STANDING COMMITTEE ON ESTIMATES

COMITÉ PERMANENT DES BUDGETS DES DÉPENSES

Wednesday 3 October 2001 Mercredi 3 octobre 2001

MINISTRY OF HEALTH
AND LONG-TERM CARE

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Wednesday 3 October 2001 Mercredi 3 octobre 2001

The committee met at 1530 in room 228.

MINISTRY OF HEALTH
AND LONG-TERM CARE

The Vice-Chair (Mr Alvin Curling): I call the committee to order for the estimates of the Ministry of Health and Long-Term Care. I understand that when we recessed yesterday there were nine minutes left in the Liberals' round. On the Liberal side, Mr Peters will start.

Mr Steve Peters (Elgin-Middlesex-London): Minister, yesterday morning we spoke on the telephone and I certainly had the impression from that telephone conversation that you were going to be looking into what was going on in London. You left the impression with me that you were going to do everything you could from a funding standpoint. Yet today the board of directors announced the discontinuance of not 14 programs at the London Health Sciences Centre, but actually 18 programs.

Mr Dagnone, the CEO, wrote me today and, including in the press release, says that these are the right decisions for the hospital to make, decisions, though, that are going to jeopardize the world class transplant program at this hospital, the pediatric cardiology programs and a number of other programs.

In your opinion, is this the right decision? Is this what we need to be doing in health? I think you're doing a disservice to families in southwestern Ontario. You stood in the House today and talked about how proud you are of the way things are going out there. To me this is a very dark day in southwestern Ontario. I'd appreciate your comments on that.

Hon Tony Clement (Minister of Health and Long-Term Care): The context of my comments today were that, if you look over the last two fiscal years, London Health Sciences Centre has had a funding increase of 26%. So in contrast to your fairly negative characterization of our commitment to health care in London, I wanted to put on the record of the House that in fact our commitment has been quite substantial. A 26% increase in the last two fiscal years is, I think, a fairly substantial indication of our commitment to Londoners and to the quality of their health care.

You make reference to the media release that came out at 3 pm today from the London Health Sciences Centre. It came out from the board of directors. It references the fact that the plans and renewal work they've been working on commenced in May 2000. So this is not something new or unexpected in that respect because the scoping exercise has been ongoing for almost a year and a half. Mr Dagnone, the president and CEO of LHSC, says in part, "We" -- meaning the hospital -- "have accepted the reality that we cannot be all things to all people and sustain ourselves as a centre of excellence. Advances in medical science and technology hold promises of unprecedented benefits to patients. We recognize that we needed a plan to guide our future direction and to ensure the future well-being of our patients."

I think that is a fair indication of the London Health Sciences Centre's position on this. My job of course, in our operational plan reviews, in our reviews of functional plans of hospitals such as the London Health Sciences Centre, is to always review those plans, to make sure the public interest is maintained, to make sure the health services system as a whole is able to present excellent quality care to the patient, as accessible as possible, as close to home as possible. It may not be the case that every single component of health care remains absolutely static for ever and ever, amen. Some things have to change.

Mrs Lyn McLeod (Thunder Bay-Atikokan): So you're saying that --

Hon Mr Clement: Excuse me, I'm not finished yet. The fact is that the question at hand is, is the London Health Sciences Centre going to move to its areas of excellence and do we make sure that the other aspects of their work previously are picked up by other elements in the health care system? I think we can ensure that, to provide better quality care for Londoners. I'm quite convinced of that.

Mrs McLeod: Minister, let's get some facts on the table in terms of deficit reduction plans and operating plans of hospitals. Your government indicated very clearly that hospitals would be bailed out for their deficits one more time and then they would be expected to get their budgets balanced. You made that absolutely clear. In fact, you had a piece of legislation that was going to make it a legal requirement, although that legislation hasn't gone forward.

I'd like you to tell me how many hospitals in the province right now have been asked to present operating plans with deficit reduction plans in those operating plans.

Hon Mr Clement: I'll defer to Mr King, but I will say parenthetically that, yes, our government favours greater accountability for all our transfer partners.

Mrs McLeod: I just want some facts, some numbers, Minister.

Hon Mr Clement: I'm sorry?

Mrs McLeod: I just want some numbers on the table. This is the estimates committee.

Hon Mr Clement: I wanted to make sure the characterization of our policy was correct, because you can characterize the policy, but it's our policy as government, and our policy as government is to ensure that all transfer partners are accountable.

Mrs McLeod: Mr Chair, I believe this is a small segment of time in which to get answers to the specific questions, and I've asked a question of the minister --

Hon Mr Clement: I'm sorry. I thought you asked me a question.

Mrs McLeod: I did. I asked a question about numbers. I'd like an answer.

Hon Mr Clement: I'm answering the question. I want to assure this committee that our government will be second to none in terms of ensuring there is proper accountability for all our transfer partners, to ensure that the patient or the recipient of municipal services or other services --

Mrs McLeod: Mr Chair, I would ask for a ruling, please. This is the estimates committee. You'll have ample opportunity to interpret the data, as I will. We'll have other forums in which to debate it. You've made some statements about numbers. I want to get the numbers on the table. I started with a very straightforward question. I'd like an answer, please, to how many hospitals have deficit reduction plans within their operating plans that are sitting on your desk right now for approval.

Mr John King: I'm John King. I'm the assistant deputy minister. There are 159 hospitals in the province. We do not have specific numbers of deficit plans because we are not finished our review of the operating plans for the hospitals. A number of hospitals have indicated that is the amount of funding they will have for this year, and they are asked to work within that, or minimize disruption to patient care or minimize their deficit or operations. But we do not have any on the books right now for approval of a deficit plan.

Mrs McLeod: How many hospitals, then, in their current operating plans -- to use your words, having been told that they know how much money they're going to get and have to live within it -- are looking at a deficit at this point?

Mr King: The first day I went through the difference in what the hospitals submit and what is acceptable, depending on what they assume. If it's a new program that is not approved, often that becomes part of their deficit. So it's very difficult to give a number, but I would say that that there were probably around 50 hospitals that indicated that without financial assistance this year, they would need to look at either some reduction or deficit plan.

Hon Mr Clement: Let me qualify that slightly, Mr Chair, with your forbearance, to mention and reiterate what Mr King said earlier: sometimes the assumptions of the hospitals, when they make those proposals, turn out to be a misinterpretation or a misapprehension of the reality they face. So that number has to be taken with that qualification.

Mrs McLeod: Fair enough. With that in mind, Minister, when I indicated in the House today that, according to the estimates books, you are intending to give hospitals $120 million less this year than they received last year according to the interim actuals, you indicated that was not correct. I would draw your attention to page 71 of the estimates book where it indicates -- and we've discussed this already in the session that Mr Maves was attending, and I do have this on record in terms of our discussion at the time -- the interim actual is $8,720,596,408. Your plan to spend in 2001-02 was actually $8.47 billion, which would have been significantly less, but I recognized you had made an announcement in July that increased hospital funding by $200 million. That leaves a deficit, in terms of the funding last year and the funding this year, of $120 million.

Hon Mr Clement: No, I'm afraid I have to put on the record that I disagree with your interpretation of our estimates and the reality we face right now, which is a $450-million increase in operational funding to hospitals.

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Mrs McLeod: If you compare the interim actual to the estimates, are you telling me that one of those figures is inaccurate?

Hon Mr Clement: I'm saying that your interpretation of the reality of the present is incorrect.

Mrs McLeod: I'm just asking for a basic bit of subtraction, Minister.

Hon Mr Clement: I've just answered the question. You are incorrect, Madam.

Mrs McLeod: Then your estimate figures are misleading, to say the least, because your estimates --

Hon Mr Clement: Well, sometimes estimates change. In this case I can tell you that since the announcement we made in July, there has been an increase in funding based on the base for hospitals, comparing year upon year, of $450 million to the positive.

Mrs McLeod: Last week in estimates committee, your parliamentary assistant read a written statement, of which we have copies, which reiterated exactly the figure you used in July, which showed that the base hospital funding for this year would be at a record high of $8.6 billion. That's the figure I'm using. I'm not using the $8.47 billion that's in your estimates book. I've acknowledged that you have increased that planned spending since the estimates books came out in June. A handful of weeks later, you increased that by $200 million in response to hospitals saying, "We need $650 million." It still leaves you, according to the printed estimates of your ministry, allowing for that $200-million increase, $120 million short of interim estimates from last year.

Hon Mr Clement: I'm afraid I must state for the record that that's an incorrect interpretation.

Mrs McLeod: Then I will have to ask for the record that you present accurate estimate figures on hospital funding, interim actuals and planned spending for this year, to this committee, because otherwise you have misled this committee.

Hon Mr Clement: That is a very intense accusation to say, Ms McLeod. I hope you would see fit to withdraw that.

Mrs McLeod: As soon as the information is presented, I'll withdraw it. As soon as the information corroborates the minister's statements, then --

Hon Mr Clement: Perhaps my assistant deputy can once again go through the correct way to interpret these things.

The Vice-Chair: I know it's not good for us to say that one is misleading the other. I'm going to have to ask you to withdraw that.

Mrs McLeod: I will withdraw that term and I will ask the minister to present corroborating documentation for the figures which he has indicated are incorrect and, if my figures are incorrect, to present accurate figures for his estimates on hospital funding. I would then ask --

Hon Mr Clement: If I could ask the deputy, perhaps, or John King, my assistant deputy, could help you out.

The Vice-Chair: Mr Minister, time is up for the Liberals. Those figures can be presented --

Mrs McLeod: Thank you. We'll wait for the figures to be presented.

Ms Martel: Minister, I would like to go back to the contract between Cancer Care Ontario and Canadian Radiation Oncology Services. I'd ask if you can answer a few more questions regarding the details of the contract. I'm not sure if you want to do this or if you want to have one of your ministry staff return.

Hon Mr Clement: It depends on how detailed the question is.

Ms Martel: I would like you to go through with the committee again your understanding of the details of the contract, specifically at what point a premium is paid.

Hon Mr Clement: OK. I think we can go through that.

Mr King: In answer to your question, the intent of the contract was such that if the after-hours clinic reached 1,000 cases, they would be paid $3,500 per case. So in that situation, if there were 1,001 cases that did occur, then they would be paid $3,500 for each of the 1,001 cases; that's part of the questions you asked the other day. To date we have seen about 530 cases through that clinic, so we haven't reached, of course, the 1,000. The key to this arrangement, which was requested by Cancer Care Ontario, was to ensure that the after-hours clinic would prevent re-referrals to the United States. That was the goal. By June 1, of course, that did occur. We were no longer sending patients to the United States. So part of the bonus system was to recognize performance.

We also, as I mentioned yesterday, provided the same to the Princess Margaret Hospital, as far as a bonus recognition for productivity.

Ms Martel: Are you aware of any other bonuses, premiums or guarantees that would involve additional money through the contract?

Mr King: No. If I could, I may also have one of the individuals involved in the -- you need to understand the contract is not with the government, it's with Cancer Care Ontario, so we are not necessarily aware of all the details of the contract.

Ms Martel: You're paying for the contract, though. Am I correct? You are providing additional funding to CCO to cover these costs?

Mr King: That's true, but hospitals have contracts with many private organizations and we do not see all these contracts, but we still pay for that arrangement.

Ms Martel: But do you feel confident that the information which has been provided to us by yourself now, yesterday by a ministry staff person and also in the briefing notes, are the real terms, conditions and details of the contract? You must, or you wouldn't have given us this information, correct?

Mr King: Yes, that's right, but I think you should be made aware that we are also doing a value-for-money audit that was requested, and we're right in the process of that occurring. I think a number of those areas will come out of that value-for-money audit which is presently underway. The ministry is co-operating fully with that.

Ms Martel: Have you seen a copy of the contract?

Mr King: At one point in time I might have seen it. I can't say I know it in detail.

Ms Martel: And Minister, might I ask, have you seen it?

Hon Mr Clement: No, I haven't.

Ms Martel: Is there anyone here today who has seen it, who might be in the room?

Mr King: I think I would ask Allison Stuart to come forward -- Allison is the director of hospital programs -- and Dr Sandy Nuttal, who is here.

Ms Allison Stuart: If the question is being directed to me, I'm Allison Stuart, director of hospital programs.

Ms Martel: Maybe I can ask, Ms Stuart, do you have anything to add further to what Mr King said in response to my questions about whether or not there were any other bonuses, premiums, guarantees, terms or conditions in the contract which would increase the amount of money paid to the private sector agency?

Ms Stuart: I have nothing to add.

Ms Martel: All right. Minister, if I might, I have some serious concerns with the information that's been provided to the committee. You would be aware that my former colleague Ms Lankin did have an opportunity to see the contract. She was afforded that opportunity by Dr McGowan.

Hon Mr Clement: Yes, I did arrange that. That's right.

Ms Martel: One of our research staff, Mr Charles Campbell, accompanied her to see it. The details we have been provided with, with respect to the contract, are different than what was provided to this committee. In fact, the notes we have from their being able to view the contract are as follows:

(1) In section 2.6, page 5 of the contract, CCO was guaranteed -- guaranteed -- that a minimum of 500 cases per year would be referred to the clinic and they would be paid for that. So a minimum of 500 would be paid for regardless of whether or not that many people came through the door.

(2) If the clinic treated more than 500 cases per year, the rate paid per case would increase retroactively to $3,250. That's at 501 patients.

(3) If the clinic treated more than 750 cases per year, the rate increased retroactively to $3,500 per case, at 751 cases.

Nowhere in the contract, at least as described to me by Ms Lankin in her notes and by Mr Campbell, does it make any reference to 1,000 cases, and after 1,000 cases getting $3,500. In fact, the contract details that they saw were far richer than has been described to this committee.

I would like to know what you are going to do to get the correct information before this committee.

Hon Mr Clement: Certainly this committee deserves the correct information. Can I defer to the ministry to respond to your immediate concern, and there might be more responses that are necessary, quite frankly.

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Mr King: We will certainly bring that back to this committee after we do our review. I can't answer --

Hon Mr Clement: We're at a bit of a loss because we don't have the contract in front of us.

Mr King: I'm at a loss because I have not seen what you're referring to and I need to make sure my staff look at that contract. I'm just not aware of this. This is the first time I have heard this.

Ms Martel: May I make a suggestion? Ms Lankin raised this issue in the Legislature in question period before she left in June. At that time, Minister, you said in response that you were quite willing to "supply any information that I have," and she obviously had access to that information as well. Anybody in this House can have the same access. I think the dilemma we have arrived at today is that we don't have similar access. I would appreciate it if you would seriously consider actually making the details of the document public.

Hon Mr Clement: It's not for me to do that, quite frankly, because I'm not a party to the contract, Ms Martel. If you know contract law and the legal framework of this province, it's not for me, as a non-party to the contract, to perhaps go as far as you suggest. What we were able to do with the consent of the parties was to make the contract available on-site for perusal. That was what we were able to arrange in a very commonsensical way. If there are other individuals in the Legislature who wish to avail themselves of the same opportunity that was afforded Ms Lankin, I have no objection to that whatsoever.

Ms Martel: If I might, Minister, I'm not a contract lawyer, but this is public money. There has to be some accountability for this public money.

Hon Mr Clement: Right. And there's a value-for-money audit that is going on right now.

Ms Martel: That's right, thanks to a resolution that came forward from Mrs McLeod.

Hon Mr Clement: A resolution that I agree wholeheartedly with.

Ms Martel: And we may not, even through that process --

Mr John Gerretsen (Kingston and the Islands): It's a quantitative issue here.

Hon Mr Clement: I don't know anything about that. Quite honestly, this was a contract between Cancer Care Ontario and a provider, so I'm quite happy to participate or to ensure, to the best of my ability within the laws of this province, that I can be helpful in any way possible in this regard.

Ms Martel: Minister, I would appreciate that. Again, I have to say in conclusion that it is public money. Your ministry would be providing supplementary funding to Cancer Care Ontario to pay for the terms and conditions of this contract. Part of the argument we have made, which you will disagree with, is that that money would have been better spent in the public system to get the job done. What I am very concerned about is that the information as it now appears, especially the information provided in the responses to us yesterday, makes it appear that the public system is receiving more money per case than is being funded for this private contract. I'd refer you to the details: question number 6 in the information that was tabled with us today. It clearly gives us the situation where per case funding with a bonus is $4,200 in the regular program and $3,500 in the after-hours clinic. I would, as you can well appreciate, want to be sure that we have the right financial information --

Hon Mr Clement: I couldn't agree with you more.

Ms Martel: -- because I remain unconvinced that this is not costing taxpayers more. I think it is money that should have been allocated to the public system that is already in place.

Hon Mr Clement: Let's get to the bottom of it. You've raised a legitimate question. We've got to get the right answer to it. I agree.

Ms Martel: Thank you. I would appreciate that.

Let me return to some of the issues that were raised yesterday as well, if I might. There was quite a discussion about the international medical graduate assessment program -- I hope that I'm naming that correctly -- and I'd like to know when that program will be up and running.

Hon Mr Clement: I believe the answer we supplied yesterday was that we were aiming for this fall.

Ms Martel: Then, if it would be this fall, you would probably have most of the terms and conditions or criteria in place for the program at this point?

Hon Mr Clement: Still working that through, I think. Is George here? He can give us a status report. I'm quite anxious for this program to get rolling, as you can imagine.

Ms Martel: My specific question would be, if at this point you can advise the committee: what would be the expectations of international graduates who are practising in an underserviced area? Are you expecting them to serve one year, to serve two? Have definite criteria been set in that regard?

Mr George Zegarac: George Zegarac, executive director for the integrated policy and planning division.

We're currently working with the COFM and the CPSO review committee to look at those return-of-service requirements. It will probably be geared to the amount of training time that we actually subsidize. If they only require six months, we will probably try to tie it to the actual amount of training assistance that we cover for the period -- if they require two years. It's part of the discussion that we're currently having.

Ms Martel: And is two years' training the maximum?

Mr Zegarac: Two years is the maximum currently in the program.

Ms Martel: Can you tell me -- I apologize if you answered this yesterday -- how many applications you have in for this program at this point?

Mr Zegarac: To be honest, the program hasn't actually been designed yet.

Hon Mr Clement: There are two different programs. So are you talking about the one that's already in existence for medical school graduates or are you talking about the one for school graduates in a foreign medical school who have also practised in a foreign environment?

Ms Martel: The second, and I apologize, because I thought MPPs received a package of information about this in June where we could actually refer people to. Is that incorrect?

Mr Zegarac: There are applications that are coming in in terms of notices of intent. I can't give you the number. Those are just to notify us so that once the program design is identified, we can share that information with those individuals so I can identify how many letters we may have received in the future. That's not a problem.

Ms Martel: That would be useful.

I'd like to return to some questions on the CCAC. When we were finishing, it was with respect to a decision that had been made by the Health Services Appeal and Review Board. My question was, at that point, when would a regulation be coming forward to deal with the decision made by the appeal board? I raised that specifically because our own community care access centre had had a meeting with Ministry of Health staff up in Sudbury and was clearly told that a regulation should be ready soon. That was on September 4. Then, Mr King, in response to my question you said that the government was appealing that particular decision. I was quite surprised by that response because it was not the information that was supplied to our CCAC. So can I get some clarification, please, on what the intention is of the government right now with respect to this case?

Mr King: Mary Kardos Burton, the executive director of the division, will speak to that item.

Ms Mary Kardos Burton: Good afternoon. The intention of the government is to put forward an appeal in this situation. However, that doesn't mean that in doing regulations, you could put in a regulation that would prevent this kind of situation happening in the future.

Ms Martel: So are you doing both?

Ms Kardos Burton: We're certainly putting in an appeal in terms of the decision the Health Services Appeal and Review Board made and we'll be looking at whether or not we put in a regulation. I won't commit to saying we're putting in a regulation at this point, but I know we are looking at that.

Hon Mr Clement: In fact, the politicians get to decide whether there's a regulation, so we haven't made that decision yet.

Ms Kardos Burton: That's right.

Ms Martel: In the respect, it would be helpful if that would be conveyed to all the ministry staff. In the briefing note I have from the Manitoulin-Sudbury CCAC it says very clearly, "During a meeting with Peter Armstrong, acting regional director, north region, Ministry of Health and Long-Term Care, on September 4, we raised this issue." That's the board of Manitoulin-Sudbury. "He stated that the Ministry of Health and Long-Term Care is developing a regulation to remedy the situation." They are obviously looking for that because they are concerned about their clients who are in a similar position as Mr Paiano.

Ms Kardos Burton: So we would be looking at developing a regulation and we may recommend it, but certainly I wouldn't commit to saying that we're putting in a regulation.

Ms Martel: Do you have any idea of the timeline for that?

Ms Kardos Burton: No, I don't, but it would be shortly.

Ms Martel: Is the ministry not concerned about cases that might be affected now while an appeal is held, if a regulation does not come forward soon?

Ms Kardos Burton: That's why we would be looking at developing a regulation.

Ms Martel: OK. Can you tell me, whom do you appeal this decision to? Back to the board or to another body?

Ms Kardos Burton: I believe the appeal is to judicial review.

Hon Mr Clement: It's judicial review, so it goes to the divisional court.

Ms Martel: Is it possible for you to tell the committee why the ministry has determined that it's going to move forward with the appeal versus moving forward with actually implementing a long-term-care act?

Hon Mr Clement: It is potentially before the court, but I guess I can say that we are dissatisfied with the reasoning of the ruling. Therefore, we question whether it's the right ruling. That's why you apply for judicial review.

Ms Martel: Wouldn't it make more sense, Minister, to bring forward the long-term-care act so that we can be clear that all the provisions around eligibility are under one statute?

Hon Mr Clement: I think that's a fair point which I have acknowledged publicly in the past, and certainly that's our intention.

Ms Martel: Can we expect that this session?

Hon Mr Clement: I'm not the House leader, so a lot of this is out of my control. But it's certainly on my radar screen.

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Ms Martel: Thank you, Minister.

The Vice-Chair: Mr Wettlaufer.

Mr Wayne Wettlaufer (Kitchener Centre): Thank you, Chair. Do we have a 15-minute round or 20-minute round?

The Vice-Chair: Twenty minutes.

Mr Wettlaufer: Minister, I think it was 1992 when the NDP limited the number of positions in medical schools in the interest of cutting OHIP costs, ie, billing numbers, graduating doctors.

I presume we now agree that was not the position to take, that it was a mistake. Given that understanding, I'm wondering how many positions could be open for foreign-trained doctors if we didn't have the agreement that we do with the College of Physicians and Surgeons?

Hon Mr Clement: I'm not sure I completely understand. How many positions could have been opened if a decision --

Mr Wettlaufer: If we didn't have the agreement with the College of Physicians and Surgeons, and if they didn't have a limit on the number of doctors who can practise.

Hon Mr Clement: Do you want to take a shot at that, George?

Mr Zegarac: Yes. The expert panel put forward a recommendation of 25, looking at the capacity to actually assess these candidates. That's one of the issues we're having to confront. We've increased our enrolment figures by 30%. This is taxing quite a few of our preceptors and clinicians in terms of being able to provide training opportunities.

One of the challenges of having additional candidates -- international medical graduates -- assessed is that we need to make sure we have the assessors there. The recommendation was 25. We asked, and had their approval, to expand that to 40. We're going to see how the 40 works, and if there's additional capacity to go beyond that, we would certainly entertain doing that.

Mr Wettlaufer: OK. How many medical school students are presently enrolled in the medical schools in Ontario?

Mr Zegarac: I think it's 672, but I can check that figure for you.

Mr Wettlaufer: Is that also taxing the system?

Mr Zegarac: It is taxing the system as we increase the enrolment again next year. It is starting to provide some challenges with regard to getting the clinicians. Again, part of the training is clinical training, and in underserviced areas we are asking the same individuals who are providing clinical services to the public to also assist us in training these individuals. We have to balance that off.

Mr Wettlaufer: OK. Do we know how many foreign-trained doctors are presently taking the test?

Mr Zegarac: I don't, but I can endeavour to see how many may have written it in the past.

Mr Wettlaufer: I asked yesterday about the cost to write the exam. I believe you said it was around $100. If I made a mistake on that, you can say so.

Mr Zegarac: It was $500 to write the international medical graduate entrance exam to enter the program.

Mr Wettlaufer: Five hundred?

Mr Zegarac: Five hundred dollars is what I said yesterday, but I also committed to check the figure and get that to the committee.

Mr Wettlaufer: I believe it's more. If we have, let's say, 500 foreign-trained doctors writing that exam, would that be a gross exaggeration?

Mr Zegarac: I would be honest and answer that I don't know what the number would be. I'd have to look at that.

Hon Mr Clement: We'll try to get that to you, Mr Wettlaufer.

Mr Wettlaufer: Are we providing them with a revenue stream through our agreement with the College of Physicians and Surgeons?

Mr Zegarac: Once they enter the international medical graduate program, which we've just enhanced, they actually qualify under the PAIRO agreement and receive salaries from $45,000 to $60,000 a year. That is part of the revenue stream they would be using to pay for any further tests they have to write in terms of their medical exams.

Hon Mr Clement: That's direct to the graduate. Are you asking about the graduate or the CPSO?

Mr Wettlaufer: I'm talking about the College of Physicians and Surgeons.

Hon Mr Clement: There's no revenue stream --

Mr Wettlaufer: By allowing them to charge $500 or more for this exam -- I believe it's $1,000 -- and it certainly doesn't cost them that much to administer it, are we not providing them with a revenue stream?

Mr Zegarac: Not knowing their cost of administering it, I couldn't answer. That's something we could follow up on.

Hon Mr Clement: You're right. They get to charge whatever the number is: X, $500 or $1,000. I guess we have to get that information to you.

Mr Zegarac: It could be that they are.

Hon Mr Clement: You could interpret that as a revenue stream.

Mr Wettlaufer: So it's conceivable that we are allowing a few hundred individuals, foreign-trained doctors, to write this exam at a cost that is far more than the administration fee and only allowing 50 to practise, regardless of whether all or a large percentage of these foreign-trained doctors would pass the exam?

Mr Zegarac: I think we have to differentiate between international medical grads in our program, who have to get graduate training to qualify to write the exams, and individuals who have already been through a recognized program internationally and could write the exams without the additional training. There are two different strands.

Mr Wettlaufer: OK, let's talk about the second one.

Mr Zegarac: There could be additional costs to the individuals, with the hope, though, that they would get licensed.

Mr Wettlaufer: Yes, but there's a limited number who can practise, regardless of whether they pass the exam.

Mr Zegarac: There's not a limited number. The only restriction is the billing numbers we put forward. We don't limit the number of people who can actually write the exam. We are limiting the number who are getting financial assistance to get the additional training to get them qualified to write the exam.

Mr Wettlaufer: I'm not talking about the limited number who can write the exam. I'm talking about the limited number who can practise, who can pass the exam, regardless of their marks.

Hon Mr Clement: I guess it's safe to say, Mr Wettlaufer, that from a public policy point of view, our interest is in these individuals practising in underserviced areas. There might be individuals who are foreign-trained, who have expertise -- maybe clinical experience in a foreign land -- who want to practise in an overserviced area or an area that already has a great number of physicians practising.

Frankly, I have less public policy concern about them than about the ones we are trying to entice to work and set up practices in underserviced areas. If, let's say, there's a particular area of Toronto that has a wealth of family physicians or specialists, and another international medical graduate wishes to practise in that area, I don't think that's our public policy concern. Our public policy concern is underserviced areas. Does that make sense?

Mr Wettlaufer: Minister, I suggest to you that no matter how many people are writing this exam, there are still only so many who are going to be allowed to practise, regardless of whether their marks are adequate to pass the exam.

Hon Mr Clement: I guess it's because we restrict the billing numbers. You're right, sir, because, as I say, the public policy on the issue is that we want to give billing numbers in areas where there is underservice. It's of less concern to the government to issue billing numbers in overserviced areas -- you're right -- so we restrict the billing numbers.

Mr Wettlaufer: I'm not concerned about the overserviced areas. I'm telling you there aren't enough doctors to practise in the underserviced areas right now.

Hon Mr Clement: And I would agree with you, which is why we have the new program.

Mr Wettlaufer: But the program is not sufficient.

Hon Mr Clement: OK.

Mr Wettlaufer: I'll get back to it after.

Mr Gerretsen: No, keep going.

Ms Martel: This is one of your own. Holy geez.

Mr John O'Toole (Durham): Minister, with your indulgence, there's a very recent --

Hon Mr Clement: I would say for the record that the expert panel we relied on had a number for international medical graduates, which we have exceeded. If I had a magic wand, I would wave it madly to get more international medical graduates in the system. We, through our consultations and through the expert advice we had, were concerned about the ability of the system to manage the number of graduates who were coming on stream, both by the CPSO and, more importantly, by the system that has to place them in underserviced areas, and so on. If we find, after year one or year two, that the system is managing 90 graduates a year rather than the 36 or 24 we had before, then I'll be the first -- or, I think, the second -- advocate for increasing it above 90. I'd be the first or second to want to do that. I'm not saying no to what you're saying, but we have to walk before we can run, I would put to you.

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Mr O'Toole: My question is of a very specific nature, but it may have a general application. As you know, my riding of Durham is serviced by Lakeridge Health Corp, LHC, and specifically there is an issue currently that has been in the media that is important to me and to my constituents: the commitment the government has made through consultation at the staff level to deal with the full commitment of this government to provide a cancer centre at the Lakeridge Oshawa site by some date in 2003. There seems to be some current oversight or investigation or review. I want this on the record, because it's probably the most important issue, to provide some clarity in that area. It's a very current issue so you may not be fully up to speed, but for the record, I'm meeting with the board this week and I've met with the foundation members. I'm sure you're somewhat familiar with the issue, as they had applied for a very ambitious capital plan, way beyond the scope of the Health Services Restructuring Commission itself, and as such, even their secondary plan -- I would like some opportunity to have a response from whoever's managing that capital file, to be able to respond in an intelligent way to public concerns.

Hon Mr Clement: Mr King and Mr Clarry are here. Either can probably answer that question.

Mr King: I will begin. We actually have been working with Lakeridge on their overall project, which also included the cancer centre. In the process, as you well know, the hospitals are looking at 2003. Many of the organizations want to go to 2008 or beyond. So we need to scale back their projects fitting with the commission's direction. Fortunately the cancer care side got caught up in those discussions. We have recently met with Lakeridge and we are pulling out that cancer part to expedite the process on moving ahead on the cancer centre.

Mr O'Toole: You deal with this on an ongoing basis. From the information I've gathered both from the media and from talking to people directly involved administratively, at the foundation level as well, I was trying to -- this is perhaps conjecture or opinion. Is it that the design concepts that were brought forward and the way they were phased made it difficult to achieve the end, that is, the cancer centre, without achieving the short-range local agenda? Is that part of --

Mr King: That's a good way to put it.

Mr O'Toole: Who would I want to get my hands on who manipulated this government? I hate to draw this at a personal level. After my review, the concept design was drafted in such a draconian way as to phase it such that we couldn't get to the cancer centre without giving them all the bells and whistles over here. At the end of the day, we as a government committed to expand services closer to patients at home. That was the thrust. The Health Services Restructuring Commission recommendations could be achievable, but there were some other bumps in the road. I need to be comfortable, because in public I am accountable. We're caught in the middle and our ministry's getting blamed for not providing that kind of service. I'm willing to be the inside person who has to live there at the end of the day. Maybe you could help me out here.

Mr Paul Clarry: I'm Paul Clarry, director of capital services with the ministry. The hospital came forward with a proposal to use a construction management style to the capital project that would get them in the ground sooner. One of the reasons for that was precisely because of the urgency to get on with both the cancer centre and some other emergency and critical care issues at the hospital. To that end, the ministry had been working with the hospital on an accountability framework that would ensure priority investments happened in a timely manner. They received an approval for an initial phase of their project, about $92 million, based on an expected cost for all the work that needed to happen at Oshawa of about $176 million.

As the hospital proceeded in its construction, and we did further design work with them, the hospital was informing us that they were experiencing significant cost pressure. It is true that as they proceeded with the project, the original concept of a stand-alone cancer centre was overtaken by an interest in putting some medical care floors above the cancer centre. Through their construction management approach, they were working on the design of such a centre when they ran into these cost issues.

I think that's one of the reasons there has perhaps been some slower progress in showing the construction of the cancer centre phase getting started, because as the cost overruns identified themselves in the work of the hospital, we had to stop and find a way to keep the entire project affordable, and at the same time meet the priorities of both the cancer centre and the emergency critical services.

As a result of all that, we too have met with Brian Lemon, the CEO. We have met with the board chair. I have been out to see the building committee myself, personally, and talked to them about how we move ahead. We had the foundation in with us as well as major funders.

We have been working diligently the last several weeks with the hospital on some options for how we can break out the cancer centre project so they can get on with the preparation of the bunkers and the completion of design, and leave the flexibility to carry on with the rest of the capital project. We have some more work to do there.

Mr O'Toole: An excellent response. I will get a copy of Hansard and deliver it on Friday at our meeting.

Just one small follow-up, a very important detail: the foundation has a silent donor who, without some sort of approval, will not commit to the initial seed funding for their major funding drive. That foundation money may be lost because of this delay, which I believe is self-imposed by the inability to bring the project together. That's the key question to this whole piece. They're ready to roll out a fundraising campaign, which is a very ambitious $40-million to $50-million deal. It's dependent on this seed money to pump it up to a number they can go to the streets with. Are you aware of this particular decision?

Mr Clarry: Throughout the discussions with the hospitals, we of course always ensure that we have a viable local fundraising plan or funding plan as well as the provincial plan. This has happened in a number of hospitals where they are using phased approaches to their projects. We are aware of the funding issues as they arise. One of the things we look at as we try to stage projects is to ensure we don't jeopardize those important local contributions.

Mr O'Toole: If I may, with the indulgence of the Chair, that local contribution is the important keystone to this piece. Some of their problems are the mixture of capital and operating dollars. It's a very quagmirish kind of thing. I'm assured that if you're going to go in and do a financial review of this thing, which could take six months, they're going to lose considerable coin from the key donor. I know that first hand from some important players. All I'm saying to you is, if we're saying, "We're taking it over and here's the delivery date," I think the foundation will release the seed money for the local campaign to begin.

Mr Clarry: We are in fact exchanging letters with the hospital to ensure that we're clear on the priority of the cancer centre. Certainly the ministry has written back or will be writing back to Brian to tell him that the priority is cancer first and foremost, and to carry on, to continue the work to see that the rest of the project rolls out in a way that is affordable to the community, affordable to the province and meets the local priorities from the health care perspective, but also meets commission direction.

The Acting Chair (Mr Frank Mazilli): With that, your time is up, Mr O'Toole. We'll turn it over to the official opposition. Just so that we have some semblance of order here, can I ask that all questions be directly to the minister and he can then defer to any of the staff members.

Mr Gerretsen: All my questions are directly to the minister, not to any staff member, even though I'm sure they are highly trained and qualified.

Minister, would you agree with me that when the hospital restructuring program was first put forward by your government, it was always done on the theory that there would be community health care available for those people who in effect were displaced or somehow affected as a result of your hospital restructuring program?

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Hon Mr Clement: I think that has always been part of our goal: the best health care available in the community as close to home as possible. That's certainly the philosophy of this government, yes.

Mr Gerretsen: It is under those conditions that Duncan Sinclair took on his task of chairing the Health Services Restructuring Commission. Would you not agree with that?

Hon Mr Clement: As an observer who was not health minister, who wasn't a minister of the crown at the time, I don't know how to answer that question, but I think it's a good supposition. I haven't talked to Mr Sinclair about the terms of his engagement. I have talked to him, though. We had a very good conversation in Kingston.

Mr Gerretsen: Can you explain to me, with all the hospitals you have closed, beds you have closed in chronic care, in acute care, in rehab, in mental health etc, with everything that's been happening, why it is that you are not funding the CCACs in Ontario to at least the same level you funded them last year, not what they budgeted for last year, but what they actually were funded for at the end of the day last year? Why are you not at least funding them to that extent?

Hon Mr Clement: Let me first tackle some of the predication of the question that was actually asked. As you may be aware, previous governments closed beds but kept hospitals open, so you had a whole series, the equivalent of 35 medium-size hospitals closed but still paying for the heat, the light and the administration.

Mr Gerretsen: Minister, my question to you is, why aren't you funding the community care access centres across the province to the same level you funded them for last year? That's the question. I'm not concerned about what other governments did five, 10 or 15 years ago. I'm asking you why you're not funding them to the same level as you did last year.

Hon Mr Clement: I understand your question, Mr Gerretsen. With the greatest respect, your question was posed with a prelude that characterized certain --

Mr Gerretsen: Not a prelude; a fact, sir.

Hon Mr Clement: I guess we're going to have to agree to disagree as reasonable people. Perhaps my staff here can talk about the funding levels for CCACs.

Mr King: The CCAC arrangement was that we would fund -- basically we are funding them at that last year's level. It is a zero increase.

Mr Gerretsen: At last year's actual monetary level?

Mr King: As I mentioned to you before, some of the CCACs were having some trouble. We took from some and reallocated the dollars. That was not a permanent arrangement. Everyone knew it was a one-time arrangement. So we are in fact funding them at the same level as last year. The difference is that at the end of the year there were a few CCACs we gave some help to, as a one-time thing, but we also took away from others to help those.

When we started off this year, we said, "We will fund at your start of the year." So really we're funding at the same level.

Mr Gerretsen: Are you saying that the CCAC, for example, in Kingston, Frontenac, Lennox and Addington is getting the same amount of money that it actually got last year?

Mr King: They are getting the same budgeted amount of money --

Mr Gerretsen: No, not budgeted. The actual amount that was spent there last year was something a little bit less than $27 million, and you gave them $25 million this year. I'm not concerned about the budget. I'm concerned about how much you actually gave them last year.

Hon Mr Clement: Mr Gerretsen, let me reiterate what Mr King said because I think it bears repeating. There were one-time arrangements made with certain CCACs to get them through what we considered to be a tough spot. At no time did we intimate and at no time was it ever suggested to them or did they agree with us in terms of the terms of those transactions that that becomes part of their base budget.

You cannot compare apples to oranges. You have to compare apples to apples. In this case you compare base budgets.

Mr Gerretsen: I am comparing apples to apples, Minister. This particular CCAC is getting $2 million less money than it got last year.

Hon Mr Clement: I would encourage you to compare the base budget to base budget because that's how we budget in this province.

I know you're very emotional today. I'm not sure why, but I can assure you that when you compare base budget to base budget, there have been no cuts.

Mr Gerretsen: I'm emotional because when I ask a minister a question I expect a definite answer. If you spent $27 million last year --

Hon Mr Clement: Mr Gerretsen, I certainly have been endeavouring to give definite answers, but I have to ensure that the prelude or the preface to the question is accurate.

Mr Gerretsen: Can't you answer to why you're not spending $27 million there this year?

Hon Mr Clement: In many cases there are inaccuracies creeping in. I apologize. I'm not suggesting it's intentional by any stretch, but I do feel it's my place to correct inaccuracies.

Mr Gerretsen: As you know, the CCAC has taken out an advertisement in which basically they're saying they can no longer take any cases for the next six weeks. This has caused a problem at the Kingston General Hospital to the extent that 33 beds are taken up by individuals who under normal circumstances, if adequate funding had been made available to the CCAC, would be taken care of under a community home health care program. That's not happening right now. Do you think that's the proper way to go about it?

Hon Mr Clement: I think I can tell you that Kingston is very similar to other CCACs in that their budgets have increased year upon year. I don't have the figures before me for Kingston, but I have been advised in previous statements that their budget has been increased quite substantially.

Mr Gerretsen: Their budget has increased, according to your own associate minister, by 20% since 1994-95, when the entire system has increased by 70% during that same period of time, according to your own figures that you filed today. So they haven't done as well as the other CCACs across the province. Provincially the system has gone up by 70% in documents you filed today, and according to what your associate minister said in the House just last week, the Kingston CCAC is 20%

Hon Mr Clement: Is 22.7% what the total was?

Mr Gerretsen: No, she said 20%. If it's 22.7%, then I'll accept that, but that's not the figure she gave in the House. It's inaccurate, then.

Hon Mr Clement: That's quite an increase, Mr Gerretsen. In many cases there are --

Mr Gerretsen: You think that's quite an increase in light of the fact that you've closed one hospital and you've closed beds in three major areas of hospital care?

Hon Mr Clement: If you want to get back to hospital funding, at no time in the province's history has there been more hospital funding, and that's as true for eastern Ontario as it is for every other region of Ontario. I can assure you that when it comes to hospital funding and making sure that the funding actually gets to patient-centred care, our government's commitment has been second to none. I agree with you that home care is part of the solution as well. That's why, across the province, home care funding has increased by 72% since 1994-95.

Mr Gerretsen: Your model, sir, is denying people from entering the hospital in Kingston right now.

Hon Mr Clement: I'm sorry, is that a question, sir?

Mr Gerretsen: That's a statement, in the same way you're making a statement.

Hon Mr Clement: I would disagree with your statement, sir.

Mr Gerretsen: I'll now turn it over to Mrs Pupatello.

Mrs Sandra Pupatello (Windsor West): I want to chat with the minister about other CCACs as well. They are all facing deficits. This is just some of them. For the Kitchener-Waterloo CCAC, I want to bring the $12.7-million deficit to your attention. The difficulty we're having with all the CCACs is that in the response you tabled today, you're boasting about how much it's increasing, but what I asked yesterday was specifically how the increases correlate to the amount of cuts in the hospitals in those same regions. We also talked about the underserviced nature of those communities, so for example, talking about community health centres, how does funding of community health services improve it at all, in the same area that's wildly underserviced by doctors, given the very community its in?

Likewise with community care access centres. In the Kitchener-Waterloo area, they're facing a $12.7-million deficit. Irrespective of how you talk about increases, if the demands are going up wildly, the demands are obviously going up more than what you are funding and what the guarantee was in the restructuring of the health system. Your commission was called the Health Services Restructuring Commission -- not hospital restructuring, but health. That meant the whole system was going to shift and you guaranteed as a government that the community would find the investment before the services were cut from other institutions like hospitals. That is not what has in fact happened. Even though you're showing increases to CCACs on paper, the demand has gone up exponentially, much greater in terms of what has to be provided now by a CCAC that used to be provided in a much more expensive fashion by hospitals.

Even though you're showing an increase in the funding levels over the last several years, you've changed the mandate of CCACs. What used to be a very simple home care program that used to keep the elderly in their homes for longer, living independently, by providing some housecleaning or some personal grooming items -- it used to be the thing that saved them from going into a long-term-care facility. We now must completely rely on CCAC services to include the lion's share, which is nursing service.

You brought that in when you created CCACs. When you did that, when you mandated utilization levels of hospitals to drop dramatically in a very short period of time, there was nowhere for these people to go other than in their home communities, and you guaranteed those home communities would make nursing services available.

The minister is probably aware that last year there were several CCACs that actually turned back a surplus. How can that be in the face of all the deficits this year? We called these places --

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Hon Mr Clement: Do you want us to answer that question?

Mrs Pupatello: I'm going to tell the minister because he probably doesn't get all the detailing now.

Hon Mr Clement: Any time you want me to jump in and answer any questions --

Mrs Pupatello: The whole of the CCACs have been turned over to Helen Johns, and Helen Johns, as of Friday, didn't know what her job was going to be, so we're having a little trouble. In fact today we addressed the Premier with the CCAC issue because I understand it may not even be in your bailiwick.

In any event, these surpluses were turned back because these providers could not provide the service because the nursing shortages in these communities were so dramatic. It has failed at every step. The demands have increased and far outstripped what you've been prepared to fund, given that you've mandated the changes that the CCACs must now accommodate. How do you address Kitchener-Waterloo, whose local MPPs are well on side with the CCACs in knowing that they're not able to provide those services and that funding is required?

Hon Mr Clement: I can tell you for the record --

The Acting Chair: Minister, if I can just interject for a second because the format seems to have changed and we have some long statements, if you don't feel there's been a particular question, you can certainly wait until one does come.

Hon Mr Clement: I was just going to jump right in with the opportunity there. I can state for the record that Waterloo region started out in 1994-95 getting $22.1 million worth of funding; by 2001-02 their annualized budget was $40.7 million, which is an 82.9% increase in their funding.

Mrs Pupatello: Yes, but I'm asking about the $12.7-million deficit. That's a deficit of $12.7 million.

Hon Mr Clement: If there is a concern in Waterloo -- I have met with that particular CCAC, by the way. We met in very emotional circumstances. It was actually on September 11 at 10:30 in the morning that we met, so you can imagine that our minds were slightly elsewhere, but we followed through with the meeting because it was important to the community. Certainly their particular point of view was taken in by myself and by Mrs Witmer, who was also available at the meeting.

Mrs Pupatello: Let me ask you about Niagara's $9.4 million because that's probably fairly substantial as a deficit. The local MPPs from Niagara are also well aware of the significant deficit of the CCAC. Perhaps you could ignore what funding levels preceded 1998 or 1999 and talk about the increase in demand, which is the question I placed on the table yesterday -- the level of demand, the number of families, the types of service now required in the Niagara region that has caused the deficit of $9.4 million. How do you address the Niagara MPPs who are facing a $9.4-million deficit?

Hon Mr Clement: I can tell this committee that in 1994-95 Niagara received $21,254,306.

Mrs Pupatello: No. Do you realize what he's doing, Chair?

The Acting Chair: You've asked the question and I will certainly give the minister --

Hon Mr Clement: Last year it was $48,518,103, which is a 128.3% increase. So certainly from our perspective --

Mrs Pupatello: Minister, are you going to ignore that the demand far outstrips what you're funding, because in each answer so far --

Hon Mr Clement: No, I think we've certainly been attempting to meet that demand, and I think the numbers I have been explaining to this committee are evidence of that.

Mrs Pupatello: Why would Niagara be in a deficit position? What is the deficit, then? Why would Niagara have a deficit?

Hon Mr Clement: I guess that's the kind of question we like to go into detail about with the providers we fund. Sometimes there are a lot of issues. Demand can be part of it and managerial decisions can be part of it. If they need some help, for instance, like Hamilton, which needed a little bit of help to get back on track in terms of their management, we went in and helped them with that. There are cases where we do that. To make sure the home care patients receive the best quality care, there were some changes made in Hamilton today where the supervisor who was sent in by this government was able to reduce the administrative staff and increase the front-line staff. That's the kind of thing I think is very positive in Hamilton, and maybe that's the same case in Niagara. I wouldn't want to speculate, but that is something Minister Johns could look at.

Mrs Pupatello: What is the reason for the deficit in York region? Is it also mismanagement in York? Are you also suggesting that mismanagement in York accounts for the $12-million deficit this year?

Hon Mr Clement: York went from $16,946,252 in 1994-95 to $51,162,395 in 2001-02, which is a 201.9% increase.

Mrs Pupatello: I'm talking about this year's deficit of $12 million. Are you considering that's mismanagement as well?

The Acting Chair: Come to order.

Mrs Pupatello: He may as well be talking about something on the moon as far as answering our questions are concerned, Chair.

Minister, I have to tell you, on the record, that you may as well be talking about a crater on the moon as answering the questions being put before you at committee. It's very frustrating.

The Premier today in the House was so glib and so arrogant on some really serious issues. I don't know if you get to meet the people who actually receive the service, but they can't stand this kind of answer. You need to answer the question.

I asked you specifically about what causes the deficit, and I want you to answer the question about service.

Hon Mr Clement: Mrs Pupatello, I wanted to provide a context for the question. I can assure you, as a member of provincial Parliament, that I meet with my constituents on a regular basis, including those who receive home care --

Mrs Pupatello: Why would all of these areas -- God --

Hon Mr Clement: -- and they deserve excellent, quality service in an accountable and sustainable manner. That's what this government is all about.

Mrs Pupatello: Unabashedly, this government has moved forward in health service restructuring. You are responsible for the outcome, and you are now abdicating your responsibility by throwing it on the management of local CCACs. That is what's happening across the board. You have regions -- York, $12 million; Simcoe, $7 million.

I read a letter in the House today from the MPP from Simcoe, who copied his neighbouring MPPs, who said you must increase funding. He didn't talk about the mismanagement of the local CCAC; in fact, he said if the management is having trouble, then you get in there and audit them. If you haven't done so, you'd better increase the funding. He said specifically, "You give them $42.7 million," which is exactly what they asked for. That's coming from your side of the House, Minister, not our side. This is not some kind of fantasy; this is very practical.

I'm assuming that Joe Tascona, who has met with the local CCACs, has gone into very great detail in determining the needs in the Simcoe area, and you are completely ignoring the question by coming in here and reading budget levels from pre-five years ago, when the mandate of the organization didn't even exist as it does today. It's not a fair answer. It's not the kind of behaviour I expect from a minister of the crown in such an important area.

I've got another question for you, which was tabled yesterday, about long-term-care facilities. I asked you specifically how you come to the $2.60 increase in funding per diem when the request by the industry was $25? The answer that was tabled is that it was a working group that involved the various stakeholders that worked on funding issues for the LTC sector. I take it from that answer that this working group came up with the $2.60.

Hon Mr Clement: I'd be happy to answer that question.

Mrs Pupatello: Minister, that working group asked you very specifically for a $13 increase, and your answer to them was $2.60.

Hon Mr Clement: There has been an expectation -- and I think a legitimate expectation -- by the deliverers of long-term care that operating funds would be modernized and improved over time in a multi-year framework. The budget was able to provide the start of a multi-year process when it comes to increasing operating funding. The budget for this year meant a $30-million increase in per diems. Next year it's up to $60 million.

So we went to the stakeholders -- the operators, ONAS, the long-term-care association and ourselves -- with us obviously at the table, saying, "This is the money as part of the multi-year commitment to date. It's part of our budget. It's part of our commitment this year and next year. How can we divide that in a way that is fair to the operators?" The operators and their associations were quite forthcoming and appreciative that the process has started.

I am aware, and they are aware, that the process doesn't end this year. I can say that for the record.

Mrs Pupatello: How many years is "multi-year?" What does "multi-year" mean?

Hon Mr Clement: It means more than one year.

Mrs Pupatello: How many is multi-year? A 10-year plan, 15?

Hon Mr Clement: That's certainly up to the Ministry of Finance and to government objectives, but it means more than one year, certainly.

Mrs Pupatello: I just wanted to see what we're dealing with, with long-term-care facilities.

Hon Mr Clement: The operators know that. They're aware it can't all be solved in one year, that it will take several years. They want to work with us to make sure the way that money is divvied up is fair and provides for the best care. That's the kind of arrangement we arrived at.

Mrs Pupatello: Could you just confirm, then, that you were asked by the working group for $13, and what you came back to them with was $2.60?

Hon Mr Clement: I wouldn't characterize it that way, Mrs Pupatello. I would say that they came to us and said there has to be a multi-year solution to this. We said, "We agree. The budget for this year has given us an indication that there's $30 million for operating next year and another $60 million growing from $30 million. Can we at least sort out how best to allocate those monies and work toward a multi-year solution that reaches levels we can agree to?" I think that's the correct characterization of what happened.

The Acting Chair: With that, your time has expired. We'll move to the next 20 minutes.

Ms Martel: I wonder, Minister, if you might table for the committee the list of CCACs that had money taken away and reallocated, and the value of that reallocation in the case of each of those CCACs.

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Mr King: Could I have clarification on that again? You're saying "taken away." It was actual reallocation of a one-time nature last year. So you would like those who had a reallocation?

Hon Mr Clement: Had a surplus, or was reallocated?

Ms Martel: Yes. In response to previous questions, as I understood it, you said there were some that had money taken away -- if that was the wrong terminology, I apologize -- and reallocated to others who were running deficits.

Hon Mr Clement: Yes. So the surplus was reallocated to the ones in need. That's right.

Ms Martel: If you could provide the list of the CCACs in question and the value of the money in each case, that would be helpful.

I want to continue to ask some questions about Cancer Care Ontario, not with respect to the contract but with respect to its future direction. Minister, earlier this spring you established a committee to look at the future role of Cancer Care Ontario, and I am concerned that where this is heading is to integrate the cancer care centres into the host hospitals. I say that because we had a situation like that in our community early on, when I was first elected, and there was great difficulty with respect to cancer services and funding being appropriately allocated to the same from the host hospital. I don't want to go back there. That's why I very much like the current structure that we have, where there are very clear divisions -- very clear divisions of responsibility, funding etc.

Could you tell me, please, what you see this com-mittee doing, and is it the position of the government that where you want this to end up is indeed having cancer services under the jurisdiction of the host hospitals?

The Acting Chair: Minister, before you start answer-ing that, could I ask members -- Ms Martel was very polite during other people's 20 minutes and other parties' 20 minutes. If I could ask the same indulgence both from the government and the Liberal sides to respect her 20 minutes and allow her so that we can all hear.

Hon Mr Clement: Thank you, Chair. In the spring, in June I suppose, we did appoint Dr Alan Hudson, who is a noted administrator and specialist, to review the progress made by Cancer Care Ontario and cancer care in Ontario in the context that when Cancer Care Ontario was first created, one of the goals was the appropriate and proper integration of services with hospitals and other providers. So that was a goal that was endorsed by Cancer Care Ontario, by its board of directors, almost at the begin-ning, as I understand it, of Cancer Care Ontario. So I have not made any conclusions. I gave Dr Hudson complete ambit to consult with stakeholders, to consult with the public, to arrive at conclusions and then transmit those conclusions to the government. I have not been privy to those conclusions yet -- he is still working on it -- and therefore I still have an open mind until those conclusions arrive.

Ms Martel: Are you aware, Minister, of some recent comments that were made by Graham Scott, former deputy, who is the interim chief at CCO now, in a submission to the same committee whereby he very clearly said that gutting its powers now could significantly disrupt cancer care, including creating variations in treatment standards? Are you aware of that, and what is your response to that concern from the individual who now heads up cancer services in the province?

Hon Mr Clement: I am certainly aware of his comments and I can state for the record that our intention is to ensure that cancer care services are approved in this province. That is our motive, so that's how we will judge whatever recommendations come forward.

Ms Martel: Are you concerned at all, Minister, of the fear that is out there that in fact the cancer service agency would end up competing for money with the host hospital, which is a problem we ran into in Sudbury some years ago?

Hon Mr Clement: Again, I don't know how to answer that. I can tell you that we have an expert review with Dr Alan Hudson. He has a firm mandate to improve cancer services by whatever structures he recommends, and I'll take his advice seriously, certainly.

Ms Martel: Is it your intention, Minister, to make public the submissions that are being made to the com-mittee?

Hon Mr Clement: As I say, I'm trying to keep at arm's length from it. So it's up to Dr Hudson, who will present a report, and I would be shocked -- I can make this undertaking: that the report, once it's prepared, will be available to the public for their consideration as well...

E08-1645-03 follows

(Mr Clement)

... the report, once it's prepared, will be available to the public for their consideration as well.

Ms Martel: What is the timeline for completion of the work by the committee? I'm sure it's in the terms of reference, which I don't have. I apologize.

Hon Mr Clement: I did not wish to hamstring Dr Hudson. He indicated that in the fall of this year he would be able to complete his work. I did not want to give a firm date, because if he wants to take an extra few days or few weeks to cross every t and dot every i, then that would be fine by me. I expect that certainly this fall we will have his recommendations.

Ms Martel: Is your staff involved at all in the organization of the committee; ie, ensuring that people who want to make public presentations have an opportunity to do so, that there is enough time for them to provide appropriate submissions etc, so that all the views are canvassed?

Hon Mr Clement: I don't think so, but maybe I'm --

Mr King: There is a staff member who works with Dr Hudson on the organization of that, but just follows that direction. It's whatever the committee has determined as far as public hearings and that type of thing are con-cerned. Dr Hudson is really responsible for the project, with his steering committee, the implementation team.

Ms Martel: Mr King, can you tell the committee how many opportunities for public presentations have been afforded at this point? Do you have that information?

Mr King: Again, this is not a ministry project. Dr Hudson is leading this. I don't know how many public hearings and I don't know the schedule of public hearings.

Ms Martel: I appreciate that it's not a ministry project, but if I might, your ministry funds cancer services in the province. Surely that would mean you would have some ongoing and important role in determining how the future organization, a CCO, is going to look. It's not just a question of letting this committee do whatever they want, being on the sidelines and not being involved. This is a serious issue. If we are going to make a fundamental change of integrating budget and governance back into the host hospital, that represents a fundamental change from what we have in place now. Surely you, the minister, the ministry, would want to know that people had their say about that.

Hon Mr Clement: As I say, I feel we have a process that will collect a lot of opinion and information that have been available for a long time. As I said earlier, Ms Martel, this is not a new issue. This was part of the foundation of CCO in the first place. We're quite anxious to see this issue resolved in the absolutely best possible manner for the patients who rely on CCO. From my perspective, that's what we're doing.

Ms Martel: Would you undertake then to provide the committee with information regarding the opportunities for public presentation; ie, if there is a schedule that exists and which communities the committee is going to and hearing from?

Hon Mr Clement: I think he's already done a lot of that kind of activity. I can certainly provide you with Dr Hudson's telephone number if you wish to talk to him personally, but I'm not going to direct the committee from on high. I'm not going to do that.

Ms Martel: Minister, I think you misunderstood me. I asked if you would provide the committee with the list of communities where there have been presentations or opportunities for presentations to be available.

Hon Mr Clement: My apologies.

Ms Martel: I would like to know what the schedule of presentations has been thus far and what it will be for the rest of the fall. If there is a list of people who would have liked to be heard but couldn't be, that would be helpful as well. That's what I am asking for.

Hon Mr Clement: I would certainly provide whatever information we have available.

Ms Martel: Let me ask some questions about community health centres. I was interested, Minister, in your response to your colleague Mr Miller yesterday when you referenced community health centres. I believe I heard you say there hasn't really been an expansion because you have been waiting for the outcome of the review of the primary care projects and how they would be integrated with community health centres. I thought that was a bit strange in terms of a response, because my understanding is that essentially the budget for community health centres has been frozen since your government was elected in 1995.

I'm wondering if you can begin by giving me an indication of what the budget for CCACs has been --

Hon Mr Clement: CHCs.

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Ms Martel: CHCs, sorry -- since 1995 and what community health centres were expanded during that time.

Hon Mr Clement: Mary Kardos Burton can gives us some of the numbers.

Ms Kardos Burton: For the community health centre program the budget is $100 million projected for 2001-02. There are, as you know, 56 community health centres and then 10 additional ones. There have been only three centres where there has been any additional funding over the last few years. The reason for that, as the minister mentioned, is that we were engaged in a strategic review the past few months. Actually, it started in December-January and we've completed that.

The reason for the review was that we got a number of requests in from communities asking for health centres. But in looking at primary care reform and the family health networks, we wanted to do a review to see what role community health centres would play in the networks. So the strategic review is in, and we're considering that review in the context of the future.

Ms Martel: Let me ask some questions. When were the three community health centres expanded?

Ms Kardos Burton: It was Crysler and Grand Bend within the two years. Do you have the exact date? I don't have the exact date.

Ms Martel: And what happened from 1995 until two years ago? Were there any community health centres expanded in the province?

Ms Kardos Burton: Not to my knowledge. I can verify that.

Ms Martel: And the review itself in fact only started about three months ago?

Ms Kardos Burton: Yes.

Ms Martel: So it's a little difficult to blame the review process on a lack of expansion of CCACs?

Ms Kardos Burton: You mean CHCs, community health centres.

No, but I think the main reason was that primary care reform has been talked about for a long time. I think we have to look at what role community health centres play. There's no question that there have been a lot of requests for community health centres in a number of communities. But I think it was a positive thing to do a review and then to try to figure out how it does fit into the family health networks, or not.

Ms Martel: I'm not disputing the importance of the review. What I was questioning was essentially the government's commitment to CHCs because there have been many applications in to this government from the moment they were was elected. The government chose not to expand any CHCs until, as you said, 1998, and then there hadn't been anything until that point. The review is important, but it only began three months ago, and much of it, as I understand it, was promoted as a result of the Provincial Auditor's report last year.

Hon Mr Clement: I would like to put my oar in the water on this. I feel very strongly that defining the appropriate role for CHCs is important as we move forward on family health networks. I wasn't even aware of the auditor's side of this. But as the minister I feel very strongly that we have to know in which communities community health centres make the most sense, in which communities we can go ahead with our family health networks and how the two intersect. I think that's a very important public policy issue so that we have seamless available service 24 hours a day, 7 days a week for our population when it comes to primary care. That's the motive for the review.

Ms Martel: I appreciate that answer, Minister. My concern has been that we have gone through a period where we had enormous doctor shortages in many of our communities. Many of the communities that are experiencing the greatest shortages also have an application in or have been working on CHCs. My community is one of them. There has been little effort to recognize the importance of CHCs in dealing with recruitment and retention. I would encourage the government to look again at the value of CHCs even in that regard, far beyond their value in terms of health promotion and illness prevention, the fact that all the staff are paid on salary etc. I think a valuable opportunity to deal with some of the doctor crises could have been alleviated if the ministry had taken the freeze off this budget, and there has been a freeze, Minister.

Hon Mr Clement: Let me just say this, though. You talk about CHCs and having doctors and other health professionals on salary. Well, if you look at the remuneration and capitation program for family health networks, it involves salary. You look at how CHCs in effect roster health professionals and make sure there's 24-hour-a-day coverage. That's exactly what family health networks are intending to do. So you can see, there's a policy intersection between primary care reform and community health centres. We really do have to know what the future role is of community health centres, where they can be put to the best use and how that intersects with the massive expansion of family health networks, primary care reform, that this government has committed itself to.

Ms Martel: Minister, if I understood you correctly yesterday, you said you were briefed on this about two weeks ago. The review is in to you now, as I understand it?

Hon Mr Clement: No, I did not.

Ms Martel: My apologies. I thought you said yesterday you'd been briefed. The review is complete and in?

Ms Kardos Burton: The review is completed. We have the report at a staff level. We're briefing senior management on it. We're going the process of briefing. I do not believe that the minister has it in his hands at the present time.

Hon Mr Clement: I haven't seen it.

Ms Martel: My apologies. Does the report go so far as to indicate potential costs of new sites to be set up, or is it strictly a review that deals with the intersection between the two?

Ms Kardos Burton: Without any decision being made in terms of the report, I think what I've done at a staff level publicly is only talk about the themes, because there's been no decision made about the final outcome of the report. It talks about possible scenarios in terms of family health networks and how community health centres can fit in, or not.

Ms Martel: Thank you. The proposal that was submitted to the ministry in October 2000 from the Association of Ontario Health Centres, talking about an expansion in the number of health centres, (a) renovations to current ones, (b) new ones: where is that project at this point? Is that waiting until the decision about --

Ms Kardos Burton: That's being considered at the same time. I should say that the Association of Health Centres was on the executive steering committee for the report, so we have been working with them.

Hon Mr Clement: I believe I did meet with them.

Ms Kardos Burton: Yes, you did.

Hon Mr Clement: I did have a face-to-face with them and they were able to get their message across to me.

Ms Martel: Can you give me some kind of timeline? Are you working with a deadline in terms of having some recommendations coming forward to the minister on this issue?

Ms Kardos Burton: Yes, we are working on our internal deadline, but I'd prefer to say that we're trying to do it as soon as possible. Whenever a report is received, there is always some need to at least have some sort of plan fairly shortly after it's received. So we are working on our internal deadlines.

Ms Martel: Then let me ask a specific question about the Sudbury community health centre, which is a francophone health centre. I'm wondering then if it is tied up in this process. There is an existing community health centre in our community. They were told in October 1995 that they would have $2 million in capital for a primary site and a satellite site. They were authorized by the former minister to put in a proposal last fall and that proposal went into your ministry in May of this year. They are waiting to hear whether or not they will be approved so that they can actually expand the services in two communities in my riding which are now underserviced. Can you tell me whether or not that is now caught up in this review or if that application will actually be considered?

Ms Kardos Burton: I know we have not been approving applications, but I can't tell you the specifics on that one.

Mr Norm Miller (Parry Sound-Muskoka): First of all I'd like comment on CCACs as they relate to my riding of Parry Sound-Muskoka and point out that in the west Parry Sound side of my riding there's a CCAC operating, one of two in the province run by a hospital, and that CCAC has never had a deficit and isn't planning one for this year. We've heard a lot of talk about deficits, but I'd just like to point that out. If CCACs are being reviewed, I certainly hope that the operations of that CCAC are looked at because it seems to be doing a good job.

Hon Mr Clement: Sure.

Mr Miller: Also on that subject, on the weekend I spoke with a ratepayers' group, some of whom were seniors and had been using the CCAC, and I had a few questions on CCACs. One of the comments from the seniors who used the service was that it had been excellent but there was no cut-off point to it. In fact, the provider of the service was encouraging them to continue to use it even though they had finished needing the service. That might also be something you might want to look at.

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If you look at the budget here, $24.4 billion on a cash basis for 2001-02 is record spending on health care. The numbers I have heard are that in 1995, 38 cents on the program dollar was spent on health care and now it's 45 cents. If we continue increasing spending at the same rate we are right now, it's going to be 60 cents on the program dollar in five years.

We've certainly heard lots of demand for various services that people want. What long-term plans are there to manage future increases while at the same time meeting the expectations and health demands of the public?

Hon Mr Clement: That used to be a $64 question. If you add it all up, it might be a $64-billion question. But I think you're quite right: we've got a number of things that are driving health care funding issues in Ontario. Part of it is health care inflation. There is inflation in health care provision just as there is inflation in all aspects of our lives. It tends to be a point or two higher than the general inflation rate, so inflation takes its toll.

Then you've got population growth. We are a successful province. We attract people. They want to live here; they want to work here; they want to raise their families here. That's all a good thing. All of that is good. However, one of the costs of it is that at some point they'll be using the health care system.

The third aspect of it is what I call utilization. Every time there's a new wonder drug, every time there's a magnificent, new medical technology, people want access to it and they want it now. We live in what I call the 30-minutes-or-free society. People have high expectations for their private services and transpose that, quite rightly, on to their public services, and that drives growth in the health care budget.

Finally, you've got demography. We are not only a growing population, but we're an aging population. Between now and the year 2015, the number of persons 65 years of age and older in the province of Ontario will double from 12% of the population to 24% of the population. It's a statistical fact, and intuitively it makes sense that those who are 65 and older, that age cohort, represents close to 50% of our health care spending. Consequently, that will drive a lot of demand as well.

The combination of those four factors, plus the decline over time that will occur in federal funding of health care in Ontario and indeed throughout Canada -- at the present rate of commitment by the federal government, it will decline slowly over time from 14 cents of every dollar spent on health care, over the next five years, down to 12 or 11 cents or thereabouts. Combine that with the four factors I mentioned and you certainly have a sustainability challenge.

Incidentally, this has been recognized, not just by myself or by Premier Harris or the government caucus; it's been recognized by Allan Rock, my federal counterpart, who said that the current system is not sustainable, that it needs some new, creative thinking. His boss, Jean Chrétien, appointed Roy Romanow, a former NDP Premier of Saskatchewan, with the mandate to review the future sustainability of medicare in Canada. One of the first statements out of Mr Romanow's mouth was that the current system is not sustainable and it needs creative thinking to ensure it is there for future generations.

I think you hit the nail on the head, and part of what we've tried to do is get Ontarians to speak their minds through the questionnaire that was released over the summer. We are still tabulating the results, but I read another 100 or so of them personally today and got a sense of what they like about the current health care system, what their aspirations are for the future of our health care system and what their priorities are. We'll continue to tabulate those results and, of course, add that to our deliberations as a caucus and as a government.

Mr Miller: Can you explain the decline in federal funding you were speaking about? Currently they are funding 14 cents on the dollar, and you say it's going to decline to 12 cents. How is that occurring?

Hon Mr Clement: You may recall that last year the first ministers, the Premier and the Prime Minister came to an understanding on future levels of health care funding by the federal government. That understanding has given us the present situation, where the federal government is responsible, in Ontario at least, for about 14 cents of every dollar that is spent on health care. There are a huge number of areas of health care spending that are not covered by the Canada Health Act but that in fact are covered by the province of Ontario, and covered much more substantially in Ontario than in any other province.

Aside from that statement, let me say that funding for drug benefit programs is 100% covered by the province; funding for home care, CCACs and community care is 100% covered by the province -- those are just two major examples; funding for other practitioners like chiropractors and physiotherapists and so on is 100% covered by the province and not covered by the federal government.

If you analyze the understanding that was reached, the money available from the federal government peaks, I believe next year or the year after, and then starts declining again. So as a percentage of total expenditures, which always increase -- as you know, in the last six years the health care budget has increased every single year. When you look at the federal contribution compared to the projections of the increase in health care spending, that's where I get the declining total, declining over time, if you look at a five-year horizon, to about 12 cents on the dollar in the near future.

Mr Miller: How much funding do you think the federal government should be contributing to Ontario's health system?

Hon Mr Clement: Premier Harris has said, and it was endorsed by all the Premiers, that in the first instance certainly the federal government should seek to get their funding back up to the 1994 levels of funding, which was 18 cents on the dollar. That was the level of funding. If you looked at the health care spending in Canada and compared it to the federal transfer of monies, it was 18 cents on the dollar. All the Premiers in Victoria in August, through their communiqué, indicated they wished to initiate a dialogue with the federal government to get back to 18 cents on the dollar as a starting point. Thereafter we wanted to get back to the initial fundamental principle of the Canada Health Act, which was an understanding that national standards were important for health care delivery in Canada, but the quid pro quo for that was that the federal government was responsible for 50% of the funding and the provinces were responsible for the other 50%.

When you get down to 14 cents on the dollar, we're very far away from 50-50. We at least suggested, trying to be fair and reasonable, that rather than trying to make up for past history, any additional dollars that are spent should be divvied up 50-50 by the federal and provincial governments. That's the position of the Ontario government, which was endorsed by all the Premiers and territorial leaders.

Mr Miller: Accountability is certainly a very important subject, especially with the $24.4 billion we're spending on the health system. Are we doing any value-for-money audits on any of the hospitals in the province at this time?

Hon Mr Clement: Yes. That's an ongoing operation. Every year, hospitals submit operating plans. When we review those plans, it could be seen in the context of a value-for-money audit. We review how they operate, where they spend their dollars and what sort of clinical outcomes are expected for the spending of those dollars, because really this is about outcomes. Dollars and cents are very interesting, and we have an obligation to the taxpayers in that regard. But the real issue is getting the best outcomes from our hospitals and other health care providers.

With respect to our hospitals, we do go through that process of reviewing operating plans. In some cases a full-scale operation review is required. Ms Martel and I were discussing that in the Sudbury case yesterday. In some cases -- in extreme cases, of course, such as the Ottawa Hospital -- there is a need for more direct supervision and thereby a turnaround plan which is embarked upon after consultation with the ministry. That's very much a part of how we do things.

Having said that, I think there's more we can do. Certainly, we have signalled through our most recent throne speech in the spring that the province should expect accountability from all health care providers for the money that is spent to ensure that it produces the best clinical outcomes money can buy. That should be our goal. As we work through the implications of that, I think you can expect more initiatives in the future.

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Mr Miller: Certainly, getting the best outcome is an excellent goal.

Last year, the Ontario government was the first jurisdiction in North America to launch a flu campaign. What are the government's plans for the flu campaign this year and how did the program work in the past year?

Hon Mr Clement: It's a $44-million or $45-million initiative of the province. It was very successful last year. What we're doing this year is expanding it. We've got a lot more workplace partners so there are a lot more venues for the influenza vaccination to be available, not only in schools, nursing homes, fire halls and other institutions but also in the workplace. So we've really expanded that aspect of the program.

I'm very proud of this statistic: the results from last year's flu campaign are incontrovertible. One of the numbers I remember, because it was most poignant to me, was that the incidence of influenza last year in our nursing homes declined by 97%. So you can talk all you want about strains of influenza, but I am absolutely convinced you can directly connect that number to our very aggressive influenza vaccination campaign.

So we're expanding it this year. It is the most comprehensive program in North America. The World Health Organization has expressed a great deal of interest in Ontario as a jurisdiction that's leading the way in this regard, and we expect it to be very successful this year as well.

Mr Miller: What sort of cost is --

The Acting Chair: I'm sorry. I don't want to interrupt, but I just want to advise there are about seven minutes left. Mr Wettlaufer originally indicated a desire to participate. I don't know if the two of you have worked this out, or if I'm supposed to adjudicate.

Mr Miller: Maybe I'll just ask my last question, then. What sort of cost is the flu campaign?

Hon Mr Clement: It's $44 million or $45 million; am I in the ballpark?

Mr King: It's $44 million.

Mr Wettlaufer: The Liberals could barely contain their glee when I was asking some tough questions before, but I notice they aren't particularly gleeful when you mention the fact that the federal government has cut their contribution to Ontario's health care spending from 50% in 1966, when the Canada Health Act came into being, to 14% this year, and it will further decrease next year. Not once in six years have I heard any Liberal, including their leader, ever suggest that maybe the feds could increase their funding.

That being said, however, I'd like to get back to some business that I'm particularly interested in, and Mr Zegarac might want to come up here again because I'm not done with this. I'm like a dog with a bone.

Mr Zegarac: And I love my dog.

Mr Wettlaufer: I'm glad to hear that.

Hon Mr Clement: I have a dog as well. I just want to say that for the record.

Mr Wettlaufer: If I am a foreign-trained physician, world renowned in my field, how long will it take me to write the test?

Mr Zegarac: To write the examinations?

Mr Wettlaufer: Yes, in order to practise in Ontario.

Mr Zegarac: If it's a jurisdiction recognized by the licensing authorities, it would be based on the next scheduled exams. To be honest, I don't know.

Mr Wettlaufer: I didn't say "jurisdiction recognized," I said I'm a world-renowned physician.

Mr Zegarac: If it's a recognized jurisdiction, again, it goes by the licensing authorities.

Mr Wettlaufer: That's bureaucratese, I'm sorry. I said I am a world-renowned physician in my field. Forget anything about a recognized jurisdiction.

Mr Zegarac: I'm assuming that --

Hon Mr Clement: Is he world renowned in Malawi? Is he world renowned in South Africa? Is he world renowned in India?

Mr Wettlaufer: Around the world.

Hon Mr Clement: OK, you're not going to tell us where he's from, right?

Mr Wettlaufer: Not yet.

Hon Mr Clement: OK.

Mr Wettlaufer: And it's not a him anyway, it's a woman.

Mr Zegarac: Again, based on the licensing authorities' requirements, it would depend on the jurisdiction that they were recognized and licensed from.

Mr Wettlaufer: So it doesn't matter how good that foreign-trained physician is, it doesn't matter how well trained that physician is, if the Ontario College of Physicians and Surgeons deems that jurisdiction not to be a recognized jurisdiction, then that doctor is not going to be able to practise in Ontario?

Hon Mr Clement: The answer has got to be yes, that's right. If they're world renowned from Ed's Medical School in Podunk, South America, I think we have a right to know whether Ed's Medical School lives up to our expectations when it comes to clinical training.

Mr Wettlaufer: I think that as long as a doctor could pass the examination, if that doctor has a world-renowned reputation, that doctor should be allowed to practise in Ontario. This particular doctor I'm talking about has written books and papers, is recognized around the world as being one of the best in the world in her field and she cannot practise in the province of Ontario. Her husband was recruited by the University of Waterloo. He's a world-renowned engineer. He came to our area thinking that, of course, his wife would be allowed to practise medicine. But, God forbid, she's not.

Hon Mr Clement: It doesn't make sense to me. I don't know all the facts, but the way you present it --

Mr Wettlaufer: She was trained in Central America and it's not recognized by the Ontario College of Physicians and Surgeons.

Hon Mr Clement: I have no answer or explanation. I really don't.

Mr Wettlaufer: What regulations do we need to change?

Mr Zegarac: To get the recognition in terms of the qualifications?

Mr Wettlaufer: Yes.

Mr Zegarac: Again, the ministry is not the body that determines standards of practice. That is a college issue. What the ministry can do is try to facilitate that by providing training and assessment opportunities, which we are doing. That is basically the role we are playing to encourage as much as possible quick and early assessments of any of these qualified candidates or individuals who we feel would be qualified to practise here.

Mr Wettlaufer: Let me go one step further. I used to be a professional in a career in Ontario and we were granted authority by the Ontario government to have our own regulatory body. That is the situation with every profession throughout Ontario. But absolutely no other body I know of restricts its numbers other than the College of Physicians and Surgeons.

Hon Mr Clement: I'll introduce you to the Law Society of Upper Canada.

Mr Wettlaufer: It's not as bad as the College of Physicians and Surgeons. I think it is high time we sit down with the College of Physicians and Surgeons and have a little dialogue with them. Yes, they have the authority, but they are granted the authority by the Ontario government.

Hon Mr Clement: Can I go one step further, since we're on this topic?

Mr Wettlaufer: Yes.

Hon Mr Clement: The role of that body, just as the role of any other body that is a self-governing body in a regulated profession, is the public interest, not the interest of the particular regulated profession.

Mr Wettlaufer: Agreed.

Hon Mr Clement: It is the public interest. I'm sure you were going to get to that.

Mr Wettlaufer: Yes, and I agree with that. I have no objection to that at all, but when a regulatory body says --

Hon Mr Clement: I'm agreeing with you.

Mr Wettlaufer: I know. But when a regulatory body says that it matters where you were trained as opposed to whether or not you can pass the examination, and our ministry has agreed with that, I have a very difficult time defending that. In fact, I'll go one step further and tell you that I will not defend it.

The Acting Chair: I really do hate to interrupt, but I should --

Mr O'Toole: She's already given you three extra minutes.

Mr Wettlaufer: You've given me some of the Liberals' time.

Mr Zegarac: If I could respond for a second with respect to an earlier question that I have an answer to, if that's OK.

Hon Mr Clement: I don't know whether we're going to be infringing upon the --

The Acting Chair: Minister?

Hon Mr Clement: I think it's the Liberals' turn, isn't it?

The Acting Chair: It is the Liberals' turn.

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Mrs Leona Dombrowsky (Hastings-Frontenac-Lennox and Addington): My question will relate to the Kingston, Frontenac, Lennox and Addington CCAC issue. You're probably not surprised this issue has received a good deal of attention in our community, because they have chosen a very different course of action in order to meet your expectation that they would operate within the amount of money you have budgeted for them. My question is with regard to the allocation that they received last year over and above what was budgeted for them. Can you explain the purpose for which that money was allocated to them?

Hon Mr Clement: I'll refer to a staffer.

Mr King: I'm sorry. Could you repeat the last part of the question? I didn't quite hear it.

Mrs Dombrowsky: Can you explain the reason why you were able to provide them with an additional in excess of $1.5 million for their operation last year?

Mr King: As I have stated before, for many of the CCACs in the province, we did a review before the last quarter to see how they were managing. A number were projecting a surplus position, for whatever reason, and a number were looking at deficits. We determined that we would do a reallocation of funds. We did this with the field. I forget the exact number of CCACs we did this with but we're going to get that information. Then we reallocated funds from within their envelope of funding.

Mrs Dombrowsky: To address?

Mr King: In some cases it was to address pressures in some areas, and also because of shortages or contracts that were being dealt with. There were a number of issues we were addressing.

Mrs Dombrowsky: Would you be able to say that if those same pressures were able to be demonstrated this year you would be able to deal with the issue in the same way as you did last year?

Mr King: This year, of course, we have indicated to those centres that they would be operating under their original allocations from last year. They are asked to work within that allocation, so within their organization they need to prioritize their services. As you know, there is nursing service, there is homemaking --

Mrs Dombrowsky: Yes, I'm familiar with the different levels. What you are saying is that while you were able to recognize last year that there were pressures that required them to operate beyond the amount you budgeted, you are not going to do that this year.

Mr King: If we look at the projected situations, many of the CCACs right now are looking at a break-even position, or they will work within the budget that has been allowed. There are others that are having some difficulty. If we run into a situation where there is a surplus amount of money at some of the CCACs, we may be able to review that again. But we have to work within the envelope of dollars available.

Mrs Pupatello: I'd like to continue questioning on CCACs and discuss the Muskoka East Parry Sound Community Care Access Centre. I know that our member from that area would have asked about this one if he maybe had the details. They are now looking at cutting services by 20%. The CCAC there is putting all new requests for home care on a waiting list because they are not able to meet the demand in that area. Minister, I would like the answer for Muskoka East-Parry Sound: is it appropriate that they just put all new requests on a waiting list? This has nothing to do with the numbers; this is just the waiting list. Should they be putting all new cases on a waiting list in Muskoka East-Parry Sound?

Hon Mr Clement: I apologize. I'm not familiar with their particular circumstances so it's difficult to answer the question without being familiar with that.

Mrs Pupatello: For your information then, coming from this group, they are suggesting there are going to be significant delays in hospital discharges -- maybe I should address the member from the area -- increased visits to emergency rooms, lost jobs, of course, and the homemaking services that do not require personal care will be eliminated completely. The next time the member from that area maybe is having a coffee with the business community there, he may want to discuss Muskoka East-Parry Sound facing a 20% cut in service.

Let me talk about the Hamilton CCAC. Are you aware of a 650-person waiting list for that CCAC that you now control?

Hon Mr Clement: You may have been out of the room, but I think it was released today that the supervisor, as you so referenced, indicated a reallocation of their human resources, if I can put it that way. They are letting go a number of the administration staff and hiring a number of their front-line staff. This was one of the issues why I decided in the first place that there was a need for some supervision of the Hamilton CCAC, and it looks like the supervisor is doing her job and they are trying to get more services for the users of the CCACs -- the patient, or whatever -- as opposed to the administration. I think that's good news.

Mrs Pupatello: Given that line of thinking, then, the North York CCAC that has 9,500 clients a day is going to be reducing that by about 1,000. They're just going to take 1,000 of the 9,500 off. Would you approve of that kind of behaviour?

Hon Mr Clement: I guess what I'm taking from the Hamilton example is that there are other creative solutions out there that put the resources into the direct front-line services rather than the administration. If you're asking what lesson I draw, that's the lesson I draw. In some cases that might be appropriate.

Mrs Pupatello: The Manitoulin-Sudbury CCAC that's forced to cut $962,000 from its budget: that's the equivalent of five full-time employees laid off. They're taking a huge chunk of that out of homemaking services. Given that they essentially are triaging what services they are providing to their list, people who used to just get homemaking, meal preparation and housekeeping are losing that service entirely. Do you think it's appropriate that in your policy direction of health service restructuring it's plausible in this day and age, rather than pay what little amount of money it would cost to continue to give housekeeping services to an elderly person to keep them in their home, that you would eliminate that service?

Hon Mr Clement: I haven't eliminated any service, Mrs Pupatello. We have, as I said, increased home care funding by 72% over the last six years. We want to work with the CCACs, and Minister Johns is working very hard to do that. From our perspective, there are solutions to some of the issues that they are facing and we want to get to those solutions.

Mrs Pupatello: Yesterday I was asking about lists of the demands. Is there anyone in the ministry who is keeping a statistical record of how the demand has increased in each community around their CCACs? For example, do you acknowledge that the type of service CCACs provided when you started them in 1997, and today, that that percentage split of acute care like nursing -- 70% hospital discharges when it used to be 30%? That is so dramatic a shift in the kind of service that CCACs have to provide today and the cost of providing a hospital discharge service versus housekeeping service, say. Just the change in what they're doing could likely account for well over what you have budgeted them for. Regardless of whether the budget goes up or down, the kind of service CCACs provide today is so dramatically different as to not even be comparable year to year. Do you acknowledge that it has gone from 30% hospital discharge to 70% hospital discharge on average across Ontario?

Hon Mr Clement: I think your initial question was whether someone is collecting the statistics in each district and the answer is absolutely there is. The district health councils, for instance --

Mrs Pupatello: In your ministry.

Hon Mr Clement: -- collect population statistics and they collect utilization statistics. They then provide that advice to us. There might be other ways that we do that. Mr King?

Mr King: We also have reporting from the CCACs on their activity levels etc. What we're looking at doing is having a common waiting list arrangement from them.

Mrs Pupatello: Mr King, will you acknowledge that the type of service CCACs now provide is pretty dramatically different from what they provided in 1997, even if you just acknowledge that it used to be 30% hospital discharges and it's now 70%?

Mr King: Actually, I have an answer. I'm not sure you received that answer, but in fact that's not the case. The discharges from hospitals to home care programs have not changed that drastically. They're still at a 60%-40% level, but it's 60% hospital. You mentioned it was 30% hospital before.

Mrs Pupatello: It used to be 30%.

Mr King: So we do have an answer to that question that hopefully you've received.

Mrs Pupatello: If you know that, that means you do keep statistics on each individual type of service that is provided by the CCACs, their nursing providers, say.

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Mr King: We have statistics on what nursing was provided, what homemaking etc, but it's after the fact; it's not the current arrangement.

Mrs Pupatello: So you would know the number of clients on the list as well, right?

Mr King: We wouldn't know the waiting lists or the clients, just like we don't know for hospitals. Hospitals have waiting lists also. We don't have full supply on demand. So it's the same with the CCAC. This arrangement is very similar to how we work in hospitals now. Hospitals have waiting lists. CCACs now have waiting lists. Service is provided when it becomes available. It's the same with CCACs.

Mrs Pupatello: Are you concerned that there are people on a waiting list and that they'll get a service when it's available? Does that concern you at all?

Hon Mr Clement: Mrs Pupatello, I don't think it's fair to ask a ministry staff official that question.

Mrs Pupatello: I'll ask the minister that. Are you concerned -- I'm going to quote you directly, Mr King -- that there are people on waiting lists who will get the service when it's available? Are you comfortable with that as the Minister of Health?

Hon Mr Clement: As we all know, they're in a system that has universal accessibility. There is a lot of demand. It's our job to ensure that the demand is sustainable, that it goes to the people who need the help. That's what we worry about day in, day out. I don't think there's a day that goes by that we as members of the government caucus don't concern ourselves with that.

Mrs Pupatello: I'm just going to quote your colleague Ted Arnott, who said in the House, "Some patients are receiving less care and some aren't receiving the care they need because they're on a waiting list ... more patients will need hospital or long-term-care beds, the very expensive and sometimes unavailable options that home care was designed to replace, where appropriate."

Minister, I've got to suggest that there is something very, very wrong with your home care program. My colleague Ms McLeod needs to ask a question on that.

Hon Mr Clement: Mr Arnott is absolutely right. That's our concern, that on behalf of the taxpayers and the citizens of Ontario we've spent many, many millions, hundreds of millions more dollars, for community care access and yet these problems do exist. I think Mr Arnott is quite right to identify that as an issue that has to be solved.

Mrs Pupatello: Both you and Mr Arnott, then, should be voting in favour of my resolution tomorrow morning. So I hope you'll be there at 10 to 12 in the House tomorrow. I'd appreciate it.

Mrs McLeod: A quick question in another area, and then I think my colleague wants to return to the issue of home care. Would the Royal Victoria Hospital in Barrie be one of those hospitals that are showing a deficit in their operating plans?

Mr King: Again, I think we're back to the situation of what they had intended in their budget this year. They have received about an 8% increase this year. So I'd be highly surprised if they were showing a deficit.

Mrs McLeod: Does that mean that all the beds in the newly built hospital are fully staffed?

Mr King: I can't respond on specific cases. There's no question that there are some issues with nursing shortages now in the system and you can only provide the service when the staff are there to provide the service.

Mrs McLeod: Perhaps I could ask it a different way. Has the budgetary deficit situation that the Royal Vic in Barrie was facing, that had one full wing of a new hospital not operating because it wasn't staffed, been addressed?

Mr King: With the Barrie situation it has not come to my attention that this is a major issue, that the funding levels they've received thus far -- they are managing within those.

Mrs McLeod: Mr Gerretsen?

Mr Gerretsen: Yes, I have a few more questions about the home care situation. You accused me of being --

Mrs Pupatello: Emotional.

Mr Gerretsen: -- emotional before. I get very emotional when services for the elderly --

Hon Mr Clement: That wasn't an accusation, Mr Gerretsen. I just want to put that on the record.

Mr Gerretsen: Well, you said I was emotional. Mr Minister, I get very emotional when we're talking about vulnerable people who have no --

Hon Mr Clement: I think you're passionate. I think there should be more passion in politics, actually.

The Vice-Chair: Let's let him get his question done.

Mrs Pupatello: It was a compliment.

Hon Mr Clement: Yes, that was a compliment; you're right, Mrs Pupatello.

Mr Gerretsen: My question is quite simply this: we have now heard from the Kingston General Hospital that there are 33 beds being occupied by people who should be getting home care. The hospital agrees with that; the CCAC agrees with that. What is your ministry going to do about that today, or at the latest tomorrow morning, to make sure that, first of all, those hospital beds aren't being occupied by people who shouldn't be there, because there are other people waiting to take those beds -- they're coming in for surgery -- and to make sure that when those 33 people get discharged, there will be home care available for them?

Hon Mr Clement: I can certainly assure you, Mr Gerretsen, that Minister Johns is concerning herself with this and I'm sure is working her way through the best way to respond on this particular issue.

Mr Gerretsen: The thing I am very concerned about is the recovery plan that the CCAC puts forward in June of this year. Your ministry knew that they were going to be forced to take the action they did by not taking any further patients for a six-week period at this time. They knew that in June 2001. I'm prepared to file a copy of this. It's the only copy I have.

I believe it was Mr Haugh knew about it, according to newspaper reports, and his exact comments were to the effect that, "Well, we knew that we had to some tinkering around with it." He knew that it wasn't going through, but there didn't seem to be the kind of concern I would have expected the ministry to have about this situation.

Hon Mr Clement: I would disagree with your characterization of that. I would dispute that there is a lack of concern.

Mr Gerretsen: What are you doing about it? You've had this since June. Your ministry has had this since June.

Hon Mr Clement: Mr Gerretsen, I believe I answered that question. I know for a fact that Minister Johns is concerning herself with this and she is on the case.

Mrs Pupatello: I am going to go back to CCACs, Minister. Would you table the response you gave to MPP Joe Tascona and MPP Marcel Beaubien, who both wrote to you with significant concerns around their CCACs from their region. Would you table the response?

Hon Mr Clement: Not without their approval.

Mrs Pupatello: OK. I want to talk about Windsor, because you were just in Windsor the other day.

Hon Mr Clement: I was. It was a great day. Do you want me to talk about that?

Mrs Pupatello: No.

Hon Mr Clement: OK.

Mrs Pupatello: The operating deficit of the Hotel-Dieu Grace Hospital, where you sat on the dais, going toward the end of this year is $17 million. This Hotel-Dieu Grace Hospital is hardly the hospital -- and we only have two left. I know that you are aware that we've closed two emergency rooms.

Hon Mr Clement: Windsor was a great community that came forward first in 1992 with --

Mrs Pupatello: So, out of the operating deficit of $17 million, this is not the hospital that can afford the extra expense of not being able to discharge patients. But that unfortunately is what's happening, because the CCAC there is in a $2.8-million deficit and they now collect statistics on how many patients don't get discharged because the CCAC, because of the deficit, won't be able to take the patients on. They just say, "Don't discharge on the weekend. We can't give you any service." What do you make of that?

Hon Mr Clement: Let me just respond generally that certainly we are aware --

Mrs Pupatello: You couldn't respond specifically to this case?

Hon Mr Clement: No, let me just say that we are aware of the situation -- I think I have admitted that to you privately -- and certainly are reviewing the situation. That's where it stands right now.

Mr Gerretsen: Could I just ask one question. This is what Mr Haugh is reported to have said: The government imposed budget restrictions on access centres in an attempt to "find out whether the system is running right, should be left alone or needs tinkering." Is that the reason you put these budget restrictions into effect? That's his quote, your PR man, according to the newspaper report.

Hon Mr Clement: Yes. I can't speak to what was said and how it was quoted.

Mr Gerretsen: Do you agree with that statement?

Hon Mr Clement: Here is how I would characterize it, Mr Gerretsen. There has been a period of six years of unparalleled growth in home care funding; 72% over six years, I believe is the number I have mentioned several times.

Mr Gerretsen: It's 20% in Kingston.

Hon Mr Clement: Twenty per cent is a lot of money.

Mr Gerretsen: It sure is.

Hon Mr Clement: It's the taxpayers' money and they deserve to make sure that money is put on the front line for direct patient services. I would never trivialize a 20% increase in funding.

Mr Gerretsen: Well, you closed the hospitals. It may not be enough.

Hon Mr Clement: Here's how I would characterize it. There certainly has been a massive growth --

The Vice-Chair: You can answer that later.

Ms Martel.

Hon Mr Clement: Sorry.

Mr Gerretsen: I guess the Chair let you off the hook.

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Ms Martel: Minister, I'd just like to return to the issue I was finishing up with in the last round, and that has to do with the francophone community health centre in our own riding. I would ask the staff to undertake to determine where this application is now at. It was submitted to your ministry in June of this year in the request for all of their needs analysis, probably pertaining to a request of about $1 million for capital for their satellites.

I would ask that if you have it you consider funding it outside of whatever process you have now with respect to a review of CHCs. I'll give you three reasons for that. One, this is a community health centre that was built under our government but received approval for expansion under yours on October 23, 1995. There was very specific commitment by Mr Andrew Szende, assistant deputy minister, that $2 million would be committed: $1 million was for a primary site; the other million was for satellites.

Hon Mr Clement: Sorry, what was the date on that?

Ms Martel: October 23, 1995. I can give you a copy.

Hon Mr Clement: We will have to track that down.

Ms Martel: I think it is a project that goes quite a ways back that should have been funded by now.

Secondly, these satellites are located in two communities in my riding that are underserviced and have been underserviced for a number of years. The expansion to full-fledged community health centres in those communities would go a long way to dealing with their underserviced problems.

Thirdly, one of the satellites now has a waiting list of over 1,000 clients, but they also have physicians who are prepared to come on salary if the expansion occurs. I would very much appreciate it if the ministry could look into this and see if this application can now be funded.

In general I just want to say, before I leave this subject, that I'm very much supportive of the CHC program. I think they have been very effective tools for recruitment, for retention and for health promotion that involves many disciplines larger than your primary care health network in terms of the health care professionals who are involved, and that, in terms of being able to respond to the needs of underserviced areas, not only for physicians but for all other health care professionals, they are the way to go. I would encourage you to do the work that must be done.

Hon Mr Clement: When you say that they are the way to go, to the extent that we should not proceed with primary care reform --

Ms Martel: Well, I was going to ask you about how that is going because you've had some criticism by the OMA. So I'm not convinced that it is going as well as you would like to portray in that regard, Minister. Maybe you can respond to that.

Let me just finish by saying I would really encourage you to deal with their proposal. But now you can answer the question about your family health network, because there was quite a bit of criticism publicly by the OMA, intimating that this was not proceeding anywhere near as well as it should. Maybe you can respond to that.

Hon Mr Clement: Yes. I think that they, in the end, retracted a lot of their statements after the kerfuffle. I don't think that that should be seen as the current official position of the OMA. From my perspective, it is a touchstone of this government to proceed with family networks, with primary care reform. There is no question in my mind that health care will be improved across the board if we have 24-hour-a-day, seven-day-a-week access to primary care away from the hospitals, away from tertiary and secondary care models at the primary care, by family physicians working in teams, being available or, when they're not available, having a trusted member of that team available to the patient. To me, that is an excellent way to provide high-quality primary care and, incidentally, take some of the pressure off our emergency wards. When a citizen knows that their doctor's office is always open and is always staffed by people they know and trust, I think it will have a tremendous impact on some of the activity that happens in our emergency wards.

The other thing that I'm very excited about -- so permit me to put this on the record -- is that as part of our way to remunerate the family physicians in these networks, of course we will take into account their roster, how sick their patients are and how old their patients are, so they don't cherry-pick the most well or the youngest and that kind of thing. We will pay them more for the sicker and the older. The other thing we will pay them more for is, incorporated into their family practice, a preventive medicine component. We will pay them more for that. I think that's very exciting in terms of wellness, the ability of our system to promote wellness, to promote healthy lifestyles and healthy living. They're our front-line troops on that. I'm quite excited about moving ahead on this.

Ms Martel: Minister, if I might, because you asked me if I would have one at the expense of the other, I think you know our position in the NDP has been that it should be mandatory, not voluntary. We certainly agree with the need to move forward on primary care reform.

I think what the ministry should be looking at, though, is that we have a number of community health centres that could be expanded without much difficulty and up and running in expanded sites in six months. I suspect that a number of those that could be expanded -- I believe there are at least 21 that would be ready to go -- would be in communities that are underserviced now. If you're trying to deal with recruitment and retention problems, it may be that those would be the ones you would go after, because they could be up and running before some of your primary care sites.

Hon Mr Clement: We will certainly take that under advisement. Thank you.

Ms Martel: Can you give me the details with respect to the funding for that very initiative? The PA in his remarks mentioned, and I hope this is right, that in the budget of 2000 there was $100 million in incentive funding that was allocated and $150 million in information technology.

Hon Mr Clement: That's right.

Ms Martel: How much of those budgets have been spent to date?

Mr King: Alison Pilla, who's the acting assistant deputy minister, will answer that question.

Ms Alison Pilla: I'm Alison Pilla, acting ADM for the health services division. As the minister mentioned, we are quite proud of this initiative with respect to the Ontario Family Health Network. There's been quite a bit of interest expressed by physicians in participating in these health networks. I think we have about 40 groups of doctors, who comprise about maybe 550 or so doctors, who've expressed some interest. We are making some good progress on developing the components that we need to roll out these networks. We have, as you know, an agency set up to do that. There's a chair, Dr Ruth Wilson, of the agency and the board of directors is in place.

The numbers that the minister mentioned are correct in terms of the budget announcement for funding for these networks, and we are currently in the early stages of pulling together the template agreements. We have a lot of that work completed in conjunction with the OMA. These are the agreements that will be rolling out. We intend to start, once those templates are approved, to roll those out very shortly. In terms of actually specifically how many dollars have been spent to this point, I would have to undertake to get back to you on the actual amounts.

Ms Martel: That would be helpful, because I'd like to know how much of that actually has been allocated. You mentioned that you have about 500-plus doctors who are interested, but the parliamentary assistant used a figure of 175 doctors who have joined. Now I'm confused, because I'm hearing you say we are at the start of a process that hasn't really started.

Hon Mr Clement: No. We have some pilot projects that are up and running. I think they represent about 250,000 patients.

Ms Martel: How many do you have, 14?

Ms Pilla: That's correct.

Hon Mr Clement: That's one group. Then we've got expressions of interest and so on, even without a contractual framework having been finalized. Our expectation quite frankly is, once we get the contractual framework finalized so that they know what sort of relationship there will be operating -- medical professional to medical professional and centre to province-once we get those finalized in the next few weeks, I think we are up and running.

Ms Martel: Are the pilots being funded out of the budget announcement of 2000?

Hon Mr Clement: I don't think so.

Ms Pilla: That was a previous initiative that was in place.

Hon Mr Clement: Yes.

Ms Pilla: Those have been in place for a little while. You're correct, there are 175 physicians participating in those 14 primary care networks that are in place now. That represents about 250,000 patients.

Ms Martel: Of those who are expressing interest at this point, how many communities then would be involved? Do you have a breakdown in that manner?

Ms Pilla: I would need to check that. I don't have that information with me, but we could look at that.

Ms Martel: That would be helpful. If it is possible, because you already have the list of underserviced areas through the UAP, could you do a match for us to give us a sense of how many of those who want to be part of this are actually in an underserviced area?

Ms Pilla: Sure. You understand that these are early expressions of interest and that we expect we will get a lot more interest once we've looked at the contract and are able to describe to people how that's going to roll out.

Ms Martel: That would be fine. When did you say that process would be complete, the template and the contract?

Hon Mr Clement: We are just in the midst of it right now, Ms Martel. I can't give you an exact date, but I can tell you it is one of my very top priorities.

Ms Martel: I have another question with respect to underserviced areas. It is a program that operates in northern Ontario -- I think it still operates; if someone could deal with this -- the northern group funding plan. Is that incentive program still in operation in the ministry?

Ms Pilla: Yes, that is. That is currently in place.

Ms Martel: Can I ask, does the criterion that communities with a population of over 10,000 are not eligible still exist?

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Ms Pilla: I don't believe that we changed the criterion for that program. I'd need to check if that was the initial criterion, because that program started a few years ago. I think the criteria that were in place then are still in place. There were a certain number of areas that were identified as being eligible and that was the list essentially of eligible --

Ms Martel: It is my understanding, and you will correct me if I am wrong, that communities having a population of over 10,000 were not eligible. As you check back on this, I would encourage the ministry to review that criterion.

In my own community, in the outlying regions, there are three communities that are over that, but all of them are underserviced and have been for quite some time. As people know, the problem of underservice is not just a problem for small communities. It would be most helpful to get a change in the criteria, because I think that would have some benefit in our community.

Mr King: I was just going to mention that Allison and I both share this program through the north and through the OMA. We have agreed with the physician services committee of the OMA that we will do a review of the underserviced area program, so that is just underway right now.

Hon Mr Clement: I announced that Monday.

Ms Martel: Let me backtrack. A review of the underserviced area program can mean a number of things. What does it entail specifically? All of the incentives?

Mr King: It's looking at all of the incentives, but it's mainly to look at whether we need to update some of them, because they have been going for some time and we haven't reviewed them. It's really to focus, in a positive way, on the underserviced area.

Ms Martel: I should assume, Mr King, that the northern group funding plan is designated as an incentive program under the underserviced area program?

Mr King: Yes. They are all included in that package.

Ms Martel: I'm worried about the length of time for said review. Do you have any timeline for this? Clearly, I would ask you to consider a change in criteria for those communities as a more immediate response to underserviced areas like my own. If the review is going to take another six or eight months, I have to say that won't be terribly helpful in our community.

Hon Mr Clement: I hear you loud and clear.

Ms Martel: Thirdly, and this goes back to under-service, I'm also trying to offer some options around dealing with some of these issues, because the immediate problem we have in too many of our northern communities is still a lack of doctors, despite the initiatives that the government has announced; some of them will take some time to roll out.

Minister, you mentioned yesterday, in some responses that came with respect to questions on nurse practitioners, that the ministry was engaged in a discussion with nurse practitioners now about how they might fit into family health networks. I appreciate that. I wonder if you would consider something else, and that is, to look at actually funding nurse practitioner positions in a number of northern hospitals. We have a scenario now at the Sudbury Regional Hospital, the St Joseph's site, where there is a nurse practitioner, and I think some of the money is coming from your ministry and some from the hospital to have a nurse practitioner who operates an outpatient clinic, which is dealing with some of the orphan patients. The hospital also has a need for a nurse practitioner in their emergency ward to continue to deal with orphan patients, because that is a major problem of people coming in. I would encourage you to look at the possibility of expanding nurse practitioners into hospitals to deal with orphan patients as well, because that's a huge problem in our community and, I suspect, in many other northern hospitals.

Hon Mr Clement: I appreciate your suggestion.

Ms Martel: One other issue, if I might. I'm not sure how much time I have. I listened, Minister, with interest to your response to the question from Mr Miller about the flu campaign. I want to follow up now on the suggestion we have made for meningitis immunization. You will know that Quebec has recently announced a major program, $100 million.

Hon Mr Clement: I saw that Mr Hampton came out quite aggressively on that.

Ms Martel: Exactly. We wrote to the Premier on this in July, and the Premier has just recently responded to say that he has sent the correspondence to you. So, can you tell me what your plans are for meningitis immunization? To be serious, we've had 65 people infected and eight people have died. There's a way to deal with this.

Hon Mr Clement: I want you to know that I'm relying upon the advice of public health officials and the provincial public health officer, the chief medical officer. In some respects, as a layperson when it comes to these medical issues, I do have to rely on the advice of clinical and scientific experts. I think that's what I can say right now. He has not so recommended at this time.

Mr King: Dr Karim Kurji is here. He's the assistant director for public health.

Hon Mr Clement: Dr Kurji, would you like to add anything to what I said?

Dr Karim Kurji: No, I believe you have covered it.

Hon Mr Clement: Thank you for your time and your --

Ms Martel: Don't go away. Let me back up. You have spoken to whom about this initiative?

The Vice-Chair: Just state your name.

Dr Kurji: I am Dr Karim Kurji, physician manager, public health branch. Maybe if I can, through you --

Hon Mr Clement: It is Dr Colin D'Cunha I rely on. He's the provincial chief medical officer. Obviously he has some expert staff here. I rely on them, quite frankly.

Dr Kurji: The ministry is well aware of the proposed national strategy document that talks about the implementation of the meningococcal immunization program in the under-20 age groups: basically, two groups of children under the age of five, and for adolescents between the ages of 15 and 19. However, the Ministry of Health is also participating in a federal-provincial-territorial process involving other jurisdictions with respect to the introduction of this particular immunization program.

The National Advisory Committee on Immunization has not yet released its recommendation. At this point in time, Ontario is certainly following whatever recommendations have been released by the National Advisory Committee on Immunization, and they suggest that meningococcal immunization be used only in certain conditions for the control of outbreaks. We are working closely with the other partners in the federal-provincial-territorial process and collaborating within that process.

Ms Martel: If I might, though, some of your other partners have already proceeded with immunization in their own jurisdictions. In Quebec, announced in July, $100 million in a campaign to combat meningitis; Alberta has launched a $22-million vaccination program this year, targeting 640,000 people under the age of 24. So I guess I'd make the argument that other jurisdictions aren't waiting for the recommendations to come down. They are moving forward with a program in this area.

Dr Kurji: With respect, we have to step back a little bit and re-examine why Alberta and Quebec embarked upon their particular line of action. Both of these provinces had seen a number of outbreaks that necessitated a large number of their population -- in fact, I would argue, much of their population -- in the cities and in the rural areas being immunized as a means of protection. This is really following the National Advisory Committee on Immunization recommendation, ie, you immunize in certain situations to control the outbreaks. Given the fact that they had already immunized a good proportion of the population in the cities, it only made sense to proceed further and have more complete protection.

Ms Martel: But wouldn't you also want to consider the incidence, both in terms of infections and eight people -- Quebec's numbers, as I understand it this year: 72 people have been infected and eight people have died. Ontario's numbers for this year: 65 people have been infected and eight people have died. They're not far off.

The Vice-Chair: A short answer would very much assist us in wrapping up our time.

Dr Kurji: Sure. When we actually consider an immunization campaign, we take into account incidence figures in the local population, and we tend to demarcate the population by certain criteria. In general, we use the figure of 10 per 100,000. Anything over 10 per 100,000 is what we would regard as an elevated incidence. So it depends on the details that have been used in each instance in terms of working out the figures.

Ms Martel: Just as I finish, may I ask, Minister: I gather that you are asking for advice on this; could I ask you to go a step further than the chief medical officer of health? We had Ron Gould at our press conference, who is an advocate of that. He is a medical adviser of the Meningitis Research Foundation of Canada, a professor emeritus of pediatrics in the faculty of medicine at the University of Toronto and the former head of the division of infectious disease at the Hospital for Sick Children, and he is very supportive of this program. I would ask, as you are gathering advice, that you include and ask for his in this very important program, because I think he has tremendous expertise as well.

The Vice-Chair: We stand adjourned until Tuesday, after routine proceedings or 3:30. At that time, we have an hour and 50 minutes approximately, and if we choose to put the Ministry of the Environment on notice, the Ministry of the Environment will then be called.

The committee adjourned at 1759.

CONTENTS

Wednesday 3 October 2001

Ministry of Health and Long-Term Care E-109

Hon Tony Clement, Minister of Health and Long-Term Care
Mr John King, assistant deputy minister, health care programs division
Ms Allison Stuart, program director, hospitals, health care programs division
Mr George Zegarac, executive director, strategic health policy, integrated policy
and planning division
Ms Mary Kardos Burton, executive director, health care programs division
Mr Paul Clarry, director, capital services branch, corporate services division
Ms Alison Pilla, director, operational support branch, health services division
Dr Karim Kurji, physician manager, population health service, health care programs division

STANDING COMMITTEE ON ESTIMATES

Chair / Président

Mr Gerard Kennedy (Parkdale-High Park L)

Vice-Chair / Vice-Président

Mr Alvin Curling (Scarborough-Rouge River L)

Mr Gilles Bisson (Timmins-James Bay / Timmins-Baie James ND)

Mr Alvin Curling (Scarborough-Rouge River L)

Mr Gerard Kennedy (Parkdale-High Park L)

Mr Frank Mazzilli (London-Fanshawe PC)

Mr Norm Miller (Parry Sound-Muskoka PC)

Mr John O'Toole (Durham PC)

Mr Steve Peters (Elgin-Middlesex-London L)

Mr Wayne Wettlaufer (Kitchener PC)

Substitutions / Membres remplaçants

Ms Shelley Martel (Nickel Belt ND)

Mrs Lyn McLeod (Thunder Bay-Atikokan L)

Also taking part / Autres participants et participantes

Mrs Leona Dombrowsky (Hastings-Frontenac-Lennox and Addington L)

Mr John Gerretsen (Kingston and the Islands L)

Mr Steve Peters (Elgin-Middlesex-London L)

Mrs Sandra Pupatello (Windsor West / -Ouest L)

Clerk / Greffière

Ms Susan Sourial

Staff / Personnel

Ms Anne Marzalik, research officer,
Research and Information Services