the mental health community, the provincial advisory committee that the minister has, to deal with an implementation plan that does attempt to provide a continuum of services in the community. We are also working very actively with the Ministry of Community and Social Services around their income support program for the disabled and their employment supports for the disabled, to one more time make sure that we are trying to provide the range of services to those individuals so they can live in the community and have the kinds of supports and services that allow them to sustain their independence.

Mrs Boyd: Where does the $54 million for supportive housing appear in these estimates?

Ms Lang: It doesn't appear in the estimates at the moment because the government has just made the decision, and that transfer will happen in-year.

Mrs Boyd: So none of the $60 million that was announced includes the $54 million?

Ms Lang: That's right.

Mrs Boyd: Okay. I do have a question about services, because I'm quite struck. I'm looking at the page I was looking at before about health insurance and benefits. I see here in the top part of the estimates -- this is page 82 -- that services in the administration of the health insurance programs have increased by 99.8%. So I started going through various pages around this and have seen incredible increases in what are called services in many parts of this budget. I think one was 358% in services. What's included in services?

Ms Lang: I think I would like to ask Louise Steele to come up and explain this one.

Mrs Boyd: While she's coming up, we were asking, just between us, where the $54 million is coming from. What ministry?

Ms Lang: The $54 million is with the Ministry of Housing.

The Vice-Chair: Louise, could you identify yourself for the purposes of Hansard, please.

Mrs Louise Steele: My name is Louise Steele, Ministry of Health. Services include a wide range of categories related to things like photocopier rental, data processing, legal services, information technology, consulting and those kinds of expenditures.

Mrs Boyd: If we look at page 22, for example, there is a 39.1% increase in services in the ministry's administration budget, 1401-1.

Mrs Steele: Part of these increases relate to a realignment of accounts that we do to more accurately reflect expenditures, but I believe they also include the realty corporation transfers that have been incorporated into ministry expenditures.

Mrs Boyd: If we look, for example, in the next section, page 26, which is the main office of ministry administration, there's a 323.2% increase in services, for an increase of $3,653,100. In that line, I see here the Ontario Realty Corp chargeback, which is $310,600. What would those other services be in the main office, in the administration portion of the ministry?

Mrs Steele: The main office vote, the largest part of the services expenditure is expenditures incurred by the health board secretariat and the costs associated with our operations.

Mrs Boyd: We go on and see that the review board, for example -- I'm not quite sure of the page -- certainly wasn't anything like 323% increase in services.

Ms Lang: Ms Boyd, if I can explain that, the health board secretariat is a staffing organization that provides support to all of the various boards that exist under statute for the Ministry of Health. The Ontario Review Board is a separate organization with separate staffing support.

Mrs Boyd: Perhaps you could explain to me why, in a year when you're getting rid of some of those boards, you're giving yourself a 39.1% increase.

Ms Lang: As Mrs Steele explained, we have been going through a process of trying to reconcile the estimates so that we are aligning the dollars to where the real expenditures were. I think there wasn't clear alignment of the various other DOE lines, and we've been trying to clean that up through the course of the year. The Ontario Realty Corp transfer has also been reflected in these numbers.

Mrs Boyd: It's the only thing that's outlined. In every case we see what that chargeback is. It comes nowhere near the kind of dollars that we're talking about in increases to services. Are you contracting out a whole lot of services that used to be done by ministry staff?

Mrs Steele: No, they reflect realignment of our expenditures to more accurately reflect them. The overall increase in the main office is actually $651,900.

Mrs Boyd: Then you must have the detail in front of you. Perhaps you could provide that for us, because in fact, on page 22, the increase is $9,024,700.

Mrs Steele: That's on main office, page 26. Which page are you on?

Mrs Boyd: Sorry, main office is $3,653,100, so I don't know where you got $600,000 from.

Mrs Steele: In the services account. The overall increase however for that vote is $651,900.

Ms Lang: Mrs Boyd, if I can explain it to you, if you look at the services, the transportation and communications and whatever other part of ODOE, you will see the net changes.

Mrs Boyd: I know what salaries and wages are, I know what benefits are and I know what transportation and communications is. I want to know what services are.

Ms Lang: As Mrs Steele explained, services are a whole range of things, including what it costs to operate various equipment and machinery within the ministry. It does deal with some of the costs associated with service contracts. It's a variety of things paid for through the other DOE line. In terms of detailed explanations, I think it's simply an attempt to reconcile where the dollars are actually being spent, as opposed to where they were reflected in previous years' estimates.

Mrs Boyd: I'm not particularly satisfied with that explanation.

Ms Lang: I understand, but I think this is an attempt on the part of the ministry to clean up its estimates. We could provide a more detailed explanation as to why we are where we are in terms of this, but I've been assured that this is an effort on the part of the ministry to realign its estimates to reflect where we've actually been spending money.

Mrs Boyd: Where does it come out of?

Ms Lang: It's all within the other DOE line. Some of the allocations of dollars were coded to things they were not spent on, so we're trying to clean it up. If you look at some of the lines, for example, transportation and communications has gone down by X amount; services has gone up. That just simply reflects that we are now coding the expenditures according to where the moneys are being allocated and spent.

Mrs Boyd: So in all the past times when we were questioning the ministry about estimates, we were not being given detailed information that was correct. Is that what you're saying?

Ms Lang: I can't comment on previous years, as you know, but I think it's an effort on the part of the ministry to realign dollars to where they are actually being spent.

Mrs Boyd: I must say that DOE has for many years been the place where you hide all sorts of things under a DOE expense that you can't manage in other lines. That's why the detail about what kinds of issues are in there is important, because it's fairly clear to anybody who has been through this process a number of times that there are ways in which -- I mean, this is supposed to be an accountability issue. I find it distressing to have you come and say, "Well, this is simply a realignment of expenses," when you can't explain -- those are fairly significant changes; $9 million is a fairly significant --

Mrs Steele: I know they were significant changes, but I think if you look at the 1996-97 actuals and the 1997-98 actuals, we actually have tried to realign the accounts to more accurately reflect where the money was spent in that year.

Mrs Boyd: But you understand that's no comfort to me when, if you want to look at page 22, your actuals were $21,677,838 in 1996-97, your estimate was $23 million for 1997-98, and you actually spent $29.619 million. Now you're going up to $32.105 million. This is scant comfort for people who are constantly being told how necessary it is for the government to be businesslike. This doesn't seem very businesslike to me.

The Vice-Chair: That just about uses up your time. Are we getting a list of those services? Did you say you were going to provide the committee with a list of those services?

Ms Lang: I think I indicated we would try to provide a detailed analysis as to why we have to do this realignment.

The Vice-Chair: Okay, that's fine.

Just before we adjourn, tomorrow, if we start on time, we will be able to get the health estimates voted on, but we will not have time to go into municipal affairs and housing, because according to Viktor, our clerk, we will only have about seven minutes left. So if we can start in time, we can vote on the estimates in health, and when we reconvene, whenever that may be, we will start with municipal affairs and housing estimates. Is that fine with everyone? All right.

Minister, we won't see you tomorrow. Have a good time. Have a good summer. Have a good holiday or, at least if it's a working trip, have a good working trip.

The committee adjourned at 1752.