SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION
LAKESHORE AREA MULTI-SERVICE PROJECT
ASSOCIATION OF DISTRICT HEALTH COUNCILS OF ONTARIO
CANADIAN MENTAL HEALTH ASSOCIATION ONTARIO DIVISION
ONTARIO COALITION OF SENIOR CITIZENS' ORGANIZATIONS
TORONTO MAYOR'S COMMITTEE ON AGING
ONTARIO PUBLIC SERVICE EMPLOYEES UNION
ONTARIO MEDICAL ASSOCIATION, SECTION ON DIAGNOSTIC IMAGING
ASSOCIATION OF GENERAL HOSPITAL PSYCHIATRIC SERVICES
ONTARIO PHYSIOTHERAPY ASSOCIATION
COUNCIL OF MEDICAL IMAGING (ONTARIO)
ONTARIO NURSING HOME ASSOCIATION
TORONTO CONFERENCE OF THE UNITED CHURCH OF CANADA
YORK REGION COALITION FOR SOCIAL JUSTICE
CONTENTS
Tuesday 19 December 1995
Savings and Restructuring Act, 1995, Bill 26, Mr Eves / Loi de 1995 sur les économies
et la restructuration, projet de loi 26, M. Eves
Lakeshore Area Multi-Service Project
Maureen Boulter, board member
Joe Leonard, director
Association of District Health Councils of Ontario
Susan Brown, chair
Gord Gunning, executive director
Canadian Mental Health Association, Ontario Division
John Kelly, president
Mamoun Gamal, community mental health consultant
Lynne Harris, branch services consultant
Glenn Thompson, executive director
Ontario Coalition of Senior Citizens' Organizations
Beatrice Levis, co-chair
Don Wackley, member of steering committee
Morris Jesion, executive director
Glaxo Wellcome Inc
Robert Last, regional business director
Paul Lucas, president and CEO
Ontario Medical Association
Dr Ian Warrack, president
Dr John Gray, chair
Dr Bill Orovan, honorary treasurer
Toronto Mayor's Committee on Aging
Lois Neely, chair
Isador Milton, chair, drug education committee
Ontario Public Service Employees Union
Warren Thomas, executive board member
Ontario Medical Association, Section on Diagnostic Imaging
Dr Phyllis Glanc, representative
Dr Arthur Zalev, university liaison to the executive of the section on diagnostic imaging
Michael Rachlis
Association of General Hospital Psychiatric Services
Jane Chamberlin, coordinator
Dr John Nkansah, president
Dr Bob Buckingham, past president
Ontario Physiotherapy Association
Signe Holstein, executive director
Resistance Against Psychiatry
Don Weitz, representative
Shalom Schachter
Council of Medical Imaging (Ontario)
Dr Desmond Walker, chair
Ontario Nursing Home Association
Dianne Anderson, president and chair
Shelly Jamieson, executive director
Toronto Conference of the United Church of Canada
Sheila Brown, representative
Bob McElhinney, representative
York Region Coalition for Social Justice
Sharon Matthews, co-chair
Patti Bell, member
Larry O'Connor, member
Michael Weinstock
STANDING COMMITTEE ON GENERAL GOVERNMENT
Chair / Président: Carroll, Jack (Chatham-Kent PC)
*Carroll, Jack (Chatham-Kent PC)
Danford, Harry (Hastings-Peterborough PC)
Kells, Morley (Etobicoke-Lakeshore PC)
Marchese, Rosario (Fort York ND)
Sergio, Mario (Yorkview L)
Stewart, R. Gary (Peterborough PC)
*In attendance / présents
Substitutions present / Membres remplaçants présents:
Baird, John R. (Nepean PC) for Mr Danford
Caplan, Elinore (Oriole L) for Mr Sergio
Churley, Marilyn (Riverdale ND) for Mr Marchese
Clement, Tony (Brampton South / -Sud PC) for Mr Kells
Ecker, Janet (Durham West / -Ouest PC) for Mr Stewart
Gilchrist, Steve (Scarborough East / -Est PC) for Mr Danford
Johns, Helen (Huron PC) for Mr Danford
Lankin, Frances (Beaches-Woodbine ND) for Mr Marchese
Also taking part / Autre participants et participantes:
Castrilli, Annamarie (Downsview L)
Curling, Alvin (Scarborough North / -Nord L)
Clerk / Greffière: Grannum, Tonia
Staff / Personnel:
Campbell, Elaine, research officer, Legislative Research Service
Drummond, Alison, research officer, Legislative Research Service
The committee met at 0903 in committee room 1.
SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION
Consideration of Bill 26, An Act to achieve Fiscal Savings and to promote Economic Prosperity through Public Sector Restructuring, Streamlining and Efficiency and to implement other aspects of the Government's Economic Agenda / Projet de loi 26, Loi visant à réaliser des économies budgétaires et à favoriser la prospérité économique par la restructuration, la rationalisation et l'efficience du secteur public et visant à mettre en oeuvre d'autres aspects du programme économique du gouvernement.
The Chair (Mr Jack Carroll): Good morning, folks. With respect for those who came on time, I think we'll get started. Just a couple of housekeeping items for the members of the committee: There's a package in front of you of submissions that were made. The spot at 7:30 on your schedule has been filled by a group with a long name: Church in Society Committee of the Toronto Conference of the United Church of Canada.
LAKESHORE AREA MULTI-SERVICE PROJECT
The Chair: Our first group this morning is from an organization called LAMP. Maybe you could all identify yourselves. Welcome to our committee. You have a half-hour to use as you see fit. Any time you allow for questions will be split evenly among the parties, beginning with the Liberals. The floor is yours.
Ms Maureen Boulter: The floor is mine. I'm Maureen Boulter, a board member; Dot Quiggan is a resident and a member of LAMP and also our program coordinator; Joe Leonard is our director.
Thank you for inviting us here. It was very short notice, but we were happy to hear that we could come.
We are from LAMP. LAMP is an acronym for the Lakeshore Area Multi-Service Project. It's a community health centre and more. I've just retired from teaching, which is why I'm able to come here now. I'm a long-time member of LAMP. I'm very, very concerned.
I'd like to comment first on this bill as a whole, not just as it pertains to this particular committee. As a board member of LAMP, I am responsible to the community of LAMP, to our clients, to our staff, to our volunteers, to see that LAMP's programs are carried out in the light of LAMP's philosophy. I'm also responsible to our funders -- the Ministry of Health, the Ministry of Community and Social Services, Metro Toronto and others -- for seeing that the public money is well spent. Every board member is aware of that responsibility.
We know this bill is going to affect LAMP in many ways, and it's going to affect the citizens of LAMP's catchment area, which is the southern part of Etobicoke. As a board member, I feel I should respond to this bill and give input on any part of it that matters to LAMP, but I am challenged by its very size and scope. We have started, but we can't possibly finish doing this job in the time we've been given. It's too big. Please break it down into digestible portions, separate the various aspects, make it possible for debate and understanding of the many proposals and of their possible consequences.
I referred to LAMP's philosophy. I'll read it to you, because it will give you an understanding of what LAMP is. It has eight parts:
(1) Everyone has the right to live in a healthy community.
(2) The community has the responsibility to address the needs of the individuals within the community and to provide the prerequisites for health.
(3) The community itself, through the interaction of individuals and groups, can best determine its own needs.
(4) The individual, LAMP and the community are partners, sharing the responsibility for meeting these needs.
(5) LAMP views the individual as a whole person in terms of cultural background and economic circumstances.
(6) LAMP recognizes each person in relation to their social and physical environment. We believe that promoting health involves improving the environment.
(7) The promotion of a healthy community includes (a) the provision of service; (b) education; (c) preventive measures; (d) client participation; (e) advocacy; and (f) community development.
(8) Some members of the community have greater needs and therefore require more of LAMP's services, advocacy and support. By empowering these members, the whole community is strengthened.
That's LAMP's philosophy. The words "community," "responsibility," "partners," "environment," "participation," "empowering," are key to what LAMP is about. I think they are key to what Ontario is about.
Our purpose is to make the Lakeshore a healthy community by contributing to the physical, emotional and social wellbeing of the people living here in our catchment area and by helping the Lakeshore community realize its opportunities and deal with its problems. Those purposes, statements of philosophy, imply involvement, participation, responsibility for the community and for oneself.
We believe this omnibus bill will undermine the health of the people of Ontario for the following reasons.
Firstly, it will lead to the undermining, the disempowerment, of people at the community level. For instance, it will give the cabinet and the Minister of Health more power over doctors and over hospitals that are currently run by community boards. The board members know their community. They have input from the community, from the doctors, from the nurses, from other health care professionals, from the patients, from the public -- a wide pool of knowledge and opinion to bring to discussion and debate. The board is accountable to the community.
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The power this bill proposes to give to the Minister of Health undermines that process. Boards will not be able to make decisions and be confident of carrying them out. The participation of the community will be at the pleasure of the minister. They will have no opportunity to participate in real decision-making. We believe that participation is critical to health, that powerlessness leads to dependency and is unhealthy.
Secondly, one of the determinants of health is income. That sounds like a tautology, but it has actually been proven, there have been studies made to show that an adequate income is an important part of being healthy. We believe this bill will stratify our society. It will separate people by their ability to pay.
The possibility of user fees for any and all municipal services, for libraries, for parks, is going to be a particular blow to families with restricted incomes, to people with restricted incomes.
The imposition of prescription fees and the payment of the dispensing fee for prescriptions will make many who are on a borderline budget think twice, maybe even forego their doctor's advice, their doctor's treatment. Also, we believe deregulation of drug prices will lead inevitably to higher costs to patients and to the government.
The changes in the pay equity laws will leave behind a permanent underclass of workers, largely women, who are in job ghettos: child care, nursing, nursing homes, things like that. They were not organized enough to take fast advantage of the equity laws when they were first in, like teachers and many professional women; they had the organization ready, they had the knowledge, they had the power and they got it. For many women, pay equity is no longer an issue, but for many, many women the lack of it is going to condemn them to working poverty.
Thirdly, we feel -- and we feel this is important -- that this bill is going to lead to a loss of public confidence. Things are going to happen, suddenly things are going to be decreed, and nobody has said why, how, what: There it is.
At present, we are governed by legislation. Legislation comes after debate by elected representatives who get input from their constituents. There are regulations. They're formed after much input and debate among various levels of government. Now this bill is going to give cabinet and ministers unqualified power -- unqualified power -- to decree changes without the checks and balances of input. There's going to be no accountability. That too will disempower people. It will discourage people. It will undermine public confidence.
I feel that although I've put this item last, that is one of the most important things, because in a democracy the people must believe in their government. They must believe that they can go to somebody and say something and be heard and that that will then be translated into action. I think we're short-circuiting all of that, so we ask that you reconsider giving ministers such sweeping powers.
Lastly, I want to say that we know this is a powerful government, but if the ministers are to be given such powers, we ask that at least there be a sunset clause, in other words, that these powers be given for a limited time. Presumably, Premier Harris feels that he has enough wise ministers that they will make only good decisions, that they will only be thinking of the public good, the public interest, and that they will not abuse their power. But consider: That can change. There might be in the future a Premier who has no wise ministers. Worse, opportunistic people might run for office simply because they are tempted by and covet that power.
I said at the beginning that this came to us very late. We sat and looked at a daunting pile of paper. I know that in it there are many, many items that I could pick out and apply to those three points that concern us most or that we felt concerned us most: the disempowerment of people, the stratification of society and the disenchantment of people with government. We would beg you to reconsider the size of this bill and many items in it.
The Chair: Thank you very much. Are you available for some questions now? Okay, we have about five minutes per group, so we'll begin with the official opposition.
Mrs Elinor Caplan (Oriole): First of all, I share your concerns, as you know, and I'm really pleased to see you again. I'm glad that you're here today. I think your request to split the bill is a very important one and I do hope that the ministry will listen to you.
Were you or anyone in the community health centre movement consulted by the government or informed as to the changes that were being proposed in this bill?
Mr Joe Leonard: No, we weren't.
Mrs Caplan: If they had consulted you, and I know that you have been consulted in the past by previous governments, both you and the CHC umbrella organizations, would you have told them pretty much what you said today and perhaps made suggestions on changes that might have assisted them to achieve their goals, but in a way that would not have been as negative?
Ms Boulter: I think this would have come to the board. There would have been a lot of discussion. We have a very capable board, various professional people and people from the community in general, and I think they would have had a lot of input, a lot of grave concerns, had we seen these intentions in time.
Mrs Caplan: I also share your concerns about the powers of the minister, and you referred to the determinants of health and the need to have information and to be able to participate. We also know that the agenda of the government is a massive tax cut. It's been described as $5 billion in value and would be $5,000 for every $100,000 of income. That's the magnitude of the tax cut. I believe, and many believe, that's what's driving this agenda to cut health services.
I wondered if you wanted to comment on that, because we know that when it comes to the health of the population, people need the basics of life.
Mr Leonard: One of the concerns we have is that we specialize -- or not specialize -- we are open to people who need us most, as when Maureen read the philosophy; a lot of those folks are having a struggle and in our community we lost a lot of jobs. Goodyear was there, Anaconda Steel. We lost, in the last 10 years, 6,000 jobs, so we feel the pinch of the restructuring of society very much in our community. There are a lot of people for whom additional costs, whether it's for drugs or for using parks and rec services, are going to be hard.
It seems ironical that the people in the middle of Etobicoke, who are able to provide their own recreation, are going to get a tax break and the people who are unemployed or people of my age -- they call people my age older adults now, and that means it's very hard to find a job if you have worked 20 or 30 years in Goodyear, and then where do you go? People with that kind of contribution to society for many decades all of a sudden seem to be having a hard go of it -- not seem to be; they are, many of them. Some of them have landed on their feet but many are having a hard go.
Our concern is that if we want to build a healthy community, it means that everybody in the community should have a chance to share in a full life. That's our concern, that some people may be punished by some of these regulations.
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Mrs Caplan: You've said that the powers should be time-limited. Yesterday the minister announced that he would sunset the commission that he's going to set up, but that would still leave the minister and future ministers those powers. Many of you have been around for quite some time. Are you aware of ministers ever giving up any powers once they had accumulated them?
Mr Leonard: Not in my memory.
Ms Boulter: Probably not willingly.
Mrs Caplan: I don't believe all of those powers are necessary and I'm wondering if your board has taken a look specifically at the powers of the minister, just those, to determine from your perspective what might be necessary and what is absolutely unnecessary. And if you do have that opportunity, would you be willing to communicate in writing to this committee your views on what powers no minister should have now or in the future?
Ms Boulter: We'd be happy to respond more fully in writing because, as I say, this invitation to come here came to LAMP yesterday at 2:15.
Mrs Caplan: Oh, heavens.
Ms Boulter: I heard about it at 3:30 and at 4 o'clock we managed to get together with one other staff person and go through and say, "What can we say?"
Mrs Caplan: Well, you've done an outstanding job in such a short time.
The Chair: Let me assure you that if you do respond and give us some more information in writing, we'd be only too happy to read it.
Ms Frances Lankin (Beaches-Woodbine): I think your last comments just underscore the problem many people are having with respect to the government's actions on this bill: This is too far and too fast and it is very difficult for people to get a hold of, number one; to have the time to go through and understand the implications and/or consult their membership about the implications; to form an opinion and be able to come forward and give informed advice with respect to the bill. This is not the way democracy should work.
Groups after groups have come forward here and have answered Ms Caplan's or my questions about consultations and have said no, that they weren't consulted. Group after group has said that there are major problems with the bill and many of the groups have indicated a problem with not having had the time or the notification to be prepared. There are others, like yourselves, who have suggested that this should just stop and the bills need to be split and we need to have the time to understand them and to work through them; not to delay the government's agenda or the process, but quite frankly to give an opportunity for some democratic input, for some informed debate and input.
I think, as we proceed over the course of these few weeks, there will be a growing cry to continue to try to pressure this government to listen to what people are saying, that there hasn't been the time for appropriate input and that these bills should be split and should be dealt with in an appropriate manner.
I appreciate your comments, particularly with respect to the issues of determinants of health. Without going into the specifics of the bill and the provisions, the overall impact of this bill, as it ties to the government's economic statement, surely is one that sets us back a long way in this province with respect to progress that was being made on the determinants of health. We will pay for that in the long run in the health care system, in the health status of our public and quite frankly in the fiscal pressures on the government in order to finance the results of that.
I know that you haven't had a chance to go through the bill in detail, but I assure you it takes huge areas of new powers on to the government, and we can see today, if you take a look at the Globe and Mail, justification for that. The minister has been backed against the wall about some of these powers, so now he's lashing out and scapegoating doctors as an occupational group. This government tends to create crises and scapegoat groups of people when it wants to bully its way through. Today's target is the doctors.
All of a sudden we hear about huge problems of OHIP fraud and doctors' fraud, whereas just yesterday the Minister of Health sat here in this room and, contrary to what he used to attack me about when I was Minister of Health, that there was $750 million in fraud, he used the numbers that I used to tell him, which was that it was only $65 million when he was trying to justify himself to this committee.
I think that your concerns overall are more than appropriate. I appreciate your having come here. I worry about the fact that you haven't had the necessary time to do an analysis and to provide us with the impact for your community and your constituency.
I want to raise one last thing. You will have gone through the process of consideration of multiservice agencies in the long-term care and you will have heard the now Health minister, when he was Health critic, refer to that whole process as a bureaucratization of health care services. I can think of no further bureaucratization than what we're seeing in this bill in terms of the gathering of powers and, quite frankly, an attack on voluntarism, when we see what will be happening with hospital boards and the undermining of the role of hospital boards.
The bill does allow for the minister to take over the running of a hospital and supersede hospital boards. Have you had any chance to look at that section, and do you have any concerns of what that might mean down the road with respect to community agencies that are run with volunteer boards, like community health centres and long-term care community agencies?
Ms Boulter: I think that community health centres are going to be targeted. If they can do that to hospitals they can do it to us. Also, of course, we are very vulnerable anyway, because one of our major funders is the Ministry of Health.
I think the minister should remember that LAMP and organizations like it, hospital boards, are run by volunteers. It is unpaid labour. It is a labour of love, usually. You can't buy that sort of input.
We don't just empower the community; we enrich the community. Every dollar that we get in is matched by volunteer hours.
The Chair: Thank you. Next for the government.
Mrs Janet Ecker (Durham West): I'd just like to thank you very much for coming in and for some very helpful comments. I don't know you personally but I certainly know of your organization by reputation within the community health field.
I would like to start off by saying that one of the objectives of the restructuring of the health system exercise that we are undertaking as a government is to stop scapegoating particular segments within the health care field. We think that's not appropriate, and I will not long forget the damage when one of the previous ministers of Health, Mrs Grier, on the front page of the Globe and Mail accused physicians of not caring about fraud and abuse and couldn't be trusted to handle the problem.
I don't think any government is lily white when it comes to scapegoating any particular groups, and that's one of the reasons why we want to restructure the system: to focus resources where they are most needed; for example, in community-based care, which is something that I think the last three governments in the last 15 years have wrestled with. It's something that I think everyone has acknowledged, that community-based care, as you have described, is more appropriate.
I guess what I'd like to hear from you is that despite 15 years of government saying that we want to shift the base from hospitals, from expensive acute care out into the community centres, has it happened? Is it happening to your satisfaction?
Mr Leonard: It's kind of like we make progress and it seems to stall, and that's because it's a real challenge to change people's thinking. I think that when you're restructuring the health system, what you're really doing is almost weaning people away from a way of looking at care into a different way. It takes a leap of faith to leave all the technology and say, "If we did more prevention, we would need much less technology."u
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But right now, we're almost addicted to the technology and to the high-priced cure. It takes a lot of government will, it takes a lot of selling to the community at large because people generally love technology. It's not only the physicians, it's also people who love it because it gives the instant cure. So when you try to restructure the health system, you also have to restructure -- that's an awful strong word -- but you have to have people begin to think in a new way.
There are a lot of reasons why restructuring is difficult, but perhaps the most difficult is having the population understand that if we prevent things and we strengthen communities and we build healthy places and safe places and good schools and good workplaces, we're going to have a much healthier environment. Truly, technology can do wonderful things.
Mrs Ecker: Yes, and I guess the concern is that after three governments trying and 15 years, we still haven't managed to do it. So I would submit that perhaps we may need a little bit more authority in government to try and get some of those resources from hospitals, which are very powerful, from some of the groups, and to try and shift that to the community-based centres. I think obviously that is something that takes some work to do.
The other question I'd like to ask is, what are your comments on misuse, fraud and abuse within the health system? Is this something that you have seen as a problem or something that has occurred in your experience?
Mr Leonard: Our physicians are salaried. We operate in a different environment entirely. I'm sure that there are some physicians that may abuse the system, but we don't run across it that much in our experience. We've referred a lot of physicians, but we have good relationships with referrals we made. We don't run across it in my experience. Now, I haven't asked our physicians directly that question; it hasn't come to my attention at least as a large problem.
The Chair: Thank you very much. We appreciate your interest in coming here today and your presentation.
Mrs Caplan: On a point of order, Mr Chair: I would like to ask Janet Ecker if she would retract her statements about previous governments. I think it is important on the record that members tell the truth. Never did I ever scapegoat doctors or ever take them on in a way which this Minister of Health has done, and I think she owes me an apology. I think the OMA will substantiate what I have just said, and if this committee is going to be civil, I have to insist that my integrity is not impugned or called into question.
The Chair: I don't think that's a point of order.
Mrs Caplan: I'm asking for an apology.
The Chair: I don't think --
Mrs Caplan: Would you allow the member to apologize?
The Chair: Voluntarily if you choose to; it's not a point of order, so you're not obligated.
Mrs Ecker: I certainly was not trying to say anything which would impugn the integrity of previous Health ministers, but what I do believe is that previous governments and previous ministers have tried to make comments and divide up the health care sector. The one specific incident I referred to was not you, Mrs Caplan, and I was specific about that. I think that this is one of the reasons that we got to move on from there and not do that because I think we've got to keep everybody together in the system to go ahead.
Interjection.
The Chair: No, that's the end of the conversation.
Mrs Ecker: Our minister wasn't scapegoating doctors either.
Ms Lankin: Please, take a look at this article today.
Mrs Caplan: That's exactly right. Just listen.
Ms Lankin: Take a look at what he has done with doctors today. If that's not scapegoating, I don't know what it is.
Mrs Caplan: Talk about poisoning the well. It's exactly what I said yesterday and that's exactly what he's done.
The Chair: Let's just keep our composure, shall we?
Mrs Caplan: Just keep it up.
ASSOCIATION OF DISTRICT HEALTH COUNCILS OF ONTARIO
The Chair: The next group is the Association of District Health Councils of Ontario, represented by Susan Brown, who's the chair, and Gord Gunning, who's executive director. Good morning and welcome to our committee. We appreciate you being here. You have a half an hour to use as you see fit. Any questioning time that you leave would begin with the New Democratic Party. The floor is yours.
Ms Susan Brown: Good morning and thank you for the opportunity to come and speak to you on Bill 26. My name is Susan Brown. I'm the chair of the Association of District Health Councils of Ontario. To my right is Gordon Gunning, who's the executive director of our association.
This morning we have a brief, which I believe is being distributed, and we'll speak to some of the high points in that for, we think, about 20 minutes, and then we would appreciate a dialogue.
District health councils have been an integral part of the health care system in Ontario for the past 20 years and they have been well supported by Health ministers and the Ministry of Health over that period of time. The present Minister of Health has called us the "eyes, ears and conscience of the local community." District health councils provide advice to the minister and the ministry on local health planning, and presently, over the past three or four years, we've been looking at health service restructuring and some integration of the health care system on the local level.
Currently, the 33 district health councils of Ontario cover 100% of the province's population, with over 8,000 volunteers who provide more than one million hours of service to their communities and, therefore, to the province. We act as agents for local change.
The Ministry of Health sets the policy and benchmarks, or standards of practice, and funds the health care system in Ontario. District health councils co-ordinate planning and provide a link between the government and communities. Communities have diverse, unique needs and priorities, not only in health care but in all of the services that they provide to their constituents.
The bulk of our conversation with you this morning will be related to the health services restructuring portion of Bill 26. We believe that there is a critical link between local health planning and implementation of that planning that needs to have some such commission as the Health Services Restructuring Commission that's proposed. We have some suggestions around that, and we have some concerns.
Implementation decisions are based on informed local planning information, and there have been a number of restructuring or rebalancing exercises in district health council planning regions throughout the province and they have been going on, as I said, for about four years. Windsor is probably the most recognizable to everyone.
Local planning is essential because it provides relevant information and needs assessment and local public involvement in affecting the outcomes of health care allocation dollars for the community. Local planning can be a facilitator and integrator role to affect system change in a local community. When you bring that together, it affects system change on a provincial basis.
Local planning focuses on achieving cost savings, reducing waste and inefficiency and duplication of operations; developing comprehensive, integrated and seamless health care delivery systems that are sustainable and responsive and relevant to community health needs; achieving better governance of systems and services; some linking of expenditures to outcomes; facilitating the equity of access of citizens to the health care system; monitoring and evaluation of the planning process and outcomes of that process; timely and accurate data and evidence-based best practices demonstrating effective outcomes.
Certainly the DHC system has been able to compile evidence-based best practices on hospital restructuring or health system rebalancing in the last four years. Local planning really focuses on the right service at the right place at the right time. That can be extrapolated to a provincial context.
The Health Services Restructuring Commission will implement hospital restructuring plans within an integrated system framework. Duties of the commission may be limited or specified by the Lieutenant Governor to specific commissioners and/or geographic regions, as stated in the bill.
Recommendations of ADHCO are to clarify the roles and responsibilities of both the commission and district health councils in order to ensure that planning and implementation of integrated health delivery systems are carried out smoothly and effectively.
Decisions of the commission should be based primarily on planning and analysis that has been conducted at a local level by a DHC so that community health needs are addressed through an approach to developing an integrated health delivery system.
Implementation of hospital restructuring must ensure that community health needs are met through alternatives in areas where hospital services have been downsized or perhaps eliminated.
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The establishment of the ministry's data warehouse and health intelligence units will enhance the ability of districts to plan for the health needs of their communities. Local hard, accurate, concrete data can only enhance the local planning function of the DHC.
District health councils require enhanced hardware and software to use this health status information to ensure that decision-making is informed.
District health councils require ministry support to advance the outcome-based planning approach as developed by the Metro Toronto DHC Needs/Impact Based Planning Committee.
A close relationship between district health councils and the commission is critical to advancing implementation of hospital restructuring.
The commission should be established to serve local restructuring implementation committees. Many DHCs have achieved a high level of support for restructuring recommendations in their communities, including all key stakeholders: hospitals, the medical society and labour. Although it may seem that this isn't a common occurrence and certainly we have examples of it in the DHC system but we can't say that it's uniform across the system, that kind of community support has been built by hours and hours of consultation with each other and negotiation, working towards achieving a broader vision than a particular perspective of one health care provider.
The commission should respond to requests for assistance from DHC implementation committees in districts where hospital restructuring is under way. Over the past four years, the district health council system has asked for and has received from other governments support in assisting their communities in health system rebalancing.
The commission should maintain ongoing liaison and consultation with the district health councils, which must educate local citizens on the need for change and tradeoffs required in restructuring the system. It would be impossible and not good planning to maintain the status quo.
The commission should maintain a status brief on implementation activities from information provided by the different DHC implementation committees. It's sort of like an environmental scanning so the commission is aware of the status of different restructuring projects, their pace and their expected conclusion throughout the province.
The commission is seen as a roadblock buster to bring to the attention of the minister changes to regulation, policy, and bureaucratic red tape that are necessary to advance implementation. One of the difficulties for some communities has been that when they come to a resolution as a community to make some changes in their health service delivery systems they are unable to proceed because there need to be policy decisions made at the provincial level or perhaps regulations in order to be able to enact some of the changes locally. And when these communities get behind these changes, it's important to support them.
The commission could act as a repository or a collator of such issues identified by local implementation committees; to analyse common trends that impede implementation of restructuring activities. As I said earlier in this brief, lessons learned from DHCs as they walk through hospital restructuring with really a blank roadmap has been that we've been able to fill in some of the topography, and we've, as a system, been able to identify some of the pitfalls and some of the bonuses for our colleagues as they undertake these processes.
The structure and composition of the health restructuring commission is of great interest to the district health council system. We strongly believe that there should be the inclusion of appointments from local health planning bodies that would bring a perspective and understanding of local planning to implementation decisions. DHCs' planning expertise can also assist the commission's operations through provision of local resources or secondment as commission staff. There is a core, a culture of knowledge out there in communities about how we have learned, in some ways the hard way, to best go through this process. And we would very much respectfully ask the government to consider that there should be at least 25% representation on this commission of both DHC volunteers and staff.
A regional mechanism should exist within the commission to interface directly with the local DHCs to facilitate implementation of hospital restructuring plans. There needs to be an excellent communication link so that communities don't feel they've been shortchanged or that they're being micro-managed and all of the work they have done has gone for naught and there's some faceless provincial commission taking over their community.
As we have said before, the commission's structure should be based on the clearly defined roles and responsibilities of the commission and district health councils.
We believe that we need a required policy for effective implementation of health system restructuring. We need cost savings -- of course, we need cost savings. We also need reinvestment. The ministry policy should provide a formula for reinvestment in the larger community of cost savings achieved through restructuring.
Funding methods should contain new models for health care facilities and physicians that provide incentives to improve utilization management.
Benchmarks: Those of you who have seen DHC restructuring studies will recognize that we have asked repeatedly for clear and aggressive planning benchmarks for health services restructuring. You need to have anchors to pin your planning on, and we need to have that support from the government.
There is a caution that the relationship between local planning and implementation of local plans is critical to the success of hospital restructuring implementation. Without clear directions, roles and responsibilities, confusion and public dissatisfaction could arise.
With regard to the amendments to the Public Hospitals Act, I'm sure that you have heard and will hear a lot of comments around this. We are not going to make too many statements. However, having been involved, as I said, with hospital restructuring in different communities in the province for the past four years, it is sometimes necessary to have an impetus to take the process just a little bit farther. We believe that an amendment to the Public Hospitals Act would provide a lever for change that may be necessary in some communities. Our caution would be that it be used appropriately.
We believe strongly in voluntary governance for hospital boards. It provides a mechanism for critical community input into decisions that affect local health care and should be respected in the decision-making process.
Human resources is an area that will require a lot of support and consideration as we move through these processes over the next few years. Hospital physician human resource plans are a key piece to health human resource planning in an integrated health care system. DHCs can provide assistance, in association with the Provincial Coordinating Committee on Community and Academic Health Science Centre Relations, PCCCAR, in localizing data and advising on the numbers and mix of doctors required at a local level.
We believe that decisions on the operation of private hospitals should be based primarily on analysis of local health needs that are provided by local district health councils.
Universal access to the best possible primary care, treatment and medical technology is highly valued by all Ontario residents, and we should continue within the government's fiscal framework. This is only possible if provincial standards on the numbers and types of health services and facilities are established within the context of ensuring universal access to high-quality care.
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Amendments to the Independent Health Facilities Act: Licensing, funding and quality assurance of non-hospital health facilities that provide selected varieties of diagnostic and treatment services should be assessed within a context for developing integrated health delivery systems based on community health needs.
Evidence-based planning of local health needs should be the justification for establishment of new services and facilities. Planning data available at the community level through DHCs should be accessed by the minister to ensure informed decision-making.
Brokerage at the local level, through local or district DHCs, may be required to ensure the forging of effective links between hospitals and community agencies by adding to the variety of services provided by independent facilities.
Provincial standards on the numbers and types of health services and facilities should be established within the context of universal access to high-quality health care. Market forces should not determine the number and types of services available. Quality of care is too important and must be preserved.
Amendments to the Physicians Services Delivery Management Act: There is an impact to the discontinuation of the physician malpractice premium supplement. We have already seen and heard some of it in the press.
The financial disincentives add to the considerable pressure family practice physicians in underserviced areas already experience in obstetrical services. Women in small communities will have to travel hundreds of kilometres, especially women who have high-risk pregnancies. Similar impacts may be expected with general practitioner anaesthetists and general practitioners providing emergency medicine.
To ensure that remote, rural and northern communities have access to primary physician care, the ministry should continue to reimburse physician insurance in underserviced areas where the lower and fluctuating volume of cases makes for an extremely sensitive break-even point between the payments received for practising obstetrics and the involved insurance costs.
In summary, then, the district health council system generally supports the government's method for implementing hospital restructuring. District health councils are willing and able to provide input and support to help maximize the value of the Health Services Restructuring Commission.
The critical link between local planning and implementation must be maintained. Local planning makes a significant contribution to achieving cost savings across Ontario. Local planning has an ongoing and essential role in developing integrated health delivery systems.
Legislation and regulation need to be codeveloped with the system around the roles and responsibilities of the commission, the structure and composition of the commission, and policy and benchmarks that will be relevant for the commission.
As we said, we believe that health services can be delivered maintaining the high quality we've come to know and appreciate in our province, by providing the right service at the right place at the right time.
The Chair: Thank you. We've got about three minutes per party for questions. Ms Lankin.
Ms Lankin: Thank you very much, Susan, for your presentation. It's a pleasure to see both of you and to hear from your association. Certainly I think there's no group that better reflects the change of understanding of what's needed in the health care system, in terms of reform, in terms of health-planning-based reform, than your association and what you have learned over the last number of years and how you have grown and taken responsibilities on in your communities.
I'm concerned that this bill doesn't build a linkage between your organizations in the regions and the work they've been doing in local restructuring, both hospital restructuring and health system restructuring plans, and this commission. Were you consulted about the formulation of the bill with respect to the establishment of this commission and what relationship there should be to the DHCs?
Ms Brown: I've done all the talking, so I'm going to give Gord an opportunity.
Mr Gord Gunning: We had an opportunity to present a brief to the minister, on November 2, so in that consultative process we did talk about our thoughts on vertical and horizontal integration and on hospital restructuring and what the next steps ought to be from the district health council perspective.
Ms Lankin: Did he discuss what he was planning in the legislation and this commission and your relationship with it?
Mr Gunning: Not to my recollection. It was too early in the process.
Ms Lankin: I'm going to try and be short, because I've only got a couple of minutes left. I personally believe that we should see the powers or the obligations or the expectations, the outcomes, wanted for this commission set out in the legislation, and its relationship to the DHCs. Is that a set of amendments that you would support?
Ms Brown: We clearly are asking for a clarification of role and responsibilities of the DHCs and the commission locally, and hoping for some support at the provincial level.
Ms Lankin: On the issue of voluntary governance, I take your cautions all the way through here about micro-management, about bureaucratization, about respect for voluntary governance. I understand that if there are roadblocks, you want to see the legislation and the minister be able to get through the roadblocks. My concern -- for example, in your reference to the supervisor's powers and running of hospitals etc, I was wondering if you had a couple of experiences with the existing legislation. There's never been a stated problem of what it is you might want to do that you couldn't do through the existing legislation and powers of the supervisor. The minister yesterday couldn't answer my question, why was he going to step in and take over the absolute, full job and powers of a voluntary board in these extraordinary circumstances when we haven't used the existing legislation that's there? He couldn't answer it.
From my knowledge of the Ministry of Health, my fear is that all of the desires and wishes of making it easier for the bureaucracy to step in and micro-manage are brought true in this legislation. Why do you choose to be supportive of that increased power of supervisor control of boards when in fact the existing powers are fairly far-reaching and we've never had a circumstance where the existing powers fell short of what was needed to be accomplished?
The Chair: We'll need a short answer on this; it was a rather long question.
Ms Lankin: I'm sorry, Mr Chair.
Ms Brown: I'm not sure there is a short answer to that question. It has been the DHC experience over the past four years that some of the roadblocks that have been put up have created difficulties within communities in terms of progress. I believe our caution is that it would useful to have this lever. We hope it wouldn't be necessary to use it.
The Chair: Thank you very much. For the government, Mrs Johns.
Mrs Helen Johns (Huron): Thank you for coming again today. I would like to comment on how much work the district health councils have done and how imperative they are to restructuring. I would like you to comment a little, if you can, about the Metropolitan Toronto District Health Council study and their focus on needing the minister to have more power to be able to implement or facilitate hospital restructuring. I would like to know why they recommended that. I'm wondering if it's because of past experience in the implementation process that's gone on.
Ms Brown: I can't speak for the Metro Toronto DHC but, having been a veteran of three restructuring exercises in different parts of the province, I would imagine that with the scope and magnitude of the Metro study, with the recommendations they have put forward, they need to have a greater amount of support for the implementation of their study. Also, I believe that the impact of the human resources reconfiguration of the Metro study will need to have a wide view at a provincial table. The challenges for implementation in a small, two-hospital-restructuring community are immense and time-consuming, so therefore I believe that with 44 hospitals and a recommendation of closure or role change for at least 12 of them, the Metro DHC is seeking the assistance of the province in moving forward in that study, as well as preserving some of the regional and provincial perspectives of the institutions that are located in Toronto.
Mrs Caplan: Thank you very much. Two things: First of all, I'm disappointed to hear that after making representation to the minister he didn't share with you for further comment what his actual proposals will be. That seems to be a consistent and unfortunate pattern.
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But the point I'm concerned about as well is the minister's plans for the district health councils. Both in the Legislature and in committee he's referred to the mandate reverting to that as was the original mandate of the district health councils when they were originally established, that simply being of advisory and advocacy and not having any meaningful role.
As you know, the role of the district health council has been significantly enhanced over the years, and while it is still advisory to the minister -- the minister makes ultimate decisions -- the district health council has had responsibility for resource allocation and is an important part of the process in the determination of independent health facilities, for example.
What I want to know is whether you are concerned that your role will be diminished as a result of Bill 26 and that the new commission that is going to be established and the new powers of the Independent Health Facilities Act and all of that will limit local community participation through district health councils if the minister follows through on his threat to dismantle the district health council role.
Ms Brown: We have, I think, as a system always loudly and clearly put forward our bias for being local advocates for the community health system in which the districts are situated, and I've had the pleasure of working with both of you, Mrs Caplan and Ms Lankin, as Health minister. You have heard our strident requests for support and clarification of the DHC role in a local community. We have had very positive meetings with the minister to date, and although we weren't directly consulted, we felt we did have some idea that there was some support for some of the larger problems we were bringing to him around health system restructuring. We will be clearly talking about the need and the continuation of the mandate of district health councils as the local health planning body in communities.
Mrs Caplan: So why do you think he's publicly saying that you're going to revert to the original mandate?
The Chair: Your time is up, Mrs Caplan.
Thank you very much, folks. We appreciate your interest in our process and your presentation this morning.
CANADIAN MENTAL HEALTH ASSOCIATION ONTARIO DIVISION
The Chair: The next presenters are the Canadian Mental Health Association, represented by John Kelly, the president; Glenn Thompson, the executive director; Lynne Harris, the branch services consultant; and Mamoun Gamal, community mental health consultant.
Good morning and welcome to our committee. You have half an hour to use as you see fit. Questions will begin with the government within your time allotted. So the floor is yours.
Mr John Kelly: Thank you for the opportunity to be here this morning. I'd like to introduce the other members of the panel. We have our executive director, Mr Glenn Thompson, with us here this morning, and two of our community mental health consultants, Lynne Harris and Mamoun Gamal.
Mr Chair and members of the committee, as president of the Canadian Mental Health Association, Ontario division, I am pleased that you have provided an opportunity for me and other members to make a presentation to you concerning Bill 26.
The Canadian Mental Health Association, Ontario division, CMHA, is an incorporated, registered, non-profitable charitable organization chartered in 1952. Approximately 4,000 volunteers are active in direct board and committee service in a network of 36 branches located in communities across Ontario. CMHA, Ontario division, and branch services and programs are funded from government grants, local United Ways and supplementary fund-raising activities.
Since our founding, CMHA, Ontario division, has made significant contributions to the development of mental health policy in Ontario. As committee members would expect, we have been very actively involved in examining the potential impact of the fiscal and economic statements delivered by the Treasurer recently. In addition, of course, we have been examining Bill 26 as the implementation device for many aspects of the fiscal and economic agenda of the government.
CMHA has in each of our pre-budget submissions over several years recommended that a central target for government be deficit reduction. It is our view that major transformational change is required in the health care system, especially in that part of the system in which we have most experience, the mental health sector.
As a result of our budget analyses, we have prepared several significant responses on the budget, and began our submissions of those documents to the individual ministers last week. Others of the documents will be completed in the next day or two, and we would be pleased to provide a package of them to each of the committee members.
It seems evident to us that it is vital to understand the budget and its impact in order to understand what type of implementation powers may be required to achieve those goals in a thoughtful and consultative fashion. We also believe it is important for the committee and for the government to have a conceptual framework within which to examine the various impacts of the budget and of Bill 26.
We believe the New Framework for Support mental health document prepared by our CMHA national organization provides that frame of reference. We have circulated a copy of that document to you and would be pleased to provide the committee with the publication concerning the framework, which has been widely circulated and is in active use in other parts of the world. The framework as a model will ensure decisions which facilitate the integration and coordination and do much-needed work to improve mental health care.
We encourage you to ensure that Bill 26 includes provision which provides authority and the impetus for positive change in the system for mental health care in Ontario.
The CMHA policy paper A New Framework for Support in Ontario notes that to live a fulfilling life in their community, persons with a psychiatric disability need more than the formal mental health services provided by hospitals, community agencies and private practice. They need to have at least the same opportunities to access basic socioeconomic support as other Canadian citizens; namely, jobs or other productive activities, good housing, appropriate education and adequate income.
Dr Fraser Mustard and others have argued that traditional health care can contribute 25% to a sense of wellbeing for the average citizen, while 50% of our sense of wellness tends to come from socioeconomic conditions. The prospect of job loss, with the potential of no longer being able to afford decent housing, adequate food and other necessities and reasonable educational and recreational opportunities for oneself and one's children, is a frightening prospect for most people. For someone with a serious mental illness, the situation is especially daunting. Not only can their illness separate them from the basic socioeconomic necessities, such as the ability to work or ability to maintain a home, but the lack of those necessities in their lives has a direct and damaging impact on their mental health, and thus prospect for recovery.
The New Framework for Support community resource base demonstrates the ideal range of resources that should be available to a person with serious mental health problems if they are to live a fulfilling life within the community. The basic socioeconomic conditions of income, housing, work and education make up the foundation of this model. If people with serious mental illness do not have access to these fundamental supports, their ability to benefit from other services available to them is severely diminished.
Now to Bill 26.
Ministerial power and authority is not new. The powers available to ministers at present will be very familiar to the former ministers who are present today. To ensure that any service system is efficient, effective decisions must be taken. As chair of our CMHA board, I am very much aware of our own organization and its need to change, decide and move on.
It is the process required and utilized in the exercise of those powers which we believe the committee members should carefully consider as they review Bill 26. A full public review of the opinions of all stakeholders in the public should be a part of any major restructuring process. In the case of health care changes, we foresee that review and consultation happening most often under the aegis of the appropriate district health council, which will then recommend to government. In especially significant changes requiring legislative changes or regulatory amendment, the appropriate legislative committee in the House should have opportunity for debate.
There is a tremendous urgency for change in the mental health field. We are not using our human and fiscal resources, not to mention the social capital of our communities, to the best advantage. Simply put, we are not doing our best to meet the needs of mentally disordered persons, their families and key support persons.
There is an excellent strategic plan for change in the mental health sector in the Putting People First document approved by the previous government and developed through a long, thoughtful process by each of our three political parties over several years.
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We encourage you as legislators to ensure that Bill 26, at the end of the day, is designed to achieve the reconcilable goals of constraint and improved services. Since the Health ministry is to retain the same budget over the next several years, the challenge will be to shift resources to the highest priority needs. Defining those priorities must be the result of a full public discussion. However, at the end of the day it is the government's responsibility to consider all of that advice, including that of an excellent public service, and then to decide to say: "Good enough. Push on." We leave our health services consumers at risk if we do not. After all, they are our reason for having a health care system.
It is well known that systems, including health systems, as they grow develop powerful entities within. We need strong leadership within the various elements within the system. At the same time, there must be mechanisms to balance those strengths to ensure a consumer focus. It is a crucial time in Ontario, and indeed in Canada, for decisive behaviour on the part of government. The state of our federation and of our economy demands it.
Mr Mamoun Gamal: Mr Chair, members of the committee, my name is Mamoun Gamal and I am a community mental health consultant with the Canadian Mental Health Association, Ontario division. My response here is about the hospital budget cuts and their impacts on the community mental health system.
The mental health system in Ontario is characterized as underfunded, unplanned, poorly coordinated, geographically uneven and heavily weighted towards provincial hospitals and psychiatric units as opposed to community services. There's a statement by Professor Harvey Simmons.
We are concerned that hospitals will concentrate more and more on core services as a strategy to streamline their spending. This approach could impact negatively on traditionally marginalized mental health units by exposing them to severe bed cuts and/or closures.
We strongly advocate that these cuts not be carried out based on absolute short-term monetary and economic gains, but rather on the long-term gains from investment in health services, especially community mental health services. These cuts must be linked to an integrated system approach, an approach which carefully studies the impacts and the potential risk involved in cutting funds from different entities of the health care system, especially psychiatric units in general hospitals, without taking into consideration the effects of these cuts.
It is worth emphasizing that the current climate of economic frugality and austerity is the very climate which produces exponential demands on community mental health services. Socioeconomic factors such as poverty and work-related stresses have been identified as major contributors to the emotional wellbeing of individuals. We are extremely concerned that as cuts occur within the hospital sector, far greater numbers of people will be seeking assistance from community services. Of course, we could always resort to the usage of volunteers, and we are actually encouraged by the government emphasis on the usage of volunteers. The volunteer corps would not only offer needed assistance to the community mental health services, but would also prove to have a very important role to play in getting the word out about the facts of mental health, thereby bringing awareness and education to their own networks and communities.
However, we also believe that effective management of volunteers needs the resources. To effectively manage volunteers, organizations need to train the volunteers about the services, thereby ensuring that the services which are offered to the community or to the clients are based on an effective and efficient manner.
With regard to the hospital restructuring commission, we advocate that the commission engage in a full but expeditious consultation that seeks the input of the stakeholders, including consumers, family members and workers in the health care system.
We believe that hospital budget cuts will not be economically sound without an integrated systems approach which takes into consideration the historical built-in vulnerabilities of our health care system.
The other response specifically addresses the impacts of Bill 26. According to Bill 26, public hospitals, among a number of institutions, will be permitted to establish crown foundations. This will allow them to have a competitive advantage in fund-raising. This situation would result in a situation where it will not only add pressure on community organizations, including mental health organizations, but also pressure on fund-raising dollars, which are already drying up.
We are particularly concerned about several sections proposed in Bill 26. One of these sections is specifically concerning the definition of "insured services." This definition, we feel, allows explicit discrimination on the basis of age. We are also concerned that this section constitutes blatant discrimination based on age in contradiction of the Charter of Rights and Freedoms, the Ontario Human Rights Code and the Canada Health Act.
In addition to that, there is another section, 29.3, which is speaking about the minister's responsibility for controlling the supply and demand of physicians. According to a government study, there is an approximate oversupply of almost 2,500 general and family practitioners. In addition, there is a large oversupply of psychiatrists in certain areas of the province.
We believe that some level of intervention may be needed from time to time in determining the supply and demand for physicians in the province. However, prior to enacting legislation, the government should consider alternatives such as incentives, improvement in conditions and differential remuneration. Linkages with the community, as well as specific population needs, must be taken into consideration before enacting drastic measures which might result in the total loss of physicians to other provinces or other countries.
In conclusion, we believe that the savings which will be achieved from hospital cuts should be reinvested into the health care system and community mental health system. The retention of this money to fund the government deficit, or even to finance the tax break promised by the government, will prove to be paradoxical in terms of opening up gaps in a highly needed and often underfunded community mental health system.
Mr Kelly: Now I'd like to call on Lynne Harris, who will speak on the impact of the economic statement on the drug benefit plan for mental health consumers.
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Ms Lynne Harris: Good morning, Mr Chair and members of the committee. I too am a community mental health consultant with CMHA, Ontario division, and I'm pleased to be here this morning to speak to you about the impact of the November 19, 1995, fiscal and economic statement and Bill 26 on the drug benefit plan for mental health consumers. Many mental health consumers are prescribed medication on a weekly basis in order to diminish the potential for overdose. This means that a person with a psychiatric disorder who is on social assistance could, under the proposed changes to the Ontario drug benefit plan, be paying a $2 dispensing fee once per week. This is a prohibitive amount for an individual on social assistance.
Similarly, a mental health consumer who is stabilized on medication and earning $16,000 or more annually would now have to pay a $100 deductible annually and a dispensing fee. The same situation would apply to an individual with a mental illness who is working and earning $24,000 annually and supporting a family. In the current fiscal environment, work is frequently contract or part-time with no drug benefit plans to offset medical costs. Psychiatric medications are very expensive and such costs could be prohibitive for those individuals in the above-mentioned circumstances.
We are also concerned about the ability of the psychogeriatric population on social assistance or a small pension to pay for psychiatric medication along with other prescription medication which they may take for ailments related to aging. Section 4 of the Ontario Drug Benefit Act is to be amended to provide that when a physician writes "no substitution" on a prescription, or the consumer requests a specific medication, the government will no longer pay the difference between the specified or "no substitution" drug and a less costly interchangeable generic product. Pharmacies may be able to charge this cost to Ontario drug benefit plan recipients.
We recommend that if a physician prescribes a "no substitution" drug, or the consumer is requesting a specific drug, it is because that drug has proven most effective in treatment, and the drug should be fully covered under the plan.
Section 13 of the Ontario Drug Benefit Act may be changed to provide that the minister may collect directly or indirectly, and use or disclose, personal information. The CMHA, Ontario division, believes that all medical information should be confidential and private. This is especially critical to psychiatric consumers who may already suffer enough social stigma and loss of confidentiality as a result of their illness.
Proposed amendments to subsections 18(2), 18(3), 18(4) and 18(5) would allow for copayment for drugs, providing different copayments for different classes of persons or drugs. The psychiatric consumer should have equitable access to medications prescribed for them, particularly the majority who are on social assistance or earn too little money to afford annual deductible costs.
Under the proposed new section 22 of the Ontario drug benefit plan, the amount paid for a specific product will be by agreement with the manufacturer. There will be no obligation to decrease the price if the price decreases in the marketplace. If there are increases in medication costs due to the manufacturer's set price, and a psychiatric consumer cannot obtain an interchangeable drug, again the consumer will suffer as a result.
The proposed new section 23 of the Ontario drug benefit plan is critical to the psychiatric consumer because psychiatric medication may not be clinically interchangeable and a change in what appears to be similar medication might result in dangerous consequences to the consumer.
Again, CMHA, Ontario division, respectfully recommends equitable access to critical, specifically prescribed medication for psychiatric consumers. We would also recommend that non-prescription medication, such as laxatives, antacids and sunscreen among others, which is taken to counter the unpleasant side effects of psychiatric medication be included in a drug plan for psychiatric consumers, as these medications are also costly. Frequently, a psychiatric consumer will go off a necessary medication because he or she is unable to tolerate the side effects.
Under section 7 of the proposed new Drug Interchangeability and Dispensing Fee Act, we recommend that the practices under the Prescription Drug Cost Regulation Act, which is the current act, be resumed to the advantage of the psychiatric consumer with a low income who is not covered under the act. This would include the substitution of generic drugs for brand names that are prescribed if, under the act, the substitute has been designated as interchangeable with the brand-name product.
The current act also covers people who are not covered under the Ontario drug benefit plan. It controls costs, it allows drug substitutions, it allows information on the prescriptions to do with the dispensing fee and the prescription, and is generally much more amenable to the psychiatric consumer.
The mental health reform process has emphasized moving the psychiatric population into the community and assisting them to lead meaningful lives. Equitable access to the medications they require is part of sustaining a psychiatric consumer in the community. Our organization hopes and expects that the government will make this possible, consistent with the principle of Putting People First, namely, the psychiatric consumer-survivors.
Mr Kelly: Thank you, Lynne. I just want to comment -- I know the time is short -- that we have some documents that are still in the process of being gotten together over at our office. We will get those over to you today. Anyway, there is a short time available for a few questions, I think.
The Chair: We have time for almost the impossible, three quick questions, starting with the government.
Mr Tony Clement (Brampton South): Thank you very much for your presentation. You've given us a lot to think about, a very thoughtful presentation.
I wanted to repeat some of the things that you said in your presentation -- that major transformational changes are necessary in the health care system -- and I echo that. A presenter yesterday, I believe it was the president of Humber College, said that the greatest threat to health care is the $10-billion-per-year government deficit, because that takes money away from necessary services in the health care system. Would you like to comment on that?
Mr Kelly: I think that there's enough money in the system; it's just a question of getting it allocated in the proper place. Our position is to ensure that we can keep the health funding envelope in place and that we can get sufficient money transferred into the community sector, where we think we can provide services at an equitable cost, an even better cost than they are today -- and better services.
The Chair: Ms Castrilli.
Mrs Caplan: If it's possible, Mr Chair, I have a very short one that can also be answered in conjunction with my colleague. I'll place it and she'll place hers and then they can respond to them both together. Is that okay?
The Chair: Okay, you've got a minute. That's all.
Mrs Caplan: I'm assuming that you were consulted by the minister on what he was proposing in the bill, and I would ask if you gave him the advice about the impact particularly of changes to the drug benefit plan during that important consultation when he shared with you what he was proposing to do. Annamarie has a question.
Ms Annamarie Castrilli (Downsview): My question really stems from a comment that you made that the release of personal records might actually undermine the mental health recovery of patients, which is quite different from many other patients in other situations. Do you believe that the minister requires those extensive powers in order to be able to accomplish the goals of restructuring within the health sector?
Mr Glenn Thompson: Can I respond to both of those questions? No, we were not consulted on Bill 26 in its creation. In terms of medical records, we've stated quite firmly the need for confidentiality of those records. We can appreciate at the same time the need for auditing, the need for review of expenditures, and I think it's quite reasonably possible to find ways to accommodate confidentiality and to have aggregated data that one can examine from an audit point of view to probe whether or not excessive charges are occurring, or whatever. We'd be very anxious to assure that the detail of someone's confidential psychiatric record not be able to be accessed other than by medical individuals.
Ms Lankin: You're one of a number of groups that have indicated they have not been consulted on this. I can tell you that there is a growing call for this bill to be split and to be dealt with in manageable pieces.
I want to ask you specifically about an issue you've raised which we haven't discussed yet here through these hearings, and that's with respect to section 11.2 of the Health Insurance Act. The amendments in Bill 26 take out the current definition of insured services, and makes reference to a new section 11.2. In that section it sets out a new definition of "insured services," and for the first time we see reference that insured services could be some services that are only for people of a certain age group and they're not insured if those things are done to people of another age group.
This is potentially very frightening. You're the first group that has referred to this explicitly and brought it to the committee's attention. We've asked the minister in the past what he meant by this new section. We've not had an answer. Could you elaborate on your concerns and your fears with respect to this section?
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Mr Thompson: Lynne, would you like to pick up on that, as you referred to it? Or was it Mamoun's reference?
Ms Harris: I think it was Mamoun's reference, but I could comment.
Mr Gamal: Actually, we find that the idea behind the explicit mention of age means a restriction of services. Particular services would not be provided for a specific age group. The whole idea about that is an idea which we feel is not conducive to the Ontario Human Rights Code and to the Charter of Rights and Freedoms and also to the Canada Health Act. The concern was that no particular group should be singled out in order to bring about saving in the system. Any group, despite this kind of discrimination, might not be conducive to the healthy community, which we aspire to have, actually.
The Chair: Thank you very much. We appreciate your interest and your presentation this morning.
ONTARIO COALITION OF SENIOR CITIZENS' ORGANIZATIONS
The Chair: The next group is the Ontario Coalition of Senior Citizens' Organizations, represented by Morris Jesion, Don Wackley and Beatrice Levis. Good morning and welcome to our committee. You have a half an hour of our time to use as you see fit. Any time you allow for questions will begin with the Liberals. The floor is yours.
Ms Beatrice Levis: On behalf of the Ontario Coalition of Senior Citizens' Organizations we'd like to thank you for providing us with an opportunity to share our views concerning Bill 26.
I would like to introduce, first of all, Don Wackley, who's a member of our steering committee, who will give general information about our position. Then I will continue particularly on the subject of user fees.
Mr Don Wackley: My name is Don Wackley. I'm on the steering committee of OCSCO and I represent the Parkdale Community Health Centre.
The Ontario Coalition of Senior Citizens' Organizations is a coalition of over 80 seniors' groups from across Ontario representing the concerns of over 500,000 senior citizens. OCSCO unites both large and small groups from community, union, women, ethnic, native and veteran organizations on matters affecting the quality of life for the senior citizen community.
Given the overwhelming scope of this bill, we will restrict our comments today to the implication for health care, specifically (1) what we believe are the underlying philosophical or driving forces behind this bill; and (2) those sections of the bill which potentially pose the greatest threat to the health and wellbeing of Ontarians.
Power: The real driving force behind this bill is the quest for arbitrary power or, to be exact, extraordinary, unprecedented and unnecessary new powers for the government, especially over the delivery of health care services. What kinds of new powers are we talking about with regard to health care?
Schedule F, health services restructuring: The proposed change to the Ministry of Health Act and the Public Hospitals Act would create the Health Services Restructuring Commission that would provide the government with sweeping new powers to take over, merge and close hospitals at will.
Schedule H, amendments to the Health Insurance Act and the Health Care Accessibility Act: The proposed amendments give the Ministry of Health or an appointed inspector new powers concerning confidential health information. Essentially, they will be able to go into any medical facility and look at, copy, remove and disclose medical records if they are of the opinion that it is "necessary" for more effective management and delivery of health care services. The Minister of Health has assured us that he will amend this section, but how exactly does he plan to amend it?
This new legislation also impedes the abilities of physicians across Ontario to deliver care. The legislation allows the government to unilaterally set fees for health care services, paying some doctors lower rates for the same services based on location and training. The government will be able to retroactively order a doctor to repay the government for services provided to patients, such as medical tests and X-rays, later deemed to be "unnecessary."
Moreover, it gives the government the power to decide which doctors can be tied to hospitals and revoke their privileges without legal recourse or compensation.
These cumulative effects are extreme and harmful to patient care. These changes will likely result in reduction in services, an exodus of doctors from Ontario and reduced choices for patients in picking a physician.
Ms Levis: Now I'll deal with the question of user fees. The support of and potential for the introduction of user fees appear to be another major underpinning of this new legislation. This is clearly evident in several sections of the proposed legislation and is a direct attack on the principle of universality.
Schedule F, health services restructuring: Changes made under this section make it much easier to charge patients facility fees for health services. This would encourage physicians to open clinics or facilities in their respective fields, such as ophthalmology, oncology, radiology and other medical specialties.
This in fact is opening the back door to a two-tiered medical system where the ones who can afford treatment will receive it. Hospitals will also become less needed, therefore allowing more privately run facilities to take over specialized care. This appears to be an attempt to copy Alberta's medical system, which has already been penalized under the Canada Health Act.
Schedule G, amendments to the Ontario Drug Benefit Act, the Prescription Drug Cost Regulation Act and the Regulated Health Professions Act, 1991: The changes proposed in schedule G have potentially devastating effects for all low-income seniors and persons on social assistance. For instance, single persons with income below $16,000: a $2 user fee for all prescriptions; persons with incomes above $16,000: a $100 deductible plus the cost of dispensing fees up to $6.11 per prescription. Many seniors unfortunately have a number of prescriptions for various ailments.
While these fees may not seem like very much, in combination with all the other cuts and user fees, seniors and social assistance recipients may be forced to choose between having a prescription filled or buying groceries or public transit tickets.
Moreover, this bill allows for the deregulation of drug prices. This government claims that prices will go down, but there is no reason to believe this. Combine this with the huge number of drugs and pharmaceutical products that have already been delisted from coverage under the drug benefit program and you have a recipe for disaster.
By implementing user fees we assume the goal is to control government spending and thereby save money. There is no proof that user fees will cut costs. Saskatchewan introduced user fees in 1968 and the end result was that there was no change in health costs.
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As many governments have since learned, user fees act as a very small source of revenue relative to the total cost of operating health care services. User fees restrict accessibility and create a two-tiered health care system: one for those who can afford it and one for those who can't.
The most serious problem with user fees is that they penalize the least healthy and often the poorest in society, for they often discourage people from seeking treatment they need. This leads to greater costs in the long run, with an increase in hospitalization cases. Preventive health care is the most effective type of health care.
Instead of targeting the Ontario drug benefit program, there are several areas your government could reform:
(1) Pressure the federal government to repeal Bill C-91, the drug patent legislation. This is one of the main causes for increasing drug prices.
(2) Save the Ontario taxpayers and treasury millions of dollars by enacting legislation similar to that in British Columbia, making it mandatory to prescribe and dispense generic drugs where available.
(3) Demand that pharmacists lower their dispensing fees. These fees make prescription drugs too costly.
(4) Overuse and misuse of medicine are both costly and unhealthy.
(5) As you know, seniors don't prescribe drugs; doctors do. As a result, many drugs prescribed are not needed. We must look at educating seniors and doctors on this issue.
(6) Some groups affiliated with OCSCO are already working on programs where seniors train other seniors on the use of medication. Your government should encourage such programs all over the province.
(7) Lastly, look at a different system of payment to physicians.
We believe that in order for your government to implement a new drug system where user fees will be incurred, it means setting up another way of cost of collection. This will add another level to bureaucracy, which your government is trying to streamline, and therefore will inflate costs to the taxpayers to run this new system.
Schedule H, amendments to the Health Insurance Act and the Health Care Accessibility Act: Amendment to the Health Care Accessibility Act opens the doors for hospitals to charge user fees for anything not covered by the Canada Health Act; for example, food, linens, bed pans, crutches etc. Given the extensive cuts in funding to hospitals, there's no telling what the cash-strapped hospitals propose to charge for. Already acute care hospitals would be permitted to charge patients on a waiting list for chronic care hospitals and nursing homes approximately $37 per day.
Schedule F, health services restructuring: In the proposed amendments to the Independent Health Facilities Act, it is clear that the government is trying to facilitate the privatization of health care. This new bill removes any restrictions against for-profit firms that want to start up independent health facilities. In fact, if our Minister of Health wanted to, he could invite for-profit health providers to set up clinics in Ontario.
In the name of hospital restructuring, chronic care hospitals are being unfairly targeted. Some chronic care units will have to close. With the proposed amendments in schedule F, it is encouraging more American for-profit nursing homes to cross the border and fill the gap. There is already in place a recommendation to privatize the Metropolitan Toronto Homes for the Aged which are renowned for the quality of care and services they provide. This movement towards privatization in the health services field particularly puts the elderly, disabled and sick at great risk, especially with respect to quality of care.
We are also concerned by the amendment that repeals an existing preference for non-profit facilities and for Canadian ownership. Is the government opening the doors to for-profit health care giants to the south?
A broader definition of health: the implication of cutbacks. Health can no longer be narrowly defined as only the absence of illness and disease. Health is far more encompassing, including the social, emotional and psychological wellbeing of individuals and communities. Ontarians are already dealing with other cutbacks, both provincial and federal, that magnify the detrimental impacts Bill 26 will have. While the changes may appear rather small and insignificant in isolation, their cumulative effects are enormous.
Let's look at the impact upon seniors. Due to cutbacks to hospitals and lack of co-ordination in community-based care, seniors are being sent home sicker and quicker. The cuts in funding to the transit system have meant that transportation is now more costly, and specialized transit services such as Wheel-Trans have been scaled back. Cuts in funding for education have meant that seniors now have to pay a fee for board of education programs delivered through community centres. Many drugs seniors rely upon, such as calcium pills, have been delisted for coverage under the drug benefit program. The plans to remove rent controls may mean huge rent increases in accommodation costs. Now, under Bill 26, seniors will see the introduction of more user fees, the closure of more hospital and chronic care beds, and decreased access to services in general through privatization.
Bill 26 was introduced under the guise of providing the public sector with the tools needed to achieve fiscal savings and restructuring. What this bill does is to confirm the authoritarian, autocratic and undemocratic nature, as well as a systemic dismantling of the social welfare system in Ontario. This legislation, through enabling others to charge user fees, is in direct conflict with the principle of universality. User fees will further diminish universal health care in Ontario, with the poor and the seniors bearing the brunt of your proposed actions.
A recently released study showed that seven out of 10 people in Canada consider social programs essential to the Canadian identity. This seems to run contrary to the cost-cutting course this government is charting, especially through Bill 26.
What this government must remember is that holding a majority of seats in the Legislature does not remove them from the responsibility of fairness, balance and respect for the democratic process in all of their activities. Therefore, we are asking this government to withdraw Bill 26 in the interests of public welfare.
The Chair: Thank you very much. We have about three minutes each, beginning with the Liberals.
Ms Castrilli: Thank you very much for appearing today. I was struck not just by the thoughtfulness of your presentation but that the presentation seeks to put into context what the impact will be to seniors, that it isn't just the issue at hand, but it's a whole host of measures that will affect the quality of life for seniors and, ultimately, for all of our communities.
I wonder, given the very large group of people that you represent, whether you have been consulted by the minister or the ministry, or had any contacts of any kind leading up to this bill.
Ms Levis: Not leading up to this bill.
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Ms Castrilli: None whatsoever? That's surprising.
One area that you did not touch but that you might want to talk about is the whole issue of records. Seniors, like all others, are going to be subject to the provisions of the act which will allow the minister to have very broad powers to look at personal records, private, confidential records of the seniors. I wonder if you have any comments on that.
Ms Levis: Yes, we actually have.
Mr Wackley: As someone who represents a community health centre, we deal with people who come to us who normally wouldn't go someplace else because they're afraid of the information that they give us -- battered women, methadone treatment people, the homeless, all of those people. If our records can be gone through and information that these people desperately don't want out -- they're not going to come and visit us and if they don't come and visit us they're not going to come and visit anybody. So as a health centre, we're really frightened about that part of the act.
Ms Castrilli: One final question: You have advocated for the withdrawal of Bill 26 in the public interest. In the event that should not occur, would you support a breaking up of the bill into sections in order that there might be more full public debate, to give you time to look at the provisions more fully?
Ms Levis: Yes, actually. I think we should have indicated that possibility. Absolutely. We think there must be more public consultation and more public debate on the various measures being proposed.
The Chair: Thank you very much. Ms Lankin.
Mr Alvin Curling (Scarborough North): I just want to commend you on an excellent presentation, especially the democratic process that this government has really shut people off from presenting --
The Chair: Mr Curling, I did not recognize you.
Ms Lankin: I also wanted to say how much I appreciated the thought that went into your presentation. I'm interested that you're yet again another group that is saying very clearly that this government did not consult you about this legislation, that you haven't had the time to prepare fully and understand the impact of this legislation on the groups and people you represent and that you're asking for the bill to be split up and to be dealt with in a proper democratic process. I just want to put on the record that this is a growing call that we're hearing from group after group after group, and this is only day two, morning two, of the hearings.
You made reference to your concerns about the level and nature of administration, the administrative burden that would be placed on the ministry to oversee the user fee. I was interested in that because I think you talked about it as another layer of bureaucracy.
As I look through this bill, there's a theme for me. There's the administration, the user fees, there's the quota legislation for doctors, there's micromanagement of hospitals -- an example of that is the minister can actually step in and can impose an amendment on the physician human resource plan -- there are new, sweeping powers to the minister and to supervisors that he appoints to go into the hospital and take over the actual day-to-day operation of the hospital from the volunteer board, so it's an undermining of volunteers and the role of volunteers in our communities. I see that very much as sort of imposing a Queen's Park bureaucracy on what should be left in the hands of communities to decide and in the terms of voluntary governance for volunteers and their role.
Seniors have been given more and more of a voice over the last few years with respect to community organizations and consumer input into delivery of services. Does this at all undermine steps that you've been able to win, to have seniors' voices heard in the voluntary governance structures of the health care system?
Ms Levis: Since part of the community care and the health, particularly the long-term care -- the government has not yet announced its position on that or proposals or what it's going to do -- all we can say is that we're apprehensive that we see this bill as certainly making it possible for all the work that has gone on in the various communities to develop the community health system and long-term care. It has the potential to negate a good deal of the local community differences and the local community organizing that's already been done.
Mrs Ecker: Thank you very much for a very thoughtful and useful presentation with some very helpful input as we continue through the hearing process here. I was interested to note that you flagged the pressure on the system from misuse, overuse, overprescribing of drugs, which I think, when we've seen the drug benefit plan costs triple in the last 10 years, have certainly been a significant cost pressure. Many other provincial governments have chosen to implement some sort of copayments, user fees or whatever to try and cope with the pressure; others have decided to delist drugs. We chose to have a small copayment system based on income so that we could do two things: (1) help reduce the cost; (2) reinvest the savings into extending the drug benefits for 140,000 working poor.
I guess what I'd be interested in your feedback is, in order to handle those cost pressures, should we have delisted drugs so that they were right off the plan at all? We felt that it was more appropriate to try and maintain that coverage and do a small user fee -- copayment based on income. I just wondered if you felt -- because I think you flagged the fact that there are some pressures in the system -- how that should have been handled.
Mr Morris Jesion: Our feelings on this matter essentially are as follows: It's going to cost more to collect the user fee than the cost of saving and, furthermore, the largest single savings will be by the provincial ministers of Health lobbying the federal government to change the drug patent legislation which gives exclusive protection for many, many years to the ethical drug manufacturers as opposed to the generic drug manufacturers. That's likely to have the largest single effect on the prices of drugs, and going the way of introducing user fees is counterproductive not only from, you know, affordability, the two-tier system, but it's going to probably cost more. The research has shown that it costs more to collect the fee than it's going to be worth in saving.
Mrs Ecker: What happens with the federal government is not within our control, so I guess in terms of coping with the pressures here in Ontario we would have been forced, I believe, to delist drugs so that seniors would not have had access to them at all on the plan.
The Chair: Thank you very much for your presentation, folks. We appreciate your interest in our process.
GLAXO WELLCOME INC
The Chair: The next presenters are from Glaxo Wellcome: Robert Last, Bruce Beamer, Bill Laidlaw and Paul Lucas. Good morning, gentlemen. Welcome to our committee. You have one half-hour to use as you see fit. Questions at the end would begin with the New Democratic Party. The floor is yours.
Mr Robert Last: Good morning. Thank you for the opportunity to appear before the committee today to present the views of Glaxo Wellcome Inc on Bill 26, the Savings and Restructuring Act.
The Chair: Just a second. Could you each identify yourselves so Hansard knows?
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Mr Last: Yes. Actually, I was just coming to that. I'll do that right now. Let me begin with Bill Laidlaw, our director of government affairs; Bruce Beamer, our manager of provincial relations in Ontario; my name is Rob Last, I'm the regional business director for Glaxo Wellcome in Ontario; and Paul Lucas, our president and chief executive officer.
Our comments this morning will focus specifically on the proposed legislative amendments to the Ontario Drug Benefit Act and the Prescription Drug Cost Regulation Act. First let me begin with some background information on our company. Glaxo Wellcome Inc is one of Canada's largest research-based pharmaceutical companies, generating sales of approximately $380 million annually. We operate two facilities in Ontario: a head office in Mississauga and a manufacturing and development laboratory in Etobicoke. In total, Glaxo Wellcome employs more than 1,100 people in Canada, and in the past seven years, Glaxo Canada, now Glaxo Wellcome, has more than tripled its workforce, with 80% of its employees located in Ontario.
Glaxo Wellcome specializes and is a leader in many therapeutic areas, including asthma, migraine, gastroenterology, oncology, epilepsy and anti-infectives. We invest more than $50 million in research and development, including $10 million in basic research in Canada annually through partnerships with companies, academic institutions and support of independent researchers, 54% of which is invested here in Ontario. We support fellowships at several universities, including the pharmacy doctorate program at the University of Toronto.
We would like to offer our views this morning on five proposed legislative amendments pertaining to the Ontario Drug Benefit Act and the Prescription Drug Cost Regulation Act: price deregulation in the private sector market; the elimination of full payment of "no substitution" prescriptions; the introduction of copayments/deductibles; negotiated drug benefit price; and linking prescribing criteria to reimbursement.
First, on price deregulation in the private sector market, Glaxo Wellcome supports the change to the Prescription Drug Cost Regulation Act which will result in the deregulation of the price of pharmaceutical products in the private market and the removal of government from playing a role in a market where it has no direct financial interest.
We would like to stress, and this is contrary to some reports in the press, that this deregulation will not result in significant price increases on patented drugs for consumers. In fact, in the deregulated market being proposed, we see competition maintaining or moving prices down. In our own case as it relates to price, I'd like to point out that the prices of Glaxo Wellcome's products in Ontario have not increased since 1993 and no price increases are scheduled for the upcoming year.
Many of you are aware that while pricing controls do not apply to generic products and those products not covered by a patent, introductory prices for new brand-name patented drugs and subsequent price increases for these medicines are and will continue to be regulated federally by the Patent Medicine Prices Review Board, regardless of changes in the provincial legislation.
Glaxo Wellcome believes that as the government withdraws from regulating price in the private market, it is of great importance that consumers be provided with all the necessary information needed to make informed choices. The requirement to post the pharmacy "usual and customary" fee, although necessary, is not enough to help consumers comparison-shop among pharmacies. Consumers have a right to know the components that make up the price of prescription medicines. Glaxo Wellcome proposes that a regulatory amendment be added to the Prescription Drug Cost Regulation Act requiring the full disclosure of each part of the total prescription, including the actual drug cost, the markup and the dispensing fee. This breakdown will enable consumers to effectively compare the service and cost of products offered by various pharmacies.
Next, on the negotiated drug benefit price, we understand the government's interest in eliminating the best available price, BAP, under the Ontario Drug Benefit Act and introducing a system in which prices are negotiated between the manufacturer and the minister. While the details of how this system of negotiated prices might work are not yet available, we would expect that the pharmacoeconomic analysis submitted by manufacturers with each new product submission will take on even greater significance.
We would like to offer the following comments on this new pricing system. First, with this greater reliance on pharmacoeconomics, it is hoped that the savings to the total health care system, and not just the provincial drug programs budget, will be taken into account when assessing the value associated with a new product's price. Second, there is a need for a clear and transparent set of rules for which negotiations on price will occur. Further, that a clearly defined regular process, either annually or semi-annually, be identified that allows for an orderly adjustment of prices reflective of the economic and competitive changes in the environment. We would further propose that a regulation be added to the legislation which prevents the possibility of price spreads developing in the government drug plan.
Next, on the elimination of payment of "no substitution" prescriptions, we understand the need of the ministry to reduce expenditures and eliminate full payment of "no substitution" prescriptions under the proposed changes to the Ontario Drug Benefit Act. It is, however, important to recognize that for clinical reasons certain patients will still require the brand-name product instead of the generic. It is therefore essential that a simple and timely process be in place to allow for these situations, in that the section 8 option requires too much time and documentation from physicians.
Secondly, consumers should have the right to be informed about product substitution before it occurs in both the public and private markets. Glaxo Wellcome proposes that a legislative amendment be added to the Ontario Drug Benefit Act requiring pharmacists to inform physicians and patients about product substitution and that patients be told that they have the right to pay the difference between the brand and generic versions of the drug. Currently, under the mandatory substitution provisions in the legislation, neither the customer nor the physician is informed when the prescribed product is switched to a cheaper alternative brand.
On the subject of introduction of co-pays and deductibles, currently Ontario is the only province in Canada which does not require a patient contribution for publicly funded prescription products. We understand and support the government's proposed model in which contributions are related to the patient's ability to pay.
On linking prescribing criteria to reimbursement, these proposed changes to the Ontario Drug Benefit Act will permit the government to restrict payment for specific drugs to situations in which prescribed clinical criteria are met. While this provision may be necessary to allow for changes in the special drugs program and/or the non-formulary benefits list, Glaxo Wellcome has concerns about the potential use of these prescribing criteria.
We are committed to the rational promotion and cost-effective use of all of our products. We support the development, distribution and adoption of evidence-based practice management guidelines in which prescribing recommendations are one component. Guidelines, however, must allow the physicians flexibility to exercise their professional judgement when treating patients. In addition, the development of guidelines or prescribing criteria must involve an open process which permits the participation of stakeholders who have expertise to contribute to such a process. We would hope that the government would utilize our expertise in the development of clinical practice guidelines.
Glaxo Wellcome is also concerned that the proposed changes to the Ontario Drug Benefit Act which allow prescribing criteria to be linked to reimbursement will result in financial penalties which may in fact supersede the professional judgement used when prescribing. In addition, linking these criteria to reimbursement will require the pharmacist to enforce these guidelines and place them in a role which they may or may not be ready or willing to assume. We encourage the Minister of Health to consult with the stakeholders in this process before implementing prescribing criteria and linking them to reimbursement.
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In conclusion then, in the absence of regulations accompanying this legislation, it is difficult to provide comprehensive input on how some of these changes will work in practice. We would, however, welcome the opportunity to review the draft regulations and provide our comments and suggestions to the Minister of Health.
With regard to the proposed changes in Bill 26 pertaining to the Ontario Drug Benefit Act and the Prescription Drug Cost Regulation Act, Glaxo Wellcome supports the deregulation of price in the private market, the consumers' right to know about product substitution, the need for full disclosure of the cost components of the price of medications, the establishment of a fair and transparent negotiation process for drug prices and the need for stakeholder involvement in the development of prescribing criteria and flexibility for physicians when implementing these criteria.
We recognize the need to restore the fiscal health of the province and are supportive of the government's general direction to achieve this objective while making Ontario a good place to do business. Glaxo Canada, now Glaxo Wellcome, has been in Ontario for over 90 years and is committed to doing business here and working with the government to address industry and government issues and arrive at solutions.
I'd like to thank you for your time and attention, and we would be pleased to respond to any of the questions that you might have.
The Chair: Thank you very much. We have about 15 minutes for questions, beginning with the New Democratic Party.
Ms Lankin: Five minutes each?
The Chair: Yes.
Ms Lankin: You could encourage me, you know. Thank you very much. I appreciate your presentation and the time that you've all taken to be here. I feel like I have an ongoing relationship with your organization. Every role I play in my political career, there you are, which just speaks to the importance of the industry and a company such as yours and how you seek to be involved in the public process.
On that point, the specifics that you have set out here, particularly in your conclusion of what you support, there's only one of them that actually appears in the bill, and that's the deregulation of price in the private market. The other elements are all either additions or amendments that you would be seeking.
Mr Last: Right.
Ms Lankin: Did you have an opportunity to discuss these with the minister in advance of the bill and suggest that these are the sorts of things that he needed to include? Did you get any feedback as to why he didn't include them?
Mr Last: I think Paul might be best to speak to that.
Mr Paul Lucas: I think that over the years, because we are a highly regulated industry, we've had the opportunity to have discussions about a number of these issues, ones that are included in the bill and others that may not be at this point in time. We've also had the opportunity through the joint liaison committee which was established back in 1994 to provide further input to the Ministry of Health, again on all of these issues.
In addition, on behalf of the Pharmaceutical Manufacturers Association of Canada, PMAC, I represented the views of the industry as a whole on many of these issues in a meeting with the minister, I guess it was a couple of months ago.
Ms Lankin: Did you get any feedback from the minister as to why, for example, a consumer's right to know about product substitution or your suggestion around full disclosure of cost components or, perhaps even more importantly to your industry, the assurance of a fair and transparent process with the negotiations of the prices and with the development of prescribing clinical guidelines and the linking of those to payment, why none of that appeared in the bill?
Mr Lucas: I think on the issue of informing the consumer when substitution occurs, this has been an issue that's been around a long time, since Bill 54 and Bill 55 were debated, and the issue has been input at various points in time. I think we were not anticipating this bill opening up at this time and therefore had not recently made any input regarding that issue, and we wanted to take this opportunity to make sure that our thoughts were heard on the consumer being informed about substitution and so on.
Ms Lankin: You're very gentle and in your approach I can see that you don't want to say to me that in fact the minister didn't discuss those with you or tell you why those ideas weren't in there. I remember hearing very directly from you as an industry. You didn't pull any punches then. But then again I wasn't offering you complete deregulation of price in the private market, so that might have been one of the reasons there.
I am very interested in the last minute we have in getting your comments on the need for stakeholder involvement in the development of prescribing criteria and the flexibility for physicians. The issue of no subs is an important one for the industry, and I understand that. It's also important in some clinical cases for the actual therapeutic treatment of the patient and the flexibility of the physician.
We've been working for a number of years on the development of clinical guidelines. It was a surprise to all of us, I think, to see this provision implemented in the bill which ties the payment and reimbursement to some internal bureaucratic judgement of what is clinically necessary. Could you talk about what your expectations are and is there a legislative amendment required or can this be done through another process?
Mr Last: On the issue of prescribing guidelines we know, certainly from our experience in the clinical development of products, that individual patients may respond quite differently to identical therapies. While practice guidelines may address the needs of the majority of patients, there must be sufficient flexibility to allow the physicians to exercise their professional judgement without penalty to themselves or to the pharmacist or to the patient.
Given our expertise, and I can only speak for Glaxo Wellcome as a stakeholder in that process regarding products in therapeutic areas, we believe that we should have the opportunity to participate in the development of those criteria and to offer input on the implications of implementing those.
Mr Clement: Thank you very much for your very cogent presentation. It shows that while we all acknowledge there has been a limited amount of time to prepare for this, there is an opportunity to prepare something which is internally consistent and helpful to the committee. I thank you for that.
I was quite taken by your remarks in your presentation that according to your analysis of the industry the deregulation of drug prices will not result in a significant price increase. In fact, you said that they would either be maintained at the current level or that they'd be moving prices down. Could you give us the Reader's Digest synopsis of your industry and what the forces at work are that lead you to that conclusion?
Mr Last: Yes, I'd be happy to. Basically, when you look at the components of a prescription, there are three costs associated with that. There is the drug cost, there is the professional fee and there is the markup. I'd like to deal with each one of those individually and explain my position behind them.
If we look, first of all, at the drug cost, drugs essentially fall into one of four categories. First, we would have branded drugs, which are genericized. If I take one of our own examples, that would be Zantac. In the case of Zantac and in the case of virtually any product like that, well over 80% of the market has gone to the generic brand, so any price increase of that branded genericized product would have very minimal impact on the market, if any at all.
The second category would be generics. We've seen again that price pressure on generics; continues to drop. We rarely, if ever -- I can't recall very many situations where generic prices have actually risen, so they --
Mr Clement: That's the structure of the industry --
Mr Last: The structure. As more generics enter the industry, the price pressures -- their only response basically to competition is to reduce price, so they would continue to reduce price.
In the third category, you have brand products for which there is patent protection and pricing in that category is regulated by PMPRB which, as you know, limits the price increases to the CPI, which again I think is very --
Mr Clement: Federal regulation.
Mr Last: Exactly. The last category, which represents a very minute category, would be branded products for which there is no patent protection and no generic -- a very unusual situation.
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We have one product like that, Becloforte. However, we also have a national pricing policy. We would hope to maintain that. We have, as I mentioned in my brief, been very responsible with our pricing practices and would not see deviating from that in the future. I can only think quite frankly of one other product that would fall into that category and that would be insulin, which might be a product similar to that, but again you have competitive pressures in the marketplace from different manufacturers.
Going back to where I began with the original, the drug component cost, we don't see any pressures anywhere along that spectrum that would result in exorbitant rises in price.
Moving down to the next two layers, the fee and the markup, on the fee side we have already seen many plans in the marketplace which cap these today. As well, we have six companies in Ontario that are either currently acting as, or have intentions to act as, pharmacy-benefit-manager type organizations.
We can look to the model of the United States when we look at markups and fees with respect to the impact those types of organizations have had on pricing. We've seen the impact in the United States; they've been very successful actually at reducing price in all three components.
The only other issue I didn't address was markup, and we already have seen one company limit the maximum of its markup to 10%. We suspect as others enter the fray, there will be continued downward pressure as a result of competition.
The Chair: Thank you for that explanation. It was the Reader's Digest version, but it took up all the time.
Ms Castrilli: I have one brief question then I'll turn it over to my colleagues. I want to thank you for coming here. Your presentation was very thoughtful on five issues that deal with the Ontario Drug Benefit Act and the Prescription Drug Cost Regulation Act.
Bill 26, however, as you know, is much broader than that. It deals with a whole host of things. It deals with changes to the Municipal Act, to the Pension Benefits Act, to the Mining Act. I wonder if that troubles you and whether you would be in support of splitting the bill to give proper and due consideration to the issues you've raised here today.
Mr Lucas: It's difficult for us to respond to that question because we haven't taken the time to look at all the implications of all of the other parts of the bill, so I don't think I can really give you an opinion on that at this point.
Ms Castrilli: My question really was, would you be in favour of splitting it so we can deal with the issues that you raised in a more thoughtful form?
Mr Lucas: I'm not sure if that's necessary. I don't understand the process enough to say yes or no to that.
Mrs Caplan: I've a couple of questions. I'm really pleased to hear that the minister consulted extensively with you and that you met with him. I do find it surprising that he didn't consult with the Ontario Hospital Association or the College of Physicians and Surgeons or the Canadian Mental Health Association or any of the consumers' groups that have been here, but the fact that he did consult with Glaxo Wellcome is important and it reflects the fact that drug deregulation and price deregulation is in this bill and that you're happy about that. Consultation is important and the fact that you've made that point is helpful to the committee.
My question is about that the amendment you have suggested which would assist consumers to do as the Health minister said, which was to shop around to get the price. Without that amendment, is it your opinion that consumers will not be able to use market forces to get the best price for the drugs they're going to be purchasing?
Mr Last: I can respond to that. I think it probably just makes it more difficult, quite frankly.
Mrs Caplan: So this bill makes it difficult for people now to be able to shop around?
Mr Last: No. I think in the absence of full disclosure of all components of the prescription cost, it would make it more difficult for consumers to assess the difference between products being offered from one pharmacy to another.
Mrs Caplan: The point I'm making is that the minister has said that price deregulation is okay because consumers will be able to shop around and exert market forces, and your point is that an amendment is needed in this bill to fully disclose that information so that consumers can then shop around and get a better price. Is that your position?
Mr Last: Yes.
Mrs Caplan: So we would expect to see an amendment from the minister to help people shop around and to exert those market forces. Have you discussed that amendment with the minister or is this the first time that you've --
Mr Last: No, this is the first time.
Mr Lucas: Yes, this is actually the first time we've had the opportunity to provide that input.
Mrs Caplan: That's great. I really appreciate that.
There was one other point I wanted to make, and that was on the establishment of practice guidelines. I very much support a role for the industry, which is very important to the province and has had extensive experience in the establishment of research and projects of that type. That experience is helpful.
Has the minister given you any indication that they intend to establish practice guidelines and that you could be an active participant in that?
Mr Last: No. Again this is part of this presentation process today. Essentially, what we are saying is we would hope that in the event practice guidelines are developed, we would be considered as one of just many stakeholders who would like to participate in that process.
The Chair: Thank you very much, gentlemen, for your presentation here today and your interest in our process.
ONTARIO MEDICAL ASSOCIATION
The Chair: Our next guests this morning are from the Ontario Medical Association: Dr Ian Warrack, Dr John Gray and Dr Bill Orovan. Good morning, gentlemen, and welcome to our committee. You have one half-hour to use as you see fit. Any time for questions at the end would begin with the government and would be shared equally. The floor is yours.
Dr Ian Warrack: I'm Ian Warrack. I'm a family practitioner from Vanier and president of the OMA. With me today is Dr John Gray, a family physician from Peterborough, and Dr Bill Orovan, a Hamilton urologist and the OMA's honorary treasurer. John is also the OMA board chair.
We're pleased to stand before you today and describe to you our tremendous concerns about Bill 26, the Savings and Restructuring Act. Never before have I seen one piece of legislation that contains such broad-ranging implications for health care. The OMA has spent the last three weeks reading schedules F, G, H and I and trying to understand what they mean. It's been a difficult job and we've likely missed some things, but I'd like to spend the next 15 minutes addressing some of our concerns about what this legislation will mean for physicians and their ability to provide high-quality medical care to the citizens of Ontario.
Since it would be virtually impossible to cover all the problem areas on a schedule-by-schedule basis in our allotted time, we'll focus on a few themes and illustrate our concerns with references to the legislation.
Before getting into our detailed concerns, let me address several of the statements attributed to the Minister of Health in the media during the past 24 hours. While seemingly urging Ontarians not to play politics with the health of the people of Ontario, the minister seems to be doing just the opposite. Political rhetoric and the generation of false impressions will not help provide the quality and accessible medical care that Ontario's 23,000 physicians want for their patients.
The Ontario Medical Association has pursued discussions with this government in good faith, and like most Ontarians we view the medical system as a true partnership. We want to work with all stakeholders to find constructive solutions to the problems we all know must be addressed. But we want that dialogue to be based on fact rather than rhetoric. This dialogue is not helped when the minister says there is little new or radical about Bill 26. In fact, it represents an unprecedented intrusion by government into the workings of the medical system.
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This dialogue is not helped when the minister says that the vast majority of the measures in this bill are supported by the public. In fact, a recent public opinion survey indicates that the vast majority of Ontarians oppose some of the government's proposals affecting the medical system.
This dialogue is not helped when the minister suggests that concerns over the privacy aspects of this legislation constitute a red herring. In fact, a number of observers, including the government's own privacy commissioner, have voiced serious and legitimate concerns on these very issues.
Finally, this dialogue is not helped when the minister reportedly accuses physicians of inappropriate conduct or of somehow holding up the process of meaningful reform. In fact, the OMA has tabled a number of constructive proposals in recent months, several of which have been adopted by the government and claimed as their own.
Mr Chairman, your job as a committee is to review the contents of this bill. Our job as the representatives of Ontario's doctors is to point out legitimate areas of concern about what is in that legislation and to do so in a factual and rational manner in the best interests of our members and our patients. That is what we now propose to do.
One of the most striking things about the omnibus bill is that it eliminates partnerships in health care. This occurs in a number of areas, but it is probably most pronounced when it comes to government's relationship with physicians and the Ontario Medical Association. In our 114-year history, the OMA has found that governments have valued the work of physicians and have actively sought to work together to improve the system. That work has taken a number of forms. Some were initiatives specific to the issues of the day and some were more process oriented.
This process work was designed to create a stable environment between government and physicians with a set of shared expectations to guide the relationship. One of the things that helped to make our partnership work over the years was the fact that governments acknowledged it wasn't practical or useful to deal with individual physicians or small groups of physicians on broad policy issues.
Governments recognized the OMA as their working partner. On the other side, individual physicians were secure in the knowledge that the OMA acted as their voice to government. Unfortunately, this government does not appear to share that vision and would be able to pursue its stated intentions to dissolve its relationship with the OMA under schedule I of the bill. It is unclear to me why this government seeks to deny physicians the opportunity to be represented by the OMA in their dealings with government and what alternatives, if any, they intend to put in place.
Dr John Gray: A careful reading of Bill 26 may give us some clues regarding Dr Warrack's last question. In fact, government does not appear to want input from its traditional partners; rather it wants to seize full control of both the system and its component parts and micro-manage them from Queen's Park.
I'll illustrate that point by noting several provisions from the bill. Under schedule F, the government is taking upon itself the ability to decide which hospitals should be open, what services they should provide and which physicians should work there. Through schedule H, it is taking upon itself the right to decide which areas of the province are oversupplied with physicians and will then prevent any new physicians from entering these areas.
Not content to limit their control to where physicians practise, the government is also planning to dictate how physicians practise, by giving itself huge new powers to decide on whether a particular service was medically necessary or not. I would argue that the reason physicians are in training for eight to 15 years is in fact to learn how to make these decisions. If government can now second-guess every test, procedure, prescription and specialist referral ordered in this province, then we're going to see physicians practising a very different style of medicine, with diminished time to focus on patient care.
The impact of government's increased presence in the system will be felt not only by practitioners but also by patients, since this government is prepared to go so far as to insert itself between the doctor and the patient by allowing itself access to confidential patient information and then claiming the right to disclose the information as it sees fit. It seems to me that this will have a chilling effect on the information the patients will share with their physicians and could ultimately have a negative impact on the care that the patient receives.
The minister has, to date, been inconsistent in his response on this issue. Initially it appeared that he was prepared to move away from this Orwellian provision, but in a later communication he was less clear, stating that we have misinterpreted the law. With due respect to the minister, I think the words in the law are straightforward.
Coupled with government's attempts to micro-manage the provision of medical services is the systematic removal of fairness and due process for physicians. Throughout the bill we see government rescind physician rights, take away rights of appeal, and then insulate itself from any legal action. While it is apparently a matter of some debate whether governments are entitled to override the rule of law by legislative fiat, there is certainly no moral debate. I cannot see how this or any other government could expect the physicians or the citizens of Ontario to trust in its integrity when it gives to itself the power to abrogate agreements signed in good faith.
Physicians don't have to dig too deeply within Bill 26 to find evidence of this. For example, in schedule I, government has the right to cancel its agreement with the OMA. It then goes further and retroactively protects itself from any legal judgements on past breaches of existing agreements. In fact, some of those breaches have been recognized as recently as the last few weeks, with the OMA being awarded a judgement in excess of $30 million and an accumulating penalty of about $1 million per month. The government can also overturn rulings of the judiciary, as seen in schedule G and drug pricing. Finally, under schedule F, government can in effect expropriate a medical practice licensed under the Independent Health Facilities Act. Physicians owning such small businesses are not even accorded the protections usually seen in proper expropriation proceedings.
Dr Bill Orovan: I'd like to expand upon Dr Gray's last comments regarding fairness and due process because Bill 26, when taken as a package, strips from physicians all vestiges of natural justice that we have under the current legislation. Billing numbers, hospital privileges and payment for services rendered are but a few of the areas in which government has removed rights or given itself unfettered powers to control the practice of medicine.
Under schedule F, physicians' rights of appeal under the Public Hospitals Act are terminated in the event that the minister orders the closure or amalgamation of a hospital and may be terminated or substantially reduced by unilateral regulation at any time and under any circumstances. Since physicians are not generally employed by the hospitals in which they work, they are not protected by the Employment Standards Act or collective agreements, so losing the right of hearing an appeal under the Public Hospitals Act essentially denies physicians any rights for due process.
Another instance of the lack of due process, perhaps even more odious than the previous example, is the fact that the general manager of OHIP may personally determine whether or not an individual physician will be deemed eligible to receive a billing number. An unfavourable determination is not subject to appeal, thereby denying that physician the ability to earn a living in Ontario.
This legislation places physicians in the unique position of being trained for a profession which they are then forbidden by law to carry out. This occurs because Bill 26 allows government to deny a physician the billing number which enables him or her to work within the government-insured system, while at the same time the Health Care Accessibility Act prevents physicians from charging patients directly for insured services.
In addition, the government has taken for itself the power to unilaterally define an insured service and to set fees for those services, including the power to make regulations which set a fee at "nil." This means the physician cannot bill patients directly for the service but will be expected to provide it for free. This is obviously unacceptable. Government must either properly fund the services it sets out in the schedule of benefits or make the political decision to delist them and allow payment for the services to be driven by the marketplace.
Government's agenda for setting fees dismisses the traditional method of fee-setting which rewards the time and effort required to perform a service, and instead allows the minister to determine by regulation the fee payable based on a variety of factors, including specialty, experience, frequency with which the physician provides the service, geographic area, and the setting in which, or the period of time when, the service is provided.
Government also leaves itself room to identify "other factors" to influence this decision at a later time. Basically this means the government can manipulate the fee schedule in order to meet its social policy objectives of the day and opens the system up to political favouritism, cronyism and regional rivalries. This will create an environment of incredible uncertainty for physicians since government may at any time raise, lower or eliminate payment for a particular procedure. This may be done without notice and is not subject to appeal.
Even where rights of appeal are preserved, Bill 26 has the effect of rendering them useless in a number of circumstances. For example, schedule H allows the Health Services Appeal Board to require a physician to provide security for any amounts deemed by the general manager of OHIP to be owing to the government. This deposit may be set at any amount and payment may be demanded before the appeal is heard. This gives the appeal board the authority to essentially deny physicians the right to appeal by requiring prepayment of monies that the general manager says are owing.
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Dr Gray: Aside from the general lack of fairness in Bill 26, there's one last issue that we would like to address and this is the announcement in the mini-budget that the government will stop contributing to the Canadian Medical Protective Association plan, the CMPA. As you know, CMPA defends physicians in actions taken against them but also acts as an insurance company and pays out on claims to patients who have taken legal action against physicians.
In Ontario the statute of limitations for initiating a medical malpractice action is one year from the time the patient knows or ought to have known about the problem. Often this information does not come to light for many years, and for children, the clock doesn't start running until they reach the age of majority. In addition, the courts have recognized that there is virtually no time limit for complaints and suits involving sexual abuse.
This means that the CMPA, as a responsible insurer, must use its best actuarial information to cover its potential payouts to patients in years to come. It is not a so-called surplus; it is a fully funded base to provide fiscally responsive payments in the future. When I compare the responsible way in which the CMPA runs its affairs with the huge unfunded liability of the Workers' Compensation Board, the Canada pension plan, or even the lawyers' compensation fund, I cannot help but wonder whether this is the type of fiscal management that government prefers.
In terms of effect on doctors, it should be noted that the government's contribution was initiated because doctors voluntarily gave up a negotiated fee increase to create a segregated fund specially for this purpose. The rebate serves to ameliorate the high cost of medical malpractice insurance in certain high-risk specialties and domains of practice, one of which is delivering babies.
For general practitioners and low-volume obstetricians, the loss of the CMPA rebate will mean that it is no longer economically feasible to continue to provide this service. An extensive study by the OMA committee on reproductive care has already identified a serious downturn in the number of physicians who make obstetrics a part of their practice, and the loss of the CMPA rebate can only exacerbate the situation.
Physicians are already planning to modify their practices based on Mr Eves's announcement. For example, in my own community the obstetricians have met and suggested that in all likelihood only one of the four of them will continue delivering babies. The other three will likely refer their deliveries to him, and new obstetrical patients will only be taken on as his workload permits. At the same time, many family physicians in the community are also reconsidering whether to continue obstetrical practice.
I think this kind of thing will be happening across the province in the very short term, and I would urge the government to rethink its position on this matter.
Dr Warrack: I hope this brief analysis of our concerns helps committee members to appreciate the incredibly negative impact this legislation is going to have upon the physicians of this province and the patients we serve. In a number of areas, for example, physician supply and distribution, government has chosen to ignore the tremendous amount of work that has been done to try to resolve very complex problems. Instead government is using a ham-fisted approach to uproot our young physicians from family, cultural, social and religious ties in order to force them to move to communities where government has decided they must practise.
This is being done without regard for the fact that their training could be inappropriate for the type of medicine that is required in those rural and northern towns. I am gravely concerned about what this will mean for these new graduates and whether medicine will continue to attract the bright, dedicated students that it has in the past.
As a final note, I'd like to emphasize the OMA's continued willingness to work with government on the various issues that Bill 26 is intended to address, including the myriad of issues that we've been unable to raise in this short presentation. We've proposed a number of creative solutions over the last few months and would like to have the ability to continue to do so in an appropriate forum. We'd like to have an opportunity to put forward some of our alternative solutions.
Thank you for your attention. We would be pleased to use our remaining time answering any questions you may have.
The Chair: Thank you, gentlemen. We have about four minutes per party, beginning with the government.
Mrs Ecker: Thank you very much for a very detailed presentation. I think you've had a lot of issues raised there. One of the things I would like to just have some comment on, with your familiarity and expertise in the appointment-of-privileges area, is that my understanding is that the appeals for privileges are still there, with the exception of when a hospital is actually being closed, so that the rights to appeal privileges and that are still there to the Hospital Appeal Board in other circumstances.
I guess what I would be interested in is why, given the fact that we've already lost 6,700 hospital beds in Ontario and that has meant significant downsizing with significant job loss by nurses and other staff who have not had a right to appeal those closings of wings and beds, I'm curious why we need to have an appeal mechanism for physicians who lose privileges because some actual hospitals have had to close.
Dr Orovan: I think you are right in saying that that provision is available in the bill if hospitals are ordered to merge or amalgamate or close, but clause (u) also gives the government the power to extend that to any circumstance in which regulations can be made to apply. So it is not just in that narrow range but in any circumstance regulations can be made for the normal operating conditions for hospitals, which would make the exact same appeal process unavailable to physicians.
Mrs Ecker: Okay. Thank you. The other question is that for many years, governments and the OMA have wrestled with the problem of underserviced areas. Many proposals have been put forward, various kinds of incentives have been used, and unfortunately we still have a growing discrepancy in the number of physicians in underserviced areas vis-à-vis, for example, the GTA.
Now, my understanding is that the minister has indicated that some of the proposals that are being worked on now through the OMA and PAIRO and other groups, he's prepared to allow those to have an opportunity to take effect before he looks at making actual legislation about limiting billing numbers or whatever.
I guess the question is, after years of not being able to solve this problem through consultations, through discussions, through many, many governments, through many, many organizations putting forward recommendations, how do we solve the underserviced area problem?
Dr Gray: If I could try to address this, clearly there is no quick fix for this problem, and we have indicated to the minister in repeated discussions throughout the fall that we do not believe that there is a simple answer. The government has indicated it believes the billing number solution will solve the problem, in the short term and the long term. We believe that is not the case.
I will admit that the incentive measures that currently exist have not proven satisfactory. We have acknowledged that. We acknowledged it in 1993 in our discussions with government and in fact negotiated what we thought would be a good solution to the problem. The government of the day failed to implement it, and this government has also failed to implement that solution. We have proposed a very comprehensive incentive program, in fact, to be funded by the doctors of the province. The minister has recently seized on this and claimed ownership of this, but in fact this was proposed by the Ontario Medical Association.
We believe there are long-term solutions to the problem, but they will take time to come into effect. If the minister is saying he's going to wait till the summer to see what happens, I think he's deluding the people of Ontario, because the newest graduates won't enter into the system until July. They'll only be starting to enter practice, so we're not going to see a solution by the summer.
The Chair: Thank you very much, Mrs Ecker. Your time is up.
Mrs Ecker: But are not the Scott recommendation implementations going to be of assistance?
Mrs Caplan: You've been very gentle, using the word "deluding." I'm going to quote what the minister said yesterday. These are his words from his opening statement:
"We want to continue to work with the medical profession in a relationship based on recognition and respect. Cooperation, fairness and equity do not come from a legal document. It comes from the will to work together.
"And Bill 26 provides many of the tools that I am sure will improve partnership and trust between physicians and the government."
As I proceed to ask these questions, I said to him after he continued on with the rest of his statement yesterday that in fact he had poisoned the well in the relationship. He suggested full consultation with you and discussion of his proposals, and I'd ask you to comment on that, but I do have a very specific question on the issue you raised on CMPA.
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The College of Physicians and Surgeons of Ontario were here. They said they warned him what would happen if he announced changes on the Canadian Medical Protective Association funding, and because I have some notion and remembrance of how that in fact came into practice, I'd ask that you talk a little bit about the discussions there have been and the issue that's been raised around the CMPA premiums. The government got involved, as you said in your remarks, regarding some negotiations. What's the best way, do you think, that those insurance premiums should be paid, and do you think there's a role for government at all?
The second question I would have on that is, there's also been -- and yesterday the parliamentary assistant, who's not here today, and I regret that, asked a question about the size of the reserve and the actuarial component. Now, none of us here is expert on that, but I think you're more familiar with it than any of us. What do you believe is the right amount and how's that determined as to what's appropriately well funded or properly funded as opposed to excessively funded for something like the Canadian Medical Protective Association?
Dr Gray: You've asked two questions and I'll try to answer each of them briefly. You've asked, what's the best way to pay and should government be involved? In fact, government pays no matter what way you look at it. We have a closed payment loop. The government is the sole insurer of medical services in this province, so physicians are remunerated virtually exclusively through the government. So whether the government pays the premiums directly or whether it pays them through the fee schedule, OHIP pays, one way or the other.
Worldwide experience has shown that in fact the best way is to reimburse the premiums directly. That is the experience in Europe. That's the experience in fact in well over half the physicians now in the United States who work in HMOs, in university settings and so on. It is not the case where physicians work under fee-for-service, and in fact the premiums are almost astronomical in the United States, $100,000 or more, and they have the ability to adjust their fees if the premiums go up. We do not have that ability, so I think the fairest and most equitable way to deal with this is for government to pay the premiums directly, as I believe, and you can check this with the minister, the government is doing with midwives now.
As far as the size of the reserves, this is a difficult question. I think there's a lot of misunderstanding of what reserves are. This is not a pool of money that's there for the use of the physicians. It's a pool of money that's there to compensate patients for years and years. As I mentioned in the presentation, we don't know how long it will take for a suit to come to court and to be finished.
The experience in the United States: Commercial insurers move in and out and leave patients and physicians high and dry. We had a similar experience in Quebec in the 1980s. A company called GESTAS in fact was lobbying very hard to become involved in the provision of malpractice insurance in Ontario. They ran into financial difficulty, left the patients and the doctors high and dry.
Mrs Caplan: And the question on consultation?
Dr Gray: CMPA acts responsibly.
The Chair: Thank you very much, doctor. Thank you, Ms Caplan.
Mrs Caplan: And the issue on compensation?
The Chair: Ms Lankin.
Ms Lankin: I have two questions for you. The first is with respect to the issue you raised on the privacy concerns in the legislation. The minister has in fact told us that nothing has changed in this legislation, it's the same as it was before, there's nothing we should be concerned about, it's completely a red herring, and yet you say there has been a significant change. I would really like you to explain that difference to us.
The second question: You've made some very clear opening statements about even in the three weeks that you've had, you've probably missed some things in this bill and it's impossible to cover all the concerns in the time allotted today. So we don't even know all the concerns that you have with respect to this bill. You've said that the bill is radical, that it's not completely supported by the public, that the privacy concerns are not a red herring and that doctors in fact are being scapegoated. While Ms Ecker disagreed with me this morning, I see headlines like, "Ontario Minister Attacks Doctors in Justifying Bill's Sweeping Powers," "Minister Uses Attack to Defend Bills."
I think we need a process in which we can hear from people appropriately and democratically about the bill. A lot of other groups have suggested that we need to stop this process and split the bills and take a bit more time. I would like your comments on that as well.
Dr Warrack: If I could just go back to one question before about the consultation from government and the minister, when we were having some discussions with the minister early, we felt that we were negotiating. He indicated that there was some legislation pending. We asked him whether or not we would be able to have access to that legislation prior to its being tabled and he said he would think about it. Well, I guess he thought about it and said no, because we had no prior knowledge of what was included in the legislation.
Mrs Caplan: That's outrageous.
Dr Warrack: Regarding the splitting of the legislation, certainly these things are so complex that, in my mind, almost every schedule could be a different process because there are so many far-reaching proposals in there. Certainly I think that we would support any call to split the legislation up and have longer hearings and have proper debate, rather than even this three-week process.
Regarding privacy, I'd like Bill to answer that.
Dr Orovan: With respect to privacy, I think we would profoundly disagree with the minister that there are no changes. There are major changes, at least two of which are that under the existing legislation, inspectors can be appointed by the College of Physicians and Surgeons to the Medical Review Committee. This legislation permits the minister or the general manager of OHIP to appoint more inspectors, without consultation with the college and without any legislative or any remarks in the bill about what their competence might be. So there's a huge quantitative difference. In addition to that, there's a major qualitative difference. Not only do these new inspectors acquire all the powers that the existing MRC inspectors do, but the provision for reasonable grounds has been removed. Now the minister or the general manager of OHIP can direct these inspectors into any physician's practice without any reasonable grounds to believe there's been any sort of wrongdoing.
In addition to that, the bill, in its proposed form, allows the general manager of OHIP or the minister himself to see the entire medical record of any patient that he or she may wish at any time. That's a dramatic new power the minister has given to himself under this bill.
Mrs Caplan: And if he inadvertently discloses?
Ms Lankin: No liability.
Mrs Caplan: Outrageous.
The Chair: Thank you very much, doctors. We appreciate your involvement in our process.
The committee stands in recess until 1 o'clock.
The committee recessed from 1158 to 1303.
Mrs Caplan: I have two points I'd like to make. I don't think it's a point of order, but it is something that I think should be on the record. I made the request that the minister table with this committee any amendments he had as they related to the health sections of the bill. The minister yesterday said that he would do that. There was a press release yesterday on a proposed amendment to the bill as it related to the restructuring commission. We've seen no amendment, and I'd ask, Mr Chair, if you would notify the minister that we would expect to see that and any other amendments today, if possible.
I think that since he made the commitment that we would have those amendments before committee so that people coming forward could know what he intends to do as far as changes to this bill are concerned, it is important that he keep his word and table those amendments as soon as he has announced them or in fact as soon as he has agreed to them. That's point 1.
The second point is that I've been a member here for 10 years, I have served on many committees and I've served as committee Chair. I cannot remember an occasion that a bill has been in public hearings without having any leadership from the government sitting at the table, either the minister himself or herself or the parliamentary assistant. I think that it is complicated, because this bill touches so many ministries and so many areas, the government maybe deciding who should have carriage of this bill, but in fact there's nobody here on behalf of Mr Eves, there is nobody here in the chair next to the research officer and the Chair of this committee on behalf of the Minister of Health, and frankly even the parliamentary assistant, who is a member of this committee, isn't here.
The message that sends out is that the government is not listening. To have some political staffers sitting in the audience I think is an insult to the people who are coming and making presentations, who are expecting that someone in elected office will have carriage of this bill and that they will be present at these hearings. I wanted to put that on the record. I'm not going to take very much time, but I would hope that the minister and the government would reconsider the way they are conducting these hearings.
The Chair: I will pass those comments along to the minister.
Mr John R. Baird (Nepean): On the same point --
The Chair: No, I don't want to get into a debate about this. We're going to get on with the first presenter.
TORONTO MAYOR'S COMMITTEE ON AGING
The Chair: From the city of Toronto, the Toronto Mayor's Committee on Aging. If you would introduce yourselves, please, for Hansard, you have half an hour. Any time you leave for questions will be divided up at the end, beginning with the Liberals. Welcome.
Ms Lois Neely: All right, I'll start. I'm Lois Neely, the chair of the Toronto Mayor's Committee on Aging. As to my experience in this field, for 20 years I was administrator of a long-term-care facility for 75 seniors. I also served on the Ontario Advisory Council on Senior Citizens. With me I have Isador Milton, who is a pharmacist and the chair of our drug education committee; Margaret Bryce is coordinator of the Toronto Mayor's Committee on Aging.
Mr Chair, honourable members, the Toronto Mayor's Committee on Aging wishes to comment on two parts of this bill: the proposal to charge user fees for the Ontario drug benefit plan, as outlined in schedule G; and the proposal to charge user fees for people who are unable to leave hospital because they have nowhere to go, as outlined in schedule H.
First, our comments on the changes to the drug plan: The Toronto Mayor's Committee on Aging believes that drug therapy is an important component of our health care system. Drugs are often the therapy of choice to manage chronic conditions such as heart and blood vessel disease, arthritis and diabetes. These therapies permit the senior to live a relatively independent and productive life. The Toronto Mayor's Committee on Aging believes that all medically necessary therapies, including drugs, should be available without cost to the senior user.
Seniors remember when insurance for physician and hospital care was not universal. They remember that some people with low incomes did not receive coverage because they had to register to be exempt from premiums. The TMCA is concerned that the implementation of this program has not yet been designed and that some people will not receive the drugs they need.
We believe that it will be very difficult for some people who receive their income in irregular amounts to pay for their first $100 of medications each year. We're told that there are at least 35,000 people on the Ontario drug benefit plan who receive over 100 prescriptions a year. It will be very difficult for them to pay the copayment of more than $700 which will be required under this bill.
We believe that the assessment for eligibility for the program should be made as simple as possible. Seniors on fixed incomes should not have to make an annual report of their income but should be qualified automatically through their income tax returns. We believe that benefits and charges should apply for a calendar year and not on the government's fiscal year. What do ordinary people know about a year ending on March 31?
We are concerned about the loss of privacy inherent in implementing this program through the pharmacies. We do not believe that store employees should have access to information about a senior's income or lack of income.
We had four public meetings in 1993 on the issue of user fees for drugs. When low- and moderate-income seniors were asked what they would do if they could not afford to pay for their drugs, they said that they would continue to take the pills which are necessary to keep them alive and forgo the ones which merely alleviate pain. We believe that this will have very unfortunate consequences for the health of these people.
The Toronto Mayor's Committee on Aging believes that the government should continue to investigate other ways to save money on drugs before considering cost-sharing. We are impressed by the savings that the homes for the aged operated by Metropolitan Toronto have made by operating a central pharmacy and by careful review of the medication of the residents. This resulted in happier residents, because seniors were no longer drugged into lethargy. But we're very disheartened that the Ministry of Health has chosen not to fund this program and that the pharmacy may be contracted out to the private sector, which will charge higher dispensing fees.
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The Toronto Mayor's Committee on Aging believes that the cost of the drug benefit plan cannot be contained unless physicians are a party to changes in the plan. One member said that he was insulted by the idea that consumers and pharmacists were responsible for abuses to the system. The government must have the will to work with the Ontario Medical Association to make changes.
We recently held a forum on seniors and drugs. You'll be able to watch it this week on Rogers TV, Friday the 22nd at 7 pm, and again on December 30 at 9 pm. We held this forum because we were concerned about the very dangerous overuse of drugs in the seniors population. Studies consistently estimate that between 20% and 30% of admissions of older people to hospitals are caused by adverse drug reactions.
We believe the government should work together with the Ontario Medical Association, seniors' organizations, pharmacists and community groups in developing educational programs which will decrease the instance of poisoning of seniors by prescribed and over-the-counter medications. This will ultimately save money for the Ontario drug benefit plan and the Ontario health insurance plan.
The Toronto Mayor's Committee on Aging is concerned that the government is proceeding with legislation to implement cost-sharing. The period of public discussion has been very short. There is no public consensus that cost-sharing is either necessary or desirable.
The TMCA is concerned about the divergence between the statements by the government during the election campaign and the policies contained in this bill. During the election campaign, the Premier and candidates for the Progressive Conservative Party promised that there would be no user fees in the health care system and no cutbacks in services to seniors and people with disabilities.
The Toronto Mayor's Committee on Aging believes that it could make a useful contribution to the discussion about changes to the plan, that there are other such organizations that could help you with practical and creative solutions. We believe that these ideas should be considered before you move to charge seniors for their drugs.
I would now like to turn to the proposal to charge people to stay in hospital while they are awaiting transfer to a transitional-care, long-term-care or chronic-care hospital. This proposal defies common sense. People do not want to stay in hospital if there's an appropriate place for them in the community.
The Toronto Mayor's Committee on Aging is a member of the Task Group on Transitional Care, which has documented the serious consequences of premature discharge of seniors from the hospital and which argues for the funding of beds for transitional care. The recently published report of the Metropolitan Toronto District Health Council on hospital restructuring has in fact taken the advice of the task group and recommends that transitional care beds be established in all but one adult general care hospital in Metro.
The restructuring report also estimates that 1,180 new long-term-care beds will be required in the next four years in Metropolitan Toronto, just to accommodate the restructuring. With the waiting list for long-term care in Metro standing right now at 3,500 and the vacancy rate consistently less than 1%, it seems that there will always be someone appropriate to take up any facility bed which is made available.
We note that residents of chronic-care hospitals do not have to pay for room and board for the first 60 days. Can we charge these same people in acute-care hospitals? We also note that Ministry of Health regulations force a home for the aged or nursing home to discharge a resident after 21 days in hospital. Will these same people be charged for refusing to go to a home when there is no bed to go to?
The funding for homes for the aged and nursing homes has been constrained, and further cutbacks are proposed. Municipalities, including Metro Toronto, are considering divesting homes for the aged, because of the cutbacks to municipalities, and Home Care has capped admissions to the program. The long-term-care sector is becoming smaller. It cannot meet the demand to place people who are ready to leave the hospital.
Until the charitable organizations and municipalities are able to provide enough beds in homes for the aged and nursing homes, it is both nonsensical and heartless to force people to leave the hospital before appropriate care is available.
The Toronto Mayor's Committee on Aging is willing to assist in any way in developing appropriate policies to meet the needs of seniors.
Isador Milton is a retired pharmacist and chair of our drug education committee. Do you have something you'd like to add to what I've said, about the drug problem especially?
Mr Isador Milton: I wish it were that simple, that I could just add to it, but I was informed of this hearing and our place in it as late as about 8:30 last evening. I drew up what my feelings are, as a pharmacist and as a citizen of Ontario and of Toronto, specifically on the proposal to introduce user fees.
As the chair of the work group on drug education of the Toronto Mayor's Committee on Aging, I have certain views about this based on some of the discussions we had at the committee. The decision of this government to introduce the so-called user fees into the Ontario drug benefit program is being seriously called into question by the Toronto Mayor's Committee on Aging, as you have just heard quite extensively from our chair, Lois Neely. This is obviously of great concern to our committee, which, as its name implies, is committed to the welfare of Toronto's senior citizens.
Bill 26, the subject of this hearing, encompasses several laws which are going to affect seniors very adversely, to which our committee is strongly opposed. I am here as one of the members of the Toronto Mayor's Committee on Aging to express this opposition. I'm going to express our strong opposition to the changes in the Ontario drug benefit program specifically, which is imposing punishing user fees on the already economically disadvantaged seniors of our city and our province.
I and our committee are not interested in coming to a hearing such as this simply to bash the Harris government, but we are deeply interested in monitoring any and all government initiatives, of whatever political stripe, which directly or indirectly affect the health and welfare of our seniors. We have a duty to assist the mayor and the council of the city of Toronto in maintaining and improving the quality of life of its senior citizens. There can be no doubt that the wellbeing of the seniors of our city is of tremendous importance to the wellbeing of the city of Toronto and thus of the whole province, economically, socially and culturally. Let us look at the economics of this huge user fee, as proposed.
The Ontario drug benefit program was introduced in 1974, providing a government-approved list of prescription drugs free of charge. To seniors 65 years of age or older, this was available. Many of our seniors who turned 65 during that period and became beneficiaries of that program are still alive and still getting their prescriptions filled free of charge.
According to the apparent philosophy of this government, this fact is contributing to the economic difficulties being faced by the province. What is their answer? Punish them for living so long by depriving them of their economic ability to continue with their medication.
What about the economic, social and cultural contributions they have been able to make to our society during these extended years of their lives? A strong case can be made that a large percentage of these seniors is alive today precisely because they have been taking medications which are consistently and increasingly safer and more effective. It is only natural and to be expected that the cost of the program would increase, but isn't there a strong probability that this cost is substantially offset by the value of the knowledge, skills, volunteerism, assistance with child care, charitable donations etc etc which seniors have been able to give to society as a result of living, and being well, longer?
There is no question that the imposition of this user fee will achieve the ill-conceived, short-sighted objective of this government: There will be a sharp decline in the use of the program, and there will thus be a so-called saving. But this could prove to be a pyrrhic victory for the government. Seniors will be hit with a double whammy. On the one hand, there will be a decline in longevity because the majority of seniors will not be able to afford the fee, and the resulting lack of medication will inevitably lead to earlier deaths. On the other hand, those seniors who survive will probably at various times wind up in acute-care beds where, in addition to the hospital costs, the government will also have to pay for the medications provided by the hospitals, which they were getting for free as ambulatory patients at home.
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That brings up a point often overlooked when calculating the cost of the drug program: Modern pharmaceuticals shorten and often eliminate entirely the necessity for hospitalization. Can you contemplate with equanimity the thought of seniors being warehoused in psychiatric institutions who formerly lived normal lives at home on the free medication they received under the Ontario drug benefit program? Can we really put a dollar value on a healthy senior citizenry in terms of its positive effect on society, the type of society that attracts industry, that type of society that attracts investment, the type of society that Ontario still is in spite of ideologically driven attacks on it?
The Toronto Mayor's Committee on Aging is inalterably opposed to this user fee because of its tremendous attack on the economic wellbeing of our senior citizens. Because many seniors take several medications, they can expect to have to come up with up to $30 a month on top of the $100 deductible, depending on the number of drugs they must take. At $6.11 per prescription, it is an unconscionable burden. It is quite possible that those earning less than $16,000 a year, who will be forced to pay a $2-per-prescription fee, will be just as severely affected.
The Toronto Mayor's Committee on Aging is inalterably opposed to Bill 26 in its entirety. Although it is proposed by a democratically elected government, the powers it confers on the various ministers and the manner in which it is being introduced run counter to democratic principles.
Thank you very much for listening.
Ms Neely: Thank you, Isador. May I just add, off the cuff, that as an administrator looking after old people, which was my career job all my life, I saw so much overmedicating of seniors. It really upsets me today to see seniors targeted as the cause of the escalating cost of health insurance, because we have to hand that responsibility back to the medical profession.
I saw -- I could not believe -- one gentleman who was a neighbour in an apartment where I was living. He had just come back from hospital, and I met him coming out of the pharmacy with a bagful of medications. He told me he had 38 prescriptions he had come home from hospital with -- 38 prescriptions. I couldn't believe it. I went straight to the druggist, who I knew very well, and said: "He tells me has this. Is that so?" He said, "Yes, I just filled 38 prescriptions."
There has to be better coordination among our medical teams in hospitals. That wasn't the senior's fault. Incidentally, he didn't live very long. How could any one person manage 38 prescriptions? Impossible.
The other cause we see, and we pointed this out in our newsletter, has been the rapidly escalating cost of drugs, particularly the cardiovascular drugs, which have gone up 240% in cost, for whatever reason, whether it was Bill C-91 under the Mulroney government -- whatever reason. But we're disturbed that seniors are getting targeted. Is it, as Isador has pointed out, because we're living too long? Is that what it's all about?
Thank you very much for this time.
Mrs Caplan: First of all, the government wanted this bill completely passed before Christmas. That was their original intent. They announced that on the day they tabled the bill in the House. You know how that happened? I can't apologize for them, for the fact that you've had so little notice on this bill, but there wasn't even time for an ad in the newspapers. There are many people who do not know what's going on, and we've been very concerned that in fact that is the government's agenda.
I'm going to ask you a very important question. I have a copy of -- remember this? It arrived at your doorstep; it's the Common Sense Revolution document. In this, Harris and the Conservative government said, "Our cuts will not hurt seniors and the disabled." They said, "No new user fees." They said not one cent, "Not one penny will be cut from health care." They promised to protect health care. In fact, I remember Mike Harris standing up and saying, "I have no plan to close hospitals."
Do you think that Bill 26 keeps those promises, and if it doesn't, do you think maybe that's the reason they don't want anybody to know what they're doing?
Ms Neely: We referred to that, that we see divergence here and it disturbs us. We're grateful that you did notify us and give us this time to present what we've said.
Mrs Caplan: Do you think the seniors in this province believe, if they knew what was going on in this bill, that Mike Harris is doing what he said he would do and keeping his promises?
Ms Neely: We're representing the seniors in the city of Toronto. We're speaking for them.
Mrs Caplan: And many of those seniors voted for them. Do you believe that the seniors in the city of Toronto think that Mike Harris is doing what they thought he was going to do when they voted for him?
Ms Neely: We've expressed our concern. This is our concern we're registering now.
Mrs Caplan: Good concern. Thank you.
Ms Lankin: I did hear you express a concern that you hadn't had a lot of time to understand the full ramifications of the bill but you appreciate the opportunity of being here. A number of other groups that have come forward have had similar problems in terms of getting the information, getting access to it and understanding it, and have raised this as a real concern and a real problem with respect to the process of public input on the bill. There has also been a growing move on the part of presenters to suggest that this bill really should be split appropriately into sections and dealt with in the normal course of events and not pushed through so quickly.
You've set out your concerns, but I need to ask you, what's your preferred route of dealing with those? A lot of work would have to be done to take your general concerns and try and turn them into specific amendments or understand how they impact on three or four different schedules under the act. While you've made a general comment, it applies to hospitals as well as independent health facilities as well as the drug plan. Do you think the act can be amended and do you believe there's time in the process to do that, or would you support the call to split the bill and to spend a bit more time working through these amendments?
Ms Neely: I think we would support that because there needs to be a very well-organized program in place before you put through what they plan to do, as we understand this bill, particularly as the drug benefits go. This is a very far-reaching and very devastating situation for seniors.
Ms Lankin: Do I have time for one more question, Mr Chair?
The Chair: A short one.
Ms Lankin: That's always a challenge.
With respect to the drug benefit program, government members on this committee have asked a number of people: "Why is Ontario different? Every other province has user fees or copayments. Why is it different here?" In your experience in liaising with other seniors' organizations, have you looked at the effect of those copayment structures in other provinces? Do they prohibit lower-income seniors from accessing necessary drugs? Do they have to make the kind of choices that you've talked about?
Mr Milton: In view of what you agree is the impossibly short period of time we've been given to prepare for this particular hearing, I can't honestly answer that question in the affirmative, because I have not been able to measure that or consider that.
But your suggestion of splitting the bill, which we support heartily, has so many positive values to it. For example, if they address the question of the Ontario drug benefit program separately, maybe that would give them an opportunity to meet with and consult with the pharmacists' association. One small example of what costs can be garnered by a rational approach to the problem is this small matter of what is called a PC-34. A PC-34 entitles the patient to receive a brand-name drug instead of a generic drug. If the patient requests it, the doctor simply has to fill out this green form. Immediately the government is mandated to pay a greater price for that similar drug under PC-34. Now, that used to be. I know there have been changes, but that's just one example.
The Chair: Thank you very much, sir. We're on a very tight time schedule here. The government, please. Mr Clement.
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Mr Clement: I'd like to thank the presenters for their submissions. You've certainly put a lot of thought into it and it's quite articulate from your perspective. We've seen a lot of presenters who have actually put a lot of time into it and were able to do so in the time constraints available. I thank you for being so thoughtful.
I just want to talk a bit more about the Ontario drug benefit situation because it's obviously something that affects a great many people in Ontario. We've had a plan whose expenditures have tripled in the last 10 years. They've gone up by a factor of three in terms of their expenditures. For the government and for taxpayers there always has to be a balance between giving out services and being responsible to the taxpayers and dealing with things like overmedication as well, which you raised, and I thought you were very cogent on that point.
My question is: If we had a choice between cost sharing and delisting, and surely we don't want to start delisting some of these drugs, if you were in our shoes how would you balance it out?
Ms Neely: That's the question?
Mr Clement: Yes. How would you balance it out if you had to make some of the tough choices that governments always have to make?
Mr Milton: As a first thought, I don't know how much thought the government gave before considering deletions or other cost-cutting measures of that nature. They have considered internal cost cutting, administrative cost cutting, like one that I've just mentioned. Also, they have to think in terms of the whole picture, as I've tried to emphasize, the social costs of deleting or constraining medication for seniors.
After all, there could be serious discussions, as Lois has mentioned, with the medical profession regarding overprescribing, and we still don't know whether that is patient-driven really, as they claim, or whether it is physician-driven. It may be a combination of both. But I think that the speed and the hurry with which this was prepared indicates, to us anyway, that still not enough thought has been poured into this whole matter as to the outcome of constricting or constraining or otherwise affecting the ability of the seniors to get medication.
You must remember this. It's not only a question of seniors coming on the stream now who are going to get this. What about the seniors who have been on this medication for many years, which would represent a tremendous hazard in suddenly cutting them off because they can't afford it. Cutting off is sometimes just as deleterious as not getting it in the first place.
The Chair: Thank you very much, sir. We appreciate your attendance here this afternoon and your interest in our process. Have a good day.
Ms Lankin: Mr Chairman, could I raise a concern, please?
The Chair: Is it a point of order?
Ms Lankin: It is a concern and I think it would be unusual if you wouldn't at least hear me out on this. It's a request that I would like to make of you as Chair.
As you know, this bill passed second reading a week ago tonight, on Tuesday, December 12, and it was the next day after that, I think, that the subcommittee of the full general government committee met to look at the process for people being scheduled for hearings. As I raised yesterday as an example, there was a woman in the audience who had called on Thursday for the Toronto hearings and had been told already that all the spaces were full and was unable to get a spot.
As you well know, we have been informed this morning by the Clerk's office that the 274 hearing spaces for the two subcommittees in the 11 communities that we'll be travelling to in the two weeks in January are already oversubscribed: 274 spots, and as of this morning there were 290 applicants, and that doesn't add the calls that came in today. Every one but one of the 11 communities, 10 out of the 11 communities, are already oversubscribed.
Given that we have a huge waiting list here in Toronto, a huge waiting list already starting in the out-of-town hearings -- and may I add that the ads have not even gone in the papers yet for the out-of-town hearings -- I would sincerely request that you as Chair of this committee convey this concern and problem to the government House leader and to the Minister of Finance responsible for this bill and request that consideration be given to either appropriate splitting of the bill or further hearings on this matter.
The Chair: Let me just comment on that, and I'll pass that question along. I do have to explain, though, that the decision about the length of the hearings and the number of people in the cities and so on was agreed on by the three House leaders. It wasn't something that the government --
Ms Lankin: I assure you that our House leader will agree to extended hearings.
Mr Clement: On a point of order, Mr Chair --
Mrs Caplan: I'd like to speak to that for a minute.
The Chair: No, we're here for public hearings. We're not in here to debate what's going on between the parties. We will take that up later at the subcommittee level. With due respect to the people who have come here to make presentations, we'll deal with that later.
Mrs Caplan: Could I request that the clerk table every day the list of those people who have been denied the opportunity because the waiting lists are full, in other words, because we have a full wait list?
The Chair: You're out of order.
ONTARIO PUBLIC SERVICE EMPLOYEES UNION
The Chair: Could I have the next presenters, please, the people from OPSEU. Thank you very much for coming to our presentation this afternoon. You have a half-hour to use as you see fit. Any time that's left over at the end for questions, the questioning will begin with the government. The floor is yours.
Mr Warren Thomas: Good afternoon. My name is Smokey Thomas and I work at the Kingston Psychiatric Hospital. I'm a registered practical nurse there. I'm also an executive board member of the Ontario Public Service Employees Union and I'm sitting in today for our president Leah Casselman. With me is Tracy Musset who, prior to joining the staff at OPSEU, worked at a community health care agency.
Our democratic union currently represents 105,000 members who will be profoundly affected by this bill. Approximately 20,000 of our members work in the health sector in hospitals, community agencies, long-term care facilities, public laboratories and as ambulance attendants. OPSEU welcomes this opportunity to present our concerns about Bill 26, the Savings and Restructuring Act, 1995.
These public hearings almost didn't occur and we're obviously pleased that they're happening. If it hadn't been for the dramatic tactics by opposition MPPs we wouldn't be here today. We appreciate that their actions were born out of frustration and anger.
Everyone who has had the opportunity to review this bill is frustrated and angry, furious in fact, over the government's proposed changes and the actions of a deceitful government. The government has shown blatant disrespect for the public and for democracy in assuming that they could ram this huge omnibus bill through. Their actions insult the intelligence of the Ontario public.
This bill is unprecedented in both size and scope. It's not just a housekeeping bill and it's not just a toolbox for implementing the economic statement. It gives this government extraordinary and unnecessary new powers. The omnibus bill repeals two acts, creates three new ones and amends 44 other pieces of legislation. This is not one bill but many. It affects municipalities and the environment, civil servants' pensions and the collective bargaining process, health and natural resources.
Every single part of this bill introduces fundamental changes. Every single schedule should have received individual attention, consideration and consultation in an open, democratic process. Bill 26 proposes changes which will destroy government accountability in many areas where it needs to be most accountable.
We are obviously disappointed about the process, or lack of process, regarding the introduction of this legislation. We are very shaken by the content. We are alarmed by the extent to which Bill 26 will impact us and our families and our communities, especially with regard to health. What Bill 26 does to our health care system and to this province is enough to make you sick.
Schedule F of the omnibus bill amends four pieces of health-related legislation. Amendments to the Health Care Act replace the Ontario Council on Health with a new body, the Health Services Restructuring Commission. The mandate of the Ontario Council on Health was to advise the minister on health matters and the needs of the people of Ontario. This new commission is to carry out the minister's bidding, performing all duties assigned to it with immunity.
At the same time that the Minister of Health insists that community planning bodies are the eyes, ears and conscience of a community, his appointees will be his muscle and teeth, a bully squad. He claims that the commission's job is to bolster community-based planning. While to "bolster" may mean to promote, strengthen or to celebrate, that's clearly not this government's intent.
The minister says the commission is needed because the 60 communities that are involved in hospital restructuring studies are not doing implementation planning, but they are, or they would be if they hadn't been told to get their studies in with or without public consultation.
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This government obviously feels that the minister's bullies can implement the changes faster and cheaper. I read this morning that his bullies have four years to close our hospitals.
Across Ontario OPSEU members are participating on hospital operating planning committees, trying to add their experience and expertise to the planning process. I'm part of a coalition in Kingston that brings people together from all parts of the community, and we're looking at how all of us will contribute to and benefit from real planning and real debate. Imagine, if you will, labour, local business people and politicians realizing that we all live, work and play and spend in the same neighbourhood.
The Minister of Health has said that the commission will operate at arm's length from the government, but it's appointed by the government, will be assigned duties by the government and will report to the government. The proposed changes to the Ministry of Health Act makes it clear that the needs of the people of Ontario are secondary to the agenda of this government.
Changes to the Public Hospitals Act, along with other parts of Bill 26, suggest new roles for the Minister of Health: hospital administrator, doctor, pharmacist, loan shark and mind reader. He'll run hospitals, he'll decide when, how much and under what conditions our hospitals will be funded. He'll impose the terms of the funding and will amend or remove those conditions and impose new ones. He'll direct a hospital to cease operating or to provide a service or not provide a service. He'll order hospitals to merge.
The Minister of Health can make any direction related to a hospital that he wants as long as he considers it to be in the public interest to do so. Under this bill he will determine what is in our interest. He will supposedly know and understand, without having to ask anyone, what the public thinks, wants and values. We are supposed to believe that his interests are now our interests when it comes to health care.
This bill reveals some of his interests. The minister, the cabinet and all of his bullies will be protected from any legal proceeding as a result of their decisions. The public may be put at risk, but even with balanced-budget legislation, the minister's salary will not be.
Investigators previously appointed by the government to report on the quality of management and the quality of care now will be assigned to look into any matter relating to a hospital.
Under the new legislation a supervisor can be sent into a hospital with no connection to an investigator's report. The supervisor will be dispatched by this government, will report to this government, will respond to and carry out every direction of this government, including the direction to close a hospital -- more bullies protected from personal liability or responsibility, as is anyone who is assigned ministerial power.
To run these hospitals, the minister will need and under this bill receives sweeping powers to regulate the purchase and disposition of hospital assets and the ownership, custody, use, disclosure, retention and disposal of medical records.
The minister is given the power to define services, a power he needs to unilaterally deinsure services, redefine what is medically necessary and introduce user fees.
Why does the Minister of Health require this unrestrained power to close hospitals without public hearings and without giving communities the right to appeal to a higher authority?
Why does a government that believes in less government want the authority to interfere with the operations and property of a hospital?
Why does this government need the authority to use, disclose, retain and dispose of medical records?
Changes to the Private Hospitals Act will allow the Minister of Health to revoke a licence and reduce or terminate funding without notice or access to appeal.
He can step in and run the hospital for six months. As in the Public Hospitals Act, there is no requirement for public consultation, there is no accountability to the public.
Changes to the Independent Health Facilities Act amend language which is crucial to our maintaining a universal, accessible, not-for-profit health care system in Ontario.
Independent health facilities can be expanded far beyond their present use and will be permitted to charge fees to insured persons: extra billing.
The definitions for "health care" and "health record" are being repealed, and "insured service" is changed to just "service."
Whose interest does it serve to take the words "health" and "insured" out of the legislation that affects the provincial insurance plan that covers our health care? That becomes clearer when we see in this bill the government's intent to de-insure services, introduce user fees and privatize our health care system. The motive for amending this act is the government's intent to privatize, to sell off our health care system.
This bill repeals the language that directs the minister to give preference to Canadian-owned non-profit facilities and to solicit proposals for new facilities from the general public. Under changes included in the omnibus bill, the Minister of Health will be able to selectively request proposals from foreign firms that want to make money from our health care programs. This government claims to be interested in fair competition, but these amendments and their refusal to allow hospital laboratories to fairly compete for business indicate otherwise.
Public tendering was invented to ensure fair treatment of bidders and the public. Its primary role is to remove the possibility of sweetheart deals and corruption of government by private interests. This is a scandal waiting to happen. The amendments in Bill 26 close down the public tendering process and open up the door to rapid advancement of the American-style health system, where five well-connected megacorporations control a system that costs more than ours and leaves millions of children without health care. The American health care system industry boasts record profits even while studies show that those profits come at the expense of the patients and workers.
American corporations are dying to get their hands on our health care system. They call it the "unopened oyster," and care for the elderly is referred to as "mining grey gold."
Profit has no place in the provision of health care services, especially at a time when billions of dollars are being removed from the system. It's clear that these changes are less about putting more money into direct patient care and more about putting more money into the pockets of shareholders. In many cases these shareholders will be handpicked by the Minister of Health.
Schedule G amends three more pieces of legislation to introduce copayments and deductibles for seniors and social assistance recipients, deregulate prescription drug costs, and allow the minister to collect, use or disclose personal information. Recipients of Ontario drug benefits, people with a limited income, will now pay $2 per prescription. In addition, some will pay a deductible and then the full dispensing cost of prescriptions. The government will no longer pay the difference between what cabinet considers interchangeable products, even if the prescription calls for no substitution. The government will add and remove drugs from the list of those that will be covered by the ODB.
If we had a cabinet full of pharmacists, this might make sense, but we don't and it doesn't. As it is, we can be sure that government will be making major drug decisions based primarily on economic considerations and not health considerations.
The minister can make regulations that provide for different copayments for different classes of drugs. He can decide what clinical criteria must be met for a specified drug product. He can make regulations requiring that other drug products or therapies be considered, that a certain physician prescribe a certain drug, and that a panel of experts prescribe the use of a particular product for a particular patient. He may make regulations that treat different classes of eligible persons differently with respect to income and family status.
These changes not only represent a fundamental shift in principles and values for Ontario, but do nothing to improve the health care system. User fees, deductibles and copayments for prescription drugs will not reduce the need for prescription medicine, but will reduce the number of prescriptions filled by seniors and individuals or families with limited incomes. That doesn't mean the drugs aren't needed; they just won't be taken.
Let me tell you what happens when patients are released from psychiatric facilities and the only thing that's keeping them off the street, out of jail and out of hospital is their medication. I work at Kingston Psychiatric Hospital. Discharged patients require tremendous community support. Someone suffering from a serious mental illness may need to take as many as a dozen different medications daily. Introducing a $2 per prescription fee will put them at risk to do harm to themselves or others, as most patients have very limited incomes and may be unable to purchase their medications.
User fees just shift the blame for the high cost of the drug program on to victims when the responsibility lies mostly with governments, doctors and the drug companies.
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The bill also gives the Minister of Health the power to collect, use and disclose personal information. What is the justification for this gross violation of privacy? Why does a government which professes to believe in less government need to peek in everyone's medicine cabinet or personal records?
Bill 26 changes the name of the Prescription Drug Cost Regulation Act to the Drug Interchangeability and Dispensing Fee Act because the Minister of Health is giving away the power to regulate the price of drugs for anyone not covered by the ODB. That means the cost of prescriptions sold to people who pay for their own drugs will go up, as manufacturers will be free to determine the price for drugs. Drug prices will soar, especially in remote locations. Those who benefit from insurance plans which cover drug costs -- employers and employees -- will have to deal with the impact of increased premiums.
It's ironic that this government talks about opening health care up to the market and to fair competition when it comes to drugs, because they've ignored pleas to let hospital laboratories compete fairly with private labs. They've turned down the potential to save money and inject hundreds of millions of dollars into community hospitals without increasing the cost to taxpayers. It makes no sense.
It's easy to see who wins and who loses under the amendments to these acts, and in whose interest these changes are being made.
Until now, our OHIP system was required to cover all medically necessary services provided by physicians. Schedules H and I change that. The bill removes any reference to the term "medically necessary." Instead, cabinet will decide which services will be insured. These amendments give the Minister of Health authority to unilaterally define what is an insured service and what fee is payable, subject to any criteria they define, including things like geography, the practitioner, the setting and the time period in which the service is provided. Certain services may not be insured unless provided in certain facilities, like the independent health facilities this government is inviting American firms to establish.
These amendments vest complete authority and control in the Minister of Health and the cabinet to dictate the terms under which physicians provide, and we receive, medical services. Universality, availability and accessibility of health care services are at risk.
During the election campaign Ontarians heard a lot of promises, and they heard that the promises printed in over 700,000 copies of the Common Sense Revolution were sacred. The promises that voters heard were clear.
This government promised it would not cut health care spending, that health care spending will be guaranteed and that health care funding would not be touched. Their sacred book says that aid for seniors and the disabled will not be cut, that how they achieve savings will be discussed in partnership with all Ontarians, and that their four-year plan is based on four years of study, analysis and consultation with workers and ordinary Ontarians through extensive public hearings. They say that they looked at user fees, copayments and delisting services, but decided the most effective and fair method was to ask individuals to pay a fair share based on income, and that there will be no new user fees.
Mike Harris said: "The Ontario Public Service Employees Union has developed commonsense proposals. We will work with them, listening to their ideas and eliciting their help in taking action." That's not happened.
Read through this bill. Read through the 44 pieces of legislation it affects. Read through the 2,000-page compendium. Read the schedules that affect health care. Re-read their Common Sense Revolution, campaign material substituting for real policy.
Bill 26 breaks every single one of their promises. It puts our health care system at risk; it puts our people at risk. What Bill 26 does to our health care system and to this province is, quite frankly, enough to make you sick.
The Chair: Thank you. We have about three minutes per party, beginning with the government.
Mr Thomas: We didn't start till almost 20 to, so we've got more than three minutes.
Mrs Johns: I would like to start, and thank you for the presentation. As you know, we're suffering a number of demands on our health care dollars these days. Past governments have closed approximately 6,800 beds, which equals approximately 30 hospitals throughout Ontario, and in closing these beds, they never closed any of those hospitals.
We heard yesterday from three CEOs of hospitals that hospitals alone could never close hospitals, that they needed to have some other sources to be able to do that. In fact, in the Metropolitan Toronto District Health Council report, they asked for a body that would help to implement many of the community-driven decisions.
It's your stand in this article you've just given us that the restructuring commission, which was asked for by the district health council of Toronto, is not something that should be implemented. Can you comment further on that?
Mr Thomas: Toronto is only one part of Ontario.
Mrs Johns: Yes. It's the first major one that's out. In fact, there are four out now.
Mr Thomas: This commission that you're proposing is about as anti-democratic a process as you can possibly get. All it really and truly is is a licence to steal, a licence to pander, a licence to feed anybody you want. It's not democratic. There's no real community input, no real community consultation. There's not been one town hall meeting in any town that I can think of about health care issues under your government.
Mrs Johns: So you're saying that the district health council is not --
Mrs Ecker: Mr Chair, that's wrong.
Mrs Johns: The district health council isn't a community-driven process?
Mr Thomas: We've been fighting for years to try and get seats on those district health councils and it's not truly representative of the community. I'll tell you what the director --
Mrs Johns: You know they were set up by the previous government.
Mr Thomas: It doesn't change my opinion. District health councils? They weren't set up by the NDP; they were set up years and years ago; about 12, in fact.
Mrs Johns: Okay. So you think there's been no community involvement in the restructuring of hospitals throughout Ontario.
Mr Thomas: Not what we would consider real community involvement. You show me where your government's actually sat and consulted with workers. Show me. Just give me one example. I defy you.
Mrs Johns: Okay. The second question I have is, as you know, there's a specific amount of money that the drug benefit program has increased substantially in the last, I think -- in the last 10 years it's tripled, and in the past, governments have said they have had to delist drugs as a result, to be able to put new drugs on or to be able to move forward with presenting new medications to people.
You have said that you don't like the idea we have of $2 for the people who can least afford it, for people under $16,000 and $24,000, and $100 after that. Would you prefer to see delisting of existing drugs, or would you like us to not add new drug therapies? What would your choice be?
Mr Thomas: How much do you think you'll really save having to set up another bureaucracy to collect that money?
The Chair: Thank you. It's time for the Liberals.
Mrs Caplan: A very impressive presentation documenting many of the concerns that have been expressed by many people.
One of the things that we have suggested to the government is that they segregate this huge, massive omnibus bill into smaller bills that could receive the kind of scrutiny across this province to allow individuals to know what is actually in here.
My question of you is twofold: Were you consulted at all by this minister, the Minister of Health, as a partner, front-line workers; second, do you support the call to sever this bill into reasonable segments and different bills that would allow for that kind of democratic scrutiny?
Mr Thomas: On the first part of your question, no, we weren't consulted at all. In fact, Mike Harris absolutely refuses to meet with the president of OPSEU. As an employer who employs over 65,000 members directly, employees, I would think that's a very irresponsible act for a CEO of any corporation or government to take. That's in my mind just not good business; it doesn't make any sense. Secondly, front-line workers, no, we weren't consulted at all. There are a lot of changes being made and they're just being made very unilaterally.
It's interesting to note that in the hospital -- in the Kingston area, for example, in the Whig-Standard this morning, the call is to merge, rationalize everything else but administrations. The only people interviewed were the administrators, and they're saying: "Yes, but we've got to keep all our own management structures. But we'll lay off cleaners, we'll lay off nurses, we'll lay off maintenance workers, that kind of thing. We'll contract out." So there's a real decided shift here I think from previous governments that were trying to look after everybody to a government that just tries to look after people who make big bucks.
The second part is, absolutely. We believe it should be separated out act by act by act, and extensive public consultations, not window-dressing. They're coming to Kingston for two half-days. Six people will get to present. Give me a break. That's not public consultation, right? We probably won't even get on, but we'll give them the reception they deserve, I can guarantee you that.
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Ms Lankin: I could tell from Ms Johns's questions of you that she hasn't been around long enough to realize that you certainly aren't partisan in your attacks on various ministers of Health, as I recall. It's a pleasure to see you here and I really do appreciate the time and effort that you put into the presentation.
I am struck by the fact you haven't been consulted at all, first of all, in general, that the Premier refuses to meet with the union that represents the direct employees of the government. But overall let's just talk about these bills and the Minister of Health.
You represent direct government employees who work the for the Ministry of Health, the people who do the OHIP cards, who do all the OHIP billings, who understand about where problems are and fraud in the system, if there is any, and how to get at it. You represent people who work in direct government-run psychiatric hospitals, nurses, health care aides, a whole range of employees there. You represent people who work in public hospitals, in laboratories, in private labs, in hospital labs, in community-based health care agencies, and I could go on and on.
Surely you are an organization that has a breadth of knowledge and experience in the health care system and the restructuring that's going on. I just say it is stunning that you weren't consulted and had not met on this.
I was going to ask you about a couple of amendments, but I think you've made your position clear: You believe the bill should be split and we should be taking this a section at time.
Mr Thomas: I don't think this bill can be fixed. I think they should just turf it out, to be honest with you. How could you amend something that's not even democratic to somehow make it palatable, knowing that they're not going to do that, because they have a majority and they'll shove it down our throats whether we like it or not? They should at least do the decent thing and split it up and let the interested parties have input that way.
Ms Lankin: I think you've just about covered everything. I should just let you know that there are already as of this morning 16 people who've applied for those six spaces in Kingston and the ad hasn't even gone in the paper yet. I was wrong on my numbers earlier: There are actually 316 people who've applied for 274 spots in the out-of-town hearings and the ads haven't even gone in the paper yet. I have requested that the Chair take this issue back to the government House leader and the Minister of Finance, both the issue of splitting the bills and the issue of additional time for public hearings.
Mr Thomas: We have problems right now with the government in that workers who are trying to be vocal or apply for standing are being intimidated and told not to and have had a very thinly veiled threat about their continued employment and that kind of thing. Not only is there not consultation; there is intimidation. It's a very real problem for us. I'll give you a classic example. You used to be Minister of Health.
The Chair: Thanks very much, sir.
Mr Thomas: In Kingston, they're hiring replacement workers in case we go on strike at OHIP.
The Chair: Your time is up.
Mr Thomas: They're paying them 45 bucks an hour and calling them consultants. Is that a good use of the taxpayers' money?
The Chair: Sir, your time is up.
Ms Lankin: This is important. He's talking about government intimidation and you're cutting him off, Mr Chair.
Mr Curling: This could have been law already.
The Chair: Thank you very much for your presentation. We appreciate your being here.
Just a couple of housekeeping issues for the committee: We have the revised agenda for this afternoon.
Interjections.
The Chair: The subcommittee is recessed until 2:30.
The subcommittee recessed from 1405 to 1430.
The Chair: Just a couple of housekeeping items for the committee before we get on to our presenters this afternoon: You have three different things in front of you: a revised schedule of presenters for this afternoon, the white page; a yellow page which is tomorrow's lineup; and the itinerary for our trip for the two weeks in January. You can digest all of those at your leisure.
ONTARIO MEDICAL ASSOCIATION, SECTION ON DIAGNOSTIC IMAGING
The Chair: The next presenters are from the Ontario Medical Association, section on diagnostic imaging, Dr Arthur Zalev and Dr Phyllis Glanc. Welcome to our committee. You have a half-hour to use as you see fit. Any time for questions at the end will begin with the Liberals. The floor is yours.
Dr Phyllis Glanc: I'm Phyllis Glanc, one of the physicians and I'm based just across the street actually at Women's College Hospital. We're representing the OMA section on diagnostic imaging. Art Zalev is to my left.
Dr Arthur Zalev: I'm based at St Michael's Hospital down the street. I serve as university liaison to the executive of the OMA section on diagnostic imaging.
We'd like to address a number of concerns today. Our section appreciates this opportunity to appear before the committee and address some of the issues in Bill 26, particularly those proposed in the Physician Services Delivery Management Act, the Public Hospitals Act and the Independent Health Facilities Act.
Our section is a specialty section of the OMA responsible for representing the interests of Ontario's 700 diagnostic imaging radiologists. Our practice is as consultative physicians. We provide services. We are qualified specialists who have completed an accredited residency program in diagnostic radiology. This includes utilization of all modalities in imaging to portray human morphology and physiologic principles and provide medical diagnosis.
The elements of a radiologic consultation include pre-examination evaluation by the referring doctor; request for a consultation; a safe patient environment in which we supervise a qualified staff. Their efforts are directed to produce a radiologic examination to give the maximum diagnostic information and the least exposure to radiation.
Diagnostic imaging is a patient care specialty. It's an important function of the radiologist to advise the referring physician about the best sequence of examinations for resolving a clinical problem quickly and with the least risk and the least cost.
The remarkable proliferation of imaging methods we've seen in recent years has enhanced our ability to visualize the human body in health and disease in ways we never before expected. Many of these tests now available, however, produce uncertainty, if not bewilderment, about their benefits, their limitations, hazards and indications. These developments have challenged physicians' abilities to use the tools at their disposal rationally and to assure that radiology as a system keeps pace with technical advances.
They've also challenged us to fulfil the responsibility of the team, which consists of radiologists, radiographers, nurses and support personnel, to provide patient care to the best of our ability. We are the stewards of the technology for establishing the level of quality that must be met in imaging studies and investigations, and also in recent years in therapeutic and interventional procedures.
Many of the factors in current developments and proposed legislation have an impact on radiologic functions. We as Ontario radiologists are prepared to meet these challenges and to assist you in government in achieving some health care objectives.
Let me turn to some initiatives that radiologists have been involved in in the past several years. These include a number of activities to promote higher quality assurance, improved quality management, increased cost-effectiveness in the delivery of health care services in this period with decreasing health dollars. The following is an indication of some of our initiatives.
We have supported the development of the Health Arts Radiation Protection Act, the HARP Act.
There've been initiatives in quality management and continuous quality improvement: The majority of the authors of the publication Quality Management Manual for Diagnostic Imaging are Ontario radiologists.
We've taken initiatives to provide evidence-based information and criteria for use of radio-opaque contrast media.
There have been initiatives for the development of Ontario's MRI expansion program.
In standards development, Ontario radiologists have provided leadership for national standards in diagnostic imagining. These standards are now part of the Clinical Practice Parameters and Facility Standards for the independent health facilities, as issued by our provincial College of Physicians and Surgeons.
Ontario radiologists were actively involved in development of the assessment program for independent health facilities, and we cooperated with both the college and the Ministry of Health in this effort.
These developments, I might add, were based on a radiology peer review program of the college and this preceded the IHF legislation.
Other initiatives: the current efforts to develop evidence-based appropriateness criteria and guidelines for diagnostic imaging, and the current involvement of Ontario radiologists in health services research including utilization and outcomes research.
Ontario radiologists, then, have indeed accepted the challenge to promote the rational and the cost-effective use of imaging services.
I want to turn to the Physician Services Delivery Management Act. Firstly, our section is deeply concerned that government has introduced this act, which for all intent and purpose is really an ill-disguised effort to extinguish the OMA as a professional association and as the representative of 23,000 physicians in this province.
We lament that the government has felt it necessary to adopt this position. The unilateral capability of designating anything in the existing agreements allows the government to disallow all or part of the agreements that we have previously negotiated in good faith through the OMA. Government's ability to provide itself with a legal teflon vest, as it strips others of their rights, is really a marked departure from the kind of fair and reasonable government to which Ontarians are accustomed.
This is peacetime conscription. It's the equivalent of conscription in wartime and I don't see an external aggressor on the horizon.
What makes this direction more troubling is the fact that every other government in the country is interested in having an agreement with its provincial medical association. We just heard last Friday that the Health minister in Alberta and the Alberta Medical Association signed a tentative three-year agreement. This agreement achieves many of the same principles that were being discussed here in Ontario.
Many of the health care elements of Bill 26 are premised on the basis that health reform can only occur by legal fiat. We don't believe that, and we don't believe they will serve the needs of the health care system or the patients who are seeking reasonable access to modern health care services. Mr Klein has come to the realization that you cannot achieve real or lasting health care reform without physicians being not only on side, but around the table as active and as full partners. Without this active involvement by means of some vehicle, such as the OMA, there can't be a health care system; there certainly can't be a quality health care system.
Our section recommends that the Minister of Health resume negotiations with the Ontario Medical Association.
I want to turn to the Public Hospitals Act amendments. These amendments allow that if a hospital board determines the hospital will cease to operate or the minister directs it to cease to operate, the board may make necessary decisions to implement the closing. These include refusal of applications for appointment, reappointment or change in hospital privileges; revocation of appointments; and cancellation or substantial alterations to hospital privileges. No hearing is required. The existing statutory safeguards contained in sections 37 to 43 do not apply. The legislation makes a dangerous break with the past because it provides immunity to the hospital and the board.
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Our section is deeply concerned that the delicate balance between the hospitals and the physicians who work in them is now decidedly weighted on the side of hospital administrators and boards. This will not result in the discontinuation of mutual respect between management and physicians in all cases. However, there's enough evidence right now that cooperative agreements of the past have broken down because of increasing financial pressures that all hospital managers face. There have been several cases where administrators have attempted to breach the Canada Health Act. They have done this by asking physicians to split their fees with the hospital. In the face of major decreases in funding, there have already been reported cases of administrators who have approached physicians demanding a share of their fees.
The same authority can be extended by regulations to allow a hospital board to exercise the same powers governing applications for appointment, reappointment or change in privileges; also, revocation of appointments or cancellation or alteration of privileges for conditions other than ceasing to operate the hospital. In this situation no hearing is required. Regulations may also provide that the hospital and its board are immune from liability.
Our section recommends that there is an urgent need to address this part of the legislation. It must be ensured that it is not a one-sided discussion where physicians' rights and patients' access to medical specialists are being breached in deference to the unseen fiscal agenda of any hospital management.
I want to turn to the Independent Health Facilities Act. We radiologists are the only group of medical specialists that is broadly embraced by the IHFA. We are in the unique position to provide a perspective on the value of the IHFA in its current format, as well as on the proposed amendments.
At the moment, we provide a full range of diagnostic services in independent health facilities with the exception of CT, MRI and most of the medically complicated interventional procedures. In the last fiscal year, over five million X-ray, ultrasound and nuclear medical exams were performed on outpatients in IHF clinics. This represents about 50% of all the outpatient imaging done in this province.
Among the new features contained in the IHFA amendments there are a number of items that are new. Based on the information available to us to date, they seem reasonable. Likewise, some of the ministry's IHFA policies were developed in many cases with radiologic input and are now being enshrined as a regulation. If these regulations retain their current spirit and intent, there will be no significant objection from radiologists.
Some examples:
-- Greater flexibility for IHF clinic operators to add new services to existing licences; also the capability of adding new modalities as they become available. This we think addresses a major weakness of the current legislation which left many clinics frozen in the past. This is because they were required to offer services that are no longer the accepted standard of care.
-- The legislation has been broadened to generally accommodate other health care providers in a manner that does not constitute a change for radiologists.
-- The IHFA relocation policy developed with the involvement of the Ontario Association of Radiologists will become a regulation.
-- Clinics that become the repeated subject of reassessments will be liable to cover the costs of these additional measures.
In another area of the amendments, there is a reference that the IHFA will be used to facilitate hospital restructuring. Our section hopes that the ministry will consult radiologists before making decisions on converting hospitals slated for closure into new IHFs. Consideration must be given to the existing IHF providers. They have made investments ranging from hundreds of thousands to millions of dollars in high-quality imaging clinics. Radiologists have a history of working cooperatively with the hospitals and with the Ontario Hospital Association. We feel it is important that this collaborative relationship be recognized, should these considerations I've outline arise.
Removal of Canadian preference: This is a concern to us. The government's proposals to remove the preference for Canadian applicants seeking a new IHF licence opens the way to allow large American entities to apply to replace local Ontario expertise. We question how the government will be able to enforce the same level of quality assurance provisions on foreign-owned and non-physician bodies.
Yesterday, from the news accounts, we understand that our Minister of Health attacked the OMA on a number of points, including utilization, so let me say something about utilization.
There are large amounts of American data in major publications showing that for-profit health care businesses lead directly to increased utilization. This is due to the rise of conflict-of-interest and self-referral considerations. In diagnostic imaging there have been major studies in the US which examine imaging clinics owned by radiologists versus those which were owned by others who had no imaging training or qualifications. The conclusions of these American studies all come to the same point: that non-diagnostic imaging interests do between 1.7 and seven times more frequent examinations as opposed to physicians who refer to radiologists.
A study done by the auditing arm of the American Congress, that is, the general accounting office, showed that non-imaging interests had a much higher imaging rate for all types of radiology services. The American government report also found increased incidences of self-referral, and I want to give you some examples: MRI, three times; CT, twice; ultrasound, four and a half to five times; echocardiography, four and a half to five times; nuclear medicine, four and a half to five times; X-rays in general, two times.
A study published in the medical journal Diagnostic Imaging looked at the quality of examinations of chest, foot, ankle and spine in both radiologist-owned and self-referring facilities in Pennsylvania. Their conclusion: a strikingly high rate of diagnostically unacceptable images among those carried out in self-referring facilities.
What have Americans done about these practices? To date, 14 states have banned self-referral. We radiologists do not believe that this form of health care should be imported into Ontario.
The last item I want to bring to your attention is specific requests for proposals. The government has given itself the unusual power to issue a specific RFP. There is no consideration given to providing existing area independent health facility licence holders a first right of refusal to provide these additional services. The specified RFP does not provide any visibility into the qualification and selection phases and removes from public accountability things that one would expect to find in a government RFP process. This approach places an unparalleled amount of discretion in the hands of Health ministers and officials without conventional checks and balances. Right now there's no information about appeal mechanisms to stop a minister from ordering a specific RFP or approving a new licence as a result of holding a specific RFP.
A specific RFP is proposed for inclusion in the IHFA to provide the minister with complete discretion. He will be able to identify specific persons or companies to submit proposals to the ministry for a licence that will establish and operate an IHFA clinic. Theoretically, an individual or company could be provided with an IHFA licence with no public consultation and no disclosure. This is a step that's inconsistent with the normal open process which authorizes all forms of government approval.
For reasons of both quality assurance and utilization control, our section strongly recommends that any new diagnostic imaging licence issued should be limited to a radiologist, a qualified radiologist, so that appropriate controls are enforceable.
Our conclusions and recommendations:
Resource allocation decisions clearly constitute a major government priority. The radiologists of this province are prepared to assist these decisions and we are prepared to encourage more optimal allocation of available resources.
A stable environment, let me point out, is one of the basic prerequisites for these developments. The provision of diagnostic imaging services in this province is already more regulated than most other medical services here or in any other province.
In closing, I'd like to thank the members of the general government committee for their attention. I'd like to remind you that physicians must be part of the solution to reforming the health care system.
I hope the section on diagnostic imaging has shed some light on how we radiologists are working with key players in Ontario's health care system. I also hope that you realize we are committed to remaining a proactive and a constructive participant. Thank you.
The Chair: Thank you. We've got about three minutes per party for questions, beginning with Mrs Caplan.
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Mrs Caplan: Thank you very much for an excellent proposal. We had a submission yesterday from an independent group of radiologists who made very similar points to the ones that you have raised.
As you know, I share the concerns that you've raised around the removal of the Canadian not-for-profit preference and also the concern about the minister's ability, without request or proposal, without any legitimate tender process, to decide who will be able to open a new facility.
But you do raise something in here that I support, and that is the flexibility in the bill that would allow for new technologies to be admitted to existing facilities. Do you see some way, or have you thought of a way, where that flexibility could be maintained without the minister having the broad powers to open new facilities or bring in new technologies without request for proposal?
Dr Zalev: At the moment, no. However, we would certainly like to talk to the minister or ministry officials about whether this is doable.
Mrs Caplan: Have you had consultation with the minister before he brought this bill in to discuss some of your thoughts and ideas?
Dr Zalev: As a section we have not. The route for consultation has been between the minister and the OMA.
Mrs Caplan: They've already told us they weren't consulted.
Dr Zalev: And the OMA subsequently passes on the important information to the sections.
Mrs Caplan: I do believe, as I say, that it should be possible to give the flexibility for existing clinic licences to be responsive to new and changing technology without giving the minister this absolute power and no process, which could lead to what I would say is both inappropriate competition and also the kind of favouritism and questions about who's getting those licences that a public tendering process has always given the public assurance on.
I guess my last question to you is, is it your suggestion that the minister sit down with the Ontario Medical Association or with your section to hammer out some amendments to this bill that would accomplish what we're trying to do or what we'd like to see, or do you think this bill should just be segregated off into a separate piece and dealt with separately so that we would have time for full scrutiny and discussion? You know, they are planning to have this bill passed by January 29.
Dr Zalev: Radiology is certainly, we feel, a distinct section within the medical profession. I don't want to call us a distinct society, but certainly a distinct section. We would like more consultation with the minister and the ministry. Our past record shows that we have been there, participating for many years. We have learned a lot. We know a lot that we feel can go towards improving health care accessibility in this province. We would like to sit down and consult.
Ms Lankin: I'm glad you raised the issue about the powers, within the act, with respect to a hospital board's either refusal or revocation of privileges, particularly because this morning a member of the committee from the government side suggested that a board could only exercise those powers and refuse the right of appeal to a doctor when it's in the situation of a hospital closure or merger. As you quite rightly point out, that's a misunderstanding of the proposals here because under clause 32(1)(u), which is a new section being added, it sets out that regulations can provide the board with those powers under any circumstances the minister deems and that there is no appeal to physicians. That's quite extraordinary.
Let me ask you, as representatives of a specialist group: If that is to be exercised and an individual's privilege is revoked -- no right of appeal -- as radiologists your other means of operating might be to establish an independent health facility, a clinic, but there's no tendering process necessarily here; what happens to those individual specialists? Where are their skills utilized in this province?
Dr Zalev: If this province loses a qualified specialist, either the specialist leaves the province or the specialist finds some other means of living.
Ms Lankin: Outside of practising --
Dr Zalev: Outside of medical practice.
Ms Lankin: The other question that I wanted to ask you touches on the comments you made under the IHFA and the minister taking away the protection that we had, which was in the preference for Canadian-owned, not-for-profit, opening the door for non-Canadian-owned, for-profit operations. You talked about the inherent conflict of interest that's there and the self-referrals and how that can add to the cost.
In fact, the minister himself yesterday, in his opening comments, raised, I guess, similar concerns with respect to the fee-for-service system that physicians are on. Without using these words, he was alluding to the potential of revolving-door practices, the self-referral or the increase in the amount of business. He seems to understand it in terms of fee-for-service but doesn't seem to understand it in terms of the inherent conflict in for-profit.
I was wondering if you could just give us a little bit more information on your views on that and also cite the references for us or provide that for us afterwards so the committee could, at our leisure, look at those American studies.
Dr Zalev: We can ask our office to send any individual on this committee references about the self-referral studies. They have been in major American journals within the last year.
I'd like to say something about referral that distinguishes our specialty from others. Almost every examination we do, the patient is referred to us by a family doctor or another specialist. We do very little in the way of generating new examinations. We might have a patient for whom we feel, on the basis of the examination the patient was referred for, something additional is required.
For example, some patients coming in for a mammogram will benefit from a breast ultrasonogram, and it might be more practical to do it there on the spot than send back a consultation report to the referring doctor and have the referring doctor send the patient in another time. But by far almost all of our examinations are referred to us. We're not generating this excess utilization that the minister has been talking about.
The Chair: Thank you, Doctor. We do have to get on to the next question. We would appreciate you sending that information to us, though, on the self-referral.
Dr Zalev: We certainly will do so.
The Chair: Send it to the clerk.
Mrs Ecker: First of all, I'd like to thank you very much for coming here and bringing your very detailed presentation with input for us. The Independent Health Facilities Act, I understand, has always had the power to refuse to renew licences based on quality costs -- there's a lot of different reasons, I understand -- without compensation.
Do you think that the amendments are changing that existing situation, or do they allow more quality control of IHFA facilities?
Dr Zalev: I'd like to ask my colleague Dr Glanc to answer your question.
Dr Glanc: Art may be more familiar, but at least two points where there are direct changes that I would appreciate. There has been an open appeal process where everybody can give in a submission, and now there can be just specific requests for proposals so that it is not an open area and there is this concern for elements of favouritism to enter into the playing field.
The second issue that is also of concern is that many of us operate clinics, to a greater or lesser degree profitably, but there is a significant investment; they're small businesses. Bill 26 now suggests that we could have that facility closed down tomorrow. Currently, you're permitted at least to the end of your licence, so you have some time line. That time line is now completely flexible, with a possible closure in -- I suppose 24 hours would never happen, but that safeguard is gone.
So those are the two points that I would offhand state.
Dr Zalev: I'd just like to add that as far as quality control and assurance, these clinics are examined by inspection from the Ontario College of Physicians and Surgeons. We especially regard it as critical that high-quality examinations be performed on outpatients seeking radiologic studies.
The Chair: Thank you very much for your presentation, and we look forward to receiving additional information from you. We appreciate your attendance.
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MICHAEL RACHLIS
The Chair: The next presenter is Michael Rachlis. Good afternoon, sir. Welcome to our committee. You have half an hour to use as you see fit. Any questions would start with the New Democratic Party.
Dr Michael Rachlis: Thank you very much. I believe the clerk is circulating a copy of my presentation to the committee. I apologize; I wasn't beaten up on the way in; I just seemed to have a run-in with my taxicab. So I apologize for this. But there may be enough doctors in the audience, real doctors, who could deal with me after my presentation.
Thank you very much for allowing me to make a presentation to the committee. I'll just introduce myself. I am a family physician; I'm also a specialist in community medicine. Although I still do a little bit of general medical practice, my main work is as a consultant in health policy, primarily to governments and health care organizations across the country.
My main message to the committee is that I feel that the government should abandon its attempt to pass this omnibus legislation, discarding some sections and promoting greater debate on others. I feel that there are some sections of this omnibus bill that are very poorly conceived and in fact are likely to promote illness and increase the cost of providing Ontarians with health care services. Other sections concern important policy matters which should be given specific open and democratic debate before they are enacted into law.
When there are so many changes to eight health statutes, it's difficult for me to focus on just a few of them in the few minutes I have to present. I do want to highlight the changes to the Ontario drug benefit plan. This is something that distresses me greatly and I think that the imposition of user charges in particular is going to harm the health of the poor. There is substantial evidence that user charges for prescription drugs as well as other health services essentially benefit the healthy and the wealthy and harm the poor and the sick. In fact, this literature was recently summarized by three of Canada's most eminent health economists, professors Robert Evans and Professor Morris Barer of the University of British Columbia and Greg Stoddart of McMaster University, along with their researcher, Vandna Bhatia, in a series of documents written for Ontario's Premier's council on health. One of their reports, It's Not the Money, It's the Principle: Why User Charges for Some Services and Not Others? contained two passages which I'd like to read which I think are particularly applicable to today's debate:
"It's hard to resist the conclusion that user fees are a way whereby payers can shift the escalating costs of drugs on to patients while avoiding politically difficult actions -- addressing prescriber behaviour and the marketing practices of drug companies -- that would be necessary to limit their inappropriate use."
A second passage:
"User charges in pharmacy thus provide a good example of the way in which such charges lead to increased costs of health care, by shifting the financial pressure away from those in a position to take effective action, and on to those who cannot."
The government is in an excellent position to both bargain on behalf of consumers in Ontario with the multinational pharmaceutical companies for the best deals. Consumers are in no position whatsoever in this marketplace to be effective consumers and bring their particular economic position to bear. It's just ridiculous to think that consumers individually will be able to do anything. Secondly, it's only government that could possibly deal with the tremendous problem we have of overprescribing of drugs. Government can't do it alone, obviously; it needs the cooperation of the medical profession, pharmacy and others, but government's actions are necessary, if not sufficient, to deal with this issue.
Estimates are that anywhere from a low of 3% to 5% to a high of 20% of admissions of people over the age of 55 to hospital are due to adverse reactions to prescription drugs. This obviously isn't just the responsibility of the present government; I'm afraid that all three parties share, to some extent, in this problem. There are literally thousands of Ontarians who are being killed every year by adverse reactions to prescription drugs, and they are in no way able to defend themselves from this problem. It's only with action that needs to be led by government that we can deal with this issue.
As far as dealing with the multinational pharmaceutical companies in terms of cost, it's very striking to watch what this province is attempting to do, which is deregulate the prices in the non-ODB sector, compared to what another province is doing, British Columbia. In fact, there has been quite a bit of discussion on this in the media, and there's an article in today's Globe and Mail which says that even before the most recent changes, which will be saving them more money, BC is saving $100,000 a day in their pharmacare program through the use of what's called reference-based pricing, where pharmacists are required to substitute lower-cost but therapeutically equivalent drugs for the drugs that are prescribed. This kind of plan is exactly what this province should be thinking of, and I think that many members of this committee perhaps know that: using the government's financial clout to bargain hard with the multinational pharmaceutical companies and lower the cost of prescription drugs that way.
What the government is doing instead is passing the cost off to other sectors, and for a government that is supposedly concerned about the province's economic position, this is going to adversely affect businesses in this province, who are going to have to pick up the extra costs of prescription drug plans. I think that if the government were really worried about the climate for business in this province, they would be doing their best to reduce the cost of health care, not just in the public sector but overall.
Other proposals in Bill 26 need more open and democratic public debate before they are passed into law. It's clear that the government is contemplating major changes in the structure and funding of Ontario's health care system. Now, I'm supposed to know something about this area -- at least, people pay me to provide them with advice on health policy -- and I can't figure out everything that the government might be thinking of doing with the changes that they're proposing to these eight health statutes. In some cases the intentions of the amendments are transparent, but in others they're obscure.
Just as an example, the amendments to the Ministry of Health Act and Public Hospitals Act appear to permit the establishment of regional health or hospital authorities, which are in fact being implemented in every other province. It's only Ontario that is not implementing these regional authorities. But is this what the government is intending? In other provinces, those kinds of actions have resulted in specific pieces of legislation which have been debated on their own. In fact, I tend to favour, with qualifications, that kind of policy initiative, but is that what the government's up to? I don't know. Or is this commission going to be making all the decisions?
Amendments to the Independent Health Facilities Act would allow the minister to bypass the normal request-for-proposals process and would delete the original preference in the legislation for clinics which were non-profit or Canadian-owned. These amendments would allow the minister, for example, to contract out all the not-for-admission surgery in Ontario to an American for-profit company. This could happen the day after the legislation gets royal assent. Now, I've heard this is not what the government is contemplating, but what is the government contemplating? I can think of many different possibilities, some of which I would agree with and would be good for Ontario's health system, others which would not. What about the amendments to the Health Care Accessibility Act, which appear to contemplate user charges for hospital services? Some of these user charges might well be contrary to the Canada Health Act. Has there been any consultation with the federal government in this regard? And so on. There are many other examples; I've given a couple.
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I think that I would add my name to the list, which is getting longer, of Ontarians who are suggesting that this omnibus bill be broken into smaller acts to facilitate public debate. There are many problems with Ontario's health care system that need remedying, and I can see why the provincial government might need greater authority to restructure Ontario's health care system. I see two former ministers of Health in the room, and I'm sure at times they would have liked greater authority to deal with the problems in the health care system. But Bill 26, I don't believe, is the appropriate method to obtain these powers.
In the Common Sense Revolution, the government, running for office at the time, promised Ontarians to cut other areas of spending "without touching a penny of health care funding." That promise has clearly been broken.
The government also promised "there will be no new user fees." In fact, there was no discussion of this being Canada Health Act user fees, and there was reference in the Common Sense Revolution to Liberal policies which did not concern user fees contrary to the Canada Health Act. So as far as I'm concerned, that meant no new user fees. The word "no " was in capital letters.
So the government is clearly guilty of breaking these two key election promises. I think it's too much now to ask Ontarians to blindly trust where the government plans to go. We need more details on the government's proposals. Maybe some of them would be good, but we need to have them spelled out in more detail.
In conclusion, I would suggest the government should withdraw Bill 26. It should eliminate certain sections, like the user fees proposed for the Ontario Drug Benefit Act and the deregulation of prices under the Prescription Drug Cost Regulation Act. The government should present others in a smaller act which would clarify its true intentions.
If I may quote what is often regarded as a very radical, left-wing rag, today's Globe and Mail, "...the government may well need special tools" to deal with the issues you have to deal with. "But democracy would be better served if we had a closer look inside the tool box." I fully agree with the Globe's editorial. Maybe what's being proposed would be good for the Ontario health system, but let's see it broken down into its components and debated properly.
The Chair: Thank you. We've left about five minutes per party for questions, beginning with Ms. Lankin.
Ms Lankin: Thank you very much, Dr Rachlis. It's very good to see you and I appreciate your presentation.
You are quite right, the list of Ontarians who are demanding that this process here be stopped and the bill be split up and that we have an appropriate process is growing. We're hearing that from virtually every group that's come forward before this committee.
I agree with you that there are some changes that would probably be good and could be very helpful in the restructuring that's ahead. These do need to be understood by people and they need to be debated and we need to make sure that we're putting the right controls on. For example, with respect to regional health authorities, which might be envisioned under this restructuring commission, there are no objectives, goals, outcome expectations, obligations of that commission in the legislation. There is no built-in relationship to district health councils and local planning that's going on. This is a huge area. I'm in a sense just reinforcing the point that you made that in so many areas we don't know what the intention of the government is.
The one specific recommendation that you do get into with respect to elements of these schedules is with respect to the Ontario drug benefit plan and the changes there. On the issue of user fees, our government colleagues raise this with most presenters who raise concerns about user fees and they say, "But gosh, every other province has them." They then go ahead to defend the fact that we're the only province that would be deregulating drug prices. That doesn't seem to be a good rationale for continuing that policy.
You, in the work you've done on health policy, have had a chance yourself to look at these issues and to discuss these issues with people like Barer, Stoddart and Evans and others who have done a lot of work. Are there studies that talk about what the effect of the user fees and the copayment and the drug plan is in other provinces? Are there seniors who are making inappropriate choices between drugs and other lifestyle challenges as a result of the user fees?
The other question I just would like to add to that is, could you elaborate on your knowledge of the counterproposals or alternatives to user fees, which would be things like clinical guidelines for prescribing and influencing doctors' practices in prescribing versus user fees on patients?
Dr Rachlis: Yes. The answer to your first question is, I'm not sure. In fact, during the preparation of my presentation I spoke with Dr Joel Lexchin of Toronto, who's well known as an authority on prescription drugs, and he wasn't sure himself. There may be a study that was done in Nova Scotia at some point which I think he and I are going to try to look at, if we can find it, that might look at the impact of user fees for prescription drugs. But there have been studies done in other jurisdictions, both for medical services as well as for prescription drugs, and they show that, depending on how they're implemented, you might reduce costs but the likely outcome would be, as in the quote I read from the Evans-Barer-Stoddart report, you'd likely increase overall costs, and you're certainly going to have adverse health outcomes.
There have been several studies done by Stephen Soumerai in the United States looking at the impact of user charges for prescription drugs. They're not exactly the same policies that are contemplated here, so they are somewhat difficult to generalize. But his studies have shown that when you cut back on drugs for poor people -- and I think that many of the people who will be affected by these policies would be poor, quite poor -- people often choose, perhaps unwisely, not to use the drugs and therefore there is higher utilization of hospitals, nursing homes and other parts of the system.
The alternative to what the government is proposing -- there are many, many different policies. I think that if you wanted to take something right off the shelf, you could take the BC policy, because the BC policy is dramatically effective and it's working. How well it's working can be gauged by the fact that the multinational pharmaceutical companies are now suing the province, it's working so well.
Other possibilities include things that might well fit in with what this government might even be contemplating later in its own agenda. Germany put some of the costs for prescription drugs into the physicians' budget, which gave physicians a direct incentive to reduce the cost of prescription drugs. Although I'm not familiar with a detailed academic evaluation of that, at least anecdotally it seems to have dramatically reduced the cost of prescription drugs. There are lots of different things you can do besides user fees.
Ms Lankin: I have one other very quick question --
The Chair: Thank you, Ms Lankin. It was a wonderful question and a nice answer, but you've used up all your time.
Ms Lankin: There's no time for a quick one?
The Chair: No. For the government, Mrs Johns.
Mrs Johns: I'd like to thank you also for coming here today. As you are well aware, the province is $100 billion in debt and in our Common Sense Revolution, as you suggested, we said that the $17.4 billion that was in health care would be there at the end of the term. We have committed to that. But we never said the status quo was what we wanted to have in health care. We are committed to reallocating funds to make sure that we best meet the needs of the people of Ontario, so a lot of these things you're seeing are the result of that and us trying our best to move to the best needs of Ontarians.
I'm interested in your last paragraph on the first page where you talk about the BC model. I know Ms Lankin touched on this a little bit, and I just want to ask you some questions. As you're aware, in our model we have said that if a doctor prescribes a medication and it comes to the pharmacist and it's not the cheapest medication, they have to give the cheapest medication. What's the difference between that and the BC model?
Dr Rachlis: The BC model is based on what's referred to as therapeutic substitution, not just generic substitution. Generic substitution means that you substitute the same chemical made by another company for the particular drug that was prescribed, but it's the same chemical constituent. The active chemical is the same.
Therapeutic substitution means that you look at a whole class of drugs which are different chemically, like the different drugs that can be used to treat ulcers, which is the first class of drugs the BC government decided to work on, and they considered the class of drugs, looked at the drugs and considered that while there were some subtle differences, basically there were no major advantages one to the other. So if a prescription is written for any of those drugs, then the cheapest one is prescribed. However, this can be overridden very quickly, almost immediately, by a phone call by the physician to a special authorization line that the government runs. So that's the difference.
In fact, this is som??ething that's been fairly commonplace in a lot of large American health organizations for almost 10 years. It requires the active participation by the medical profession and pharmacists of course as well, but it can only be done if government takes the lead.
Mrs Johns: Can you just give me a quick number of the difference in dollars saved between the method that we're going after, which is the same classification of drugs, versus the therapeutic? You've said it's a $100,000 saving per day. What would it be with the process that Ontario's talking about?
Dr Rachlis: Those savings in BC, which has approximately a third of the population of Ontario -- I won't get into all the details but I think that you could almost multiply that by three to get what the likely results would be in Ontario. That $100,000 a day was just for the anti-ulcer drugs and the angina drugs. Now that they've just started the arthritic drugs, or non-steroidal anti-inflammatory drugs as they're called, at least anecdotal estimates that I've been hearing unofficially from people are that they are looking at maybe another $100,000 per day. So in Ontario, we could be looking at hundreds of millions of dollars that could be saved from the Ontario drug benefit plan with therapeutic substitution and with better prescribing.
Mrs Johns: I know that you have agreed in here that there need to be changes and really that the direction needs to be better formulated for you to be able to decide if it's something you agree with or not. Inherently, you believe in the restructuring of hospitals and the need for the government to have more clout to allow that to happen?
Dr Rachlis: Before I answer that question, I want to deal directly with something you said earlier. I've heard a number of times from the government and people from the government that the plan is to have the Ministry of Health budget be at $17.4 billion at the end of the day. I will make a bet to anyone on this committee or outside this committee that that will only happen if the Ministry of Community and Social Services is disbanded, which is certainly what the rumours are. Then the plans that one hears, at least the scuttlebutt, is that the Ministry of Community and Social Services would be broken up, disbanded, and part of its programs and funding will move to the Ministry of Finance and part will move to the Ministry of Health. Therefore, you'll be able to cut the Ministry of Health in real terms by several billion dollars and have its budget at the end of the day be $17.4 billion.
Mrs Johns: I'll bet you on this, bet two bucks.
Dr Rachlis: If you plan to have the budget for the Ministry of Health, for the programs that are in the Ministry of Health right now, be $17.4 billion at the end of your term of office, I will bet that. I will bet $2.
The Chair: On that note, we'll record that bet and we'll go on to the Liberals.
Mrs Caplan: I think Dr Rachlis is absolutely correct.
Mrs Johns: Do you want to put your $2 in too?
Mrs Caplan: Let me tell you something, I would suggest you not bet your mortgage.
It's exactly what we're hearing. Dr Rachlis has worked in government and advised governments. I guess my first question is, given your expertise, given the fact that you have advised governments not only in Ontario but across the country, and given the fact that you're an author of, I think, a very important book calling for health reform, Second Opinion -- I'll give you a plug -- did the minister or the ministry invite you in, share with you what they were proposing, and did you give them your advice?
Dr Rachlis: On my own initiative, I have had a meeting with someone on the minister's staff. I must say it was, at the time, a friendly meeting and I feel that my words were heard.
Ms Lankin: He's sitting behind you. Let's ask him why he didn't pass them on.
Mrs Caplan: Does this bill reflect your advice?
Dr Rachlis: I would say in general, no. In fact, I dealt specifically with the user charge question for drugs, because this is something that's been around for a long time and I knew it would come up again. But it's hard to answer your question because I don't know what the government contemplates. This bill gives so much authority to the Minister of Health that the minister could do anything, some things I might agree with and some things that I might not agree with. So I can't tell.
Mrs Caplan: You know it's the government's intention, or it was their original intention, to have this passed before Christmas. It's now their intention to have this passed on January 29. We've been informed by the clerk this morning that every slot for public hearings is filled in Toronto. We haven't even had time to advertise in communities around the province and every slot is filled across the province. We've got waiting lists of people who want to come to this committee.
Frankly, I think your recommendation is a very good one, to break this bill into pieces that will allow for appropriate scrutiny. We're not talking about massive delays. The government, if they insist they want this, could have it in a reasonable period of time.
How much time do you think should be given to just the health components of this bill? I'm asking that question as someone who's aware of the time that's been given to other health legislation. How much time do you think the health section requires as far as public scrutiny?
Dr Rachlis: I think it requires more than what is contemplated, but what I would really appreciate as an analyst is if there was a bill specifically on the health changes, if we could have a better idea of what the government really has in mind, because I don't know. Does the government really plan to contract out all the cataract surgery in the GTA to the Health Care Corp of America? If you're not contemplating that, then let us know.
But the real problem for me is that I don't know what the government is planning and I would appreciate a clear piece of legislation that was specifically on the health questions that spelled out what the government was looking for. I think, in fact, if that were the case, the government might well find that it could have some support; it may be limited, but it might well have support for certain aspects of its legislation. But I think, as you're probably finding, you're likely not going to get support for this legislation in its present form. I think you're going to get almost no support for it in its present form.
The Chair: Thank you very much, Dr Rachlis. We appreciate your participation here today. I really enjoy the fact that I ended up with four bucks.
Dr Rachlis: It's all right. I have a bet with someone in the federal government as well that's waiting till the next election.
The Chair: I hope we haven't inadvertently introduced user fees to the committee process.
Dr Rachlis: Thank you for giving me the opportunity to present to you today.
The Chair: We appreciate your attendance here today.
ASSOCIATION OF GENERAL HOSPITAL PSYCHIATRIC SERVICES
The Chair: Our next presenters are the Association of General Hospital Psychiatric Services, Bob Buckingham, the past present, and Jane Chamberlin, the coordinator. Welcome to our committee. I obviously missed one name, so when you get a chance, if you would introduce yourselves for Hansard. You have half an hour to use as you see fit. Questioning would begin with the government party at the end of your presentation. The floor is yours.
Ms Jane Chamberlin: You missed an important name, that of John Nkansah, the president of the association. This is Bob Buckingham, and I'm Jane Chamberlin, the coordinator of the association.
Our members are the psychiatric units in general hospitals in Ontario, particularly, mostly, the larger hospitals which have a full range of psychiatric services and are known as schedule 1 facilities. Our concern with the omnibus bill therefore is about its effects on hospitals and about its effect on psychiatric patients, particularly the severely mentally ill.
Dr John Nkansah: I'd like to thank you very much, Chairman, for inviting us here to make our presentation before the committee. As Jane has indicated, our association is very concerned and very disturbed about some of the bill's enactments. The association does feel that the bill, as presently enacted, relating to health care and also to psychiatry naturally, gives extraordinary powers which we believe at the very least should be time-limited.
We clearly see a need for change within the health care sector, including psychiatry, and we clearly all applaud your action and orientation with respect to wanting to bring this about. However, the milieu within which this is being contemplated gives us serious concern, as I have indicated, and even if we were to have a so-called emergency War Measures Act, a sunset clause would be indicated.
We are concerned about possible misuse which could be implied in whatever idea indicated, and as well, about the unilateral powers without due process, and specifically it seems to wish to avoid due process in court challenges and appeals.
We are aware that the ministry will have authority to establish the Health Services Restructuring Commission and for some of the areas where this will indeed be most helpful in bringing about some coordination, integration, of the health services sector and allow certain decisions to be made which hitherto have been very difficult to be made within the current environment. So we see restructuring as being necessary in most areas, but we also feel that due process, through the district health councils, is an area which is important and where the implementation process needs to take place and where recommendations, after due process, can be implemented. The need to ensure due process is a good one, and we would strongly suggest that this be taken into account.
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In so doing, we would also like to clearly emphasize that there be representation from all stakeholders. I say that primarily because recently in one of the district health council committee hearings, providers such as physicians were eliminated. They were not on the committee and therefore had no voice, and we had to literally embark upon a considerable amount of fighting, if you'd like to use the word, in order to be able to get access to the membership and to have input. We feel that is something we would like to avoid in the future, and that if we are to all work together cooperatively, there should be adequate representation.
From the point of view of psychiatry, we are very, very concerned -- indeed, extremely concerned -- about government authority to view confidential medical records. As a practising psychiatrist, and I have talked to a number of my colleagues, our ability to be able to work with our patients is based on trust. That trust is extremely essential and important, without which we cannot do our work. If patients are to come to us and know that what they tell us in confidence and in the privacy of our offices about the deepest personal secrets and problems they have could be unilaterally given access to by the ministry, people will simply either not seek treatment when it's needed or, if they do, they will not share some of the things they are most troubled about, which will mean that people will continue to remain ill or have illnesses that might, in the long term, lead to hospitalization and an increase in the cost of health care. So we are extremely disturbed and extremely concerned about confidentiality of records.
In this latter regard, we agree with the Human Rights Commission, which has already indicated that this particular section, which allows review of confidential medical records, is, at the very least, improper. We want to be assured by the government that confidentiality will be assured and that we'll be able to continue to work with our patients, who deserve to be able to talk about their problems without fear or intimidation that somebody else is going to be looking in, or Big Brother's watching, or that somebody's going to be reporting or releasing records about their most intimate affairs.
I'll stop here and pass on to Bob.
Dr Bob Buckingham: The present government has indicated that it is continuing the direction of the mental health reform policy that was developed by the two previous governments. This reform is predicated on the premise that there are no new dollars, which we all accept, but that the dollars that are spent in the area of mental health care need to be redistributed, with the idea that fewer people may need to be treated in the expensive care of hospitals if community supports and services are increased and more adequate.
One of our concerns with the present process of restructuring and the Health Services Restructuring Commission is that again the principles of mental health reform will be lost. Our association within the general hospitals has been fighting a battle to attempt to maintain the proportion of dollars that is spent in the area of mental health care, and because the psychiatric units of the general hospitals, which certainly treat a significant number of the severely mentally ill in the province, have less clout perhaps in the restructuring and the planning of budgets, they have traditionally suffered a disproportionate loss of resources whenever there is pressure on those dollars.
There's nothing that suggests we are going to learn from the past and prevent this from being repeated again. Many of the restructuring plans that are being prepared across the province by district health councils really are not addressing specifically the need to preserve, and in fact the Metropolitan Toronto district health plan points out that by the year 2001 the need for psychiatric beds within the hospital system will have to increase by 3%.
However, again I think that there has not been any way of protecting the mental health dollar by enveloping the total amount, and we're concerned that this will not be part of the agenda for any Health Services Restructuring Commission. Certainly if the legislation allows the powers to be used on behalf of the most vulnerable group, then I think something positive will come of it. But I guess traditionally we have not been able to rely on good faith alone, and I think we are in danger of repeating the mistakes of the 1970s, where dollars were removed from the institutional side of care for the mentally ill without it being reinvested in the community, and we had the end result that the most severely mentally ill were worse off. I think we are entering a period where we are about to repeat those mistakes unless there is specific protection provided by the government and any legislation that directs the changes that are to come about.
Certainly there has not been so far in the reform process -- although there have been many dollars removed from the mental health services provided, both within the provincial psychiatric hospitals and the general hospitals -- investment except for a small amount under the last government in increasing the community supports, even though governments have promised that the institutional resources and services would not be cut until the community services had been increased. So this legislation gives powers that could be used for the benefit of the most vulnerable group, the seriously mentally ill, but our concern is that those powers will not be used in that way and that other factors will again lead to the neglect of this group and they will end up worse off at the end.
As was mentioned, even the idea of a very modest drug benefit charge of $2 seems reasonable but when it gets applied to, again, the seriously mentally ill, it becomes a barrier to adequate treatment. This group is often among a significant percentage of the homeless population, and the illness they suffer from, schizophrenia and major effective disorder, there are more effective drugs. If there is a deterrent to obtain those drugs, because of modesty, then it is likely that more of them will opt not to take medication. Even now the compliance, getting many people within this population to comply with medication, is an ongoing struggle; and so what seems like a very reasonable user fee becomes a barrier to care for this group.
It was mentioned, I think, that rather than save money, it will have the potential of leading to increased costs, because if the major psychiatric disorders are not treated in the early stages, they become worse and they end up requiring a much more expensive, lengthy period of hospitalization. We are especially concerned about the ramifications in the health area on the group that we provide service to, the seriously mentally ill in our population.
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The Chair: Okay, we've got about five minutes each for questions, beginning with the government.
Mr Clement: Thank you very much for your very thoughtful presentation. Certainly, you've given us a lot to think about. Thank you for taking the time to be here.
Is your association at all concerned about inappropriate billings with respect to psychotherapy services? Is that a problem that you've identified?
Ms Chamberlin: Our association is an association of all the professionals who work in general hospitals and our concerns are largely with the provision of services through hospitals.
Mr Clement: So it's not applicable to you.
Ms Chamberlin: That's not our central concern, no.
Mr Clement: Let me then paint a wider picture of some of the things that we've been hearing over the past couple of days now. I just wanted to get your reaction because you are providers in a very specific area, but there are also wider issues at stake as well. I guess the first question is that a number of presenters -- one in particular, a president of a hospital, has said that the greatest threat to health care services is in fact the $10-billion deficits that the government's been running over the past few years, because that sucks money out of the system to pay for the interest on the debt and it means that areas such as mental health which should be a priority maybe don't get the amount of recognition and service dollars that they need. Do you have any comments on that? Would you like to comment on that?
Dr Buckingham: I think the deficit is of concern. I have seen the budget for mental health services be reduced to pay for a general hospital deficit. It tends not to be the psychiatric services that generate the deficits; it's the more high-tech, expensive services that are costly. But because we provide our services through the general hospitals, we are expected and required to support cost cutting. In that sense, a deficit is of concern.
Mr Clement: It really affects all of us, anyone who is a resident of Ontario. I'm talking about the general deficit now, not specific to a --
Dr Buckingham: But I guess we've always been in a position where we've been less able to shoulder some of that. A 5% cut to the provision of mental health services within a general hospital reduces the ability to deliver service much more than a 5% cut to the department of surgery, which is a much larger service within the hospital.
Mr Clement: Yes, it affects you disproportionately.
Dr Buckingham: That's right.
Mr Clement: You said at the outset of your presentation that you felt that the ministry was proposing extraordinary powers, and I believe that you said these should be time-limited. You may know that the minister has proposed to this committee an amendment that would make a four-year sunset for some of the minister's and ministry's powers with respect to hospital restructuring. Does that go a certain amount of the way, at least, to alleviate your concerns?
Dr Nkansah: I raised that point in the presentation. Four years is a long time. When we thought about this, our time frame was that about 18 months might be more suitable than four years. Four years takes us pretty well towards the very end of the mandate of the government, if I understand it correctly, and that means that throughout that whole period we may be subjected to certain decisions about which we would feel totally impotent to do anything about or to influence.
Mr Clement: You want more consultation. It's kind of hard to have consultation, at the same time limiting to 18 months the amount of time to actually do something, wouldn't you say?
Dr Nkansah: I'm not suggesting that you have to do something in 18 months. What I'm suggesting relates specifically to the extraordinary powers. I'm not suggesting that consultation should not occur. What I'm suggesting is that consultation should occur in an atmosphere that is conducive to each party feeling that they don't have a club over their head, so that if I'm in consultation with you and I know right from the word "go" that if I really don't agree with what you say, you're going to implement it anyway, the whole process of consultation doesn't really become a consultative process at all.
Mr Clement: You don't think the Health minister should have that power?
Dr Nkansah: No --
The Chair: Thank you, Mr Clement. Mrs Caplan.
Mrs Caplan: Thank you very much. I think you've given us an excellent portrayal of the impact of this very complicated bill on people, particularly some of the most vulnerable people in our society who require the services that are delivered in general hospitals, and I'm talking about psychiatric services.
We've heard the minister say that there are no new powers for inspection and yet we know that in this bill it creates a new government inspector who will have all the powers of the assessors and inspectors, which now are only in the hands of the Medical Review Committee and the College of Physicians and Surgeons. This is a new power of the minister, and it allows access to the most sensitive files that patients have. That's just one section, that's one part of this bill.
The other thing that you've identified is the potential for non-compliance and higher costs as patients who could be functioning in the community actually are readmitted because they haven't taken their medication, likely because they haven't been able to pay the user fee that is being imposed in another section of this bill. I would say to you that in the 10 years I've been here I've never seen any power sunset. What the minister has agreed to is that the restructuring commission would be sunset at the end of four years, that there would be just a sunset review at the end of four years, and that's to give everyone confidence. I guess my question is, given the complexity of this bill and the concerns that you have and the fact that there are so many people who want to learn more about the bill, would you agree that rather than having it rushed and finished by 29 January and proclaimed, it should be broken into smaller bills or groups of bills for more scrutiny, so that we can further understand exactly what it is that the government intends to do and why it needs these extraordinary powers that would jeopardize people's health and also jeopardize their privacy? Do you think they should split this bill?
Ms Chamberlin: I think Dr Rachlis made an excellent point, which is that it's very difficult to tell what the government wants to do. There's a huge amount covered in this bill, and a lot of it gives extraordinary powers without of course any indication of exactly what they're to be used for. I think, though, that as a group we have some sympathy with the government's wish after many years of consultation, like that which went into the Metropolitan Toronto District Health Council hospital restructuring in Toronto, to see some action. I would think that our group would be in favour of facilitating the government's ability to act on issues that have already been through a thoroughgoing consultative process and that have a fair amount of consensus and can demonstrate their validity. It may be, in certain cases, time to act, and we have some sympathy with the government's desire to give itself the ability to act.
We are obviously concerned that the ability is unlimited, very wide and very unspecific. One way of the government's reassuring us would be that it shortens the term in which it feels it's necessary to act unilaterally, and with these extraordinary powers, to something like 18 months or perhaps two years; secondly, that it only do so in cases where there's already been an adequate consultative process and the direction is clear; and, thirdly, that it demonstrate its goodwill towards the really vulnerable people in society and protect the mental health funding envelope which stands. If hospitals are not notified immediately that they must protect the mental health dollar in their budgets, they will cut those budgets and the money will vanish, as we have seen it vanish so often in the past.
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Those people who are the least able to protect themselves, the severely mentally ill, you do not see clamouring on your doorsteps. They are not people who have occasional cardiac misadventures. They are chronically, severely unable to advocate for themselves, and their services need to be increased. As was demonstrated in the Metro Toronto hospital restructuring report, they are one of the few groups of acute-care patients who actually need an increase in services. Efficiencies may be possible, but they are specifically targeted for an increase in that report which in virtually every other area of care is looking at consolidation and downsizing. We cannot emphasize to you enough that this group must be protected and the funds that care for them must be protected because they cannot protect themselves.
Ms Lankin: That was a very, very cogent argument that you just set forward. Your whole presentation was terrific, but that last summary was very important, and I'd like to request that we could get a Hansard copy of that as soon as possible.
There are a few things that you set out that I just want to say that I would agree with you on. I implore the government members to think about the possibility of splitting these bills up and of dealing with them in chunks that are possible. I would commit support immediately for a bill that dealt with the implementation of things like the necessary decision-making powers out of the Metro restructuring report. Where there's been all the consultation, there's a great deal of consensus and we need to move ahead. I don't want to see things like that held up, but I think the powers that are in this bill are too broad, too undefined. There's no definition of the restructuring commission's role, its relationship to the DHC, those consultative reports etc. I think that's an excellent suggestion that you've made.
There are three things that you touched on that I hope I have time to ask you about. Number one, the issue of user fees on drugs: There is obviously an ideological debate that may take place around universality of the drug program versus what's happening in other provinces. Let's set that aside. There is an issue that we have heard raised on behalf of poor seniors and whether or not they would be making difficult choices. Let's set that aside for a moment.
You raise an issue which we heard earlier today from a psychiatric nurse -- it's the first time we've heard these arguments put forth today -- that there are very vulnerable people who are without housing, without supports and without money, who already have a problem with medication compliance. I just wonder if you could tell us a bit more about what it means for the life cycle of some of these people. I suspect it means chronic readmissions.
Dr Buckingham: It does indeed. I think that individuals who suffer from serious mental illnesses, if their symptoms are not controlled on medication, then they gradually over time have a recurrence of symptoms that lead to a decreased ability to maintain their stability in the community, often will then progress to psychotic thinking and their behaviour or affect or thinking precipitates an emergency that does lead to hospitalization in an acute decompensation, which then requires a longer stay in hospital to again get them back to a level of health that they are able to go back into the community.
Because that medication is not continued, for many people the revolving-door syndrome has been present for a number of years. That's when medication has been provided. Often they don't understand the need to continue on it. Any additional barrier, such as a $2 fee, is going to increase that difficulty and going to result in more of those individuals going off medication or failing to have a prescription filled.
Ms Lankin: I had two other questions, but in deference to the Chair I'll cut it down to one.
I heard you talk about the need for a commitment on the reallocation of institutional dollars into the community. Earlier today we heard a similar plea from the district health councils in terms of a percentage allocation so that we know what's happening. In the Metro report, for example, all of the recommendations about hospital restructuring are absolutely reliant on the recommendations about community investment. You can't do one without the other. You'll have gaps in the system if you don't increase the spending in psychiatric and mental health care, as they say.
I wonder if you could elaborate on that. Do you think it would be helpful for that kind of recommendation to be spelled out in the legislation so that if we are going to seal the health envelope and the restructuring is going to be facilitated by these extraordinary powers to downsize, merge and close hospitals, should we be also setting out restrictions on what the government does with that money, ie, it gets reinvested in health services as opposed to being put against the tax break for the rich?
Dr Buckingham: If that would ensure that it be done, I would certainly support that. I don't think that good faith alone will see it happen. There are too many competing interests and the group are not able to advocate for themselves, so legislative protection would be desirable.
The Chair: Thank you very much. We appreciate your interest in our process and your presentation here today. Have a good day.
ONTARIO PHYSIOTHERAPY ASSOCIATION
The Chair: The next group is the Ontario Physiotherapy Association represented by Signe Holstein, executive director. Welcome to our committee. You have half an hour to use as you see fit. Any time left for questions would begin with the Liberals.
Ms Signe Holstein: My name is Signe Holstein. I'm the executive director of the Ontario Physiotherapy Association. Before I took this job, I was a practising physiotherapist.
The Ontario Physiotherapy Association is the largest voluntary professional association for physiotherapists practising in Ontario. The association has been in existence since 1924. Our current membership is about 3,500 physiotherapists. Our members practise in a range of venues across Ontario: in hospitals, in home care, in various types of community-based facilities, in private clinics, in industry and so on.
Physiotherapy is one of the continuous threads in Ontario's health care delivery system.
While we appreciate very much the opportunity to appear before the committee and to put our views on the public record, I must point out that it is difficult, especially for a voluntary association such as ours, to devise a position that represents the considered views of our membership in such a short period of time. We, like everyone else, only saw Bill 26 for the first time a month ago and we were advised only yesterday that there was an opportunity for us to appear today before this committee. It has been made doubly difficult by our need to comprehend proposed legislation that is both voluminous and complex.
While we see a host of new powers being granted to the minister, we have been given no idea how the minister intends to exercise those powers in the long term. What is missing from the exercise, in our view, is a clear and comprehensive statement of the objectives being sought or the vision for the health care sector that the government intends to use this legislation to achieve. If both had been enunciated, we'd be in a far better position to evaluate this bill. However, we're a bit in the dark; we're shadow-boxing. We can only comment on what might be done with the powers proposed in Bill 26.
Our first concern is a general one about the enormous centralization of power in the health care sector contemplated by Bill 26. The past decade or so in health care has seen a gradual trend of decentralization and devolution of powers from the Ministry of Health to various types of community-based organizations. Similarly other provinces -- I have in mind as examples Alberta and Saskatchewan -- have decentralized delivery and funding decisions to regional or community organizations within the province's overall fiscal and public policy envelope.
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Bill 26, in order to achieve certain fiscal objectives, abruptly reverses this trend. While we understand the reasoning behind it, we don't think it makes long-term sense.
Community-based decision-making means that the configuration of health care can be adapted to the circumstances and requirements of each community. Community-based decision-making makes the community part of the process and, as such, democratizes and potentially depoliticizes the hard choices that have to be made about health care delivery and funding.
Community decision-making encourages the community decision-makers to devise seamless continuity of health care delivery in each community. Community decision-making facilitates consultation with local health care providers and constituencies. Community-based decision-making does not mean that the provincial government loses spending control. In Alberta, the new model of regionalized decision-making is being used to reduce health care spending.
In Ontario, we have in place the network of district health councils that is being pushed aside in hospital restructuring by the hospital restructuring commission. We recognize that DHCs have had their problems and have not been as effective as they might have been. But Bill 26, in general, and the hospital restructuring commission in particular, could undermine the DHCs and make them somewhat redundant. We think the DHC system should have been fixed, not pushed aside. In our view, the hospital restructuring commission is a typical bureaucratic response to a public policy failure: Rather than fixing an organization, another organization is being superimposed on the existing one.
Another issue we'd like to address is the question of hospital appointments and privileges under the Public Hospitals Act. Currently, only physicians, midwives and dentists may register people as outpatients in public hospitals. Physiotherapists believe they should have admitting privileges to public hospitals.
With proclamation of the Regulated Health Professions Act in December 1993, physiotherapy became a direct-access profession. A physician's referral is no longer required by law to access physiotherapy assessments and treatments.
Requiring a physician to admit a physiotherapy patient leads to a delay in treatment that may retard recovery. Delayed recovery usually means more treatments, more cost to the health care system and more cost to the economy generally.
The requirement for a physician's admission also means duplication of effort which means, in turn, that the health care system pays two health care professionals for something that, in most cases, requires only one.
Bill 26, in particular the proposed amendments to subsection 44(1) of the Public Hospitals Act, addresses the issue of hospital privileges but only in the context of hospital closings and only with respect to physicians.
For nearly five years now, the Ministry of Health, the Ontario Hospital Association and the health care professions consulted on the development of a more rational and up-to-date model for hospital privileges.
We were advised that ministry officials suggested that Bill 26 provided a handy mechanism to implement a new model for hospital admissions and privileges but the government rejected the idea. We think the government missed an opportunity to modernize hospital privileges and to make health care delivery most cost-effective and efficient in the process. Perhaps the committee may wish to revisit this issue.
Our third concern relates to the proposed amendments to the Independent Health Facilities Act.
Under the terms of the social contract, physiotherapy has been consulting with the Ministry of Health on alternative funding and delivery models for physiotherapy in the province. Currently, physiotherapy outside of hospitals, when provided by licensed clinics, is an "additional insured service" under OHIP. The physiotherapy clinics licensed to bill OHIP for physio services are now known as schedule 5 physiotherapy clinics. There are currently 101 such clinics actively billing OHIP.
Essentially from day one of these consultations, the ministry has pushed the independent health facilities model as a replacement for the current schedule 5 system. It is our clear impression that the ministry sees IHFs as a panacea for resolution of a range of funding and delivery questions in the private clinic sector.
We have, as a profession, expressed major reservations about the IHF model that we wanted the ministry to address. Time doesn't allow me to review them all, but let me give you a few examples.
We think the IHF model is too bureaucratized. It centralizes control over the location, configuration of services and funding of each IHF in the Ministry of Health. We are very concerned that the IHF model will not allow physiotherapy clinics to adapt to rapidly changing circumstances and requirements; for example, the closure or downsizing of a rehabilitation facility at a local public hospital.
For historical reasons, a number of schedule 5 physiotherapy clinics are owned by physicians. In addition, there are what we call physician-owned, G-code clinics. These are clinics that provide what are referred to as miscellaneous therapeutic procedures to patients under a physician's delegation or supervision. Many of the services rendered in these clinics are physiotherapy services. In 1992-93, physicians billed OHIP $17.9 million under G467, another $9.8 million under G700, and an untold amount in payments to auto insurance companies.
Finally, there's been an explosion of physician-owned rehabilitation clinics, largely in response to the demand created by motor vehicle accidents and no-fault insurance. Many of the services provided are physiotherapy services. We think physician-owned physiotherapy clinics cause problems. For example, they give the physicians-owners the ability to generate business for their own clinics by referring their patients to that clinic. We think this is thinly disguised self-referral that is contrary to the patient's best interests.
We are also concerned about the impact on our professional standards, ethics and regulatory accountability when one regulated profession, in this case physiotherapy, is employed by another profession, in this case medicine.
With that as background, let me return to the amendments to the Independent Health Facilities Act proposed by Bill 26. We fear that the proposed amendments to section 4, titled "Designated services and facilities," will allow the minister unilaterally and with the stroke of a pen to designate schedule 5 physiotherapy clinics as IHFs.
This in itself is bad enough, but in doing so, the minister could also grandfather existing physician-owned schedule 5 clinics, G-code and rehabilitation clinics as IHFs, thus confirming or even exacerbating a situation we feel is already untenable and costs the province tens of millions of dollars annually in OHIP billings.
We are also very concerned about the proposed powers, in amendments to subsection 5(1), whereby the minister may sole-source or limit-source proposals for IHfs. We were, quite frankly, stunned when we first heard this idea and thought it must be a mistake.
A sole or limited sourcing proposal system raises at least the perception of favouritism. The competitive bidding process, with all its imperfections, tends to keep the process honest, tends to generate the best proposals and is relatively transparent. Sole or limited sourcing achieves none of these objectives, and quite frankly, we find it abhorrent in a general public policy sense.
There is a great deal of concern among health care professions, and I venture to say within the public at large, about the intrusion of American-style, for-profit health care clinics into Ontario and all that they entail, including the migration of American-style attitudes to health care delivery.
American HMOs and so on will already have an advantage in bidding for IHFs by virtue of their size, their wealth, their experience, their political connections with the right-wing in the US and their lobbying abilities. We would be very concerned -- perhaps "outraged" is a better word -- if the minister's sole sourcing power were to be used to grant IHFs to American-owned IHFs.
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We simply to not understand the need for or the logic behind any sole sourcing power, especially from a government that places such confidence in the abilities and disciplines of the market. In a competitive, open bidding process the market will assure a level playing field, will assure highest-quality proposals and timely responses. Sole or limited sourcing is simply more trouble than it's worth.
Our final concern relates to access to patient records by government inspectors. You've heard from other witnesses on this matter, so I won't belabour the point.
I can't think of another issue that cuts so deeply to the heart with health care professionals as does the issue of practitioner-patient confidentiality. Throughout history, our professional ethics have charged us with the protection of personal records against the prying eyes of everyone, including an increasingly intrusive state. We recognize that the government feels that it must have this power in order to address fraud. We assert that there are better ways.
As a profession we are keen to work with the government on effective ways of getting at systemic fraud using the existing powers of the regulatory boards. On a case-by-case basis, if the government suspects practitioner fraud it should seek the patients' consent for access to patient records. It should not have the power, without a judicial warrant, to go on a general fishing expedition. Otherwise, the government has created a very slippery slope. Fraud today, but what tomorrow? And at what cost to the personal privacy of individuals?
In closing, for the past five years health care professionals in Ontario have had to face and deal with a virtual blizzard in public policy initiatives and funding constraints. Many of these initiatives, I am sure, were well-meaning. Many were driven by ideology or preconceived notions. Some resulted in net benefit to the health care system; many did not. They were, virtually all, destabilizing to one degree or another. What Ontario has not had for some time is a comprehensive vision of the future health care delivery system for Ontario.
In the absence of such a vision, ad hockery, incrementalism and major policy reversals and adjustments have prevailed. Because there has been no vision, there has been no consensus on objectives, there has been too little partnership among the stakeholders, too little consultation and too little coordination. As a result, our health care system is in a fragile state.
The government has developed the health care amendments in Bill 26 as a specific response to a specific situation: the need for consolidation, rationalization, efficiency etc in the hospital sector. But Bill 26 goes far beyond the hospital sector and raises issues far beyond those of consolidation, rationalization and efficiency. Bill 26 and the comprehensive powers it includes, once passed, will be on the books for a long time and for any purpose for which the government, this or any future government, decides to use them. That concerns us.
Having said that, we know what happened last June. We know that Ontarians elected a government committed to fiscal conservatism and restructuring because Ontarians are concerned about their future and their children's future. While there is much in Bill 26 that concerns us, we recognize the popular will and commit ourselves to helping the government make its health care restructuring work for the benefit of our patients.
Thank you for your attention.
The Chair: Thank you. We now begin questions, about four minutes each, with the Liberals.
Mrs Caplan: As always, an excellent and thoughtful presentation.
The first question that I have for you is, were you consulted by the minister, the ministry? Did you have an opportunity to meet with the minister and see what was being proposed in the legislation and have any discussions about how it might potentially affect physiotherapy?
Ms Holstein: No. Certainly not before it was presented. We were invited to the briefing sessions following.
Mrs Caplan: Have you had any indication from the minister that they intend to include physiotherapy? We have not had any stated intention. We don't know how the government and the ministry, the minister, intend to use these massive and absolute powers. You have every right to be concerned. What I'm trying to find out is, have they told you that you're going to be affected by this?
Ms Holstein: No. We have no reason to believe one way or the other. We're really basing our concerns on what we see and can understand from the legislation and from discussions around other issues with ministry staff.
Mrs Caplan: My reading of the bill suggests that every place where insured or uninsured physiotherapy services are provided could be required, under this legislation, to be part of an IHF. Is that your reading of the bill?
Ms Holstein: That's certainly the way we interpret that it could be utilized. Whether it would is another question, but the permissiveness, if you will, is there.
Mrs Caplan: I find it just amazing that they wouldn't have discussed with you if they had any intention of doing that so that at least, when you came forward, you'd know what the intent was.
Would physiotherapy support having this massive bill broken into individual bills to allow for greater scrutiny and hearing from the minister what his intention is? Right now he seems to be suggesting that this has to do just with bricks and mortar and moving around governance structures of hospitals and that kind of thing. Would you support having a process that would allow greater scrutiny individually, bill by bill?
Ms Holstein: I think we would support anything that would allow us a greater understanding of what the objectives were and what the expected outcome was to be.
It's really hard to comment on this when, other than fiscal restraint, you don't understand what the objectives are or the context is. So we are, in effect, commenting on a bill in a bit of a vacuum. We understand that there is a need for fiscal restraint, we understand that we will be part of that, but we also want to be a part of how that is shaped, because we do believe that we have some good ideas to bring forward and some very positive ways that we can contribute to that restructuring.
Ms Lankin: I appreciate the thoughtfulness of your presentation and I think you raise some issues that complement some things we heard earlier today, particularly on the section about the IHF, when the radiology section of the OMA was here, and similarly last night when MICO presented. They raised concerns about the removal of the preference for not-for-profit, Canadian-owned health facilities and in particular made reference to self-referrals, and you have this experience with some of the physician-owned physio clinics, and I'm concerned about this.
The minister does seem to understand that, for example, in fee-for-service billings of doctors there is a potential for a individual doctors to control ie, increase, the volume of their work. He said this to us and I think yesterday he went off the deep end when he attacked doctors around some of these issues, but he seems to understand, in the payment schedules for doctors, that potential but yet is prepared to open up health facilities to for-profit operations, and it's beyond me; I don't understand how that could be helpful.
Your profession, as we struggled through the Regulated Health Professions Act, finally becoming a direct-access profession -- was that, Elinor, through three governments and eight ministers of Health that it took to implement that?
Mrs Caplan: At least; 11 years.
Ms Lankin: You're there finally, and I suspect with time we will understand that that in fact is a saving to the health care system. Like others -- chiropractic, for example, the Manga report on control of low-back pain -- physio is a profession that can deal with certain situations more effectively and in a more cost-effective way than through the medical route.
I'd worry about your profession being jeopardized in terms of direct access if in fact we open up the IHF to profit-making organizations. I think first of all they'd come from the States; secondly they'd come more like health care management operations, and physio is just simply an employment group, not a profession within it.
Have you looked at any of the US examples, or how do you think that would play itself out here?
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Ms Holstein: We've begun to look at the US models, because they are of concern to us, and we have had some discussions with colleagues in the States who are involved in those kinds of models now. Certainly, the environment in which physiotherapists practise in the United States is quite different from the way we practise in Canada, although there are a lot of similarities.
We would prefer, quite frankly, to see the profession practise in the way that the Regulated Health Professions Act and some of the other legislation in Canada have set the stage for the profession to practise: as an independent health care profession that is part of a team of providers in the community, where the most appropriate provider is the one who is providing care; that it's based on evidence-based practice and not on a checklist of who should provide what and what can be billed for. So we have considerable concerns about the American style of practice.
We believe that certainly the need to be cost-effective, the need to be able to show that what you do is of value is a very important component, and that we need to do that in our own Canadian way.
Mrs Ecker: Thank you, Signe, for coming forward with a very good presentation. You've made a number of excellent points which are going to be very helpful.
I was pleased to see you highlighted the overuse and abuse in the rehab clinics that have involved both physicians and physiotherapists, and I know both regulatory colleges have been trying to figure out how to address that.
One of the values of the Independent Health Facilities Act, which has been again supported by all three governments, is that it sets up a quality assurance process that is multidisciplinary. The teams of professionals who work within the system work to establish, as you quite rightly pointed out, evidence-based, clinically based procedures within the clinic, and frankly some of those rehab clinics might well benefit from the fraud and misuse that may well be happening and some of them might well benefit from those quality assurance provisions that might well be in the Independent Health Facilities Act.
The other question, though, that I actually wanted to get at was, you acknowledged the need for restructuring, and again you quite rightly pointed out that is something that district health councils and local community input should be guiding. The concern that the minister has been trying to address is that we have the district health councils out there doing precisely that. For example, in my region the district health council did an extended public consultation process to do this, but there's been no mechanism for the minister to implement those community-based plans and recommendations. So the hospital restructuring commission was the non-political body that he was proposing to set up to try and implement those. If we do not use that mechanism to implement those community-based plans, how should the minister do that?
Sorry; I didn't mean to put you on the spot.
Ms Holstein: I think, though, that there are a lot of strengths even yet in the district health council system, and maybe looking at where the really positive, very good activities in terms of district health councils already are in place; how do you strengthen that system? Do you need to go back and take a look at, do you extend some of those powers that we're talking about in the restructuring committee in some fashion with the district health council or a community-based council rather than another piece of bureaucracy? I have that problem with anything, why we put another layer in anywhere; it doesn't matter what we're doing.
Mrs Ecker: How do you stitch them together, though? I think that's the challenge. You've got a district health council here, a district health council there and they need to do this. How do you stitch that together in a provincial health plan which, as you quite rightly point out, we need a vision here to do?
Ms Holstein: But you also have an organization of district health councils. You've got an association of district health councils; you've got executive directors of district health councils who meet on a regular basis. Are there ways of working with what's in existence in terms of that association or the collegial? There are political problems between district health councils, just like hospitals or anything else, but I don't see that a hospital restructuring commission isn't going to have politics involved in it either. Everything in life has politics in it.
So you have an association of district health councils, you've got district health councils that talk to each other, you have some district health councils that certainly need some help to become more sophisticated and able to implement plans, but surely there's some benefit in looking at that structure as well.
The Chair: Thank you for your presentation this afternoon. We appreciate your interest in our process.
RESISTANCE AGAINST PSYCHIATRY
The Chair: Our final presenter before dinner is Don Weitz, from Resistance against Psychiatry.
Mr Don Weitz: I just have to plug this in.
The Chair: Okay, no problem.
Mr Weitz: It's a tape recorder, okay?
The Chair: Welcome, sir. You have half an hour to use as you see fit. Any time you leave for questions will be divided evenly among the parties, beginning with the New Democratic Party. The floor is yours, sir.
Mr Weitz: Thank you, Mr Chairman. I wish to start off by introducing myself. I am a proud psychiatric survivor, a published writer, a radio host at CKLN, operating out of Ryerson. I'm co-editor of what I like to say is the critically acclaimed book Shrink Resistant: The Struggle Against Psychiatry in Canada -- it came out in 1988 -- and cofounder of the anti-psychiatry magazine Phoenix Rising and a human rights advocate.
Unfortunately, I'm unemployed, like at least a million -- well over a million -- people here in Canada. I was thinking of applying for one of the advocacy positions, but Mike Harris and his henchmen saw fit to abolish government-supported advocacy in Ontario.
I am going to focus my remarks on one of the most outrageous violations of human rights, which others have touched upon and discussed, including the previous speaker: the alleged right of the Minister of Health to access, to disclose and to copy any citizen's medical record.
I will repeat the relevant quote from part IV, I think it is, under schedule F, the Independent Health Facilities Act section: "These amendments would give the minister power to collect, use and disclose personal information for specified purposes and to enter into agreements for the exchange of personal information for specified purposes. The director would be allowed to require licensees to provide information for specified purposes."
In that statement there are no guidelines, no limitations, no restrictions to this ministerial power, which I consider another power grab, over access to one's own records. Apparently, no consent of the patient is mentioned or required either. The phrase "specified purposes" is not defined or explained in that section; it's not qualified. The term can mean and apply to virtually anything or anyone the minister wants it to mean or apply to.
To whom can the minister disclose one's personal medical or psychiatric records? Silence in the bill. Silence in the statement. No clue or indication: blank cheque. Fishing expedition. That was the phrase used by the previous speaker. I was careful to remember that phrase: a fishing expedition. Which, of course, is what we would expect in a dictatorship, or certainly in a fascist state: a blank cheque, no accountability, concentration of power, and of course full support from the rich corporate boys on Bay Street and other places in Ontario.
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I have personal knowledge of people being hurt, harmed, often permanently, by non-consenting disclosure of their records by a professional body -- not a person -- such as the College of Physicians and Surgeons of Ontario, against their will. She had to have psychological counselling -- it's in her chart -- after she was sexually molested by her son's paediatrician. Sharon Danley has testified publicly yesterday to this. She is a friend of mine, comrade, close friend, terrific advocate and very courageous woman, very courageous.
This is allowed, to use one's medical record as a weapon to discredit a person's testimony before a tribunal such as the College of Physicians and Surgeons. Now we know of course the Supreme Court of Canada will allow a woman, whether she has a psychiatric history or not, who has been raped and who complains, who dares to accuse a man of rape -- her records, her previous medical records, can be used against her by the accused.
Is Ontario going to just jump on board and say: "Oh, that's fine, let's do it. Hey, this is great stuff"? No, it is not great stuff. It's a serious violation of trust. It's a serious violation of doctor-patient confidentiality. I'm sure I'm not the first and I won't be the last to say it. It's a serious human rights violation, and yet this minister, with the blessing of a lot of members of Parliament, says: "It's okay. Put it in the bill." I say it should be immediately stricken. It is not only obscene but unethical and seriously threatening in this ominous bill. It shouldn't be called an omnibus bill, but I use the word "ominous," like Mayor Barbara Hall did. I think that's an appropriate term to use to characterize this very, very threatening bill because it threatens so many of our rights.
Psychiatric survivors, of which I am one, really shouldn't be used to -- although unfortunately I have to say many of us have been common victims of this kind of violation of our rights. In fact, very rarely are we told our rights when they're taken away, such as when we are in a psychiatric ward anywhere in this province or country. So this is nothing new, but we had a little bit of hope over the years, as human rights became fashionable to talk about, particularly as they applied to patients and particularly as they applied to people in psychiatric facilities, that maybe the government would be a little bit more sensitive for a change. Of course, not with the Harris government. We have seen just the opposite.
To grant the minister such unbridled, unrestricted power is bad enough, but what is also disturbing is there's no recognition that other current legislation does restrict the right of a doctor or anybody else to disclose your record. You know, in the Mental Health Act, bad as it is -- and I've been a vocal critic of this for some time -- still, in the Mental Health Act of Ontario a 1987 amendment very clearly says that, for example, if anybody wants to subpoena your medical record, it's got to be decided in court, not outside of court. A judge has to decide. Well, this minister apparently hasn't heard of that or chooses to ignore that restriction. When the disclosure is refused by a judge, that's it, but the point is a judge can decide that, and the doctor has to make a case that disclosing your record will interfere with your treatment or hurt the patient or probably cause emotional or physical harm to a third party. But that's in the court.
This minister, Jim Wilson, wants: "Oh, we're not going to deal with such frills as appeal processes like tribunals or courts. What I say goes. That's it." This is the mentality that informs this so-called omnibus bill, that informs this government. Rule by fiat, force. "I say it. It must be right. Don't question me. Don't discuss." In fact, I'm lucky to be here, I should add.
Any capable or competent person has the right to see or copy his or her own medical record, in the Mental Health Act of Ontario, with a few qualifications, of course, when you're judged "incompetent" or "incapable," which is a highly subjective, dubious concept to begin with. Still, you go to the review board. That's an appeal process. The minister doesn't mention an appeal process. Once again we have an appeal process in the Mental Health Act when someone wants your record. No mention of that in this great bill.
If you are presumed incompetent in a psychiatric facility, you can appeal that. Many of us have been judged incompetent to understand our medical record. Mind you, it's not so easy to understand, particularly the way doctors write in psychobabble, but still we have a mechanism through the review board. No such appeals or safeguards in Bill 26.
In the Substitute Decisions Act there are restrictions on who can see your record. Well, I know this government was arrogant and contemptuous of any attempt to provide advocacy, so please bear with me while I mention the Substitute Decisions Act, which had some good things in it. It had some safeguards, damn good safeguards.
The public guardian and trustee cannot access your medical record for any personal information as defined in the Freedom of Information and Protection of Privacy Act. It also cannot search. This public guardian cannot search your records kept by the person who has custody or control of your record. The public guardian and trustee needs the consent of the person -- needs consent of the person -- to remove any records for copying. I mean, just to get your record to go to the Xerox machine, he needs the consent, your consent, and rightly so. The public guardian and trustee must return all records within two business days and give receipt for records to person holding the records.
See what I mean by restrictions? It's not a fishing expedition in that act. The public guardian and trustee cannot remove any records needed for care of any "incapable person." The justice of the peace can issue a warrant for your record if the public guardian and trustee's request to see your record is refused. There are strict conditions of access spelled out in the Substitute Decisions Act.
Silence, a wasteland, from Jim Wilson here on Bill 26. This is from the Substitute Decisions Act, "A person who obtains access under this section to a person's clinical record within the meaning of section 35 of the Mental Health Act shall not disclose information from the clinical record to any person directly or indirectly, except in accordance with that act."
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That's as legalistic as I want to be. I'll say a few more remarks and be open to questions or comments. I can tell you this. I've been advocating, usually -- well, always -- without pay, and that's fine, up to a point, about how people can get their records. I've been trying to help people get hold, sometimes, of their records. I've been trying to help people stay clear of psychiatric abuse, which unfortunately is routine in virtually every psychiatric facility in this province. It's not a question of if it goes on, it's a question of how much and how much damage is done.
I'm very sensitive to rights, but when a minister, Jim Wilson or whoever, is arrogant and contemptuous enough of our rights to put this in a bill and expect us to swallow it or bow down and say, "Oh, thank you, thank you," he's got another thought coming.
I'd like to know, and I'm going to ask this question of everyone of you here, and I'd ask this of Mr Wilson himself: Why do you want this power? Why do you, Minister Wilson, want this power? You justify it to the people of Ontario. I want a straight answer -- none of this bureaucratese and efficiency crap we fear. I want a straight answer that I can understand. I think the people of Ontario have an absolute right to get that answer. Why?
So far, all I've heard is, "Well, we want to go after medical fraud," this and that. Fraud certainly goes on, no question about it, overbilling of OHIP, which you probably all know about, billing for services not rendered. Ms Sharon Danley eloquently spoke to that issue. But that is a criminal act, the province of the Attorney General. It's a crime, so why the hell does the Minister of Health have this power to try to detect fraud? Fraud is a criminal act. This is beyond the jurisdiction of the Minister of Health, or it should be. This is the responsibility, in my opinion, of the Attorney General.
I don't know. Am I wrong? Here's the Minister of Health who wants to act like a prosecuting attorney or something. It sounds like it.
I want to end now with some general statements about what I consider to be in back of this Bill 26, particularly this heinous section which gives the minister the power to go after anybody's record, often without their knowledge and consent. There's nothing in here that says he has to tell you he's looking.
I have to say I detect a strong neo-Fascist motive or process going on. It has all the hallmarks of it: concentration of power, lack of accountability, ramming through this bill and others like it, with no public discussion. The only reason we're having the discussion is that one or several courageous members of Parliament one night decided not to leave the Legislature and forced the government to take a look at itself and what the hell it was doing.
I know I smell that Fascism is informing this, in a so-called democratic society. I smell it. I don't know how else you can characterize this grab for power, trampling on people's rights, forcing through and virtually getting rid of public discussion on such an important bill. It concerns a deprivation of our rights. I won't say anything more about that, because I don't want to be accused of, "There goes Don, sounding rhetorical." But if the shoe fits, it should be worn.
Yes, I do want a straight answer about why Minister Wilson saw fit to grab for this power over people's files. I want a straight answer. If I don't get it from anybody here, I'm going to ask Mr Wilson to his face, one way or the other.
Frankly, I don't like being victimized again. I was victimized and abused when I couldn't get my records many, many years ago. I do not appreciate this government sanctioning this secret, spying type of -- yes, it is spying on us through getting our records. God knows what's going to happen to them or who's going to have them.
Anyway, you can be sure that a number of us who cannot be here and probably won't be here because they didn't have enough time or for a lot of good reasons, others who are much more eloquent than me -- I wish they could be here to express what it means to have your records used against you, like Sharon Danley did.
I think I'll close now and open for questions. I do plan to submit some kind of brief. I understand I have until -- what's the deadline? Sometime in January now?
The Chair: January 18.
Mr Weitz: Thanks. I'll do my best to get something in in writing.
The Chair: We look forward to your written brief. You've left two minutes per party, starting with the NDP. Ms Churley, do you have a question?
Ms Marilyn Churley (Riverdale): Yes, I do. It's nice to see you again, Don. I should say that Mr Weitz has been a very strong and long, long-term advocate of psychiatric survivors, and I've had the privilege of working with him over the years to try to right some wrongs in the system. Your presentation demonstrates fairly clearly for me how very frightened vulnerable people in our society are when they hear about some of these powers being taken on. That's what came through for me.
We just have a little time here, so I'll ask you, have you personally been consulted -- I know you're well-known in your community for being an advocate -- or any of your colleagues, psychiatrists and others who are leading the fight against some of the injustices and difficulties they see in the system? Do you know of any consultation that has taken place?
Mr Weitz: Oh, none. Do you mean with the government taking the initiative and contacting any of us?
Ms Churley: Yes.
Mr Weitz: No, and I'm in touch with quite a few individuals who are active in groups, and I would have heard. I know no one called me to consult.
Ms Churley: So as far as you know, no.
Mr Weitz: As far as I know, no.
The Chair: Thank you very much.
Ms Churley: Is that two minutes gone already?
The Chair: Yes. It was a long question, Ms Churley.
Mrs Johns: Thank you very much for being here, sir. I want to say that your presentation has been very informative about some things. There are some things I disagree with, obviously, being the government. I believe the Harris government is caring, in the fact that it cares about the future of our children and is trying to make a sounder future for them.
I just want to clarify that we offered more consultation than this, over a shorter period of time, and it was refused by the other parties.
You asked us to talk about why we put this into the act. The act is prefaced by the fact that there is abuse and misuse of billings by physicians. I think you probably agree that that is the case.
Mr Weitz: Oh, certainly. There probably always has been since the start of OHIP.
Mrs Johns: What we're trying to do is work at correct ways of making sure we can stop some of that abuse and misuse. As you know, the Ontario college of physicians has a process where they are allowed to look at their doctors and decide exactly how to detect inappropriate billing. We're looking at a process where the Ontario government also could do that, because the process with the college of physicians costs in the neighbourhood of $22,000, it only sees a hundred people a year, it's three years backlogged. We don't think that's very appropriate for the taxpayers of Ontario.
We have brought this in. What we're saying is that the people who look at your records will be doctors and will therefore have the same kind of regulations as the doctors.
The Chair: Do you have a question, Ms Johns?
Mrs Johns: Do you think that doctors will inappropriately use your records?
Mr Weitz: I have good reason to believe that yes, they will, but it may be not just doctors. I happen to know that a number of my friends did not give their permission for some of their records to be given out over the years, and they're very surprised and alarmed to find out that somebody else knew about some of their past. And I know some people whose records were stolen from a doctor's office.
Yes, fraud exists, but I think this is the absolutely wrong way to go about it. That's my point. I already said it should probably be the Attorney General or an independent lay commission.
The Chair: We have one more quick question for you from Mrs Caplan.
Mrs Caplan: Thanks, Don, for appearing -- an excellent presentation and I think very legitimate concerns. One of the suggestions I've made is that the minister take all the parts in Bill 26 that would potentially affect patient confidentiality or the need to deal with access to records and bring it in in a separate piece of legislation that would afford the protections. We would want something that would satisfy the privacy commissioner but that would also address the fraud issues.
Unfortunately, in the way the minister's presented this, he's tended to broad-brush a whole profession and tarnish their reputation, and that's unfortunate.
Mr Weitz: Everybody.
Mrs Caplan: That's right. We all recognize that fraud exists. What I want to know is, would you support that approach, that says, bring in a separate bill, let's review it, let's see if the privacy commissioner would support it, let's deal with fraud in a way that makes -- how about using this term -- common sense?
Mr Weitz: Common sense is in short supply in general in this government. I should say humane sense.
Sure, I would be interested to see a bill. Look, I'm not a legislator, I don't have any expertise in drafting. All I know is that there are too many loose ends here. If that could help close the gaping loopholes, chasms, caverns of loopholes regarding rights, fine. For myself, I would seriously consider it. Others I know who are activists, who are advocates in the community should take a close look at that.
The Chair: Thank you very much, Mrs Caplan, and thank you, Mr Weitz. We appreciate your attendance here this afternoon and your interest in our process.
Mr Weitz: Thank you. I will try, Mr Carroll, to do my best to get something in in writing.
The Chair: Okay. Send it to the clerk.
We stand recessed till 6 o'clock.
The committee recessed from 1653 to 1801.
SHALOM SCHACTER
The Chair: Welcome back to our committee. Our next presenter is Shalom Schacter. Good evening, sir. Welcome to our committee. You have a half-hour to use as you see fit. The questions would begin with the government when you're finished. The floor is yours.
Mr Shalom Schacter: Good evening. First of all, I appreciate the opportunity to make submissions to the committee and the fact that committee hearings are being held. In all honesty, I have to indicate that the task in front of us is really overwhelming and virtually impossible. There needs to be a lot more time to study all of the information in the bill. The government needs to release a lot more background material as to why all of these different revisions are being proposed. I support calls that have been made by other groups that the government should not proceed as quickly, should segregate different elements of the bill so that hearings can be held separately.
I do, however, appreciate that the government wants to begin action very quickly in the area of health service restructuring. I would offer one proposal, and that is that the government proceed initially only with the health service committee portion, as long as that body, although it would begin a study, would not in fact take any actions until there were further deliberations by this committee and by the House. But at least the restructuring committee could begin its work and then, upon final passage of other legislation in the House, it would have its reports ready and the government would then not have a delay in taking further action.
I'm going to address comments tonight to two particular schedules. The first is schedule F, and then afterwards schedule G.
Dealing first with schedule F, I think that there is merit in setting up the Health Services Restructuring Commission. I think, however, the statute should make clear that the scope of the commission should be the entire health sector and that it's not just focusing on hospitals. If there is going to be an effective allocation of resources in the health sector, it needs to be looked at as a whole and not piecemeal. I would recommend that the statute itself recognize that and not simply leave it up to the minister or the government to delegate additional powers to this commission.
Secondly, I think the commission should only investigate situations when there is already a report on the matter from a district health council and the commission should not engage in any initiative without there being already a report from a district health council on the matter.
Those are comments with respect to part I of the schedule.
I now turn to part II and I address the powers of the minister. The minister is really being given awesome powers in this bill.
Firstly, I would recommend that the statute make clear that the minister could only act after there was a report on the matter from the Health Services Restructuring Commission.
Secondly, the minister should only be able to act after the minister had given prior notice to the public of an intention to act, either in accordance with the recommendations of the commission or in some other way.
Finally, the minister should act only after there has been an opportunity of this or some other legislative committee to hold mini-hearings so that when the minister finally does act, it's on the basis of the opportunity for public input and for comments to be made by members of the Legislature. These are massive powers, and if the power is going to be taken out of the Legislature as a whole and given to the minister, then these safeguards have to be included.
Furthermore, section 9.1, which identifies the kinds of matters that the minister or the government can include in determining what the public interest is, needs to be tightened up. It cannot be left open. All the criteria that the government thinks are relevant to the determination of what's in the public interest need to be specified in the bill.
Then I would turn to subsection 9.1(2); that's the immunity from liability. I guess I find that the most questionable. It seems to me that this government, in campaigning, desired a mandate to have government operate more efficiently, more competently, yet the only conclusion I can take from this section is that the government wants to have a statutory shelter for negligence, for inefficient and incompetent regulation of a very vital public service. Again, I find this section inconsistent with the mandate that the government sought and I would urge that this section be withdrawn.
Finally under part II of schedule F, the explanatory material at the beginning indicates that there is going to be a requirement on hospital foundations to provide documentation to the minister. I think this is an excellent provision. Foundations have been funded in some part, if not in large part, by previous surpluses of funds supplied from the public purse and foundations should have an obligation to report to the government on how they intend to deal with those moneys. But I feel that the reports from the foundations should not just go to the government but should be part of the public domain. Members of the community, the Legislature, other people of the hospital community have an interest in knowing what's happening in these foundations, and the reports should not just go to the government itself.
I now turn to part IV of the schedule, dealing with independent health facilities. Others have pointed out how these changes would allow for privatization of health facilities. Again, I'm struck by an inconsistency. The government has already recognized the self-interest of members of the medical profession, and this bill contains a number of sections that will allow it to deal with that self-interest, yet the government fails to recognize that privately operated health facilities also have a self-interest in maximizing profit, and that will come about in large part through either increased cost or reduced levels of service. It seems to me before the government embarks on any initiative that would allow for privatization of health facilities, there should be some independent, professional study that identifies what possible benefits could come to the public from allowing private operation of health facilities.
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I'm also wondering why the government is moving to avoid having to have a full, advertised, open tender. Again, if the object is to have health services provided at least cost, why is it that you're not giving everybody the opportunity to put in their proposal so that the government and the public can see whether in fact the tender that's accepted is the one that's going to provide best service at least cost?
Finally, I'm struck by the action over independent health facilities and the absence of any action over private labs. If the intention of the government is to operate the health system at a reduced cost, why is the government not moving to deal with reports that it is paying far too much for the operation of private labs? Public hospitals have indicated that their labs would be able to do outpatient and other tests at less cost than private labs, and yet they're prohibited from engaging in this type of activity. At the very least, the legislation should be amended to allow for hospital labs to compete in the marketplace with the existing labs for the services that hospital labs are now precluded from engaging in.
With that, I'll turn to the next schedule, dealing with the drug benefits. I have to say that, like others, I'm troubled by the imposition of user fees or copayments, or whatever it is that you choose to label such payments. If the intention is to reduce the unnecessary use of drugs, it seems to me a far better focus for government action would be on professionals -- doctors and pharmacists -- to try and ensure that drugs were only prescribed when they were medically warranted.
It's been documented that a large part of health expenses deals with seniors who have taken inappropriate drugs -- inappropriate not because the doctor didn't prescribe it, but because the doctor did prescribe it. It seems to me the government can do a lot to reduce the health bill by eliminating unnecessary expenses through better monitoring of the issuance and filling of prescriptions rather than penalizing the members of the public who are taking drugs that are prescribed by making them pay different kinds of user fees.
I'm also struck by the provision in the bill that would allow the minister to say, "We're only going to pay the cost of a certain drug or procedure," and if your doctor prescribes some more expensive drug or procedure, you're going to have to pay the difference. It seems to me that if a doctor certifies that the special treatment was medically necessary, then the fact that there is a less costly but less effective or ineffective procedure is irrelevant. The government should pay for the full cost of the drug or procedure that has been prescribed, if it's medically necessary.
I'm troubled by the complete deregulation of drug costs when they are not under a government plan. I can understand the desire of the government to limit its costs from the public programs, and if it feels it's in a position to negotiate a more cost-efficient agreement with drug suppliers, then all the power to you. But why leave ordinary citizens, who do not have your bargaining market power, at the mercy of suppliers of these services? The only consequence is that their costs are going to go up and they will be unprotected to be able to do that. You should be able to accomplish your objective of negotiating a better deal for the government plan without removing the protections of caps on prices that are paid by members of the public.
It seems to me that if the government wanted to lower drug prices, one element of its program would be to lobby the federal government to repeal the actions of the previous federal government in extending the patent protection for drugs. We should move back to a shorter period of protection before generic drug suppliers are allowed to compete in the marketplace with the brand-name manufacturers.
In part III of this schedule you make certain amendments to the Regulated Health Professions Act, and while these sections deal specifically with drugs, I'm struck by the failure of the government to make other amendments to the Regulated Health Professions Act that would bring about efficiencies in cost in the delivery of health services.
One area that the government could move in would be to expand the scope of practice of registered nurses to allow registered nurses to perform functions that they are competent to do, that they have been trained to perform but that right now are within the exclusive legal ability of doctors to perform. There have been other suggestions for nurse practitioners, nurse clinicians. The nursing profession is an educated and competent profession and they can take over functions that would provide good-quality service to members of the public while at the same time lowering the government's health bill.
My final comment to you is on the section that will relieve the government of legal liability in the event courts uphold certain rulings that have been made in connection with drugs. It seems to me that this is an unjust proposal. Your federal colleagues are complaining about the actions of the present federal government which is trying to limit its liability in connection with the Pearson airport deal, and yet you are embarking on much the same course of action in trying to limit your liability here in the province.
It sets a very bad precedent. It seems to me a future provincial government could come along and try and undo many of the initiatives that your government is undertaking. For example, if you do privatize any of the health sector, a future government could come along and legislate that it's going to be once again put under the public sector and legislate that there be no compensation and eliminate any possible legal liability. I'm sure you would holler at that, and I can't understand why you feel it would be appropriate for you to try and engage in the same actions.
These are the only comments I feel able to make at the present time given the massive nature of the initiatives in Bill 26, the limited amount of explanatory material that the government has been distributing and the limited amount of time that's been available to analyse these things, although I'll do my best to respond to any questions that you have.
The Chair: Thank you. We've got about four minutes per party, beginning with the government. Mrs Johns.
Mrs Johns: Thank you very much for coming today. We appreciate all your comments and we certainly know as a government that this is a large bill and very difficult. It's difficult to restructure government and to move from the status quo we've had for a number of years into something that's a real change, so we appreciate you looking at this and offering some help to us.
The first thing you talked about was restructuring. I understand that you want the district health council involved first, as we all do, because that's the only link we have with community, and we want these to be community-driven incentives, obviously.
You suggested that you didn't want to see the commission implemented right away, I think. As you probably know, the Metropolitan Toronto District Health Council has said that it needs to have another group in there to be able to implement this process. Why would you disagree with that recommendation by the Metropolitan Toronto District Health Council?
Mr Schacter: I'm sorry you misunderstood me. I was very clear that I'm not opposed to the immediate establishment of this commission, and I recognize that at least one district health council has called for some similar-type structure to be established. I'm simply indicating that the commission should only deal with subject matters that are covered by different district health council reports and should not go off on an initiative without there being a report, and finally, that it should not be in a position to implement any actions following this report until there is some kind of notice to the public, with the opportunity of final comment by members of the public and by members of the Legislature.
Mrs Johns: We certainly agree with most of that because we believe that it has to be driven by the consumers, and we have to have the district health council and then they have to implement those recommendations. So thank you for that.
Mr Schacter: But that should be written into the bill.
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Mrs Johns: Okay. You asked me about independent health facilities and why we may not put them to tender. One of the reasons we may not put them to tender is, for example, if only one person provides the service. Let's say that a company in France comes up with a new method for doing something and they are the only people who can provide that service. If we put that out to tender, it's costing a lot of time and money for only one or two people who we know can provide the service. Possibilities? What do you think of that?
Mr Schacter: I think the fact that there is a particular process that only one company provides doesn't mean that it should be given a contract. There should be some kind of hearing, that providers of other but equivalent services should be able to say that service is not the best medically, and it's also not the most cost-efficient.
Mrs Johns: I understand what you're saying. The problem we have with that is that we're trying to do better with less, too. We don't want to bring more bureaucracy into this. We're trying to work in the most efficient, managed system. You also commented that it's the intention of the government, I think you said, to operate a system. It's certainly not our intention to operate anything, when you were talking about independent health centres. It's our intention to manage the health system and make it grow and make it accountable and look for outputs, so from our standpoint we see it a little differently than actually getting in there and operating a system.
The Chair: Mrs Caplan.
Mrs Caplan: I shouldn't put words in your mouth, but I'm tremendously frustrated when the parliamentary assistant for the minister suggests that things are in this bill that clearly are not there and that things that are not in this bill are clearly there. For example, the broad and absolute powers given to the Minister of Health, we've heard from deputation after deputation, could permit him to micromanage the system, such powers as the ability to tell hospitals the level of service they can provide; the ability to dictate their manpower plans and the ability to actually write hospital bylaws; the fact that if he believes it's in the public interest, without any specific criteria he can send in a supervisor. If any board in any way resists his orders he can send in a supervisor and effectively take over, wipe out the volunteer board and run the hospital. That is micromanagement.
The parliamentary assistant today -- and we're going to be looking at Hansard very carefully -- has left the wrong impression with deputations that have come before this committee and I think that is unfortunate. I know she wouldn't want to do that and so tomorrow I'll be raising some of those and ask her to apologize and to correct the record.
What I've heard you say is that you recognize there is a need for restructuring. What I want to know is, are you aware that this legislation gives the minister absolute powers without any process from the DHC? It doesn't mention DHC reports at all. It gives the minister absolute power to decide if a hospital should close, merge, amalgamate. He doesn't even have to make that decision. He can give all of those powers to an unelected, unaccountable, restructuring commission.
What he said in a press release yesterday was that he would disband the commission, sunset it -- have a "sunset review" was actually his words -- in four years. But those powers would still remain in the hands of one person, namely, the Minister of Health. Do you believe that any Minister of Health should have those kinds of absolute power without any process or procedure or accountability or scrutiny, without any opportunity for the public to come before him?
And do you think that he should have the power to delegate those powers? Do you think he should have the ability to give an unelected authority -- and it could be one individual from this commission; it doesn't have to be a whole group -- to implement the kind of massive restructuring, even that is being contemplated at district health councils and recommended by them, without accountability and scrutiny by anyone? Is that what you're saying when you say, "I support a commission"?
Mr Schacter: First of all, my understanding of the bill is identical to yours. These are absolute powers being given to the minister, and the thrust of my presentation is that the bill needs to be amended so that the intentions of the parliamentary assistant be adopted, which means that there should be accountability built into the bill. Right now there is no accountability at all.
Mrs Caplan: Right.
Mr Schacter: The thrust of my submissions is, in a number of ways -- through specifying the criteria, through eliminating the immunity from liability, through the requirement for notice and public hearings -- an accountability system could be built in.
Mrs Caplan: And if those amendments are not included in this bill, should it be withdrawn?
The Chair: Thank you very much, Mrs Caplan, your time is up. Ms Churley.
Ms Churley: I'll ask the question for you. If that amendment isn't included in the bill, should it be withdrawn, in your opinion?
Mr Schacter: Yes, it should.
Ms Churley: Well, that's pretty definitive.
I was interested in your approach because I think you took a very calm and sensible approach to what I consider to be a really draconian and really scary piece of legislation that's coming forth, and regulations in many cases yet to come. I know, and I believe you expressed it, that it's very hard to analyse this bill in such a short time.
So far everybody I've heard believes that this bill should be split, because it is so big and it is so complex, so that each area can be dealt with separately and people can at least have an understanding of what's being talked about. I submit that government members, for their understanding as well -- because as my colleague from the Liberal Party said, and I don't believe anybody would deliberately try to mislead our presenters here but I'm astounded by some of the responses that are given to presenters. It all sounds very nice, but in my view it's not the correct interpretation of this bill, which is quite unfortunate.
Having said that, I ask you if you would see that as a positive step to take.
Mr Schacter: There's an expression, "Just because I'm paranoid doesn't mean they're not after me." I have to agree with you that this is a very draconian piece of legislation, and I think it's important for the government to put on the record its intentions. We've heard the minister say, "Just because the power is in the bill doesn't mean I'm going to exercise it." I think it's important to put on the record in some accountable fashion the intentions of the government so that the exercise of these powers be limited to those intentions if in fact the Legislature should choose to adopt the bill.
Again I emphasize I think it is crucial for the bill to be broken down, for more information to be put forward by the government as to its intentions and for more time to be given to study the bill, although I recognize that at least with respect to the ability of the Health Services Restructuring Commission to begin its operations, it's possible to hive off that portion of it and pass that so the commission can begin its study.
Ms Churley: That's an interesting thought. You didn't get into it -- do you have any thoughts on the disclosure of private information, your information? The minister can essentially give that information to anybody he or she chooses.
Mr Schacter: This government sought a mandate for less government and yet it's trying to get more powers over individual citizens' private information that should be protected. If there is a legitimate use of that, it needs to be tightened up.
The Chair: Thank you very much, Mr Schacter. We appreciate your interest in our process and your presentation tonight. Have a good evening.
Mrs Caplan: Question, Mr Chairman?
The Chair: Yes.
Mrs Caplan: I'd like to place on the record a question for the ministry to answer. We had a representation from the Ontario Physiotherapy Association --
The Chair: Can we do this at the end of the presentations?
Mrs Caplan: Sure. That will be fine.
COUNCIL OF MEDICAL IMAGING (ONTARIO)
The Chair: The next group is the Council of Medical Imaging. You have 30 minutes to use as you see fit. Question time will be divided evenly, starting with the Liberals. The floor is yours.
Dr Desmond Walker: Thank you very much. I'm Dr Desmond Walker. I'm a radiologist. I am the chief of diagnostic imaging at Markham-Stouffville Hospital, and I'm also the chairman of the Council of Medical Imaging (Ontario).
The council very much appreciates the opportunity to appear before the committee to address Bill 26, and we'd like to fill you in on some of the things the council does.
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Back in 1992, radiologists in the diagnostic imaging industry agreed there was a need to work together to address some of the issues facing the field of diagnostic imaging. The council was formed to do several things: to promote the practice of medicine in the area of diagnostic imaging; to hold conferences, meetings, seminars and exhibitions for the discussion of issues involving the practice of diagnostic imaging -- diagnostic imaging, for those of you who are not aware of the latest medical terminology, includes X-ray, ultrasound, nuclear medicine, CT and MRI. We try to establish and maintain educational training programs, to initiate projects to address improved quality management practices, and to engage in medical research.
The members of the CMI include a number of professional radiology organizations as well as almost every company involved in the diagnostic imaging industry. More than 30 companies belong to the Council of Medical Imaging. This includes medical equipment companies, film companies, service organizations and pharmaceutical contrast manufacturers.
To go back a little to the beginning, when I was appointed the chief of diagnostic imaging at Markham-Stouffville about seven or eight years ago, this was a 200-bed hospital with four X-ray rooms, some nuclear medicine. The approval from the ministry was to go ahead and plan the department. It was evident to me, having been a chief in another hospital, that CT, even though many people regard it as esoteric, had a place in almost all community hospitals, because if you don't have the CT on site, what you end up doing is doing all kinds of different tests -- barium meals, barium enemas, IVPs, nuclear brain scans -- and at the end of the day, having spent all that money, you end up having to send the patient to another hospital with a nurse in an ambulance. It costs a lot of money, you waste a lot of time and you do unnecessary things.
So I talked to administration and we began to have discussions with the Ministry of Health and we presented a business case for a CT scanner. If you worked out what the costs were, it became evident that it was cheaper to have the CT scanner on site than to send patients by ambulance to other facilities.
As time went by, I became involved in the Ontario Association of Radiologists and, having worked with the ministry on this, we began to talk to them about new guidelines for the CT scanners. There were guidelines like you had to have a referral base of 300,000 and so on and so forth. Over a period of time we came up with some new guidelines for CT scanners, and we worked with the Ontario Hospital Association, the district health councils, the Ontario Medical Association, the Ministry of Health. I think we're beginning to show here that we can all work together. I think it's important to remember that.
We presented some principles about who should have the CT scanner and the use of it and so on and so forth. Briefly, you had to demonstrate the need for a CT scanner, that you had the kind of workload that required it. You had to have the support from your local community, such as the district health council; assess the impact of the CT scanner on the region's health care services; and show the ministry what the financial implications were and the hospital's ability to finance the cost without incurring a deficit as far as operational costs were concerned. As you probably know, the capital acquisition costs are the responsibility of the local community.
We developed clinical guidelines, because in smaller hospitals people did not know how to use this modality; it was a strange, different beast, and they'd been used to ordering all the routine tests. Now they had to be taught how to go straight for the jugular, how to go straight for the CT and save all the unnecessary things. A quality assurance program was important, even beyond what's required by law in the HARP Act. There was also an annual report to the Ministry of Health to show what patients had been done, what the types of diagnoses were and what the financial implications were.
We feel this approach is very beneficial. For the first time, we felt that as physicians we were able to talk to people in the Ministry of Health. Before that we didn't know who to talk to. We would send a proposal; it would lie there gathering dust on a desk. We didn't know who to talk to, and we felt we were making a lot of progress. Having gone through all this process, what we felt we had achieved at the end of the day was that we had a consistent decision-making process. We had CT scanners where they were needed. Their use was managed. The ministry knew what the costs were. It took away the feeling that every time you had to make a decision, you had to go to the top. It enabled people on the ground -- the troops, if you will -- to make that decision. More importantly, it standardized the ministry's policy for approving and operating CT scanners.
I have to tell you, from beginning to end this process took four months, which I think is the speed of light as far as the ministry is concerned. The person we worked with was eventually promoted to another job, I think in recognition of the good job he had done working with us producing these very sensible guidelines.
The ministry now regards CT as a routinely used technique, and that one per 300,000 population has gone. The waiting list for CT scanners has been dramatically reduced. People were waiting six months, almost a year. Now my own hospital, the waiting list is two or three weeks. Other hospitals have longer waiting lists, depending on what their referral base is. Since this policy was approved, there have been approximately 19 approvals for CT scanners.
The access is just -- it's used as an ordinary diagnostic imager modality. In my own hospital, for instance, all our technologists are trained to do CT scans. If a patient comes into the emergency department on the weekend, the technologist on call does a scan. We don't have to have a standby technician, to bring somebody in to do it at great expense. It's just a routine part of the study. Actually, the cost of doing a CT scan to the Ministry of Health is approximately $1.50 more than doing an X-ray of the skull, which is a completely useless examination. It means that we can move on and get a quicker diagnosis, and the patients can get treatment and have a better chance of having successful therapy. That really is the important part of it. We really want to make sure our patients are getting the best treatment as economically as possible.
Having developed a business case for CT, it was evident to us that we should talk to the Ministry of Health about a similar approach to MR scanning, because looking back two, three, four years, there were only 12 MR scanners in the whole of Ontario. At this time, the Council of Medical Imaging had come into being and felt it was a project they could help with financially, but also provide background material and inform us of what was happening in the rest of the world, because it's very easy when you're living in a certain milieu to think that's how the rest of the world operates, and that isn't exactly true, actually, as I'll show you towards the end of this talk.
In fact, when we approached the ministry about this, they said: "We're glad you talked to us; we're glad you called us. We were just getting ready to develop new guidelines for MR scanners." All the teaching hospitals in the province had an MR scanner and they were thinking, well, you know, "It just seems reasonable. How do we broaden the scope now?" We had a very collaborative relationship with the people in the ministry. We shared our information with them. In fact, when we said to them, "We're working on this document," they said: "That's great. Let us have your document when you have it." We said, "When do you want it?" They said, "Well, it would have been great to have it yesterday." We let them have that document within about four weeks and, as you know, approval in principle was given several months ago for additional scanners.
We believe the imaging modalities to examine patients should be available in such a way that the most appropriate test can be done when the patient is either booked for an examination or arrives for an examination. Basically, that means the imaging modalities should all be available on the same site.
In Ontario, for instance, since CT scanners are only available in public hospitals, we feel that MR scanners should be located similarly, because there are many tests that can be done by either modality but there is an optimal test for each condition. For instance, much of the neural work, if you have good access to MR scanners, should really be done by MR, but if you're going to have to wait three months or six months, people feel it would be reasonable to go to a second-best modality, and maybe eight times out of 10 you'll get the right answer.
A similar thing was happening with MR that was happening previously with CT. They were going through a series of tests without getting the answer, instead of going straight to the MR scan. MR is magnetic resonance imaging; it used to be called nuclear magnetic resonance, but the phraseology now is MRI scanning.
If there were a reasonable number of MR scanners available in the province, it would give the patients in this province good access to this modality regardless of where they lived. The people in northern Ontario have no access to MR scanners. They're going to the States, they're coming down to Toronto, at great expense, I might add. I think the MR scanner would reduce the utilization of CT scanners, some nuclear medicine procedures would be reduced, and some surgical procedures would be reduced, like diagnostic arthroscopic surgery, where the surgeon puts a wide needle into a joint and looks around to see what's happening in the joint. That's a pretty painful thing to have. If you can do it on an MR scanner, which is non-invasive, with no radiation dosage, just a 15- or 20-minute examination tells you what's happening and you can avoid that hospitalization, that surgery and so on and so forth.
It improves the quality of patient care, getting the right diagnosis as quickly as possible. We have many horror stories of patients who have gone through many uncomfortable procedures when a simple MR scan could have given them the diagnosis. Patients with blocked spinal cords have to have a myelogram, which is an invasive procedure, it gives them a terrible headache, and it doesn't give you the answer every time. An MR scan would give you the answer right away.
It also reduces the cost of patient care, because many MR studies can be done as outpatients rather than admit a patient to hospital for another procedure.
When we looked around the country, when we looked around the world, we realized that Ontario was an undeveloped country as far as MR scanners were concerned. I think we all believe that perhaps in the States there is an MR scanner on every corner and maybe that's too much. But maybe we should be compared to the European countries, where they have a scanner ratio we should be aiming for. We'll come to that later on.
We strongly support the fact that it should be available in a hospital because you need access to other imaging modalities, and when the patient comes in you may change the test you're going to do because you find something in another test that might help you decide which way to go. We do not think standalone facilities are the way to go because a patient arrives and the people on site there don't know what the patient's had, and half the time they don't take their other examinations. You find, if you read the American literature, that it's a disaster. It's not good patient care.
As I said, there was an announcement that an additional 23 scanners would be approved in the province of Ontario. This will considerably decrease the waiting list and improve the access. As I said earlier, central nervous system diseases are optimally studied by MR, and things like prolapsed disks in the spine are better imaged by MR than CT.
Access is so bad in Ontario that for many conditions in which it's very useful, like abdominal imaging, even breast imaging, it is almost not done because there's not enough equipment to do the things other than the bread-and-butter stuff. If you look outside, there's a lot of literature about things like that, and we're just not even able to do it. In cancer patients, for instance, MRI is very useful, but it's not used very often because MR scanners are taken up doing the head work and the spine work and there just is not facility to do the other things.
I'm not sure whether you're aware of what the background is to the approval process, but this is virtually a no-cost option to the Ministry of Health. Capital costs will be borne by the local communities. There is a $150,000-a-year operational cost given to each MR unit, but this is money which is now largely being paid out anyway for additional shifts by the teaching hospitals to run their units over extended hours, weekends and so on and so forth.
There are no other technical fees for this procedure. That's all the hospitals will get. They will have to find the additional operating costs from within their own budgets, and the hospitals have indicated they can do this because they see savings elsewhere. As far as professional fees are concerned, that will not be an additional cost to the ministry because it will come out of the global pool.
There will be savings to OHIP because of other tests which are not done, like CT scans, like myelograms. In London, for instance, they do virtually no myelograms, because they have good access to MR, but in Ottawa, there is one hospital which does 750 myelograms per year because they have virtually no access to MR. This is the kind of barbaric process we're doing in our medical care system because we don't have access to civilized investigative methods.
As I say, it's a no-cost option as far as the government's concerned, and it provides superior patient care. This process is moving slowly through the ministry. There is no reason it should not be approved quickly and we can get on and provide decent care for our patients.
What the CMI has done -- there's no point in just going out and buying an MR scanner. There are a lot of things: How do you choose the right one, are there enough people trained to operate it, and so on and so forth. We've addressed all those issues. We are developing a technical checklist for people to select the appropriate equipment. We are arranging seminars for radiologists, technical managers and administrators on how to most cost-effectively purchase an MR scanner.
There's a network of MR radiologists in teaching centres who are ready to help in the decisions. There are new radiologists graduating every year who are trained in MR, and they're going to the States because there is no capability to practise what they have been trained for in Ontario. One thing we had to make sure is that there will be facilities for radiologists to be trained in Ontario when these scanners are approved.
Again like CT, where MR is most appropriate, it means quicker diagnosis, more accurate treatment, saving money if a patient's lying around in a hospital bed, and avoiding a lot of radiation exposure. CT is a tremendous diagnostic tool, but it's really quite a high-radiation test. It disproportionately produces radiation that goes far beyond the number of scans that are done, but it's the only way we can diagnose things at the present time, whereas MRI is completely non-invasive and there are no adverse effects.
I think the lesson to be learned from this is that we have shown as radiologists that we can work with different people. We can work with technologists, we can work with the OMA, we can work with the OHA, we can work with the ministry, and we can work together and produce something that's really worthwhile, like this MR business proposal. We strongly urge the Ministry of Health to go ahead and approve these MR scanners so we can begin to produce the health care system that is appropriate. We're not suggesting anything inappropriate.
I'll pull this block schematic out now, which was provided by -- it's a little free advertising for Siemens here, but they produced these figures. This is one of the many pieces of factual information they provided; they provided information on operating costs and so on.
At the left of the graph, it shows how many units there are per million population. Japan is the highest, with 18 units per million population. The US is next. Somewhere in the middle is Germany, Italy, Spain, Korea. Down at the bottom, what do we see? Turkey with 0.8 MR scanners per million, and who do we see next to Turkey? Ontari-ari-ari-o. I have to tell you the Ministry of Health officials were shocked when they saw those statistics, but unless you look around you, look in other countries, other provinces, you're not aware that this is happening. You tend to think what's happening in your province is the norm, and it isn't.
I also have to tell you that since this graph was produced, Turkey's bought another four scanners, and we think we're behind Turkey now.
This is the kind of document we've produced. There are proposed guidelines, a position paper. We outline the benefits of MR, the different field strengths and so on and so forth, clinical indications. This was sent to every radiologist, to every hospital administrator. We're all ready to roll on this, and we hope the ministry will move ahead and approve these scanners, because it doesn't cost them anything to do it. Thank you very much.
The Chair: Dr Walker, thank you very much for your presentation. You've used up all the time allotted to you, so there's no time for questions, but we appreciate your interest and your involvement in our process.
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ONTARIO NURSING HOME ASSOCIATION
The Chair: Our next presenter is the Ontario Nursing Home Association. Good evening, ladies, and welcome to our committee. We appreciate your attendance this evening. You have a half-hour of our time. Questions, should you leave time for them at the end of your presentation, will begin with the Liberal Party. Identify yourselves, please, for Hansard, and the floor is all yours.
Ms Dianne Anderson: Good evening, ladies and gentlemen. My name is Dianne Anderson. I'm president and chair of the Ontario Nursing Home Association. In my working day, I am administrator of the North York General Hospital seniors' health centre and a vice-president of North York General Hospital.
Thank you for this opportunity to present our views on this important piece of legislation. We were called yesterday to present today, so we have concentrated on only a couple of issues.
We wish to applaud all parties of the Legislature for their role in this regard, the opposition parties for their persistence in ensuring a public debate, and the government for listening to them by holding these hearings.
Ms Shelly Jamieson: Good evening. My name is Shelly Jamieson. I'm the executive director of the Ontario Nursing Home Association.
ONHA is an established provincial association providing professional leadership to the long-term care sector. The association has a membership of over 302 nursing homes, which represents over 90% of the province's nursing home sector. Our member homes accommodate about 28,000 seniors and employ in excess of 27,000 people, and that makes us a pretty key element in the long-term care system in Ontario.
We're going to focus our attention this evening on the health care components of Bill 26, specifically sections F, G and I.
By way of background, we are appearing before you today to support the government's initiative in introducing this act. While we have some concerns, we are reminded that we have typically had comments on every piece of legislation introduced in the last few years. We appreciate this chance to participate and hopefully to influence positive change.
Frankly, we believe our health care system is broken. We believe that anyone defending the status quo in health in Ontario is a dinosaur. While the June election might have introduced a new style of government, it did not introduce this serious problem in health care. In fact, we would hope that the definition of the problem would be an area where there is three-party unanimity.
The style difference which I referred to just before is primarily one of speed of action. We applaud the swiftness of action in providing the health care system with the tools necessary to meet the challenges ahead.
Of course, with haste can come errors. It is apparent that some of the provisions of Bill 26 are not yet fully conceived. We hope that when this committee finishes its mandate, you can agree to productive suggestions which will advance the goal of an improved health care system. ONHA believes that there is enough money in the health system, but we must, as a society, use the resources we have in a more prudent manner.
Ms Anderson: I'd like to refer to section F of the bill, which specifically speaks to health services restructuring.
We support the coordination of the many restructuring exercises and their approvals by the Health Services Restructuring Commission. We suggest that the commission have a broadly based membership to counter and balance the often dominant world of hospitals and the medical model generally.
In our opinion, hospital restructuring needs a kickstart. There has been much credible and detailed work done to date. Within hospitals, there has also been a lot of re-engineering work done, resulting in closed beds, shorter lengths of stay, shared services and even new revenue-generating enterprises. These are new ways of doing old things.
To really restructure the system, however, resources, including people and funds, have to be reallocated. We have to do new things with our system. This, we would argue, is the tougher work. Bill 26 provides the framework for this restructuring. It may not be popular, but we believe it's necessary.
An example of how far we have yet to go is in long-term-care facility funding. The Liberal government, then the NDP government, and now the Conservatives, all agreed with the need to reinvest from chronic care to long-term care. Yet still today there is resistance, even at the senior levels of the bureaucracy, to make these changes. We run into this resistance every day at the provincial level and in community settings.
Ms Jamieson: I'd like to take a bit of time to talk on the topic of the independent health facilities covered in Bill 26. On this topic, we would support, and have consistently supported for a long time, the notion of best quality for most responsible price. We believe that those who oppose this concept undersell Canadian companies.
In today's global market, Canadian companies compete and win contracts on the basis of their expertise and knowhow. Look at the previous government's interhealth initiative as a glowing example. One example in our own industry is Extendicare's reputation as a health care provider in Canada, the United States and the United Kingdom. Companies which cannot compete in a Canadian competitive environment, or indeed the world stage, probably don't have a place in the next 10 years in our system, because they are neither leaders nor innovators.
Ms Anderson: Section G also has some sections relating to drug benefits. I would like to address these changes as they affect our environment. We believe Ontario is the last province to introduce cost-sharing relative to prescription drugs. We concur with the concept, for those persons who are able to pay. We see two benefits: first, there is the much-needed revenue for the government, and second, and likely more powerful, is the notion that this nominal charge may signal the need to alter behaviours and attitudes of health care consumers and perhaps some of the medical profession.
To call this charge a new user fee is a misnomer. As we all know, user fees are not allowed under the Canada Health Act, but the Canada Health Act does not state that medications are free. If it did, mine would be free, and they aren't. However, the implications of those changes to drug benefit coverage for residents in nursing homes are less straightforward than they first seem. Residents will be charged $2 for each prescription filled, including renewals. This charge will come from the residents' so-called comfort allowance of approximately $112 per month.
We have several concerns. First, residents in nursing homes take an average of five prescriptions per day. While many drugs are covered by the Ontario drug benefit plan, residents are increasingly paying for more of their own medications as drugs are delisted by ODB.
Second, the impact of changing behaviours of our residents as consumers will be negligible. Seventy per cent of our residents suffer from cognitive impairments, preventing them from participating as consumers in such a transaction. Many others suffer from a multiplicity of diseases which are chronic conditions. Their medications are complex and multiple.
Third, who will collect all of these $2 invoiced amounts? The job of nursing home administrators is currently encumbered with red tape, so it won't be us.
Fourth, what will pharmacists do when a resident does not pay? Will the pharmacy stop supplying the medications? Bad debts from unpaid resident accounts is already a serious issue in nursing home operations.
Will doctors, who know family circumstances, perhaps not alter medications as frequently as they might have otherwise? Often great success is achieved by the medical profession when they experiment to find the best medication mix for residents. Remember, our residents are on several different medications, which can be constantly changing either due to the chronicity of their disease or the unstableness of their condition.
We recommend that residents of long-term-care facilities be exempted from this change to drug benefits. We query whether the administrative headaches, which cost money also, will make the revenue worth the effort, and we are not likely nor inclined to change the consumer behaviour of an 85-year-old.
Ms Jamieson: In section I you've laid out physicians' services delivery management issues. We believe, quite frankly, that it is the mandate of the Minister of Health to ensure coverage for all Ontarians. In what locations doctors practise has been an issue for ages, and it seems to us that voluntary solutions have more or less run their course.
Taxpayers pay to train doctors, since their education and their training is heavily subsidized. It seems reasonable to ask that the minister have a say, at least in the short term, in where new doctors practice to alleviate the situation and provide coverage for all Ontarians.
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It's interesting to us that there is a parallel issue in the nursing home sector. If the Minister of Health wants more beds in an area, he or she issues a call for proposals. There aren't incentives or enriched rates. If you want to provide nursing home services, that's where you go to provide them -- where the minister has designated in the area. If the minister doesn't want any more long-term care beds in an area, he or she doesn't approve licence transfers. After all, he or she represents the payor.
We hope, in any event, however these issues are resolved after these hearings, that this bill provides an incentive for government and physicians to improve their relationship. We believe the relationship of the last few years has not served Ontarians well.
In summary, we suggest to the government that it tie the broadly based powers -- they seem to be the ones which are making the people most uncomfortable -- to the task of restructuring. This could be accomplished either by setting a time frame similar to the social contract legislation, which in our opinion also took broad liberties, or by empowering the government only to use certain powers when pertaining to restructuring issues and not for other issues.
Every time we as an association suggest reform to this government, we are met with a litany of obstacles which prevent the actual reform. The tools for both employers and the government are necessary for the type of massive reform which we believe is ahead of us. In addition to the topics we've mentioned this evening, we endorse the notion of a message to arbitrators, the notion of clarification of pay equity and the provisions to support the development of an information technology framework specifically for health. In removing these obstacles, however, we recognize that we must be diligent that we don't unwittingly compromise the integrity of the health care system, which is so important to all of us.
We thank you for your time. As you can see, we've left ample time for your questions.
The Chair: Thank you. We have about five minutes per party, beginning with Mrs Caplan.
Mrs Caplan: Thank you for a very comprehensive and thoughtful brief. I'd like to ask, Mr Chair, if the ministry would respond to the questions that were raised in this brief, beginning with who is going to collect and so forth. I want to make a couple of points. I don't know that it is a question; I think it is something that I'd like you to consider and then, if you want to make further representations to the committee, I would appreciate that.
You seem to be under the impression that the $1.3-billion cut in the hospital transfers somehow is going to find its way in a reallocated process, some of it going to long-term care. It's gone to the tax cuts, and that's the reality. The reality is, they promised a $5-billion tax cut and so the dollars that have been taken from the hospital sector are not going towards balancing the budget, are not going towards debt reduction and are not going towards long-term care.
If you're under the impression that the economic statement tabled by the Finance minister had a bottom line on it that included all of those reductions from the Ministry of Health, I just wanted to point that out to you, because a lot of people think, "Well, the copayment or the user fee for drugs is going to go back into the health system or into health care." That's not going in; it's going into that big, consolidated revenue pool from the Finance minister, because they see it as a $225-million saving which they're taking out of the allocation from the Ministry of Health. That's what the Finance minister said. So you should be clear that this is not part of a reallocation.
The other thing is that the $17.4-billion commitment that they make is a $500-million reduction from the present spending level. So that is a real and absolute cut, and their commitment to maintain that $17.4-billion level at the end of their mandate, everyone is aware their intention is to move Comsoc programs into health. So if I'm posing suspicions, it's because that's the rumour, that's what everyone is expecting will happen. In order for them to increase the allocation back to the Ministry of Health, they'd either have to increase their deficit financing and borrow more or raise taxes, and they've said they're not going to raise taxes. So there's no revenue pool out there. I wanted to make sure you understood that.
The other thing is that when you talk about the powers that the minister has and their relationship to restructuring, I have concerns as a former minister because I don't believe that any minister needs all of those powers. I think that restructuring could be accomplished without the minister telling every hospital what their manpower plan should be, and he has that power. I think that they could accomplish restructuring without him having the power to tell every hospital what program they can provide, what program they cannot provide and what service level of that program they can provide. That's micro-management of the system; that is not just restructuring.
The other point I want to make is that there will be ongoing and continual need for rationalization of service, for shifting of how services are delivered as new technologies come. I'm telling you that future ministers will be able to argue that if those powers were given once for the purpose of restructuring, the term "restructuring" is so broad that, if this minister gets all of those powers as presently contained in this bill without restriction, I think you should fear how those powers will change the nature of delivery of our health care in this province, which has always been on the basis of the minister as perhaps a partner. Although, frankly, I remember the day when a hospital board chairman said to me: "Who invited you to be the partner? We liked it better when you were just the banker." I told him if I were just his banker, he'd be in receivership. So the nature is changing from just the minister as a partner in management to having absolute, total control and absolute power.
While I listened very carefully to your presentation, I'm not sure that you realize all the implications in this bill and I hope that you will reconsider your support for all of the aspects of it, with the few exceptions.
The Chair: Thank you, Mrs Caplan. Your time is up.
Ms Churley: I believe you said in your presentation that you were just asked yesterday to come today, so I think that in a very short time you've pulled together very quickly, and I appreciate that. But I also think it indicates part of the problem that we've been hearing from all presenters -- that there's been very little time to deal with such a comprehensive bill and all of the ramifications. Certainly, now that we have further hearings in January, there'll be more time for people to analyse the bill a little better.
One of the issues that you raised briefly was long-term care and that previous governments have tried, and we were certainly almost there -- and not without controversy, I know. There was controversy in my own community, Riverdale. But something that our government did recognize, and I think all do, is that while trying to save money in the health care system and reallocate it with an aging population, especially if hospitals are to be closed, we have to reallocate the dollars into the community and into long-term care.
One of the concerns I have, as my colleague said, is that we have absolutely no evidence that this money is being reallocated. On the contrary, what we're seeing is that there's a huge, multibillion-dollar tax cut that this government has to find the money for, as well as eliminating the deficit. That, frankly, is our fear. We cannot see that there's any possibility of reallocating that money.
I want to ask you briefly further about the drug issue. It's a concern of mine, and all of the presenters that I know of have expressed concerns, particularly about seniors. Whether you call it copayment or user fee -- let's forget about what we call it for a minute -- I think that question does have to be answered.
Another concern I have, for instance, is homeless people, many of whom are mentally ill -- some are schizophrenic, some have other problems -- who go to hostels like Seaton House. As you may know, sometimes the patient is not given the prescription directly, but workers at Seaton House will send that prescription right to the pharmacy, so that the person does get the drug and will take it, because in some cases they are incapable or don't have enough money, or whatever, to get the drug themselves and take it. This is another serious problem, as well as the one you raised about seniors. I don't know if you have any thoughts on it but certainly we need that question asked. Who's going to pay that $2 fee for those people? How is that going to be dealt with? Are we going to have certain people on the streets and in shopping malls and in other locations having serious medical conditions because they're not taking their drugs, which ultimately will cost the system more?
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Ms Jamieson: Mr Chairman, are we able to respond to these questions?
The Chair: At some point in time, I think we'll give you a chance. Yes, you can answer this question.
Ms Jamieson: I can answer this one? Thank you very much. Relative to user fees, I just want to be clear: We spoke specifically about residents of long-term-care facilities. I can't speak, unfortunately, to the situation of Seaton House, although I'm sure there will be people who will appear and address it who are more familiar than I am.
We are not opposed to charging seniors the fee based on their ability to pay, and we think it's an important signal, based on our understanding of the kinds of signals we have to give to people about how they're going to utilize the system.
Our concern is the $112-a-month comfort that our residents are left with. Frankly, we don't see anybody gaining admission to a nursing home to avoid a prescription fee; this isn't going to be a dodge. We're concerned about the administrative elements and the number of medications and scrips which our docs can only prescribe for a period of time, although someone might be on a prescription for the rest of their life while they live at our facility, and the chronicity and the complexity of our residents.
We're quite concerned about the volume. We did some calculations. We were looking at maybe 10% of their $112 might end up going on a monthly basis. That's a big hit, and that's a much bigger hit than the $2 or $14 estimate that had been given previously for people in the community. So I just wanted to make that differentiation.
The Chair: For the government, Mr Clement.
Mr Clement: Thank you for your presentation. I guess all members of the Legislature were looking forward to these hearings, but I was looking forward to hearing from you rather than making speeches, so I'll actually ask you a question, if you don't mind.
The issue for us is restructuring the hospital sector to address some of the areas in the system that aren't getting the money they need. Assuming that we can restructure -- this bill goes through -- how would you like to spend the resources that are freed up in your sector?
Ms Jamieson: We wouldn't necessarily only spend them on our sector. We would invest in community-based services and invest in our aging population, the future of our population.
One of the accidents that quite frankly happened is that when Bill 101 brought in the new funding model for long-term-care facilities, through a mistake, really, and a change in the inflation rate and a series of other things, it was underfunded. That remains today. There's not enough money to do the job that the law says we should do, that we're all prepared, with homes for aged, to step up to the mark and do. In the health care budget, we're not talking about a lot of money, but we are talking about something between, say, $25 million and $50 million that needs to be reallocated to make the facilities function in the way that was envisioned.
On the community services side, we're looking at a much more massive expansion that all governments, I think, have endorsed, to make sure that seniors are able to get the services they need. Right now, many of the services provided in the community are operating on what I call shoestring budgets, and that's not going to get us through the time ahead. So we just think communities tend to be conditioned to look at the bricks and mortar of hospitals as the central focus of their system. We'd like them to start to look at health as in being healthy and in terms of getting services all over the place. It's going to take a shift from that medical model and the hospital-dominated discussions at district health council levels, all the way through the system, even within the Ministry of Health, frankly, so that we can get to talking about solutions that'll really work for all of us as a society.
Mr Clement: I might add that Mrs Caplan is tragically wrong when she says that the money that we save is going to go to the tax cut. In fact, it is going to be reinvested in the system. Given that fact, are there things in terms of the delivery of the services that you just mentioned that you see as a priority for the government?
Mrs Caplan: Where is the reserve fund?
The Chair: Mrs Caplan, when you were speaking, he didn't say anything. I expect the same respect.
Mrs Caplan: I apologize, Mr Chair.
Ms Jamieson: We are eternal optimists and we are hoping that this government will keep its word and reinvest in various components of the health care system. We were a little surprised by some of the shifting priorities and we were a little alarmed by the economic statement, but we believe that the minister continues to be clear about his intent to reinvest.
We would see long-term care facilities as a number one investment priority -- at least one or two on that list -- and we hope that we'll be able, in the facility world, to do the things for half the price that are done currently in chronic care and acute care settings. We're all set to do IVs, tube feedings, all the various things that are now in law. It's really unusual to have the law ahead of the practice, I find. Just an observation.
The law is in place. We're ready to step up to the mark. We're spending 48 cents a day on nursing and medical supplies per resident. Can't do it; can't be done. We need to be invested in so we can get on with our job. You'll see savings at the other end of the spectrum.
The Chair: Thank you very much. We appreciate your presentation tonight and your interest in our process. Have a good evening.
TORONTO CONFERENCE OF THE UNITED CHURCH OF CANADA
The Chair: Our next presenters are the Church in Society Committee of the Toronto Conference of the United Church of Canada, represented by Sheila Brown and Bob McElhinney.
Mr Clement: Mr Chairman, I have the responses from the ministry to the questions that Mrs Caplan asked.
The Chair: We will deal with those when the presentations are finished.
Good evening and welcome to our committee. You have a half-hour to use as you see fit. Any questions, we will start with the New Democratic Party at the end of your presentation. The floor is yours.
Ms Sheila Brown: This is a submission of the Church in Society Committee of the Toronto Conference of the United Church of Canada around the proposed Bill 26.
"The purpose of the bill is to achieve fiscal savings and promote economic prosperity through public sector restructuring, streamlining and efficiency and to implement other aspects of the government's economic agenda." That's a quote from Bill 26, explanatory note, page 1.
The government of Ontario has acceded to the petition to hold public hearings on Bill 26, the Savings and Restructuring Act, in Toronto, December 18 to 21, 1995. As a community of faith, Toronto Conference of the United Church of Canada believes that three questions must be answered if Ontario is to be a healthy democracy as well as to have economic prosperity.
First: What dignity do we ascribe to citizens of Ontario and what place do they have in society?
We hear different voices and experience contradictory actions in the midst of the Common Sense Revolution initiated by the present government.
I quote from a letter from Premier Harris to the president of Toronto Conference, November 23, 1995: "I would like to assure you that our government remains committed to supporting the most vulnerable in our society."
Another quote from a letter from J.S. Gilchrist, MPP for Scarborough East, November 23, 1995:
"It's important that all of us, government, churches, businesses and volunteer agencies, move quickly to find the only thing that will give dignity to those trapped in the cycle of welfare, namely, a job.... Already, in the last three months, almost 100,000 people who were on welfare have left that support and, presumably, found employment."
The Christian community has always believed that the dignity of each human being is a gift from God the Creator. To categorize people because of their economic status is a denial of this God-given dignity and therefore a blasphemy. The fundamental question for any society is to find ways to respect God's gift of dignity by ensuring that the basic needs of people, especially young children, are met.
The recent severe cuts in welfare grants and the continuing reduction of hand-up services are clearly reducing the health and the dignity of hundreds of thousands of people. The dignity of all citizens of Ontario is threatened when the least among us are blamed for the debt and targeted for cost-saving measures while large corporations, especially banks, make excessive profits.
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Some 2,000 years ago, Jesus Christ offered humanity a different view of the dignity and the place in society of those with the least power and the least resources:
"When you give a banquet, do not invite your friends or your relatives or your rich neighbours, in case they may invite you in return, and you may be repaid. Instead invite the poor, the crippled, the lame and the blind. And you will be blessed, as they cannot repay you." Gospel of Luke, chapter 14, verses 12 to 14.
We experience the dignity of many citizens of Ontario being not simply ignored but increasingly demeaned. Recent cuts in welfare grants affected 1.3 million people, including over 500,000 children. The dependence on food banks has increased by over 95%. Over 80% of the children served by the children's aid society are from poor families. Proposed user fees in many areas will restrict, humiliate, many people from using services now available to all. Agencies which have given people a hand up for decades are facing severe cuts prior to any alternative being in place. Volunteers, such as church members, are scolded for not doing more while also being turned away as they seek, peacefully and non-violently, to speak to the government.
When we respect God's gift of dignity to all humanity, we are led immediately to consider a second question.
Mr Bob McElhinney: As a community, how do we listen to one another and how do we come to a common mind for the common good?
Consultation among people is essential to the process of coming to a common mind, particularly when there are significantly different understandings of what is the common good and how it can be achieved. The provincial government is calling on churches to fill in the massive gaps left by the drastic cuts to the social security system. The pace of these changes and extent of the reductions are making it difficult for churches and community agencies alike. Churches have done creative work in low-income communities where values of fairness, human dignity, sharing and interdependence are emphasized. We are loath to return to an old charity model which creates dependency and diminishes self-worth.
As citizens and as a church, we have experienced virtually no willingness on the part of this government to consult, either with those affected by policies or with those who have the experience to offer insight and constructive alternatives. Without a process of genuine consultation, the community as a whole cannot be of one mind and, therefore, is limited to a strategy of protest.
Bill 26 illustrates perfectly different understandings of what constitutes consultation. The word "consultation" has three accepted meanings:
(1) Making a decision unilaterally but informing those affected by the decision before it is implemented.
(2) A body which has the authority to make a decision invites all parties which might be affected to share insights and discuss the merits of alternatives. The inviting body then withdraws to make its decision.
(3) A body which has the authority to make a decision invites all parties which might be affected to share insights and explore alternatives. The bodies continue to meet until they achieve a common mind at which time the inviting body accepts the common mind as its decision.
Bill 26 in its present form clearly opts for an understanding of "consultation" which is based on an enormous concentration of power in the cabinet; no need to consult with persons or bodies affected prior to making fundamental changes in the structures of society; a willingness to make decisions with such rapidity that it allows for no alternatives to be presented or considered.
If decision-making is done without need for meaningful consultation, then a third question needs to be considered.
Ms Brown: How will people and institutions in Ontario exercise effective stewardship of their resources?
We are confronted daily with sad illustrations of how it is proposed that economic prosperity will be achieved. The total of the proposed personal income tax breaks for the chairmen of the five largest banks is $462,000. This tax break is made possible by reducing the welfare cheques for 290 single mothers and their children. As each social service program is reduced or eliminated, the long-range projections are that the cost to society will increase significantly both in dollars and in suffering.
Within the Christian tradition, stewardship means accepting the resources freely given by God and sharing them so that all will benefit. There are communities with vast resources where many go without food, shelter or hope. We also know of communities such as the aboriginal village of Kispiox, which happens to be in northern BC, which has 85% unemployment, where no one goes without food, shelter or support because everything is shared.
Bill 26 proposes to amend the Ontario Drug Benefit Act, allowing user fees and scrapping regulation of drug prices generally; amend the Municipal Act, giving the Minister of Municipal Affairs unilateral power to restructure municipalities; amend the Pay Equity Act, impacting 80,000 of the lowest-paid women in Ontario, including day care workers, nursing home assistants and children's aid workers; amend the Mining Act to give mining companies more freedom to be less constrained by regulations regarding environmental concerns; amend schedule K to raise fees for freedom of information requests, making it easier to deny requests for documents and making it harder to win an appeal; open the door to user fees for vital public facilities, such as libraries and recreation centres.
Stewardship deals with the sharing of resources, openness to information and consultation, and commitment to just decisions. In its present form, we believe Bill 26 does not promote good stewardship, either for economic prosperity or human relations.
We believe that our province needs much more of a common mind on the three questions we have raised before Bill 26 should be enacted in any form. Until the concern for human dignity is seen as integral to any plan for economic prosperity, we cannot support the intentions or the implications of Bill 26.
The Chair: We've got about six minutes per party for questions, beginning with Ms Churley.
Ms Churley: I would like to thank you for coming to present to us tonight and in general would like to thank the church community, particularly lately, but I know all along there have been some voices out there, for speaking so loudly and clearly. You carry a moral authority that I think is extremely important to be heard out there now, which will cut across all political party lines and all political forces out there.
This government tends to refer to people who disagree or groups who disagree with their policies as special-interest groups. Of course, banks and financial institutions aren't called special-interest groups and, in my view, they're the biggest ones out there. Boy, are they raking it in. But having said that, I think everybody, including this government, will have concerns about calling our churches special-interest groups. Indeed your churches are special-interest in that you have concerns about the poor and the disadvantaged in our society.
I noted with interest on page 4 of your brief that you gave three definitions of "consultation." Certainly, something that we're hearing over and over again is that this government is taking your first approach. What we are hearing from people is that this bill is so complex and so huge that it's very difficult, in fact impossible, to analyse the whole thing, and they would like to see the bill split into various components and people be given more time to analyse and deal with the different components separately.
How do you feel about that? Do you think that would be a good approach and perhaps might lead to your second and third approaches to consultation?
Ms Brown: I think it's essential that the bill be split up because it is so complex and people cannot deal with it in its entirety. There are so many little aspects, and one thing impacts on another.
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Mr McElhinney: I'm a community minister with the United Church working in a low-income community in the west end of Toronto. I've seen the impact of the government cuts, of actions that have been taken since last June on my community, on the people, the drastic impact on poor people, people on fixed income, on agencies that have been affected so that community supports have been weakened.
In answer to your question, the implications of the act affecting the relationship between the province and municipalities is a whole issue in itself, when poor people and marginalized people, affected as drastically as they've been affected the last six months, are then confronted by things like user fees for libraries, let alone the whole implications for health care. There just is no margin for these people now to be able to cope. There's no choice. We really have to start to think of the implications of what is being done.
Ms Churley: I have heard some members of the government today say that this government really does care about children and poor people, and you will hear this a lot, that we have to deal with the debt and deficit because otherwise we won't have the health care system and the social programs we have today, that there has to be some suffering now in order to make sure the care is there for people down the road. I'm wondering what you would have to say to that comment, given what you see on the front lines now.
Ms Brown: Are we to sacrifice this whole generation of women and children for the future? That's my first reaction. The other thing is that we have to think of our definition of health. Health is not just the absence of illness but health encompasses the determinants of health, the things that determine how healthy we are: adequate housing, adequate income, social support, a safe environment, peaceful communities. These are all things that have an impact on our health, and if we don't have those -- I see, with the implications of these cuts and changes for people, that we are not going to have communities as safe as they were before. We're going to have a whole lot of implications that don't have anything to do with the illness care system we have. Access to medical care comes way down on the list of determinants of health. If we're looking at a bigger picture, we have to take into consideration the whole community.
Ms Churley: And ultimately it will cost more and we'll pay more down the road too.
Ms Brown: We certainly will be paying a much higher price.
The Chair: Thank you very much. For the government, Mr Christie.
Mr Steve Gilchrist (Scarborough East): Close enough. Thank you for making your presentations. Given that I'm quoted in your presentation here and that you've cited the scriptures -- just as sort of a preamble, this is from Paul's second letter to the Thessalonians:
"In the name of the Lord Jesus Christ, we urge you, brothers, to keep away from any of the brothers who refuses to work or to life according to tradition we passed on to you.
"You know how you're supposed to imitate us: Now we were not idle when we were with you, nor did we ever have our meals at anyone's table without paying for them; no, we worked night and day, slaving and straining, so as not to be a burden on any of you.
"We gave you a rule when we were with you: not to let anyone have any food if he refused to do any work. Now we hear that there are some of you who are living in idleness, doing no work themselves but interfering with everyone else's. In the Lord Jesus Christ, we order and call upon people of this kind to go on quietly working and earning the food that they eat."
It goes on to talk about the greater dignity, the greater self-respect, the greater self-assurance that comes from having a job.
When people come and make presentation on the course we're trying to set for this province, and the one that was recognized by a majority of the voters on June 8 has being the one they wanted to see their government articulate, I have a hard time reconciling that the statistics you quote in your document all arose under the last two governments, under a supposedly socially motivated regime.
You talk about food banks, none of which existed in 1985. You talk about 1.3 million people on welfare and you talk about ladies and children being written off, an entire generation, yet we gloss over the fact there are now more women on welfare than there were total welfare recipients in 1985. I can't for the life of me understand how anyone could accept the morality of the last 10 years, the fact that one out of every eight Ontarians today is living on government assistance, unable to find jobs, unable to fend for themselves.
Surely you would agree that a sharing of resources we have, which was the concept of tithing, not speculating about future income, which is deficit financing, is the way that a true Christian should comport themselves. Surely you agree that the morality of bankrupting future generations to pay for the excesses and the errors of today is totally repugnant and is something that our government must not allow to continue.
Mr McElhinney: It's interesting that you quote from St Paul. St Paul had a standard of work. If ever there was a workaholic in the world, none of us could measure up to the standards of St Paul. St Paul is hardly the objective one here. Frankly, sir, I find that a regrettable passage to quote from because it can so easily perpetuate the stereotypes of people on welfare. To quote a verse that talks about "idle" -- the fact is that the vast majority of people on welfare do not want to be on welfare.
Mr Gilchrist: I agree.
Mr McElhinney: They would really do anything they could to get off it and would love to have the sort of job that would get them out of that dependency. But we are faced with a situation -- believe me, I'm working in a low-income community that was once one of the major industrial areas of the city. There are not the jobs there. We've been beating the bushes for two years trying to come up with jobs and work with people. We're doing all we can to do that, but it's a tough time now.
To make the assumption that somehow getting that sort of job or being able to find that job is going to be the sort of thing that makes it work for people -- we need the safety net to provide the basics for people to be able to move off that dependency. The facts, if you look at them, are if you give them that basic security, people will do what they can to move off that dependency, with encouragement and help. But you've got to provide the basic infrastructure, especially in low-income communities so we'll be able to continue to work at that.
Mr Gilchrist: I certainly agree with you that most of the people out there genuinely want to break out of the cycle of dependency. However, when the system made it more lucrative to not find a job at the lower end of the work scale, clearly that became a disincentive. The fact that the changes we've made so far make a clear distinction between those who can't work and those who won't work -- family benefits weren't touched, the disabled and the seniors were not touched, only those that were able-bodied.
The fact is that one of every seven people on that supposedly insoluble problem we had just three and a half months ago, one out of every seven able-bodied people, is now not on the welfare rolls. I challenge your submission that there are no jobs out there, because one seventh of the people have already been stimulated to do that.
Clearly, there is a lot of work remaining ahead of us, but that's what this bill speaks to: clearing the path and allowing the government the opportunity to create jobs by getting other levels of government and bureaucracy out of the way when they aren't being representative of the people.
The Chair: Thank you, Mr Gilchrist. Mrs Caplan.
Ms Churley: Good luck, Elinor, after that.
Mrs Caplan: As Mr Gilchrist was speaking, I was just appalled at the perpetuation of the myth about people on general welfare assistance. I had a call today from a man who has been looking desperately for work and finally got a part-time job, and now his wife and three children are subject to a clawback. He says he can barely feed his children on the amount he is receiving. This is not going to be a merry Christmas for them. He's been looking for work for 15 months, desperately looking for work. He's not on family benefits; he's on general welfare assistance. I can tell you the calls to my constituency office from people on general welfare assistance who beg me to help them find a job. To say that your cuts are not hurting people who want to work is simply not true. I'm not going to get into that.
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What I wanted to say is that this is an excellent presentation. As a former Health minister, I regularly said in my speeches that all health policy should be tested against three objectives: (1) whether the quality of care they would receive in the health system would improve, (2) the quality of life as a result of their contact, and (3) the dignity of the individual. If we test those in this legislation, it is deficient in at least two of the three, and in some areas three out of three.
I feel there were two very important areas missing from your presentation, and I'd ask you to comment on them. I believe that Bill 26 creates a sense of powerlessness, and when you create powerlessness you also affect dignity. That powerlessness is because this bill removes due process, the opportunity for consultation, the right of hearings and appeals and access to the courts.
Further, I think the dignity of the individual is threatened with the potential disclosure of private information. Just the fear of that is not only a threat to personal dignity, I think it also threatens the quality of their life and of the quality of the care they will be receiving if they are fearful of disclosure of that information.
I'd ask you to comment on those aspects of this legislation. I believe there are some parts of this bill that are worthy and deserving of support; I'm not going to say it's all bad. But the cumulative effect of it all, unless it is parcelled out into pieces that can be scrutinized individually, suggests that either the whole bill should be withdrawn or split and separated. I'd ask you to comment on that.
Ms Brown: I would agree that there is a lot of powerlessness created by this bill, and it extends to the people who are working in the health care system: the physicians, the health care workers, the nurses, the nursing assistants and everyone who works in the health care system. This doesn't have to be so. There has been restructuring in this province, in Windsor-Essex, which was done through consultation with all the people involved. There was, to use some of the jargon, downsizing and rationalization, and a model came out of that exercise. I fail to see why the Minister of Health needs to grab all this power to effect this kind of thing when it can be done with consultation of all the people involved.
Certainly, I would support certain parts. I can see that there's a need, say, for some support of the district health council's report for Metropolitan Toronto. We don't have a system of hospitals in this community; we have a whole lot of fiefdoms. But this still needs a lot of consultation with the people involved. The six months allowed by the district health council is not nearly enough time. It took four years in Windsor-Essex to accomplish all this. I fail to see why there's such haste to accomplish everything all at once in this instance.
Mrs Caplan: The suggestion that's been made is that the bill be split. I hear from you that you would support that approach that would allow for the individual parts of this bill that are related to each other, by policy, actually, to be dealt with. Would that give you some comfort? Do you think that's the best approach for this government to consider, splitting this bill and allowing it the scrutiny and public consultation that would answer your three very important questions?
Mr McElhinney: Yes. What we've said is that within the context of the experience we've had, of no consultation but having drastic measures come down that the community and individuals have had to react to and scramble to survive in the face of, especially in our low-income community, we simply need a process of consultation. Yes, you're right, people are feeling powerless and attempting to come together to gain support from one another. We had a town hall meeting in our area and it was a great thing because it did bring people together. People were able to meet together and come out of their isolation.
The Chair: Thank you, folks, for being part of our process. We appreciate your attendance here this evening.
YORK REGION COALITION FOR SOCIAL JUSTICE
The Chair: Our next group is the York Region Coalition for Social Justice, represented by Sharon Matthews, the co-chair; Patti Bell, a member of the coalition; and a little political plug here for Larry O'Connor, a former parliamentary assistant to the Minister of Health. Welcome to our committee process. We appreciate your attendance. You have a half-hour to use as you see fit. In the time you allow for questions, we'll start with the government and it will be evenly divided. The floor is yours.
Ms Sharon Matthews: On behalf of the organizations and individuals who are members of the York Region Coalition for Social Justice, we're pleased to participate in these hearings on Bill 26. Our coalition is, however, strongly opposed to much of the content in this omnibus bill. We believe this bill moves too far, too fast and has had no significant public input.
Our presentation deals with the health section of the bill, specifically schedules F and G. In our opinion, these portions of Bill 26 would give the Minister of Health the power to make decisions that would change completely the delivery of health care services in Ontario and the operation of our public hospitals, without public input and without community involvement.
These amendments to the Public Hospitals Act give the Minister of Health almost unlimited powers regarding the operation, funding, closure and amalgamation of public hospitals. Instead of the power to fund and to remove funding from hospitals being determined by regulations under the act, these amendments allow the Minister of Health to decide all hospital funding matters at his absolute discretion. The minister also has, under these amendments, given himself the power to close hospitals, order amalgamation and specify the services to be delivered by a hospital if he considers it, and I quote, in the "public interest."
We believe hospital restructuring is necessary, but it should not be done without a community role. In this omnibus bill the government gives no guarantee of public participation in the major reform of our health care services. One would have to ask what alternatives this government would be prepared to consider if public opinion continues to be so opposed to health cuts as it is now.
In York region, we have always been shortchanged in hospital funding. Our region is growing rapidly and the Metro hospital restructuring project was originally initiated to allow funding to move from the overbedded city core to the hospitals in areas like York region that are facing high growth and need more funding to cope with the huge increases in their population. With the funding cuts already made to all of our hospitals by this government, we are facing the loss of services in York region hospitals, and this bill does nothing to address the funding inequities already present in our community.
We believe that the expanded role the district health councils have been given in health care planning over the last few years has given communities the opportunity to be involved in the decisions that affect the delivery of health care services in their areas.
The hospital restructuring plans developed by DHCs in Windsor, Sudbury and Metro Toronto should be given an opportunity to succeed. Let the process already under way have a chance to work before the Minister of Health gives himself such extreme and unlimited power as he does in this bill and dictates a solution from the top down. Community groups want the solutions to come from the bottom up. They want to be part of the process, as they always have been under NDP, Liberal and even under more progressive Conservative governments in the past. There is no justification to shut the public out.
In Ontario, we've been proud to have a single-payer system of health care. We don't want to move in the direction of a two-tiered American health care system that this bill seems to be taking us.
In our communities, we had a public role to play in this system on boards of hospitals and community health centres, on our district health councils, on long-term care committees and working with volunteer agencies and boards.
Our coalition understands the need for change in the health care system, but this minister's way won't work. Change must be developed with full public input and participation. Clearly this government does not want to give communities the opportunity to participate in the planning process. Even these brief hearings were only allowed after a battle.
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The association of district health councils should have been consulted and involved in any changes involving hospital restructuring. They've been working on these issues for years and we believe they have much to offer. Without paying attention to public opinion, the current government shows clearly its disregard and disdain for any other existing form of community planning and control already in place and operating well.
We want local communities to have the power over their own health care. We believe Bill 26 will change completely the relationship between public hospitals and government by taking away the independence of our public hospitals and the communities they serve and giving total control to the Minister of Health. In the name of the public interest, but with absolutely no public process, the minister has complete power over our hospitals and our physicians.
We have great concern that this bill will allow for-profit US health care providers to operate independent health care facilities in Ontario and be given preferential treatment by this government. There is no other logical reason for removing the limitations on foreign for-profit operators. And once again, the health care providers in our communities are not being consulted or involved in this very major decision.
Ms Patti Bell: The human cost to the user fees proposed in this bill is not tolerable. Our coalition believes user fees are a tax on the sick and are one more financial attack on the vulnerable in our society by this government.
We believe that the benefits of our health care system should be distributed on the basis of need alone and the costs of the system should be distributed on the basis of ability to pay alone. User fees reverse this. And once user fees are in place, there will inevitably be increases coming along with each new budget.
User fees restrict accessibility and create a two-tiered health care system: one for the rich and one for the poor. And user fees do not save money in the long term.
The poorest in our society have more health problems than the rich. A single mom who is struggling to feed her children on social assistance, already cut by 21%, may often have to buy four, five or more prescriptions each month. Choosing to feed her children over paying the user fee, which she doesn't have, may result in a stay in an acute care hospital bed, costing the system much more than we take in with user fees. This government is out of touch with the reality of poverty if they think a $2 user fee can be paid by social assistance recipients. Seniors will be paying the first $100 each year plus over $8 per prescription on their very limited incomes.
We don't need user fees that hit the most vulnerable in our community. We believe there is already enough money in our health care system. We just need to spend it smarter.
We should be paying for only the most effective drugs, and this decision should not be made by the Minister of Health. The government should establish an arm's-length committee of experts to make recommendations to the government on the appropriate drugs to be covered under the Ontario drug benefit plan.
The government should be providing medication awareness programs to the public and to health care professionals to avoid over- or inappropriate medication, especially to seniors.
We believe the deregulation of drug prices will cause prices to soar in Ontario. We are very concerned that Bill 26 allows the Minister of Health to establish clinical criteria to determine what drugs the Ontario drug benefit plan will cover.
This bill also gives the minister wide power to collect, use and disclose the confidential medical information of Ontarians.
The Minister of Health is not a medical doctor and we have grave concerns that Bill 26 takes medical decisions out of the hands of physicians and other health care providers and places them in the unskilled hands of the minister.
The public is becoming aware of the draconian measures introduced in this bill and they're afraid of what these changes will bring to the health care system they care deeply about: the decision to cancel existing agreements with Ontario's doctors instead of negotiating; repealing the process always used to settle dispensing fees with Ontario's pharmacists, and the removal of the term "medically necessary services" from the Health Insurance Act and allowing government to determine what's medically necessary instead of our doctors and nurses.
We are deeply concerned about the impact the cuts made by this government have had on our communities because we cannot ignore the broader determinants of health. To maintain a healthy population, all residents of Ontario need jobs, food, security, adequate housing, quality child care, education, health care and a safe environment in our homes and in our community.
Members of the York Region Coalition for Social Justice are working with the vulnerable every day in our community and the cuts imposed by this government are dangerous to their health. We can't make further cuts to their health care and we can't take the decisions about the health care they need away from their doctor and give it to the Minister of Health.
We would like to take this opportunity to point out that our coalition is not a special interest group. We represent a broad cross-section of our community and our members come from all walks of life. We believe that these health care cuts and user fees will hurt the poorest in our society and are being implemented to give a tax break to those who already have the most.
We understand the difficult work of restructuring our health care system. It must be done and we believe it must be done in the full light of public process. The health care groups in our community want to continue their partnership with government, keeping Ontario's health care system the very best in the world. We ask this government to withdraw the health sections of Bill 26 and have full public consultations to develop changes in a democratic and open fashion.
No mandate has been given to this government to turn Ontario into a dictatorship. A society is measured by the care they give to their vulnerable. Let's start caring again in Ontario. Thank you.
The Chair: Thank you very much. You've allowed lots of time for questions, beginning with the government, about five, six minutes.
Mrs Ecker: Thank you very much for coming this evening and providing your views; very helpful. Thank you very much for coming and welcome to a former member back in the halls of the building. It's good to see you again.
Ms Churley: Oh, but he's non-partisan tonight.
Mrs Ecker: Oh, I'm sure. Anyway, one of the comments that you made in your presentation I thought was very excellent. You said that you believe that there's enough money in the system; it's just a question of how to spend it smarter. We would support that very strongly, and that's what the restructuring exercise is all about which we're trying to do in the system.
The other point that I think you made in your presentation, which was very good, was about the importance of local planning, the importance of the district health councils in local planning for restructuring the health care system. I think it's important to note that nothing in Bill 26 changes the vital planning role of the district health councils. That will still be there.
The minister has been very, very clear about that, that he wants the district health councils, with the public consultation and the community support that they have, to continue to do that. If you have any suggestions about how we can clarify that in the legislation, we'd certainly be very interested to hear that because we don't wish that to be misunderstood.
The other point I think is, we've been asked by some communities to actually clear the roadblocks that they're finding. You've mentioned Windsor, Sudbury, Toronto. In Sudbury specifically, they've been mired in controversy. They would like to have somebody, the ministry, come in with some lever, as the Association of District Health Councils of Ontario said earlier today, to solve some of those roadblocks to restructuring. The district health council association earlier today again made some excellent recommendations for how that commission can work more effectively.
I just wondered if you had any further comments. If we don't use some sort of commission of that kind to make this restructuring happen based on the district health council planning, how else are we going to implement such a restructuring which we all agree needs to be done?
Ms Matthews: I'm going to ask Larry to answer this.
Mr Larry O'Connor: Thank you. I think that it's important, first of all, to recognize the work that has been happening within different communities that have seen the restructuring take place.
As we've mentioned within our brief, York region hasn't seen its fair share of funding and it's a high-growth area. The hospitals working within that area have been very patient, recognizing the high growth and felt -- and have been reassured through the government -- that in time you're going to see some of that funding shift because we've got far more hospital rooms and hospital beds than we need here in Toronto.
The problem we have here is, the legislation looks like it's going to pre-empt everything that's happening here in Toronto. The community is working darned hard right now. I think that they can get to where they have to be themselves without the minister saying: "I can do it better than you can. I know better than you do," or "I'm sorry, but we're going to take the management of that hospital over. We're going to put a supervisor in there." I think that before you even dangle a carrot out there, you've got a whole armful of sticks. Something isn't quite right here.
Just the health sections alone is enough for probably half a dozen pieces of legislation, at least what I've seen in my five years as a member of the Legislature. I think we have to have separate hearings just on the health portions alone. I think we have to give the stakeholders ample time to prepare. You haven't given the public near enough time to prepare. I'll tell you, they're very nervous out there.
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Mrs Ecker: Yes, but the district health councils are doing the consultation on how the restructuring should happen. So we need to spend many months to do that.
Mr O'Connor: Except that the minister's got the stick.
Mrs Ecker: No, the minister is not going to short-circuit that process and that's why I think it's important for us to be very clear about it.
Mr O'Connor: Will he remove it from the bill?
Mrs Ecker: He's talked about restructuring, for one thing. As I said to you, if you have amendments or suggestions for how we can make that clear in the legislation, we'd be very pleased to hear them, because that is clearly the intent.
We'll move on to a second question, then.
Mr O'Connor: Removal from the bill would be the suggestion we'd make.
Mrs Ecker: We've had district health councils ask us, including the Association of District Health Councils of Ontario, which said to us it needs a lever to make those changes. So we are responding to what we've been asked.
You make another comment about fears about a two-tier American health system being allowed to come in under the Independent Health Facilities Act legislation. If that's indeed what was going to happen, I would very much share your concern, because I don't believe we want the American-style health system here in Ontario either. But I guess what I was curious about is why you would think that would happen, given the fact that the Independent Health Facilities Act legislation would regulate -- regardless of what the ownership was of an independent health facility, it would be the same regulation. That regulation is dedicated to quality assurance, and that's what it's all about: to have good outcome measurement done with a multidisciplinary team within the system to set clinical parameters to measure quality. That's the regulation. So I don't know how that would create some sort of two-tier concept. No matter what the ownership is, they would have to meet quality standards.
Mr O'Connor: If we take a look within the legislation -- and as presenters all we can do is take a look within the legislation. Of course, looking within this legislation, not everybody is fortunate enough as maybe a former member to have a set of the old statutes kicking around. When you go in there and you open it up, and anything that refers to Canada and Canadian content and not-for-profit is being pulled out by this bill, what else are you led to believe? We're trying to open up the doors so that we have far more for-profit-making enterprises being involved in it. Why would they take out the Canadian content?
Mrs Ecker: Why would something that's properly --
The Chair: Thank you very much, Mrs Ecker. That uses up all your time.
Mrs Caplan: I'm going to put a perspective on the table and suggest to Mrs Ecker that you have every reason to be concerned, because while she is interpreting the bill, I would tell her that there is nothing in the bill that does what she says it's going to do. In fact, there's nothing in the bill that preserves any process or any role for the district health council. There's nothing in the bill that defines any process at all for the community consultation. In fact, what the bill does is give unprecedented, broad, sweeping, absolute powers to the minister, without any process, and it allows the minister to delegate those authorities to an individual or organization or association without any accountability.
The scary thing is that what this minister is saying is, "They're going to make all the decisions, not me." There's no mandate or criteria or anything upon which to judge either the minister's judgement or this restructuring commission, other than the term "public interest," and even that is not clearly defined. So it would be nice, Mrs Ecker, if what you said was reflected in the bill, but it's missing.
Secondly, on the issue of Canadian, not-for-profit preference, the existing legislation says that when all things are equal, when there are two proposals for the best quality at the best price, if one's Canadian and the other is not Canadian, you give preference to the Canadian. It doesn't say you give preference if it's more expensive. It says sure, Canadians can compete. But not only does this remove the preference for non-profit Canadian when you have a level playing field, this bill removes all process. There's no requirement for a tender. There's no requirement for a request for a proposal. It gives the Minister of Health absolute and unfettered power to decide who is going to deliver that service. Nothing in this bill gives any comfort to the community.
There's such broad regulatory-power-making authority in this bill that in fact the community is cut out of it entirely, the DHC potentially. If this minister says he's not going to do it, a future minister could. Ministers of Health don't last long around this place. Once a minister has these powers, that's it. A sunset review doesn't mean those powers are going to disappear.
Now, my remarks, Mr Chair, I know are more directed at Mrs Ecker, because I don't believe that what you said to this deputation, Janet, reflects what's in the bill. If that's your intention, then withdraw this bill and bring in a bill that reflects what you have just said. That's what they're asking you and that's what we're asking you and that's what we've been hearing.
There has not been consultation on this. Your intention is not clear. The powers are so broad that the minister could virtually do just about anything he decided he wanted to do without talking to anybody. If it's not his intention to do that -- and I suspect or hope it would not be -- put those procedures back in the bill. Why does the bill wipe out all avenues of hearing and appeal and access to the courts for dispute resolution? Whether it has to do with independent health facilities, whether it has to do with doctors, whether it has to do with other providers or hospitals, all process is removed from this bill.
I would say to the deputation that your presentation is well-founded, it's very articulate and your fears are not unfounded. This bill is unclear about what the actual intent is, and I hope that the government will listen to you. I hope that Mrs Ecker, who is well-intentioned, will take the message back to her minister that if they want to do what she says they're going to do, put it into the law so people will have comfort that that is what is going to happen. Isn't that what you're asking?
Ms Bell: I'm glad you pointed that out; it's exactly what we're asking. We want public consultation and we want time to make appropriate responses and submissions. Also, because the conversation, Mrs Caplan, was quite well-worded in your response, and Mrs Ecker had said, why do we think that there will be a two-tiered system, we think that because user fees indicate a two-tiered system to us. I work with abused women and their children, and they cannot afford $2 user fees. It may seem like spare change in your pockets, but that is not what it is to these women and children. These people will not get the medications that they need. That's a two-tiered system; that's user fees to us.
Ms Churley: Thank you for your presentation. It's nice to see you again, Larry. I think it was a very good presentation, and what's interesting is that it follows the pattern of the presentations that we're hearing. Almost all of them reflect many of the same concerns and come to some of the same conclusions around perhaps splitting the bill, dealing with it in a more comprehensive way.
I cannot let the comments from Mr Gilchrist that were made earlier go by. I want to comment on them and hear what you have to say. I've been in government and I know what it's like to be sitting at a table and have people come in and not agree with your position. It's not very pleasant at times, but I have to say that I found Mr Gilchrist's responses to the church group that came in to be profoundly arrogant and insensitive and totally lacking in any understanding of what's going on out there in our communities. In fact, I would say that some of his views appeared to me as quite sexist. The word "ladies" was used -- "more ladies on welfare" -- and I appear to be shaken --
Mrs Ecker: Give me a break.
Mr Gilchrist: Oh come on, Marilyn.
Ms Churley: I have the floor. Perhaps some people say I'm too sensitive to these things. I don't bring up my personal life very much, but I was a single mom on mother's allowance once. These days that's something to be ashamed of, the way it's talked about by members of this government. I fought my way out of that and I'm proud of how I've managed to live my life, and I'm extremely offended by sexist comments about "more ladies on welfare." I would say to this government that if they really do want to give the hand up that they talked about in the election campaign, they wouldn't be talking about dismantling day care, cutting subsidies --
Mrs Ecker: We're not.
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Ms Churley: -- which they've already done -- Jobs Ontario -- cutting the subsidies, cutting training programs, some of which this government brought in -- nothing to replace them. I know women who have literally already had to drop out of training programs or school because they've had to take their kids out of child care because of the 80-20 cuts. Municipalities are not picking up the 20% cut; the women cannot pick it up. They're dropping out of school; they're going to stay on welfare.
Mr Gilchrist says that the disabled haven't been touched. Well, it's yet again another reflection of this government -- not, I'm sure, deliberately misleading people, but they must be misunderstanding what is in this bill and what's happened in terms of other cuts that they have made before this bill. For instance, the disabled: They are being redefined. There are some people who are disabled -- we read about one in the paper today; a column by Thomas Walkom -- who committed suicide. There is some indication that her being cut off welfare has something to do with that. There are people who have lost transportation because of that, who are having higher transportation costs. They are going to pay now for drugs.
I mean, the reality is, I don't know if you guys are really seeing what's going on. They had church people in here who are working on the front lines and are seeing the real human suffering, and what does Mr Gilchrist do but sit and lecture them about what's really going on in our society and dismissing --
Mr Clement: As opposed to what you're doing right now, Marilyn.
The Chair: Ms Churley has the floor. When you were speaking, she didn't say anything. So we owe her the same respect.
Ms Churley: I was profoundly disturbed by those comments. I'm certainly asking this government to pay more attention to what the cuts are doing to real people out there and do what they said they were going to do, which I think is partly why people voted for them. They offered a hand up, and I know welfare recipients who thought they were going to be given a job by this government. In fact, they've lost: They're losing training, they're losing child care, they're losing money. They feel profoundly betrayed.
If I have any more time left, I would ask -- I don't. So they cannot comment on my comments.
Mr O'Connor: Mr Chair?
The Chair: Just 30 seconds.
Mr O'Connor: Thank you very kindly. I have something that I'd like to table, given that we don't have time. It was a letter to the editor that showed up in a local newspaper that described the user fees placed on the Ontario drug benefit plan as euthanasia in disguise. It's kind of scary, but I hope it opens an eye or two.
On the way down here, one of my colleagues here had mentioned that in the past at their women's shelter what was a commonplace was people used to bring in gift baskets with a few presents and toys for the children. Not this year. This year, the mothers who are going to the women's shelter are asking for food, because the food banks only give out food once a month. These women are asking for food to feed their children.
The Chair: Thank you. We appreciate your involvement in our process and your presentation here tonight.
Our last presenter for the evening is Dr Michael Weinstock. Is he here? If he's not here yet, Mr Clement, do you want to hand out those answers?
Mr Clement: Oh sure, yes.
The Chair: You had one other question.
Mrs Caplan: I appreciate the ministry's response to the questions from yesterday and I want to put that on the record. I know how hard the staff are working to do that, and it is very helpful to have the questions answered expeditiously.
The physiotherapy association, which was here today, I thought raised an interesting point, and that was the lack of clarity about the government's intention of who they intend to bring into the independent health facilities legislation and whether or not it is their intention to bring in all physiotherapy services that are provided in both insured and uninsured services and if it is their intention to in fact bring in all services that would be considered health care and put them into independent health facilities under this legislation, whether they are provided in insured and uninsured.
We know the legislation permits that, but I think that people have a right to know what the ministry's and minister's intent is. So I'd ask if they would give a statement of intent of what they expect to do. Because when we spoke to the physiotherapists they said they did not know, they hadn't been consulted and they were anticipating what might be. I think that would be helpful, not only for them, but for others to know what the government's intention is. That was one.
The Chair: We can get back with an answer for that tomorrow.
MICHAEL WEINSTOCK
The Chair: Dr Weinstock, we appreciate your being here, sir. Have a seat. We're just a tad ahead tonight, which is unusual, but welcome. You have 30 minutes of our time. Any question time you allow at the end will be divided up evenly, starting with the Liberals.
Dr Michael Weinstock: Mr Chairman, I've prepared a statement. If I can read it, it won't take very long, and then I'm finished.
I appreciate this opportunity to address this committee. I'm a family physician. I've been in practice for 22 years. My practice profile is that of the average family practitioner -- paediatrics through geriatrics.
I work long hours, about 10 to 12 hours a day, as do most family physicians. I do not complain about the hard work as I enjoy what I'm doing. I enjoy the respect of my patients. Many families have continued in my practice for the full 22 years, in spite of moving away from my office vicinity.
But I come before you as a physician who is demoralized. I come before you as a husband and father who is frightened about his future. This anxiety increases daily, especially after I read the front page of the Globe and Mail today.
I come before you to explain how Bill 26 will affect me. I am concerned about the loss of my rights for fair negotiations with this government.
I'm concerned that this bill will give the Ministry of Health and the general manager of OHIP the right to second-guess my clinical judgement.
This bill will remove the rights of the OMA to negotiate on my behalf. I feel helpless about my future as my basic rights are being dismantled.
This bill will allow the Minister of Health to unilaterally set my fees, demand reimbursements and even force me to provide services for free.
This bill will allow Ontario to be the only province that will refuse to negotiate with the provincial medical association. Even in Alberta, where Ralph Klein has set the standards for fiscal restraint, the government negotiates with the Alberta Medical Association.
This bill will allow inspectors to come to my office, to take away any charts they wish and to determine at will that a service was medically unnecessary. I realize that the intent is to prevent fraud, but I'm worried about the potential misuse of this power. Who will monitor the monitors?
Every physician can recall cases where the history and examination of the patient appeared to be absolutely normal, only to have the patient deteriorate over the next few hours or days. Will the inspector look at the visits and deem those visits medically unnecessary? Will the inspector discuss each case with me?
I fear that this bill will allow arbitrary judgements against a physician. I realize that I will be allowed to appeal, but the appeals will cost an enormous amount of money. I understand that there will be a fee. There'll also be a bill of about $20,000 a day. It will require me to hire a lawyer and to leave my office. This, in effect, leaves me without any possibility of appeal; I cannot afford that.
I feel that this bill will force me to be torn between my responsibilities as a physician and my concern that an inspector who may not be a doctor may deem that service to be medically unnecessary.
I ask each of you to think about a visit that you or your family made to a doctor's office when you were extremely anxious about a concern that you had -- a swelling, some type of pain. How did you feel when the doctor was able to allay your fears, that the problem was nothing serious?
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My question is this: Is there a possibility that service could be deemed medically unnecessary? I fear that the answer is yes. I worry that this bill will paralyse physicians from practising reasonable medicine for fear of further repercussions. This bill is intrusive and offers the physician no protection.
I have watched the demands on our health system increase by AIDS, by increased violence in our streets, by patients living longer with incredible surgical and medical advances. I have seen patients becoming more sophisticated, having access to the Internet, having lengthy printouts from pharmacies about their medications. These patients are aware of the medical advances and investigations and are more demanding.
I serve this system honestly and fairly. I do not knowingly increase the fiscal pressures on the system. I do not understand why I and my colleagues have been chosen for the loss of our rights and for the arbitrary punishments in this bill.
I feel that I have been drafted permanently.
I finish with a quotation from the article written by Terence Corcoran in the Globe and Mail on December 5 under the heading of "Ominous Bill."
"Bill 26 is a draconian power grab by the Health minister, who will be handed arbitrary powers to open and close health facilities and hospitals at will, regulate health services at will and -- most ominous of all -- dictate where and when doctors can serve their patients. While it may be politically acceptable to boss doctors around, the conscription proposed by Bill 26 is the most extreme coercion imposed on any group of employees since able-bodied men were drafted into the military."
Thank you very much.
The Chair: Thank you, doctor. You've allowed lots of time for questions. We'll begin with the Liberals who've got about seven minutes.
Mrs Caplan: How did you find out about these hearings?
Dr Weinstock: I was talking to some patients about my concern, and someone who had previous experience working at Queen's Park called me and told me about it.
Mrs Caplan: My concern is that not enough individuals know that they can come forward and make representations. You're one of the few who have come forward in the last couple of days. We have a huge list of organizations and individuals that have been turned away, and I'm really pleased that you're able to come and talk as an individual who is concerned about the massive powers in this legislation.
The other question I have for you is, what does it do to morale when you see this kind of -- I don't want to use the rhetoric of power grab, but I can't find anything else to describe it, when the government and the minister -- I'm a former minister so I know of whence I speak and I know the impact that has on providers. How does it make you feel?
Dr Weinstock: As I mentioned in my presentation, I really feel thoroughly demoralized; and I can tell you that to a person, every physician I have spoken to, friends or colleagues -- and not calling up and saying, "What do you think?" but just in referrals and such things -- it always comes up in conversation. Everyone is feeling absolutely demoralized, anxious for their future.
Mrs Caplan: I know that many doctors voted for the Conservative member in their area. I'm wondering, and I know most of them read this and I've had a number of discussions with people about how they were going to proceed and what they were going to do and the promise to protect health care. I think the thing that struck me, without the sort of no new user fees and protecting the health budget and all of that was the -- and I referred to this once before -- "We're ready to listen and to learn and to work with anyone who wants to join us and who could show us more creative and more effective ways to end waste and duplication," and then at the very bottom line of the document is, "...but how we get there will be discussed in partnership with all Ontarians."
My question is, do you feel like you're a partner? Do you feel that they're willing to listen to you and to learn and to work with you and other providers? Is this what you expected when you read this document?
Dr Weinstock: I spoke to my MPP before the election, and his quotation was: "We hear you. We hear you loud and clear." I would just be repeating myself. I do not feel a partner in this. I feel that I've been drafted, as I mentioned. I really have no say in my future here. That's my feeling.
Mrs Caplan: That says it all. No further questions.
Ms Churley: I too am pleased to see an individual come down and speak to us. I think that what you have indicated by your comments is something we continue to hear over and over again: that there is real fear about this bill, whether you are a doctor or somehow involved in the health care field. I'm just talking about the health care sphere here. I have been also, at times, attending the other hearing that's going on just down the hall, and we're hearing the same thing from people. What we're hearing consistently is the lack of partnership, the lack of consultation and the lack of time to understand the implications of the total bill.
It's clear from what you said that you have some understanding of a few pieces which you know are going to have a direct impact on your life and your practice. Beyond the few areas of interest to you, do you have any other idea of what the bill entails overall?
Dr Weinstock: The one area that some of my patients have raised with me is the area of privacy, the access to their medical records. They've asked me, "You mean someone can just walk in and take my records, and this can become public knowledge?" I say, "From my understanding, yes."
Ms Churley: Well, we say yes too, but the government members say no. But our understanding, our legal reading of the bill is yes, they can do that.
Dr Weinstock: I'm mainly focused, of course, on the effect it's going to have on the medical system. Even this was complicated for me to understand, and I had to depend on the OMA and some other sources, but the other areas I'm afraid I really have not had -- I understand that there are many other areas, municipalities etc, but I'm a busy family doctor.
Ms Churley: No, I understand that. Certainly not everybody can pay attention to every aspect of the bill, which is what's been good, that we've had different -- I'll dare to use the word -- special interest groups come in and clarify and give their opinion on some of the items.
Our government, when we were in government, the NDP -- it's pretty obvious that our relationship with the OMA and doctors was not always an easy one. There are certain problems that we tried to deal with and I would say that this government does have to deal with, I think we all have to agree. In some areas, we were successful; in other areas, we weren't. I certainly believe it's important that this government proceed and try to deal with some of these problems.
I'd like to ask your opinion, for instance, on whether or not you think it's true, as a doctor, that there are some problems that need to be worked out with government in partnership. Let me give you an example: for instance, this government arbitrarily telling new doctors where they can and can't practise. We know there's a problem in some underserviced areas. I don't agree with that kind of draconian way of dealing with it. But would you, for instance, have any suggestions to the government? Because we do have to solve that problem. I don't mean to put you on the spot. If you'd like, just refer to the partnership in general and what you think is needed here.
Dr Weinstock: I think it would be much more comfortable for me to realize that there was some negotiation and discussion about some of the difficult areas. From my understanding in speaking to friends at the OMA, there are people who are ready to work in underserviced areas. There would have to be some agreements about time and salaries or methods of payment etc. But I'm not sure how big a problem it is. I know it is a problem in many areas. But I think your basic premise of having some sort of negotiation would be much more favourable for me to see.
Ms Churley: Do you think that if this bill is passed basically the way it is, more doctors will move to the United States? Do you think there's a real threat here or could it be just rhetoric to try to get the government to back down? Do you have an opinion on that?
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Dr Weinstock: My opinion is that it's a real concern and it's not rhetoric any more. When physicians are faced with the inability to have any discussion, to negotiate for themselves, to be told where, when, even provide services for free if necessary, who knows what can happen next. Everybody is just plain scared, and there are people I know who have already made increasing arrangements to move to other areas, particularly the United States. It sort of stopped when the PCs were elected. There was a little bit of --
Ms Churley: There were high hopes there for a while.
Dr Weinstock: -- a quiet time. Then as soon as we heard that there was a breakdown in negotiations with the OMA, they walked in and said, "You guys are history" about a month or two ago, it spread like wildfire. Everybody heard about it in about a day or two, and there are people talking, and very, very seriously, about leaving.
Mr Clement: Thank you for taking the time to be here. It has given us a lot to think about. I want to thank you for your very thoughtful presentation.
Do you think we've got a financial and economic crisis in Ontario right now?
Dr Weinstock: Yes.
Mr Clement: You've heard the Finance minister -- $1 million an hour more in expenses than revenue we're taking in. Have you heard that figure?
Dr Weinstock: I've heard that figure.
Mr Clement: Have you heard the figure that right now we pay $9 billion on interest on the debt, which is more than we spend on hospitals?
Dr Weinstock: I've heard that.
Mr Clement: So, you would agree with me that the status quo is not an option. In fact the status quo doesn't exist. We have a deteriorating status quo, which is causing us more and more problems in terms of jobs, opportunity, health care. Is that fair to say?
Dr Weinstock: I would like to stick to my area as a family physician.
Mr Clement: You're a taxpayer and a voter, aren't you?
Dr Weinstock: Yes, I am. I appreciate that there are problems. I feel that we as physicians have given money back to the system. I feel that 10% of my income is a lot of money and it's left me with very little at the end of the month, the 10% that I've been paying back for the past few months. So, yes, I feel that there is a problem. I feel that we as physicians have kicked and screamed a bit but we understand our responsibilities.
Mr Clement: And that's fair. I mean, you've got to represent your interests but you understand the wider interests as well.
Dr Weinstock: Yes, but there were negotiations and there was give and take. No one likes to have to have a clawback, I appreciate that, but my concern is that we won't have a say. It could be 10%, 15%, 20%, 25%, and then, to be very honest, I'm finished, I'm history. I can't handle any more than 10%, 12% to my practice.
Mr Clement: I perfectly understand that.
Dr Weinstock: Yes, I'm sure you do.
Mr Clement: Let me just say for your edification that -- I think you've heard this before during the campaign -- we are listening to you, we hear you. Certainly, if you do have amendments to this legislation that you feel will alleviate some of the concerns but will also allow the government to restructure the health care system for the benefit of all Ontarians, either by written submission -- I'm not trying to put you on the spot now because you just recently heard about this process, but we would love to hear from you.
That's what this process is all about, quite frankly. I don't think anyone, least of all the Minister of Health, least of all the government members of this committee -- we are not committed to the bill as is. We want to see changes. We want to see amendments. So your input on those amendments would be very, very helpful to us to ensure that we have a proper bill that is going to deal with the problems that Ontario faces. I just wanted to say that right up front.
Dr Weinstock: Thank you for mentioning that. It's always good to know.
Mr Clement: Thank you. That's about it for me.
The Chair: Thank you very much, doctor. We appreciate you taking time to come and be part of our process. Your input is valued.
The committee stands adjourned until tomorrow morning at 9 o'clock in the other room. So take your belongings.
The committee adjourned at 2035.