SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION
CANADIAN MENTAL HEALTH ASSOCIATION, ELGIN BRANCH
NURSE PRACTITIONERS ASSOCIATION OF ONTARIO, SOUTHWESTERN REGION
MEGAN WALKER
LONDON AND DISTRICT ACADEMY OF MEDICINE
ONTARIO ASSOCIATION OF OPTOMETRISTS
LONDON SOCIAL PLANNING COUNCIL
LONDON AND DISTRICT LABOUR COUNCIL
ONTARIO COLLEGE OF FAMILY PHYSICIANS
LONDON BATTERED
WOMEN'S ADVOCACY CENTRE
RON WEXLER
RAFFAELE FILICE
LONDON INTERCOMMUNITY HEALTH CENTRE
PERSONS UNITED FOR
SELF HELP LONDON
ACTION LEAGUE OF PHYSICALLY HANDICAPPED ADULTS
CHATHAM AND DISTRICT LABOUR COUNCIL
LONDON-MIDDLESEX TAXPAYERS' COALITION
CONTENTS
Tuesday 16 January 1996
Savings and Restructuring Act, 1995, Bill 26, Mr Eves / Loi de 1995 sur les économies et la restructuration, projet de loi 26, M. Eves
Victoria/University Hospital
Ross Batson, chair
Kelly Butt, vice-chair
Tony Dagnone, president and CEO
Canadian Mental Health Association, Elgin branch
Martha Connoy, program coordinator
Nurse Practitioners Association of Ontario, southwestern region
Carolyn Davies, member of the executive
Megan Walker; London and District Academy of Medicine
Dr Larry Patrick, president
Dr Fred Sexton, vice-president
Dr Denise Wexler, past president
Ontario Association of Optometrists
Dr Richard Kniaziew, president
Dr Mira Acs, past president
London Social Planning Council
Gary Davies, president
Alice Kendall, vice-president
London and District Labour Council
Rick Witherspoon, president
Jim O'Leary, representative
Ontario College of Family Physicians
Dr Lynn Nash, president
Dr Ralph Masi, president-elect
London Life Insurance Co
Jim Etherington, vice-president, corporate affairs
Kim Noble, manager, health and dental products, employee benefits division
Jim Connor, market manager, employee benefits division
London Battered Women's Advocacy Centre; Ron Wexler; Raffaele Filice
Julie Lee, executive director
London InterCommunity Health Centre; Margaret Gregory
Shanthi Radcliffe, executive director
Ted Town, community worker
Persons United for Self-Help, London; Action League of Physically Handicapped Adults
Bonnie Quesnel, president, PUSH London
Patti Doolittle, chair, ALPHA
Shirley Van Hoof, treasurer, ALPHA
Steve Balcom, member, executive board, PUSH London
James Rourke
Chatham and District Labour Council
Buddy Kitchen, president
London-Middlesex Taxpayers' Coalition
Jim Montag, president
Robert Metz, representative
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:
Clement, Tony (Brampton South / -Sud PC) for Mr Kells
Ecker, Janet (Durham West / -Ouest PC) for Mr Stewart
Johns, Helen (Huron PC) for Mr Danford
Lankin, Frances (Beaches-Woodbine ND) for Mr Marchese
Also taking part / Autre participants et participantes:
Boyd, Marion (London Centre / -Centre ND)
Caplan, Elinor (Oriole L)
Crozier, Bruce (Essex South / -Sud L)
Cunningham, Hon Dianne (London North / -Nord PC)
McLeod, Lyn (Fort William L)
Pupatello, Sandra (Windsor-Sandwich L)
Wood, Bob (London South / -Sud PC)
Clerk / Greffière: Grannum, Tonia
Staff / Personnel: Fenson, Avrum, research officer, Legislative Research Service
The committee met at 0900 in the Radisson Hotel, London.
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, everyone.
Mr Mario Sergio (Yorkview): Good morning, sir. How are you doing?
The Chair: Fine. Thank you, Mr Sergio.
Mr Sergio: It was nice of you to provide candies this morning.
The Chair: London does things in a special way. That's why we have candies in London. Welcome to everyone this morning. We are delighted to be in London as another stop on our tour through the province. We welcome everybody who is here this morning to listen to the presentations on Bill 26. Before we get on to our first group this morning, we have a couple of motions that we want to have introduced by Ms Lankin and debated very quickly. So, Ms Lankin, I will give you the floor.
Ms Frances Lankin (Beaches-Woodbine): My first motion:
Whereas there has been overwhelming public interest in Bill 26 and that 46 groups and individuals have requested to appear before the standing committee on general government in London, which far exceeds the 15 spaces available today for hearings;
I move that this committee recommends to the government House leader that when the House returns on January 29, 1996, that the order with respect to Bill 26 be amended and that the bill be returned to the standing committee on general government so that further public hearings can be arranged for the community of London;
Further, that this committee recommends that the three House leaders meet as soon as possible to discuss this issue.
The Chair: Can I have all-party approval to limit the debate to one speaker for one minute. Agreed.
Okay. Ms Lankin, the floor is yours.
Ms Lankin: I'll reserve a couple of seconds just at the end in case there's anything that Mr Clement says to provoke me that I need to respond to.
Mr Tony Clement (Brampton South): Who me?
Ms Lankin: The bottom line here is that while there was an agreement for the schedule of hearings, we all know the overwhelming public response that we have seen. We know that there are over 1,000 groups and individuals who have applied to come before the two subcommittees in the two weeks that we're travelling and there are less than 300 spaces available.
I hold firmly the belief that this bill is too large and too complex and needs to be divided up, and I commit to our party's agreement to pass necessary parts of the bill on the 29th, but pieces that could take a longer look and need a longer look, to have that done. But the bottom line I think is that in a participatory democracy, when this many people want to be heard, I think the opportunity should be created, and that's why I ask the government members to join me in this recommendation.
Mr Clement: I sympathize with the intent of the motion but I don't agree with its premise. I think that certainly by the end of this week we'll have had 750 presenters at both sides of the committee who have been able to present to this committee on this very important bill; very different approaches by some of the presenters that we've had so far, some highly critical of the government, some positive on some aspects of the legislation and some like the entirety of the legislation. So we've seen the variety of views, and I think in that sense the process is working.
But at the end of the day, we as legislators have to get on with the job to restructure the health care system to ensure that we have a health care system that is viable, and that means that we have to stick to the agreement that has been outlined by the House leaders and get this bill through by January 29. So I'm comfortable that we're on track.
Mrs Sandra Pupatello (Windsor-Sandwich): The comments made by Mr Clement certainly support the motion and I hope he'll vote as such. I must say that especially in the area of health, where every day, as Mr Clement mentioned, we are finding all of these new nuances in terms of how the bill affects us, it's in our best interests, it's in the health of Ontario's best interests that we continue the hearings. In particular, in light of the number of people who do not get the opportunity to speak, any kind of extension is going to be welcomed by the Liberal Party.
Ms Lankin: Mr Clement, I just want to come back to one point that you raised, which is that you think health care restructuring needs to happen and we need to get on with it, and on that point I agree. I believe, however, those processes are under way and are continuing in communities. The problem I have with the nature of the bill is the wide-sweeping powers taken on to the government, without definition, without parameters, without an agreement of where your framework for health care restructuring and reform is.
With all of the powers that can lead us to, whether or not that's your intent, a two-tiered health care system, a violation of the Canada Health Act, I want public debate before we undermine medicare and in this province and in this country. I believe this bill can lead to that and that the protections need to be put in the bill, not in the good hands of the minister and a couple of cabinet ministers around the table.
The Chair: We'll vote on the motion now.
Ms Lankin: Recorded vote, please.
The Chair: Ms Lankin has requested a recorded vote. I'll just explain to the audience, by the way, only two people on this side have the option of voting, and three on the government side.
Actually, Ms Pupatello doesn't. She's not subbed in officially?
Clerk of the Committee (Ms Tonia Grannum): No.
Mr Bruce Crozier (Essex South): She's a regular member of the committee, is she not? Mr Chair, it's my understanding that a regular member of the committee --
The Chair: Unless they were subbed for.
Mr Crozier: The clerk can clarify it. Perhaps it's Mr Sergio who can vote.
Clerk of the Committee: Mr Sergio can vote. When Elinor comes back, she can't vote --
Mr Crozier: The rest of the day.
Clerk of the Committee: Yes.
Mr Crozier: No problem; tomorrow.
Ayes
Lankin, Sergio.
Nays
Clement, Ecker, Johns.
The Chair: The motion is defeated -- narrowly.
Ms Lankin: I'm very glad that we got sorted out who could vote on this side. It had such a big impact on the outcome.
Interjection: As usual.
Ms Lankin: As usual, that's right. People in the audience might know from my tone that I expected in fact to lose that motion. This is not a surprise. This is a position that I have been putting forward in hearings every day, calling on the government to understand the overwhelming response that there's been. It was clear to me that the government in fact will not entertain even a recommendation to the government House leader to consider more time on certain aspects of the bill.
That being the case, my second motion reads as follows:
"Whereas there are only four days remaining for public scrutiny on Bill 26; and
"Whereas public interest in this bill has been overwhelming; and
"Whereas the vast majority of presenters to the standing committee on general government have recommended major changes be made to the bill,
"I move that this committee recommend to the government House leader that the 106 individuals and groups that requested to appear before the standing committee on general government in London be given the opportunity today to see the government's amendments to Bill 26."
Very quickly on this, we have only four days left in both committees to receive public deputations to this committee. Beginning next Monday, the two subcommittees will be rejoined in Toronto in a hearing room to go over the bill clause-by-clause and to debate amendments. Amendments, under the rules, must be tabled by that first Monday morning.
It is both customary and appropriate that the government table its amendments in a timely fashion so that members of the public would have an opportunity to comment on those amendments as to whether or not they are in fact addressing the key concerns that have been raised and so that the opposition has an opportunity to prepare its amendments in light of the known intentions of the government. That's the way it always works.
On the first day of public hearings in Toronto, I put the question to the Minister of Health. He assured me that he would file the amendments in a very timely fashion. I'm asking him to live up to that. I'd expected them before we started travel. Here we are four days away and we still don't have them. I hope the government members will support me on this motion.
Mr Clement: Again, as I was yesterday, I'm quite sympathetic to the intent of Ms Lankin's motion, and as she knows, so is the Minister of Health. He has stated that publicly. The government has no amendments to present to the committee today, but you can rest assured that the government is working on it. We want to make sure that the amendments reflect properly the deputations and the excellent input we have had to date. We also do not want to make mistakes on it, which means that we have to do it in a considered fashion and not in a hurried fashion, as Ms Lankin is suggesting.
She says that it's customary to present as soon as possible. I understand the custom to be divided on that one. But I think it's certainly appropriate that we table them as soon as possible. You certainly have the government's undertaking to do so, but we cannot do it today.
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Mr Sergio: I think there's more than one reason why the motion deserves support. We have seen that the bill, when it was presented, was not understood even by the members of the government. Now we will be dealing with a bunch of amendments, not only from the government side but also from our side as well, and I think at the end no one will understand, again, an amended bill with various amendments. So I think it makes eminent sense that more time is given to hear the people who haven't been heard who want to be heard and to really delve into the matter as it stands now, as the bill plus the amendments. So I would hope that the government side will find some common sense and support and give us the time needed.
Ms Lankin: Mr Clement's sympathy is nice but it doesn't get me anywhere. It doesn't get me the amendments, it doesn't make me a more informed member in trying to deal with this legislation on behalf of the public concerns I've heard for eight days during the hearings.
I have to say that I expect there will be a vast number of amendments, given how quickly the bill was put together. I guess I'm sympathetic with Mr Clement in terms of the fact they don't want to make mistakes in the amendments the way they did in the bill. But if you drop a whole raft of amendments on us at the last minute, you will be perpetuating the way in which you've managed this bill, which is to ram it through without full knowledge, without full understanding and without full debate.
I'm aware that P and P, the policy and priorities board of cabinet, passed a package of amendments a week ago. That should be shared with us even in a draft form. I really believe that the way in which you're continuing to approach the management of this bill is inappropriate and fundamentally anti-democratic.
The Chair: We'll vote on the motion now.
Ayes
Lankin, Sergio.
Nays
Clement, Ecker, Johns.
The Chair: The motion is defeated.
Thank you very much. I appreciate your patience in allowing us to go through that process. I do have to comment on Ms Lankin's and Mr Clement's mutual sympathy for one another. It's nice to see.
VICTORIA/UNIVERSITY HOSPITAL
The Chair: Our first presenters this morning are the Victoria/University Hospital; from the board of directors, Ross Batson, the chair, Kelly Butt, the vice-chair, and Tony Dagnone, the president. Welcome to our committee. You have a half-hour of our time to use as you see fit. Questions, should you allow the opportunity for them, would begin with the Liberals.
Mr Ross Batson: Good morning. My name is Ross Batson and I am the chair of the board of directors of Victoria/University Hospital. With me is Kelly Butt, who is the vice-chair of our board, and Tony Dagnone, the president and CEO of the hospital.
We appreciate the opportunity to participate in the public hearing process concerning Bill 26, the Savings and Restructuring Act. As board members of the second-largest teaching hospital in Canada, we believe these hearings are an important first step towards ensuring quality health care for the citizens of London through dialogue with the key stakeholders.
We wish to begin our presentation by acknowledging our commitment to the delivery of quality, cost-effective health care which will meet the needs of our community and our region. Our board also recognized the difficult task the government faces in trying to preserve quality health care while responding to fiscal pressures. As members of the community and taxpayers, we recognize that all Ontario citizens, including those involved in the health care sector, must face tough fiscal decisions if we are to ensure the long-term economic prosperity of the province.
As a teaching hospital, we believe that education and research activities in academic hospital and medical centres such as ours are at the heart of our ability to meet the future health care needs of Ontario. Our hospital has a multidimensional mission: quality health care, education and research. The combination of quality patient care, education and research will help ensure the best available health care now and in the future for the people of Ontario.
We welcome the opportunity for frank discussion and dialogue. The focus of our presentation will be to document our thoughts concerning hospital restructuring, drawing upon our own experience with a major hospital restructuring in our community, and to share with you our views on the legislation as it impacts the restructuring of hospitals; to discuss the changes to subsection 9(1) of the Public Hospitals Act; then Kelly will provide comments on the impact of the proposed legislation on our academic physicians; and we will discuss changes in the interest arbitration process.
We sincerely wish to offer our constructive suggestions for amendments to Bill 26. Our board is fully committed to working with the health care system and with our district health council to provide quality, patient-centred care for our community and the whole of southwestern Ontario. We recognize that all hospital boards must be ready to adapt to change and take decisive action with respect to hospital restructuring.
We support the government's initiative in proposing the creation of the Health Services Restructuring Commission suggested in schedule F of the Savings and Restructuring Act. We do believe, however, that voluntary governance through local hospital boards and district health councils remains the most effective way of achieving local hospital restructuring in our communities. We recommend that it would be best if the commission were to act as a body to review disputes that may arise with respect to suggested options for hospital restructuring in local communities.
We believe our own hospital is proof that voluntary restructuring, led by committed local boards, works. Victoria/University Hospital, in the space of six weeks in June and July of last year, was able to successfully complete the significant portion of a merger process involving two large and complex teaching hospitals while continuing to ensure the involvement of key stakeholders, including the University of Western Ontario and the Thames Valley District Health Council. Our only goal was to be able to better serve the citizens of London. Our board championed this cause because we saw the need for bold change by hospitals and were committed to preserving quality, effective health care.
Our experience has been that quick action and a commitment to the whole health care system are vital. Since member approval of the merger, we have able to complete the following:
We have implemented a new hospital board structure that has brought together two previously separate hospital boards. We now have single ownership and management under the authority of a single board of trustees.
We have significantly restructured and streamlined senior management. As little as three years ago, we had 22 vice-presidents between Victoria and University hospitals. Today we have eight.
We have redesigned our hospital's organizational structure from a department-based model to a patient-centred, interdisciplinary, team-based approach to health care delivery.
We have redefined and streamlined the middle management structure of the organization.
We are currently actively working for the integration of our medical-dental staff to make it more responsive to community and education and research needs, with a target date of June 1996.
Within the next 45 days, we will have developed a methodology to redesign our patient care programs and budgetary process which will link budget development more closely to the volume of health care delivered.
Our goal, even in light of the announced reductions in base funding, is to maintain the volume and quality of patient care in the new economic environment. This is a huge challenge. Our experience tells us that voluntary restructuring, championed by members of the local community, is the best way to address the need to maintain quality health care and reduce costs. Yes, there are some difficult decisions that need to be made in bringing together the structures and practices of two large successful organizations. However, Victoria/University Hospital is a fine example that it can be done if the resolve and commitment exist among community leaders.
We strongly recommend to the minister that he encourage all hospital boards in a community to come together and work for the benefit of the community as a whole. The forum for such a process may need to be determined by local situations in collaboration with district health councils. However, mandating annual conjoint meetings of regional-local hospital boards with an agenda to examine potential strategies for collaboration and cost savings may be an important first step. We would welcome the opportunity to develop a framework for such a collaborative process in any way we could. With the minister's support, we believe our experience can be a catalyst for significant further change within the hospital sector.
Again, to make our position perfectly clear, we strongly support the government's proposal to create a Health Services Restructuring Commission suggested in schedule F of the Savings and Restructuring Act. We agree, as a board, that government needs effective mechanisms to ensure that hospital restructuring occurs in order to preserve quality health care and facilitate deficit reduction. However, it is also our belief that the powers attributed to the Minister of Health in the proposed amendments should be used only when disputes arise or when voluntary governance models with the involvement of the local district health councils have failed in their attempts to achieve the necessary restructuring.
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We also strongly support the minister's recent announcement in the Legislature suggesting that the restructuring commission exist only for a three- to four-year time frame. This announcement helps to clarify the time frame for hospitals within which this government expects significant restructuring and affirms the long-term role of voluntary governance in hospital administration.
Moving to subsection 9(1) of the Public Hospitals Act, under that subsection the Lieutenant Governor in Council has the ability to appoint a supervisor to conduct a hospital investigation if the quality of management or administration of the hospital or the care and treatment of patients in the hospital have been questioned, subject to a 30-day period under which the hospital may respond to the question.
Under the revised subsection 9(1) as amended by Bill 26, the response period has effectively been eliminated, which severely impacts any hospital's ability to be accountable for its actions. We believe the hospital should be entitled to account for its actions within a reasonable time frame before the appointment of the hospital supervisor and that the hospital be given a reasonable amount of time to correct any concerns before the minister exercises that authority.
It appears as well under clauses (c) and (d) of proposed subsection 9(1) of the Public Hospitals Act that the Lieutenant Governor in Council may appoint a supervisor for a hospital if he or she considers it in the public interest to do so. In determining what is in the public interest, the Lieutenant Governor in Council may consider the proper management of the health care system and the availability of financial resources for the management of the health care system and for the delivery of health care services.
We believe it would be reasonable in the circumstances for the powers vested in the Lieutenant Governor in Council under the provisions of 9(1), as amended, to have a termination clause of three or four years so that the extraordinary powers which may be needed to effect health care restructuring are available but do not become a tool to micromanage the system in perpetuity.
Mrs Kelly Butt: Victoria/University Hospital, as Ross said, is London's largest acute care teaching hospital, and it is Canada's second-largest university teaching hospital complex. Our hospital plays a vital role in southwestern Ontario and in the provincial health care system as a provider of specialized health for children and adults. Included in our many health care programs are cardiac care, transplantation, critical care transport, dialysis, and cancer care.
Not only do we provide high-quality health care, we are a teaching hospital. We play a vital role in the education of health care professionals, including physicians, nurses and other caregivers. We are also a site for leading edge health care research. Much of this research is done by physicians associated with the University of Western Ontario. They treat patients, they teach and they seek new knowledge. The provision of the best medical treatment and care to Ontario people is highly dependent on acute care teaching hospitals. We find the new treatments, we teach others how to deliver these treatments and we care for the patients who have special needs in southwestern Ontario.
We must be able to recruit and retain the most highly qualified physicians available, not only from Ontario but in competition with other academic centres in Canada, the United States and the rest of the world. The effects of the proposed legislation, in particular schedules H and I, on our physicians and on the environment in which they work are of grave concern to us.
We understand that the revisions to the Health Insurance Act and Health Care Accessibility Act, schedules H and I, together with the proposed Physician Services Delivery Management Act, will give the government the unilateral power to decide which medical services will be insured and the total amount payable to the physicians providing these services.
Together, these changes also permit government to vary the basic fee for insured services for different classes of physicians and practitioners and increase or decrease this fee on certain factors set out in the regulations, including the specialization of the physician or practitioner, the relevant professional experience, the frequency with which the service is provided, the geographic area in which the service is provided, and finally, the setting in which the service is provided.
Our board has no particular position with respect to the best way of compensating physicians for their services, but we do need a system which enables us to recruit the most highly qualified physicians for service, education and research. We are concerned that the proposed legislation will drive the best physicians out of Ontario.
In a recent report by the faculty of medicine at the University of Western Ontario, it is estimated that the direct economic benefit to the London community from education and research is over $100 million. We cannot lose that.
We strongly encourage the minister to reconsider the position with respect to these schedules. We agree that physicians must do their fair share to work within the financial constraints of the province, but we need legislation which creates an environment which encourages the behaviour we want rather than a punitive one. Should this legislation be passed, we strongly encourage the minister to put in place an alternative compensation system for academic physicians which acknowledges the unique role they play in finding new treatments and teaching the next generation of health care providers. We strongly encourage the government to work with these providers of health care to find a solution that works for all. Again, we offer the help of our organization in bringing together a solution for the government.
Let me turn now to interest arbitration. Within schedule Q of the proposed Savings and Restructuring Act, the government has made significant strides to amend the Hospital Labour Disputes Arbitration Act. We applaud and support these changes but we do not believe they are strong enough to bring about the desired results.
Victoria/University Hospital is in the midst of a merger which will have a significant impact on labour relations. In light of our own restructuring, and undoubtedly the reorganization of dozens of hospitals over the next few years, the amendments to the Hospital Labour Disputes Arbitration Act must be more clearly defined and delineated. For our new hospital, every single percentage point increase in wages awarded by interest arbitrators means $3.5 million more in salary costs. This translates to $3.5 million less for patient care. In the past, interest arbitrators simply did not care; ability to pay has not been an issue of concern for this group.
We then urge the government to consider the following:
First is the creation of a fixed panel of informed and knowledgeable individuals to arbitrate these disputes in a truly disinterested manner rather than the current process of union-employer selection.
There must be a clear understanding as to the type of evidence a board of arbitration is to consider when addressing the ability to pay. Our recommendation is that a board of arbitration must accept as its final evidence the organization's financial record as verified by the organization's auditor or senior financial official.
Paragraph 9(1.1)2 can be interpreted as giving arbitrators the right to impose reductions in service levels if funding levels are not increased. We believe this goes beyond the authority arbitrators should have, and as a result recommend that hospitals must continue to have the authority to determine where and how service cuts are to be made.
Paragraph 9(1.1)4 states that comparisons will be made between "comparable employees in the broader public sector." Our belief is that "comparable" is not a specific enough term and can be open to interpretation. We recommend that "employees performing similar jobs including in the broader public sector and/or the private sector" be substituted for the term "comparable."
We also believe that a board of arbitration must not require parties to include a clause in any agreement that would limit the employer's ability to contract out or to determine who shall do the work.
We strongly believe that amendments to the act should apply to any and all disputes which have not been decided at the time Bill 26 receives royal assent. If disputes already at hearing were to be exempt, one could be sure that awards would most certainly exceed the employer's ability to pay.
Finally, we support the OHA's recommendation that a decision or award be reviewed by a commissioner to ensure that the decision or award conforms to the criteria under subsection 9(1.1), and that the commissioner has the ability and the right to amend the award to ensure that the criteria have been met. We also believe the commissioner's decision should be final.
It is our belief that these proposed amendments will ensure that arbitration awards are more reflective of the fiscal realities faced by our hospitals and others in the province.
In conclusion, we appreciate the opportunity to make this presentation to you today. We have a lot of experience with hospital restructuring. We're here to help. We thank you for hearing us out.
The Chair: Thank you for your presentation. We've got about three minutes per party left for questions, beginning with the Liberals.
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Mrs Elinor Caplan (Oriole): Thank you for a very excellent and thoughtful presentation. I want to point out that I think the advice you've given to the government is the sort of advice that it should be hearing. If they had passed this bill before Christmas, as they had planned, we would not be here in London today or at any time to give you this opportunity. I'm sorry there are so many people who want to come before the committee who will not be given that same chance.
You refer to the minister -- and I'm going to use your terminology. I don't want to use the word "imposing" when you talk about alternative: "Should this legislation be passed, we strongly encourage the minister to put in place an alternative compensation system for academic physicians...." Are you supportive of the Queen's model and do you think that should be imposed, or should the academic health science centre be able to modify it so that it perhaps reflects the individual needs?
Mr Tony Dagnone: I believe the Queen's model is something that is one option only. I believe that through further discussions and trying to reflect on current circumstances within UWO, there is still room to improve. But those improvements will only come through a lot of dialogue between the university officials and the physicians involved in the system.
There is genuine goodwill out there on the part of the physicians to really look at a better way to compensate and to recognize those services. I believe that the Ministry of Health is also there willing to listen to looking at developing a model. Obviously we're very, very interested in doing that because the past will not carry us through in terms of the future.
Mrs Caplan: One of the concerns I have is that when you say, "The minister should put in place," that would imply fewer negotiations than you've answered in your question. I think it is important that it be done through consultation or that the academic health science centre be able to put forward proposals that can then be discussed. I would not want the minister imposing, and I'm glad that you clarified that point. I agree there is a tremendous amount of goodwill and there are multiple models that would be appropriate and perhaps different for the different centres.
Ms Lankin: I appreciate your presentation. I know a bit about the history of the restructuring you've gone through in the merger of the two hospitals and I know at times in the community in the beginning it wasn't easy. I applaud the outcome and the commitment to providing improved quality of health care in the London-Middlesex area.
I reflect on that because I have heard many times from members of the government side that all these studies were happening and nothing is being done. "That's why we need these extraordinary powers." I have to say it provokes me whenever I hear that, perhaps because I've got a little bit of vested interest in this in terms of my past. I see so much being done so well on a voluntary basis with assistance and facilitation from the ministry.
Some of the suggestions you've made with respect to powers being sunsetted, with respect to I believe some controls on when a supervisor is actually used in this extraordinary manner, all those things we agree with and we've been urging the government to make amendments along that line. We would be supportive of those kinds of amendments.
I want to make a quick comment on your position on interest arbitration, and it's to say that I understand the difficult position, as a hospital, you're in when under this new legislation you're going to be directed even more as to what services you have to provide and your funding level is being determined, yet you have no control on the other end. You're squeezed and the government is essentially a ghost at the bargaining table.
I urge you to take some caution in thinking it through, though, and I want to give you an example. A for-profit nursing home, which comes under the same labour legislation that hospitals bargain under -- the Hospital Labour Disputes Arbitration Act -- gets to decide what their profit margin is, determine what they have available left in terms of resources for expenditures, including salaries and benefits, then goes to an arbitration panel and sets that forward as the ability to pay. To me, there's a real problem with how this is constructed in terms of its impact, particularly on that sector of very low-paid workers. I ask you to think it through. It may not be the panacea and it could create significant problems for workers.
I'd like to ask you to make a quick comment on an issue unrelated to this bill but related to health care restructuring. The government has cancelled a program called ONIP. Your hospital has been in the lead of bringing together an amazing project called LARG*net, which has leveraged all sorts of investment. Could you just give us an update on it and let the government know the importance of that to the future of health care reorganization?
Mr Dagnone: In answer to that, yes, London is making very good progress with the help of the government grant that was provided to us. Although the program was cancelled, we are making renewed representation to government because I believe they are interested in capturing the kind of technology that we must have in the health care system so we can really do the kinds of things we're here to do in terms of improving the system.
I am optimistic that we can regroup and go forward with a request in making sure that we don't lose sight of the leadership role that London has here in the area of technology. I say that in all sincerity in the sense that it is London, the university and many other agencies, that has come together and really, in my opinion, is a demonstration site for others across Canada. We are making good use of those dollars we received in the past, and it our hope and desire that the minister will see fit for us to continue with that good work. Otherwise it's going to be waste.
Hon Dianne Cunningham (Minister of Intergovernmental Affairs, minister responsible for women's issues): Welcome to the committee, to London and to my colleagues from other places. It's a great city to live in, and I'd also like to say to the representatives of the VUH how proud we are of the leadership you've shown in the province with regard to restructuring. I know my colleagues here are very proud to be able to say thank you in the company of our members from other parts of the province.
I have three questions, probably four, so I'll go fast. Page 7, with regard to the response period, where you're talking about the supervisors: Could you talk a little bit more about the problems you've got in this area with regard to the response time?
Mr Batson: As I understand it at this stage, the way the legislation reads is that the supervisor essentially could move in with no opportunity for the hospital to even determine if the complaint or the request that was made was a valid one. It appears there's no time for the hospital to make any kind of response or comeback.
Hon Mrs Cunningham: Are you recommending that it be 30 days, or is there another time period? What are you looking for?
Mr Batson: It's 30 days now, and I don't think we have a problem with the existing time.
Hon Mrs Cunningham: Is your recommendation then that it's working now and it should remain at 30 days as a reasonable time?
Mr Batson: Yes.
Hon Mrs Cunningham: On pages 11 and 12, with regard to the interest arbitration, the ability to pay -- I have to be honest. Sitting on a school board here for many years and looking at the kinds of arbitration awards that drove the costs up in so many instances where we didn't have the ability to pay, I'd be interested in your specific recommendation with regard to this fixed panel of informed and knowledgeable individuals. Have you had experience with this in other provinces or somewhere else in Canada? I know Mr Dagnone has been involved many times. Why are you recommending this specific approach?
Mr Dagnone: We need a renewed partnership between labour and management, and arbitration is a very, very important part of the process as we try to settle disputes. It is our view that there is a lot to be gained by getting a fixed panel there so that they can develop the necessary skills and knowledge. They've got a better read of the situation as opposed to putting new people at the table every time there's a particular item to be dealt with.
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I really think we need people with the breadth of experience, people who are very, very knowledgeable in terms of new trends of labour management and have an appreciation of the kind of affordability crisis that we're in in terms of health care. Certainly I'd like to believe that Ontario could show the way and at least try it. Let's try it out a couple times and see if in fact it brings even better results for both labour and management. This is not something put forward here in support of management's position as opposed to what is really, really best for the shareholders, and the shareholders, in my mind, are the members of the public who end up picking up the tab.
The Chair: Thank you, folks. We appreciate your presentation and your interest in our process.
Mr Dagnone: Mr Chairman, may I make just one remaining statement? I really call upon, I put a plea out for all political parties to really come together, because if we're going to meet the obligation to the Ontario citizens to bring them quality health care, we need to work together. We need the minister to show leadership. We need the boards of directors to show leadership. I'd like to think that if anybody can get through this affordability crisis, any province across Canada, it's going to be Ontario.
We do have the goodwill there by the health care providers, and I think we're talking about strong leadership here through the minister. We need his energy to create a vision. We need that vision to be articulated very, very strongly. We need all of the stakeholders behind it. Unless we do that, we're going to lose this precious commodity that we call health care. Ontario has been seen as a leader. We can't let that escape. I guess that's why I'm calling on all parties to please come together so we can get the job done. We owe it to the people of this province.
CANADIAN MENTAL HEALTH ASSOCIATION, ELGIN BRANCH
The Chair: Our next presentation is by the Canadian Mental Health Association, the Elgin branch, represented by Martha Connoy, the program coordinator. Good morning and welcome to our committee.
Ms Martha Connoy: Mr Chair and members of the committee, as the representative of the Canadian Mental Health Association, Elgin branch, I thank you in advance for this opportunity to make a presentation to you concerning Bill 26.
The Canadian Mental Health Association, Elgin branch, is a member of a national, incorporated, registered, non-profit, charitable organization. Our branch received its charter in 1961. We are one of the 36 branches in the province of Ontario. Currently we provide support services to those adults in our county who experience a serious and chronic mental illness.
These services are a range of supported residential programs: a cooperative group home, rent-geared-to-income apartments and 24-hour case management support for those living in market accommodations. Other support programs include a psychosocial clubhouse model activity centre which provides life skills for those who are living in our community.
We also offer a quality-of-life recreational program for our psychogeriatric population, along with self-help and peer support programs. Our particular branch channels our resources to developing and implementing direct service programs such as the aforementioned as well as providing community education and awareness regarding mental illness and mental health issues. It is our role and function as advocate which brings me here today.
Since our founding, CMHA has made significant contributions to the development of mental health policy. I understand this committee has heard a presentation from our provincial president, Mr John Kelly. In keeping with our provincial organization, this branch also supports the government's view of fiscal responsibility. It is agreed that this is an opportunity for transformational changes in the health care system and in particular the mental health care sector. We agree that Bill 26 will impact significantly on the delivery of mental health care services.
As a direct service representative, I encourage the committee members to review the New Framework for Support that was offered to you by John Kelly. This document, we believe, provides a framework which examines the impact the economic statement and Bill 26 will have on our sector. This document presents a model which illustrates the integration and coordination of an improved mental health care system.
A New Framework for Support notes that persons with a psychiatric disability need more than the formal mental health services provided by hospitals, community agencies and private practice. As other citizens of Canada they need to have at least the same opportunities to basic socioeconomic support, namely, jobs or other productive activities, good housing, appropriate education and adequate income.
Individuals with a serious mental illness find they are unable to or have great difficulty in attaining employment and maintaining a home. The lack of these necessities often has a direct and damaging impact on their mental health and thus their prospects for recovery.
A New Framework for Support illustrates the ideal range of community-based resources that should be available to persons with a serious psychiatric disability, particularly if they are to live fulfilling lives within our communities. The basic socioeconomic conditions of adequate income, housing, work and education make up the foundation of this model. It has been documented that if people with a serious mental illness do not have access to these fundamental supports, they will benefit very little from other services provided to them. A comprehensive delivery system is essential.
Bill 26 sets forth mechanisms not only to achieve fiscal savings but to restructure, streamline and make services efficient. There are, however, some aspects of the government's economic agenda and proposed implementation strategies that have caused our consumers and our association concern.
As you are no doubt aware, the St Thomas Psychiatric Hospital has been identified as a facility where resources can be amalgamated with London Psychiatric Hospital, thereby achieving fiscal saving congruent with government policy. We would encourage you as legislators to ensure that Bill 26 is designed to reconcile government policy with improved services. Should our psychiatric hospital services become regionalized, provision for support services in keeping with mental health reform need to be available in smaller communities, as discussed in Putting People First. This was the strategic plan for change in the mental health care sector, and this document prioritizes services upon which mental health reform was based.
It would be anticipated that should an amalgamation be realized, there would need to be a transfer of resources to community mental health programs. This has been done in other jurisdictions. It's been done in New Brunswick, Vermont and Massachusetts without comprising care. There is evidence that clinical outcomes and quality of life for consumers have improved. Availability of and close proximity to crisis short-term hospitalization, outpatient and community support services are paramount.
A reality of our client or consumer group is that they endure a frugal living situation. The majority of our clients live on a disability pension or are Canada pension plan recipients. Transportation is often a barrier to accessing services for our citizens as they rely on public transit or require resources to be within walking distance. For those living in outlying areas, our clients depend on the generosity of family, friends and neighbours, as rural public transit is non-existent. Few seriously mentally ill consumers for whom our association provides services enjoy an employment status where they can afford a vehicle.
As previously mentioned, our organization believes that access to educational, vocational and social opportunities should be ensured. Presently, initiatives promoting psychiatric consumer involvement have been limited. Our local PPH has developed a community-supported employment program; however, that's been limited to a few individuals. In general, educational opportunities remain open to all members of our community, the well and disabled alike. Regrettably, there is little support or understanding available for those who suffer cognitive, social and physical impairments as a result of their psychiatric symptomology. Society often displays intolerance of those with a serious mental illness. This is not stated to imply that programs should be established to meet the needs of this disenfranchised group but to suggest that resources be made available to ensure access, education and awareness opportunity to alleviate intolerance and reduce stigma.
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We realize that decent, affordable housing is not the Ministry of Health's responsibility. However, we would be remiss not to acknowledge that one's living environment has a significant impact on one's sense of wellbeing. It has been determined by a working committee of the mental health working group of our local district health council that there is not a sufficient range of appropriate housing options for our consumer group. Again adequate income remains an issue. It is our understanding that all public housing and non-profit housing developments in our county have lengthy waiting lists. Should St Thomas Psychiatric Hospital indeed downsize and realign services to London Psychiatric Hospital, housing and support services will be necessary in the individuals' home communities. I urge this committee to consider these issues as they relate to the health service restructuring implementation plans.
I would now like to speak about specific concerns about proposed changes in the Ontario drug benefit plan. As previously mentioned, the majority of our clients are receiving social assistance or at best supplement their income with part-time or contract work. Dispensing fees and deductible premiums are prohibitive for the seriously mentally ill. It is our experience that many mental health consumers receive weekly prescriptions in order to monitor the effectiveness and to minimize the potential for overdose. Paying a dispensing fee for each prescription would become costly for those on a limited income. For those engaged in part-time and contract work for which there is likely no drug benefit plan, an annual $100 deduction and additional dispensing fees again would be prohibitive.
It should be noted that psychiatric medication is often very expensive and generally consumers are required to maintain their medication for an extended duration. It's not like an antibiotic course that you would take for a week or two. It is medication that people are required to take often for the rest of their lives.
We would also like to recommend that consideration be given to extending coverage of non-prescription medications and treatments taken to counteract the unpleasant side-effects of psychiatric medication. For example, sun screens, antacids and even laxatives are necessary but costly, and not currently included in the Ontario drug plan.
We understand that section 13 of the Ontario Drug Benefit Act may be changed to provide that the minister may collect and use or disclose personal information. CMHA Elgin supports Ontario division's belief that all medical information remain confidential and private. This is critical to psychiatric consumers, as they have experienced social stigma and loss of confidentiality as a result of their illnesses.
Proposed amendments to subsections 18(2), (3), (4) and (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 Act, the amount paid for a specific product may be agreed upon with the manufacturer. There will be no obligation to decrease the price if the price is decreased in the marketplace. If there are increases in medication costs due to manufacturers' set price and the psychiatric consumer cannot obtain an interchangeable drug, again the consumer may suffer as a result.
The proposed new section 23 of the Ontario Drug Benefit Act is critical to the psychiatric consumer because psychiatric medications may not be clinically interchangeable, and a change in what appears to be similar medication might result in dangerous consequences to the consumer. CMHA, Elgin branch, respectfully recommends equitable access to critical, specifically prescribed medication for psychiatric consumers.
Under section 7 of the proposed new Drug Interchangeability and Dispensing Fee Act, we recommend that the practices under the current Prescription Drug Cost Regulation Act be resumed to the advantage of the psychiatric consumer with a low income who is not covered under the act; that is, 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.
Mr Chair and committee members, it continues to be our mission to provide support services to the seriously mentally ill in order for them to live successfully in the environment of their choice with the least amount of professional intervention. We look forward to the government's assistance in this task as the strategies of the economic statement and Bill 26 are implemented.
Mrs Marion Boyd (London Centre): Thank you very much for the presentation. I think it is a very good outline of some of the concerns of consumers in your sector. I've met with a number of them, and certainly you represent very well the consumer concerns, and I congratulate you on that.
I was a little surprised that you didn't put more emphasis on the records part of the bill, the possibility of the privacy of people's psychiatric records being breached by this act. I wonder if you could comment on what you're hearing from some of your consumers about their fears in that regard. We know that acceptance of service for psychiatric clients is often one of the biggest barriers to their continuing health. Can you describe some of your experience of how that might be a barrier?
Ms Connoy: For those of our clients who become well enough to engage in social activities in our community or educational opportunities and vocational opportunities, they feel their history is their business. When they're applying for jobs and someone says to them, "Where have you been for the last three years?" it's very difficult for them to say, "I've had a major psychiatric disability and I've not been employable."
It's very difficult for people to come to terms with their illnesses, very difficult for them to acknowledge, because of the social stigma and the intolerance of people who don't understand that a psychiatric disability doesn't necessarily mean they are all categorized in the forensic category, or that they are in some way cognitively handicapped to the point where they're not employable or would not be able to maintain a good employment standard. As soon as people state or it becomes known they have suffered a disability, they feel they are going to be disqualified unfairly.
Mrs Boyd: As you went through, I was really struck by what you see as the cumulative effect of the various individual provisions within this act. What you didn't mention was that the cumulative effect -- the cost of medication, the proposed merger of the hospitals and therefore a possible loss of service if dollars are applied to the deficit as opposed to being transferred to community care -- really come on top of a whole lot of other issues for the clients you deal with.
You remarked that the vast majority of psychiatric patients living in the community are on social assistance. That of course has dropped. Many of the extra supports, the living supports, have dropped because special assistance has generally been deleted from budgets. Can you comment on the cumulative effect of this government's policies on the clients of CMHA in this area?
Ms Connoy: From my particular experience, I work primarily with the case management programs and the residential support programs, particularly rent-geared-to-income housing. Our clients feel that a number of initiatives mentioned by this government are going to impact on them. I've had several calls regarding people's concern that their rents are going to go up and they will be evicted from their homes because they can't pay their rent. They are concerned that if the hospital services go, they are going to be left with no psychiatric support.
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Certainly our agency will pick up as much slack as we can. However, we're more a direct service, more an intervention and crisis intervention. We are not therapeutic and clinical. For a lot of our clients, their experience has only been the St Thomas Psychiatric Hospital; they have come to that hospital from other communities within the catchment area of St Thomas Psychiatric Hospital. They have not had the support services in their home communities, so when they've been discharged they have then relocated to the St Thomas area to access the services of that hospital. Over periods of years that has become their home, their support system; their doctors and social workers have become their support net. They are very concerned that with the downsizing of the hospital or the realigning of those resources to London, they aren't going to have those supports any longer.
Mr Clement: Thank you very much for your presentation, which mirrored a great deal what we heard from the Canadian Mental Health Association in Toronto.
Let me deal with your comment in terms of reinvesting the savings found as a result of hospital restructuring. I think I can speak for all members that we agree with that point. Talk is cheap, so we will be at least partially judged as a government on how successful we are in reinvesting the savings that occur from restructuring into the community. But that certainly is what the Minister of Health has been talking about, why we need to have the restructuring now rather than put off for another year or two, because we want to plow those savings back in.
To talk a bit about the medical records situation that Ms Boyd mentioned as a concern, we had some discussion at earlier meetings of this committee about that section, how it impacts on mental health patients. There is a section of the Mental Health Act, section 8, which protects and trumps -- if I can use that term -- other legislation when it comes to patients in psychiatric facilities or in hospitals. I put it to you that they are still covered. Nothing in our legislation changes that.
The concern is valid when it comes to patients in the community. Are you looking for an amendment that would perhaps make anonymous the names of patients in terms of our application of this particular section? There is a deemed-to-disclose medical records section already in the act, but if we strengthen it a bit to make sure that in 99% of the cases we have to deal with there is anonymity for the patient, would that go a ways to alleviating some of your concerns?
Ms Connoy: Our primary concern is that people's records and their personal histories remain anonymous. I'm not criticizing, nor is it my place to judge legislation particularly; I'm not that well versed in the making of legislation. If people want to find out information there's often ways of doing so, but it's our responsibility to ensure that people's records remain as anonymous as absolutely possible.
Mrs Pupatello: I'd like to concentrate on the area of redirected savings into community services. Your organization is on record as supporting this kind of move to services within the community. From an economic argument alone, you are much better able to serve your clientele, with less money, by doing it in the community as opposed to in hospitals.
I want to tell this to the government members, who perhaps haven't been keeping with the minister's statements in the House. I come from a community in Windsor where we've gone through a reconfiguration process of four hospitals to two. We did that on the advice of ministers that all savings would be redirected into the community for community services. The minister has now reneged on that promise, and that will not happen. The minister is on record in the House -- Mr Clement should know this: When asked specifically if saving from the hospital restructuring would be directed back into our community, we were told unequivocally no.
London is considered in other places in Ontario a mecca for health service. You're a teaching hospital centre, you're well funded, you have an adequate supply, if not oversupply, of doctors. When you come from a place like London, I submit that the likelihood of savings being redirected into your community is far less. When Windsor, which is underserviced, not a teaching centre, has been told clearly by the minister that he is not redirecting savings into our community, the likelihood is that London, the mecca, likely will not either.
I say that because you've concentrated so much on that, because that's what your clientele needs. It's the best kind of service and it's a less expensive way to address the services your clients need. How does that make you feel?
Ms Connoy: I have a great deal of concern as well. We're from St Thomas, which is 20-plus miles away from our mecca of London. Unfortunately, it's not just St Thomas consumers who would be looking at trying to approach the services here in the London area. It's pretty much the catchment of the existing St Thomas Psychiatric Hospital, which reaches as far as Windsor. It's the small, rural community where there are no support services.
Services need to be redirected, in our experience, with people who have relocated to St Thomas or that surrounding area. They're doing that because they have no support network in their smaller home communities. To some extent, the citizens of our community even feel that somehow they are supporting other people from other localities, which may or may not be factual, but that's the interpretation they have.
There will be a significant cost saving with a realigning of the services from a psychiatric facility that could be reallocated to the smaller communities to ensure that people have the supports they require beyond the psychiatric, medical support.
The Chair: We appreciate your presentation and your interest in our process. Have a good day. Thank you.
NURSE PRACTITIONERS ASSOCIATION OF ONTARIO, SOUTHWESTERN REGION
The Chair: Our next presenters are the Nurse Practitioners Association of Ontario, southwestern region, represented by Carolyn Davies, a member of the executive.
Ms Carolyn Davies: The NPAO appreciates the opportunity to present the concerns of nurse practitioners related to Bill 26.
The Nurse Practitioners Association of Ontario is a voluntary, non-profit association representing nurses working in the expanded role. The concept of nurse practitioners has been in operation over 25 years in Canada. We are registered nurses working in the advanced practice role, oriented to the provision of health care as a member of the team of health care professionals related to families on a long-term basis.
Primary health care includes the initial contact between the client and health care professional, continuing care, and the promotion and maintenance of health. The nurse practitioner is committed to primary health care for individuals of all ages and families in the community. Nurse practitioners work in collaboration with physicians and other health care professionals. Physicians and nurse practitioners complement each other.
Our primary attention is directed towards screening, monitoring, counselling and health education necessary to improving the client's knowledge about health so that we might make informed choices and develop a sense of self-responsibility towards their own health care.
Currently we are working in urban, rural and outpost locations. Many are employed by medical services and function independently in isolated areas. They are also found in urban, rural and community health centres, health service organizations, family practice units, occupational health, ambulatory care, emergency room care, private practice, acute-care settings and educational institutions.
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While the NPAO has always been a voice of progressive reform in health care in Canada, we are concerned that the amendments proposed by Bill 26 will have a negative impact on the health care of Ontario citizens. We are fully aware that reform is needed, but reform based on strategic, long-term planning. In our view, the proposals in Bill 26 will have ramifications down the road that have not been realized without more thorough consideration for long-term consequences beyond the fiscal agenda. This presentation is in support of the RNAO's position on Bill 26.
In December 1994, Premier Harris indicated an important government direction in Bringing Common Sense to Health Care. He promised "to empower the consumer of the health care system with the rights to proper care and to participate in decisions regarding that care." This government gave a commitment for public input in the determination of programs and services for the community.
We are concerned that this input has been noticeably absent in the introduction of this bill. The initial push to pass the bill without the opportunity for debate and the difficulty experienced by many members of the public to access these hearings are but two manifestations of this problem. We are very concerned at the absence of critical public debate on issues affecting citizens. With this bill, the government is putting itself at risk of compromising the partnerships and trust built over time between the government and the public. A possible effect is a building of distrust by the voters for the government towards the democratic process.
The NPAO recommends the government consider dividing the act into smaller acts, thereby allowing more discussion. In this way, the government is able to fulfil its promise by granting more opportunity for public participation in critical health care issues.
The NPAO believes the government's energies would be better spent designing, supporting, coordinating and funding a comprehensive health care system. We are most concerned that in its efforts to cut costs the government is forgetting some of the important elements of the change process, such as appropriate consultation. The NPAO strongly urges the government to consult in a meaningful way with the public and health care providers in its health care reform agenda.
There are several areas we're going to deal with: changing ministerial powers, restructuring, public interest, privatization, user fees and insured services, and health human resources planning. For the benefit of time, I will skip over some statements since you have a written copy.
Changes in ministerial powers: The NPAO acknowledges and supports the government's effort to introduce more quality assurance measures in its provision of health care. We believe this carries the potential to address care problems that may go beyond the power of individual practitioners. Many of our nursing colleagues have witnessed difficulties in delivering optimum care because of inadequate or inappropriate staffing, resulting from unaccountable restructuring.
We are pleased that there will be entrenched recognition of the accountability of organizations. However, we have some concerns about the actual changes in ensuring improved care since there is very little recourse for appeal or consultation prior to decision-making.
Generally, the increase in ministerial powers can be noted for many proposed changes. The minister is empowered to reduce, suspend, withhold or terminate services or funding and accept or reject proposals in the establishment of facilities and services with little or no appeal by the public. The power is poorly defined. There is no description of how these powers will be exercised or their extent or their duration. We support the concern that this much power cannot afford an ambiguous definition. We're concerned that the abuse of power, either intentional or unintentional, could be a possible effect of this strategy.
The NPAO recommends that the minister's powers be defined and terms and conditions be clearly articulated to avoid any ambiguity. Furthermore, we urge the introduction of a sunset clause to ensure that powers are appropriately limited.
We get a sense that the proposed expanded powers tend to move the government into a more micromanagement role in some aspects of clinical decision-making. We support the belief that the government's energies are better spent in designing, supporting, coordinating and funding a comprehensive health care system. There is no question that the government plays a critical role in assisting and guiding the public and providers to determine the appropriate health care services for each community or region. But we are very concerned that in its effort to cut costs, avoid duplication and increase efficiency, the government is forgetting some of the important elements of the change process, such as appropriate consultation. Some of the possible effects might be that the needs of health care consumers will not be met adequately or appropriately in relationship to the uniqueness of the community.
NPAO recommends that the government continue to consult with the public and health care provider groups in its health care reform agenda.
According to current legislation, the minister has the power to determine fraud and to investigate. These powers already have implications for compromising privacy or confidentiality of records. Health patient records are highly confidential and access should ideally be restricted to the client, the health care provider, or a specified and regulated review such as an OHIP investigator.
However, Bill 26 contains provisions that will allow the government unprecedented access to personal records. We don't argue that the government has the right to investigate fraud within the system, but we believe that these increased powers of access and disclosure are unnecessary. The opportunity for unnecessary breach of confidentiality is enhanced when more individuals have access to confidential data. Furthermore, the government's freedom to disclose information with any party it chooses is trouble because of the potential loss of control to organizations that may be beyond Canadian governance. Possible effects might be that these powers cause very ill people to avoid seeking help and prevent practitioners from fully charting findings on the charts.
NPAO recommends that the appropriate criteria for accessing patient records-health information be clearly delineated and strictly enforced. There also needs to be consistency with the Freedom of Information and Protection of Privacy Act. NPAO also recommends that whenever the government deals with external agencies or organizations there exist clear criteria regarding the control and protection of confidential information.
In several sections of the bill, the government or its delegates are protected from liability. For instance, some of the proposals are couched in such terms as the government cannot be held liable for "any act done in good faith." Bringing Common Sense to Health Care emphasizes the importance of accountability at all levels of the health care system. We do not believe this double standard proposed by the government to be acceptable, and a possible effect in the case of accidental disclosure of confidential information is that the government will not have to be held responsible or accountable. Government will lose its credibility with the voters.
NPAO recommends, as a necessary and critical connection in the health care system, that the government must be held accountable for all its actions. We suggest that criteria and guidelines for some of the minister's intended actions be clearer to avoid ambiguity and chances for error. NPAO recommends that in the interest of the public good, alternative mechanisms should be instituted to facilitate an appeal process.
The second area we have looked at is restructuring.
The Ministry of Health Act allows for the establishment of a province-wide Health Services Restructuring Commission to carry out duties assigned by the minister. While the commissions's role is to "facilitate and accelerate the implementation of hospital restructuring," it appears only to address the restructuring of the hospital sector. Reform that addresses only one sector at a time will encourage a fragmented rather than an integrated health care system. Possible effects are that the health care resources in the community will not adequately meet the needs left by changes in the hospital structure. Services will be fragmented.
NPAO recommends that the role, mandate and terms of reference of the restructuring commission be clearly articulated to take other sectors into consideration and to avoid public confusion and critical gaps in care.
The NPAO supports other bodies in the concern about the possibility of service gaps that will compromise the health of Ontario's citizens. The definite plan to accelerate the process concerns us. We believe that changes that occur in hospital services must reflect changes in community services and health care practices and vice versa. Recent trends clearly indicate that community support services must be available and in sufficient number to support hospital restructuring. For example, the reduced length of stay in hospitals increases the need for home care support services for medically complex patients. The increased use of ambulatory care centres also increases the need for accurate assessments both pre-admission and pre-discharge.
The trends to deinstitutionalize patients in order to care for them in the home and the use of more volunteer labour must be addressed before province-wide restructuring begins. This dependency on volunteers requires a more flexible, educated and knowledgeable workforce that can quickly assess changing circumstances in a client population. If these service gaps are not addressed first, we believe that more suffering will be experienced and more money spent due to complications of inadequate care. A possible effect is revolving-door hospital care due to inconsistent voluntary care and understaffed community response.
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The NPAO recommends that changes in non-hospital sectors such as long-term care must not only be identified but that strategies for implementation must be clearly articulated and resources committed to these activities prior to the implementation of any system-wide hospital restructuring program occurs.
The restructuring commission is ready to start work as soon as the bill is passed. However, restructuring has occurred at different rates in all regions across Ontario. In Bringing Common Sense to Health Care, the public is identified as a key player in determining local community health care priorities. The NPAO agrees that there must be an opportunity for each community to discuss and voice its needs for successful province-wide restructuring to occur. The current district health council structure enables this type of public participation to occur. Possible effects are that different regions will on one hand not have their health care needs met and on the other hand will have health care imposed on them that they do not require.
The NPAO recommends that the commission continue to work with the existing district health councils to allow for planning and decisions about regional health service needs that are sensitive to community differences.
The proposed legislation states that the commission members from the health sector, business and the broader community are to be appointed by the ministry. We support the belief that it is important to have nursing representation on this commission. Nurses are active participants across the entire spectrum of health promotion and care provision. This expanse and scope of experience is critical to any comprehensive health care planning and restructuring. We recommend registered nurse representation on the restructuring commission.
The third area is public interest.
The NPAO supports the concern that this proposed legislation contains the frequent use of the expression "public interest." The minister is given powers to reduce, spend, withhold or terminate funding to hospitals if it is in the public's best interest. While we commend the government's intent to determine services and funding in consideration of public welfare, the concept is not well defined. Who determines public interest? Whose value system defines public interest criteria? The term "public interest" is also inconsistently applied.
While this term is used extensively throughout the Public Hospitals Act to rationalize the minister's power to intervene, for example, while we recognize that the public interest is a changing reality that depends on specific community values, there must be province-wide consistency in closely considering public interest. An effect we are concerned about is that the citizens of Ontario will perceive the government to be paternalistic in using a undemocratic decision-making process.
The NPAO recommends that "public interest" be clearly defined and that there be a consistently applied rationale underlying all health care reform.
The fourth area is privatization.
The amendments of the Independent Health Facilities Act may well challenge our universal, accessible, publicly administered health care system in Ontario by creating an environment that allows more privatization. Proposed amendments in section 7 repeal the language that directs the minister to give preference to non-profit facilities and protection or priority to Canadian-based proposals, which will encourage proposals from for-profit, non-Canadian organizations. Although this signifies the government's receptivity to foreign firms entering Canada's health care market, we are doubtful that the majority of Ontarians share this view.
These amendments increase the opportunity for conflict of interest and enhance the potential for a two-tiered health care system that argues that those who are willing to pay for services will be allowed this choice. However, considerable data indicate that a two-tiered health care system is not only more costly but can also leave millions of citizens without equal access to services. The NPAO believes strongly in preserving the Canada Health Act and the Canadian health care system. A possible effect is that Ontario will develop a more Americanized, costly health care option and in many cases receive unnecessary procedures for a privileged few.
NPAO recommends clear directions, guidelines and control to ensure that non-Canadian corporations and organizations meet the standards integral to the Canadian health care system. Mechanisms such as quality assurance controls must be essential aspects of this contract.
The fifth area concerns user fees and insured services.
Despite election campaign promises not to introduce user fees, the proposed medication copayment under the Drug Benefit Act is fundamentally the introduction of user fees. These fees have several ramifications for social assistance recipients and seniors receiving guaranteed income supplement, who will now be required to pay an annual deductible fee and all dispensing fees. We are in effect punishing the elderly and disadvantaged for being ill. Furthermore, the human cost of this policy will have a tremendous cost on children and families. User fees and copayments will not reduce the need for prescription drugs but will reduce the number of prescriptions filled by individuals and families on limited incomes. We believe that when confronted with these extra charges, individuals will be forced to choose between food and medication.
We are convinced that instead of saving money, this particular approach will result in greater expenditures. The complications and side-effects suffered by those unable to afford the needed medication will be even more expensive to treat. This move will take the health care system back to the 1950s when people were not able to afford the cost of care and got so sick before seeking treatment it was costing the system in hospitalization and in the critical rather than primary care stage.
The issue of drug use needs to be addressed in a way that does not disadvantage those in greatest need. Rather, the health care practitioners need to take more responsibility to review prescribing habits that reduce the unnecessary use of prescription drugs.
The NPAO recommends that government address the issue of proper drug utilization programs as opposed to charging fees as a solution to the rising costs of the drug plan.
Under the proposed subsection 4(4) the government will no longer pay differences between what are considered interchangeable products, even if the prescription calls for no substitution. This means that if the individual requires a specific drug no longer paid for by the plan, they will have to pay the difference.
While the NPAO supports the principle of interchangeability, in practice this is not always feasible. A cheaper drug may not be a possible alternative. Some individuals experience adverse effects to non-therapeutic components of the generic components. There is a mechanism in place now where the health care practitioner may apply for approval for brand-name drugs to be used. We encourage the government to allow the individual needs and differences to be considered in developing drug policies.
The possible effects are that those patients unable to pay higher costs of non-generic drugs may not fill their prescription and the resulting increased costs of untreated illness will be passed on to taxpayers through the cost of hospitalization.
The NPAO recommends that the government consider alternatives to the generic approach such as the BC drug plan, which considers not only generic substitutions but also therapeutic substitutions.
Within the Health Insurance Act changes, the minister is now able to determine that insured services are unnecessary. This means that services can be removed from the OHIP schedule of benefits at the minister's discretion without consultation. This has significant implications for the status of Ontarians. Those who can afford it will be able to obtain these delisted services. Furthermore, this government promised Ontario citizens that OHIP decisions would no longer be made behind closed doors and would include public input. We are concerned that the government is taking a path that will inhibit rather than enhance public input and are concerned about the erosion of the public input into the decision-making process related to health care issues.
The NPAO recommends that any changes to insured OHIP services and benefits be made in consultation with health care providers and through public debate. Changes must be made recognizing the diversity of needs, values, culture and socioeconomic status.
Number 6 is health human resource planning.
Under the Health Insurance Act, section 29.3, the government proposes by regulation to "fix or vary number of physicians, or the number of physicians in a class of physicians, who may become eligible physicians in an area" and so forth. Similar physician resources management is evident in the Public Hospitals Act and schedule I, Physician Services Delivery Management Act, 1995.
The NPAO supports other health care professional groups in their position complementing government attempts at health care resource management, though we feel its energy should be focused more widely instead of micromanagement. The NPAO recognizes that there is an uneven distribution of medical specialties and an overabundance of some specialities in urban areas and fewer in rural areas and northern communities. However, we are concerned that these amendments will not resolve the issue of health resource planning. Rather, they are a Band-Aid solution to a critical distribution problem.
The issue of supply and demand and distribution of health care providers has been a discussion in health care for some time. The nursing profession has experienced the fluctuation with the need for nurses. Graduates of 1995 are extremely underutilized, with restructuring of all sectors of the health care a principal cause. This in itself is a waste of taxpayers' dollars. As with nurse practitioners, many nurses are not only not used to their full scope of practice but are being lost to downsizing. This costs all Ontarians.
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Long-range health human resource planning must be part of a larger picture of health care reform. As part of the integration into the economic formula, this planning of the health care industry is essential. This kind of planning takes into consideration the present and future health human resource requirements and uses health care needs as the starting point. Once these needs or goals are identified, issues such as the numbers educated and distribution can be appropriately assessed. This way, not only will there be a better sense of the numbers required, but we will also be able to more accurately assess the needs for and distribution of certain types of specialist. If we are to have a well-planned health care system, we must aim for a flexible, innovative health care provider workforce capable of providing quality, cost-effective health services to meet population needs.
The NPAO supports the belief that while alternatives, such as incentives, improvement in conditions and differential remuneration, help in some of the shortages of practitioners in some areas, an established system-wide health human resource planning would alleviate these persistent problems in service delivery in the long term.
Possible effects: A system-wide planning approach would assure an appropriate mix of health care providers to meet population needs.
The NPAO recommends that system-wide, comprehensive and integrated health human resource planning be initiated.
Finally, the NPAO believes that it's logical and efficient that practitioners practise according to their full scope of practice. We, as nurse practitioners, are one notable example of underutilization in the health care system. Freeing the nurse practitioner to provide care according to his or her full scope and ability allows the medical practitioner to attend to more complicated medical problems. This reduces the pressure on the health care system to provide appropriate care for consumers and allows the medical practitioner to attend to more complicated medical problems. The public can only win in a situation in which the appropriate provider is able to give the care he or she has the skill and expertise to provide. The nurse practitioner is cost-effective, provides quality, adequate care and has a high level of consumer satisfaction.
NPAO recommends changes to the Regulated Health Professions Act, thereby allowing the nurse practitioner to practise according to their full scope of practice.
In conclusion, the NPAO appreciates the opportunity to speak to these very critical issues on health. While we recognize the government's commitment to fiscal reduction as mandated, we are very concerned that this proposed legislation as it stands not only goes far beyond the platform of the past election but will put the progressive changes in health care reform at risk.
We believe that public hearings such as this are critical to the wellbeing of democracy, but these hearings represent only part of the democratic process. The opportunity for public input alone offers few guarantees. There must be an accompanying commitment on the part of government to carefully take into consideration the voices of concerned citizens and consider that input. We ask the government to remember its role in the democratic process of change with the people of this province.
Mrs Janet Ecker (Durham West): Thank you very much. You make a recommendation about, "Mechanisms such as quality assurance controls must be an essential part of any contract." The Independent Health Facilities Act, under which this would be done, does have that in it. Nurses have been involved in making those quality assurance decisions as part of the teams with physicians. Do you believe the quality assurance provisions in the Independent Health Facilities Act are appropriate and would they suffice for continuing to do that with the clinics and the facilities?
Ms Davies: I think that we have to make sure that we're getting across-the-province input, that health care professionals at all levels are being consulted, not only particular groups, and I do think that yes, we need to continue on with consulting with the health care providers in the progress of the health facilities act.
Mrs Pupatello: What consultation have you or your organization had with this government?
Ms Davies: We have only had some minor invitations with the Minister of Health to talk about the nurse practitioner initiatives and the direction that we will be going with expanding the Nursing Act.
Ms Lankin: Mr Chair, I'm genetically incapable of asking a question in 30 seconds. So let me thank you for your presentation and let you know that a number of the areas that you raised are areas of concern that we as a caucus have and that we will be putting amendments forward on, and hopefully, if we can see the amendments from the government in the next day or two, we'll have an opportunity to assess whether any of your concerns will be met or not.
The Chair: Thank you, Ms Lankin; I appreciate your honesty. Thank you for very much for your presentation this morning.
We're going to have a quick three-minute recess before our next presenter, who is Megan Walker, a councillor from ward 6 here in London.
The committee recessed from 1037 to 1040.
MEGAN WALKER
LONDON AND DISTRICT ACADEMY OF MEDICINE
The Chair: Okay, we now have Megan Walker, and the London and District Academy of Medicine: Dr Larry Patrick, Dr Fred Sexton and Dr Denise Wexler.
Ms Megan Walker: My name is Megan Walker, and beside me is Dr Larry Patrick, who is the president of the London and District Academy of Medicine. Beside Dr Patrick is Dr Fred Sexton, who is the vice-president, and at the end of the table is Dr Denise Wexler, who is the past president. I was given a time slot to appear before you last week and contacted Dr Patrick to seek some clarification and advice. At that time he notified me that the London and District Academy of Medicine had not been given a time to speak, and as a result of that, I have presented my submission in writing and have given my time today to the academy of medicine. I hope you will take the time to read my submission, and if you have any questions or concerns, please feel free to contact me, but at this time I would like to turn the floor over to Dr Patrick.
Dr Larry Patrick: Thank you very much. Mr Carroll, just as a backgrounder, I'm an internist at Victoria Hospital, Fred's a family practitioner in town and Denise is a dermatologist. We ask the committee to please listen, because we feel that certain provisions in Bill 26 may actually cost lives.
Mr Chair, members of the committee, usually at this point I would be thanking you for the opportunity to present here today. However, it is apparent that the sincerity of this process we are undergoing here today is in question, considering that the local medical academy, which represents over 1,500 physicians in London and the district, was not given an opportunity to present today. I'd like to thank Megan Walker for offering to share her time with us, although it is less than a satisfactory solution. As well, we recognize that the committee has a very difficult job due to the very limited time made available for you to assess the information collected before the line-by-line review of the bill prior to the third reading beginning on January 29.
Physicians have always been willing to cooperate with government when it is in the patient's best interests. Although we feel strongly that the proposals in this bill are not in the patient's best interests, we would like to continue a working relationship with the government that works towards achieving the best-quality patient care possible.
Canada -- and Ontario -- is said to have the best medical health care system in the world. This system has always been based on a working relationship between government and physicians, and now the system is being dismantled and physicians are being shut out of the decision-making process.
Dr Fred Sexton: This bill would allow the decision as to the necessity of medical services to be determined by a bureaucrat rather than a physician. Second-guessing of medical decisions by a bureaucrat based on outcome carries such dangers that one can only fear the reduction of care to patients.
As an example, let me tell you of a patient who had a severely damaged foot. The first surgeon who saw the patient recommended amputation. A second surgeon, consulted at his request, offered to try to save the foot with a complex operation which had a small but a very real chance of success. After some time and expense, the attempt failed and the foot was amputated.
I suggest that this type of situation could result in the surgery being declared medically unnecessary or inappropriate and the physician asked to repay all fees associated with this under this current bill. Two things would certainly occur: the cheaper and less expensive therapies would be promoted and a new, riskier but potentially better therapy would be avoided.
A second example would be the patient who presents in the doctor's office with an episode of chest pain. The doctor would be obliged to distinguish the aetiology of the chest pain, which would cause him to do electrocardiograms and perhaps blood tests to eliminate a possible heart attack. When that chest pain eventually turned out to be nothing other than heartburn, the physician would be obliged to repay the cost of the cardiogram and the blood work under this current bill, as it was in fact medically unnecessary for the condition treated.
A physician who is subjected to this type of bureaucratic decision-making won't take any chances and won't try anything new. Who would you rather determine necessary medical procedures: the regressive Conservatives or your physician?
Dr Denise Wexler: Why are so many physicians leaving Canada? Doctors are leaving this province, not, as believed, for higher incomes, but for the freedom to be a respected professional. Last night we saw a list of doctors who had left the province from the Thunder Bay area and within five minutes we had drawn up a list of doctors who have left the London area. We have a list of 26 physicians, and I'm sure this is only the tip of the iceberg. If Bill 26 is passed in its present form, I'm sure it will only add to this exodus. The frightening thing is that from London alone we have lost four orthopaedic surgeons, two neurosurgeons, two intervention cardiologists, one radiation oncologist. All of these people are already in short supply and are very hard to replace, so it's not like we can just go out and find a body.
It has been said that 90% of new graduates in the Toronto family practice program will leave as well if the bill goes through. We must not forget that the USA can easily absorb the total output of our Canadian medical schools for the next 10 years. In particular, there's a great demand for family physicians in the United States. They have always recognized the superior system of primary care that we have in Canada.
In 1986, the government agreed to pay increases in CMPA fees in lieu of fee increases. Bill 26 proposes to end this payment, causing grave concerns for the availability of health care. This committee has already heard about the difficulties that this change will make for the delivery of obstetrical care across Ontario. As well, however, we have concerns about the availability of a number of other specialty services. To name only a few: neurosurgery, orthopaedic surgery, cardiovascular surgery, plastic surgery, general surgery. So all of us here, if we want our brain tumour removed, our hip replaced, or perhaps even our appendix removed, had better do it quickly while these doctors are still in Ontario.
Dr Patrick: With Bill 26, the government proposes to restrict new billing numbers to those geographic areas deemed underserviced by the government. This will dictate to all our new medical graduates areas where they must live and practise. I'd like to have you consider, if you will, a family member -- a brother, sister, son or daughter -- who has just finished an intensive post-graduate medical training and with this bill will be forced to go to a geographic area that may not be in their best wishes or, for that matter, they possibly may not be trained to go to that area.
Dr Sexton: Retiring physicians from one of the 12 so-called overserviced areas of the province, which includes this London area, will not be replaced. I'm sure that many of you here today have felt the frustration of trying to find a new family physician. This bill will further interfere with the continuity of care.
Another proposal in Bill 26 is the tying of billing numbers to hospital privileges. This means that a physician must have hospital privileges to bill OHIP for services provided. With the coming hospital amalgamations and closures, many physicians will lose their billing numbers and be unable then to practise. With Bill 26 there will be absolutely no appeal process for these physicians.
Dr Wexler: In the so-called best health care system in the world, it can take up to seven months to get an appointment for back surgery, 14 months for elective hip surgery and over two years for specialized ankle surgery. Before I came here, I saw a few patients and the last patient that I saw was a 15-year-old girl. She had damaged her knee a year ago, skiing. In July she had arthroscopy. The procedure was successful but she was left with a tender lump on her knee. She is now unable to participate in sports without pain, has some difficulty in daily activities because of pain limitation. She went back to see her physician. He booked an MRI -- this was in November -- however, this will not be available till February, and she won't see her doctor again until March. So we're probably talking about a two-year span.
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However, fortunately I was able to give her a hot tip, because this was in the Globe and Mail last week. Basically, there's a 1-800 number for the University of Virginia Medical Center, and if you call this number you can begin making arrangements to receive your new hip, your knee or whatever surgery you need within a matter of weeks. Surely, there's something wrong with our system. I think people would be willing to pay to be pain-free and functioning with little delay. This might even set us up in a bad situation where we might pay for inappropriate care. So all around, it's a terrible scenario.
Dr Patrick: Physicians know it's time for a change, but let's not throw out the baby with the bathwater. Rather than tearing up the agreements with the OMA, this government should recognize that the OMA represents the physicians of Ontario and they must be included in the future administration of this health care system. We are very sceptical as to whether Bill 26 will even save money. We have not seen any proposal of the cost implications for all of these inspectors and bureaucrats that this bill seems to mandate.
Dr Sexton: A local MPP was quoted this weekend as saying that 99.9% of doctors are honest and hard-working and that the provisions in Bill 26 are needed to catch those 0.1% who are overbilling the system. Has the government considered the cost of this added bureaucracy, an infringement of doctor-patient confidentiality, to catch these 22 physicians across the province? Couldn't we devise a better method to deal with these rare individual cases than this current piece of dictatorial legislation?
Dr Wexler: In conclusion, on behalf of the 1,500 physicians whom we represent, we would like to stress that although we cannot agree with Bill 26 in its present form, we are willing to work together with the government to provide the best possible health care for the people of this province, because we realize that physician input is vital to the success of the process.
Mr Bob Wood (London South): I think this submission makes some very good points, and I don't think the issue on the question of review is whether or not there's going to be a review; obviously, when the government spends the many billions of dollars it does on health care, we have to make sure we're getting value for the money that's spent. I think the issue is, what's the right mechanism of review for the money that's spent?
You have before you what's, in effect, peer review. It's going to be done by doctors. They're going to look and make sure that the services billed have been medically necessary. Of course, the decision's going to be made by the physician and the patient. How would you do peer review to avoid medically unnecessary procedures or fraud?
Dr Wexler: We already have a system in place with the College of Physicians and Surgeons. It could perhaps be expanded so that there are not only physicians represented in the peer review process but some of the lay people at the college are also involved in the process. That might help solve the problem to some extent of the fact that it's just physicians reviewing physicians.
Mr Bob Wood: How is that different in principle from what's in the bill?
Dr Patrick: One of our problems with this bill is the fact that physicians don't like governments --
Mr Bob Wood: Lots of others don't, too.
Dr Patrick: -- and this bill is not making that any better. We have a feeling that politicians, and you probably don't, have a vested interest: bean counters, outcome analysts. There is a process that I'm sure we could work out that would not appear to be as heavy-handed or as interfering as this current piece of legislation. All you're going to do is piss us off even more.
Mr Bob Wood: We're not interested in doing that. I'm not sure I see a major difference between what you folks are saying and what's being proposed in this bill, provided it's done properly. A bad review system is a bad review system; no doubt about that. I think the system that you're proposing and what we're talking about is really quite similar.
Dr Wexler: I think the major difference is that you're talking about having a government bureaucracy or government officials go in and look at doctors' practices; the system that is in place now through the college has physicians involved. Physicians would be totally out of the loop as the situation is to be set up in Bill 26.
Dr Sexton: There is another difference that I think is really critical, Bob. The assumption that most people would make is that we know what appropriate medical treatment is at some point in the process, and if one looks retrospectively at what was appropriate, if you look backwards at what the government has suggested as the outcomes, it mirrors what I talked about with the chest pain. Once we arrive at a diagnosis, it can become quite apparent that unnecessary tests were done, but looking from the point of time that the physician looks at it, it is a medically necessary test to eliminate possibly life-threatening disease conditions.
If we look in the end at what we eventually arrived at and say, "Those tests that were done along the way now appear to have been unnecessary" and the doctor will be responsible for those, that will be a decision that will be a Gordian knot. We don't have that answer, but I do believe those are the kinds of standards we talked about developing through ICES and through further negotiations with government.
Mr Bob Wood: I think certainly the minister has made it quite clear. This is not a matter of second-guessing people at a later date. This is a matter of looking at what was done and determining whether or not that was reasonable in the circumstances.
I'd like to go on to one other point because time is limited. The physicians have come up with a plan that they think will solve the problem with respect to underserviced areas, and the minister has made it quite clear that if that works, that's the end of the matter and the physicians' plan will be accepted and nothing further is going to be done. Do you have confidence that this plan is going to work?
Dr Patrick: Dr Jim Rourke from Goderich will be addressing this issue this afternoon. He has some plans that will involve underserviced communities, the universities, and in fact he'll point out to you that Ontario -- and probably Canada -- is about 10 years behind the United States in encouraging young physicians to go to underserviced areas. This is a problem that we've not got into overnight, and we're certainly not going to fix overnight.
Mr Sergio: Thank you for a good presentation. I enjoyed it very much, especially your frankness as to what you think of the content of the bill and politicians, if you will. When we are presented with such a piece of legislation, I don't blame you for thinking that way.
Let's get back for a moment to the intention that you have in providing and delivering the best health care to our people. As the bill as presented to us says that the minister has all the power to say what kind of care and who is going to get the type of care, are we moving to a two-tier system? Are we leaving universality as we know it here in Ontario? If that is the case, how are you going to deliver the best possible care to our people?
Dr Wexler: We already have a two-tier system in Ontario. People who want their cataracts fixed and don't want to wait will go to the United States if they can pay. People who want hip surgery will go to the United States. So we have a two-tier system. It's just that people leave the country.
Mr Sergio: What about universality as we know it?
Dr Wexler: As it is at the present time, everybody has access has access to a certain standard of care, but that may not be the standard that everybody wants. I couldn't work as a dermatologist if I couldn't see, so if I developed cataracts, I don't want wait a year and a half to get my cataracts fixed. You might not want to wait a year to get your hip seen.
Mr Sergio: But when we have the minister that says you can only provide specific services to specific areas and specific people, then are we really providing the best possible service to our universal population, those who can and those who cannot afford it?
Dr Wexler: Probably the best possible.
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Dr Patrick: We understand money is short and we can't do everything and be everything to everyone. That's not possible. It wasn't possible 10 years ago, it isn't possible now, and if the government's going to get out of trouble in the next two years, we're going to have to really crunch down on the system.
Mrs Pupatello: Dr Wexler, you asked about a willingness to pay -- what would we be willing to pay to be pain-free and functioning, with little delay? -- and you held up that ad. That's what's written, but what you said was people would be willing to pay. So you're advocating a two-tier system within Ontario.
Dr Wexler: I'm not. I'm saying people would be willing to pay to go to Virginia. That's all I'm saying. And I'm sure they will get some responses to that ad.
Mrs Pupatello: Is the purpose of doing that so that then we should change the system so that people can pay in Ontario, stay within our borders and have that service provided and so have a two-tier system in Ontario? Is that what you advocate?
Dr Wexler: That may in the end make the most sense, but right now we can't do that because of the Canada Health Act. An individual province, as I understand it, can't just make a decision to bring in two-tier medicine.
Mrs Pupatello: So would you advocate jumping the queue then for those who can pay to access surgery in a quicker manner?
Dr Sexton: You're going down the wrong road with this, Sandra. What we're trying to say is this: Basically what this act did was it created a situation where the United States could, first of all, come in and rape our country of its best young medical minds, its best young physicians. We've said that 90% of these physicians are going to go to the United States because of the repressive nature of the health care atmosphere here.
The secondary point that we added to that was that this same bill allows the exploitation of people who are in pain and have specific medical needs, because the system can't meet the needs. These are people whose needs are so great that they would make a financial sacrifice. We did not make any point other than that they were about to be exploited by the United States system.
Ms Lankin: Thank you very much, councillor and doctors. We appreciate your presentation. One of the concerns I've had about this bill is, I believe that it's poorly understood by a lot of people, including a lot of members of provincial Parliament.
With all due respect, I must say to Mr Wood, his understanding of the changes around assessment of medical necessity by the general manager of OHIP is completely and utterly wrong. This bill is a fundamental change from the past, where if there was any concern about a doctor's billing, the general manager of OHIP would refer it to peer review under the College of Physicians and Surgeons. The medical review committee would look at that, in consultation with the practitioner, and try to determine whether or not there had been some inappropriate billing that had taken place, and make that recommendation back to the bureaucracy.
Now you have the bureaucracy, not a professional, not any kind of peer review, making second-guessing decisions about whether or not what a doctor has ordered in terms of treatment for his patients was in fact medically necessary -- a fundamental change in the power structure.
Mr Bob Wood: Do I get a minute to refute this?
The Chair: No.
Ms Lankin: I think it's very important that we understand that there are people who are going to be voting on this bill who don't understand what in fact their government is doing.
Dr Sexton, let me put this to you. In the brief you talk about issues of hospital privileges and billing numbers. There's another aspect to hospital privileges in this bill that is of concern to me. You're right that under a hospital closure there can be a complete revocation of hospital privileges without any appeal, and in terms of where those doctors go in the system, you raise a legitimate concern.
But there's another new addition in this bill which says the minister can set out any other reasons, other than closure, under which revocation could take place, and set out whatever procedure or no procedure that the minister wants and bypass all of the due process protections that are there.
We've heard from physicians about their role of patient advocate, for new technologies, for appropriate budgets, for certain disease-centred areas of treatment, how sometimes they're a thorn in the side of hospital CEOs, and the chilling effect this will have on that patient advocacy role if a doctor believes that a CEO can just unilaterally revoke privileges. Can you comment on that? Is that a reasonable concern for physicians?
Dr Sexton: There's a high level of anxiety here in London with hospital restructuring going on, and that's quite pertinent to the types of possibilities that could come here within the next year or two. Different types of practice may be localized in one hospital or another hospital, and this would of course leave certain physicians without a practice; it would leave them without a billing number and no means of appealing the process. When they're without a billing number they will not be able to practise in London any longer. That also should be regarded as an abruption of the continuity of care to the patient. That physician basically has no ability to maintain a continuity of care, London being designated as an overserviced area.
Dr Wexler: The other issue, though, is that many physicians do not have any connection with hospitals and I'm not quite sure where this came in. To tie billing numbers to hospitals makes no sense at all. Some physicians would not ever use a hospital. For those physicians who are in hospitals, they are always jockeying back and forth with the administration about trying to get equipment and staff for their particular section, and this could end up in them losing their privileges, their billing numbers, and they're gone.
Ms Lankin: In fact, if you believe in the move from institutional care to community care, and this has been pointed out to us, for example, in terms of community psychiatry, that's an important shift in the practice of psychiatry that's starting to take place and those people don't need to have any relationship to a hospital and yet now they will have to. With the minister being able to impose physician human resource plans on hospitals there are a lot of unanswered questions. One of the concerns I have -- and it was best put by a presenter in Thunder Bay who said: "The government is asking us to give them a blank cheque. The problem is, they're not telling us what number they're going to write in before they cash it." Do you have any comments in terms of, do you know how the minister intends to use these new provisions around revocation of privileges? Do you know how he intends to handle doctors who are community-based and not hospital-based in terms of billing numbers? Have you been consulted on that?
Dr Patrick: We haven't been consulted but he has said we should trust him.
Ms Lankin: You're a bit sceptical, I think.
Dr Patrick: I don't even know him, so why should I trust him? The other part of the problem is, if he thinks this bill is so good, why has he removed us from legal due process? If someone has been arbitrarily removed from hospital staff, this bill says that individual has no due process in law to be able to complain to anybody. This is blatantly unfair. This is picking out a group of individuals and saying: "You people are going to pay for this one way or the other. Either professionally or financially you're going to pay."
The Chair: Thank you very much, doctors, and I want to add my thanks to Megan for giving up her time for the doctors; we appreciate that.
ONTARIO ASSOCIATION OF OPTOMETRISTS
The Chair: The next presenters are the Ontario Association of Optometrists, represented by Dr Richard Kniaziew, the president. Welcome to our committee.
Dr Richard Kniaziew: Greetings. Let me begin this morning by introducing myself, my colleagues, our profession and the organization I represent. I am Dr Richard Kniaziew, president of the Ontario Association of Optometrists. With me today to make this presentation is Dr Mira Acs, our past president.
I will try not to take up all the generously allotted time, but I'll take a moment to explain who we are and what we do. The Ontario Association of Optometrists is a voluntary membership association representing more than 90% of the approximately 1,000 active licensed optometrists in Ontario.
Optometry is an independent, self-regulating, primary health care profession with a long and successful history of self- regulation. Ontario passed its first Optometry Act in 1919 and the current act, which is part of the regulated health professions legislation package, in 1991.
In the past decade, optometrists provided more than two thirds of primary eye and vision care services in Ontario. Optometrists are university educated, clinically trained and provincially licensed to assess, diagnose, treat and prevent diseases and disorders of the eye and visual system.
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Provincial legislation provides the framework for optometrists' professional responsibilities and for their accountability. The Regulated Health Professions Act, the Health Insurance Act, the Health Care Accessibility Act and the Optometry Act are the principal pieces of legislation governing optometric practice.
The Ontario Association of Optometrists, incorporated in 1909, is the voluntary professional association authorized by the Health Care Accessibility Act to represent Ontario optometrists.
The College of Optometrists of Ontario has been given the task of ensuring that high professional standards are maintained through their quality assurance programs, through adherence to published standards of clinical practice and through strict enforcement of regulations and guidelines by such committees as the optometry review committee, which reviews the OHIP billings and the patient records of individual optometrists who have been referred to them by the general manager of OHIP. The College of Optometrists of Ontario has taken a leading role among professional registration bodies in Canada in establishing written standards of practice. The Guide to the Clinical Practice of Optometry published by the College of Optometrists of Ontario is regarded as the primary reference for standards of optometric practice. Since 1972, this guide has been revised three times.
The Health Insurance Act provides for the payment of most optometric diagnostic services under two billing codes. Additionally, optometrists are permitted to provide non-OHIP-insured treatment services to their patients. Like the physician or dentist providing non-OHIP-insured therapies, the optometrist charges a professional fee for providing these services. Such is the case with the provision, for example, of spectacle therapy or low vision therapy.
Now we come to the reason for our being before you today, Bill 26, the Savings and Restructuring Act. Optometrists are not strangers to abrupt and surprising announcements on health care services and funding by the Ontario government. Despite the value of the services we provide, we are all too frequently informed by the Ministry of Health of important health announcements after the fact or by reading them in the Globe and Mail. So the abruptness of these announcements was not new or shocking to us. What we did have trouble comprehending was the breadth and sheer volume of the proposed changes. While most of these changes do not specifically address the profession of optometry, they are fraught with implications for the future viability of our health care system, and as responsible providers we must participate in this process.
Partly because of the scope of the announced changes, our inexperience with certain elements and the brief time we have had to prepare ourselves, our remarks today will be confined to selected issues only.
Dr Mira Acs: So in no particular order, then, we refer to schedule H with its proposed amendments to the Health Insurance Act and the Health Care Accessibility Act. We are most concerned with announced changes allowing the Minister of Health to collect, use and disclose personal information, beyond what is currently provided for in the existing legislation, concerning insured services provided by physicians and other health care providers. We are not convinced this is necessary, and moreover we are sure it violates patients' basic rights to privacy of their personal health information.
With respect to the proposed amendments which affect the supply and distribution of physicians, one word describes our reaction: "Wow," followed up by a big question mark. Are these measures really necessary?
We know that physician manpower has been the subject of intense discussion and debate in recent years. It was because of restrictive measures to control physician numbers, proposed by the former government in its 1993 expenditure control plan, that the Ontario Association of Optometrists negotiated a manpower review process under our social contract agreement which is just now finishing a 12-month joint manpower exercise with the Ministry of Health. I hope we are not being naïve if we assume that staff recommendations to the minister concerning this profession will be discussed with us first and perhaps may even be joint recommendations.
We understand and are sympathetic to the minister's concern with controlling expenditures for physician services, and we have read reports of many communities that are medically underserved, but the list of amendments in schedule H to permit the government to, in its words, better manage the supply and distribution of physicians is too restrictive, too far-reaching and removes too many of the basic freedoms that all self-employed people in Ontario have come to expect. I believe the minister has stated that he will hold off proclaiming these sections and will wait to see if new incentives help to improve distribution of physicians. We strongly encourage him both to hold off on these measures and to work out a long-range plan in cooperation with the medical profession.
Amendments with respect to physician OHIP payments in schedule H directed at defining insured physicians' services, setting thresholds, setting fees payable for specific services, and the collection of moneys in excess of the prescribed amount are somewhat of a mystery to us. We say this because optometric OHIP-insured services are defined by the government and the fees for these services are set by the government. The existing legislation has allowed the general manager of OHIP to refer optometrists, when and as deemed appropriate, to the Optometric Review Committee. This committee has diligently reviewed patient records and has been successful in obtaining reimbursements to the government. Further, it has been established on the basis of an appeal to the Health Services Appeal Board, and is accepted in optometric cases, that in the absence of the required notation of information on a patient record, a service will be deemed not to have been provided. In the case of OHIP services, this would be a matter of automatic repayment.
Since the signing of the independent health practitioners social contract in 1993, optometric annual service billings to OHIP have been frozen at their 1992 level less 4.2%. As optometry is a young profession, with half of our members having graduated in the past decade, optometric practices are growing, and as the profession continues to grow in public trust and acceptance, our annual billings to OHIP have continued to grow. In year one of the social contract, our members had their monthly remittances reduced each month by an average of 7.5%, in year 2 by 9.28%, and in year 3 by 11%, which we have been recently advised will not be enough, so the average holdback for the year may well rise to 14%.
We have no problem, then, supporting amendments to the Health Insurance Act if we are correct in interpreting their intent and effect, which is to allow the Medical Review Committee to enforce reimbursement for the inappropriate billing of medical services and to allow OHIP to enforce repayment of moneys over the cap on medical services. This is no more than the situation that optometrists and other independent health practitioners live with now. In fact, under our social contract we asked for the establishment of a tripartite committee -- college, OAO and OHIP -- to review the criteria by which referrals were made to the ORC to see if these criteria needed strengthening. This committee never needed to function because the ministry had no problems with optometric referrals to ORC.
Dr Kniaziew: Schedule I, the Physician Services Delivery Management Act, will allow, we understand, the minister to proceed with initiatives which may not be consistent with his obligation under previously executed agreements with the OMA, including the 1991 framework agreement and the 1991 interim agreement on economic arrangements, and will remove all risk of legal action for doing so. Specific items that have been reported as ending are the government's subsidization of Canadian Medical Protective Association liability insurance premiums and the joint management committee of the Ministry of Health and the OMA.
Again, we find ourselves in some agreement with the outcome of this action but we disagree with the method, which we understand empowers the cabinet to tear up the previous agreements made with the OMA.
Physicians were given a unique concession, at a not insignificant cost, never afforded to other health service providers when the government began to contribute to their liability insurance premiums. The amount of this contribution to physicians' liability insurance premiums equals approximately 20% of the total OHIP fee-for-service dollars budgeted for the services of chiropractors, dentists, physiotherapists, podiatrists and optometrists combined.
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In a similar manner, we do not believe the establishment of the joint management committee was a good move. Why should one provider group, albeit a very significant and essential one, be recognized in this fashion? Since the establishment of this committee, it has been our unfortunate experience that issues that affect all service providers or even just some providers were delayed while separate consultations took place with the OMA. If the OMA did not wish to discuss these issues, there was no opportunity for anyone to do so. This is not in keeping with the spirit or intent of the Registered Health Professions Act when it was passed in 1991. At that time, all three political parties hailed this legislation as establishing a new era in health care in Ontario, one that would move away from a medical model of health care delivery and recognize the contributions and expertise of other health care providers.
Significant issues in health care delivery, with significant cost implications, including the full integration of non-medical providers into the health care system, exist beyond the boundaries of hospital and physician budgets. A few examples that come to mind are the development of nurse practitioners, the acceptance of direct optometric referrals by physicians, the extension of hospital privileges to chiropractors and optometrists, and the restriction of physicians from filling health care functions for which they have no specific training, such as refracting physicians examining eyes.
Schedule G changes the basis of the Ontario drug benefit program by introducing user fee payments into the program. We are told that this program has user contributions in other provinces and that to this point Ontario has been unique in providing a feeless drug program to seniors and welfare clients. User fees are not new to the delivery of health care services in Ontario, so we express no concern on that basis alone. We do wish to express our concern, however, with the fee structure that is being proposed. We are not economists and we have no knowledge of how this fee structure was arrived at. We therefore urge caution and would like to see some further public consultation with the affected groups. This would certainly help to provide reassurance that the government intends to protect the health care needs of the vulnerable in Ontario.
Before concluding, we would like to make one suggestion that might be applied to all aspects of this legislation, or at least to the ones which override existing agreements and affect rights of appeal and limit the powers of hospital boards, and that is the introduction of a time limitation clause. If such widespread powers are necessary to deal effectively with a range of health care issues -- and we have expressed our concerns about some of them and our support for others -- then some haste must be made to deal with them and then move on. Unrestricted powers are not democratic and should be challenged.
A lawyer writing on the op-ed page of the Globe and Mail noted the other day that even if the government had invoked the "notwithstanding" clause in the constitutional Charter of Rights, it would have suspended rights for only five years. So again we urge you to include an amendment to place a time limitation on this legislation.
In conclusion, members of the Ontario Association of Optometrists and our board of directors thank you for this opportunity to appear before you today. Health care is important to all citizens of Ontario, and preserving a system that can continue to meet the needs of Ontarians must be our collective goal. Prudent fiscal management of our existing resources is essential, and we sympathize with the task of the Minister of Health. From our experience, we know that healthy eyes and vision are positively related to our ability to meet demands in both educational and occupational environments. Early intervention and treatment can effect success in these environments. Furthermore, the research evidence suggests that groups already disadvantaged are more at risk for debilitating eye and visual problems and therefore less likely to obtain care.
Thank you.
Mr Crozier: I should tell the committee at the outset that the fact that Dr Kniaziew and I come from Leamington and that he is an outstanding athlete and I am a couch potato will in no way influence the questioning.
Doctor, welcome today. I want to start out by just pointing out, and I think you touched on it in areas of your presentation, that with regard to health care I don't think we should be under any illusion. This bill that's before us is a finance bill. It was presented by the Minister of Finance. It's called an Act to achieve Fiscal Savings and to promote Economic Prosperity through Public Sector Restructuring -- which of course health care is part of -- Streamlining and Efficiency and to implement other aspects of the Government's Economic Agenda. So I think the name of the bill alone tells us the objective of the bill, and that's to save money. So anything that we propose to the government should go to that end.
I don't disagree that we have to limit our spending, we have to reduce our deficit and work on our debt. When you mention consultation, or the lack of it, and your concern for your manpower review process, could you elaborate for the committee as to whether this manpower review process would have, as part of its objective, savings?
Dr Acs: Yes, it absolutely would have. When you're looking at eye and vision care in Ontario, you have to look at a little bit more than just the optometric profession. There are other providers involved in the system, so the picture becomes much broader. Unless you look at ophthalmologists and unless you look at opticians, and also, to a great degree more and more, look at refracting physicians, you don't look at the big picture. You cannot look at optometry alone. So it becomes a very complicated process.
But then when you start looking at optometry and the other professions, you start looking at things like geographic distribution of the various people who are involved in eye and vision care, the demographics, the primary versus secondary versus tertiary care that is delivered, and the level of training and the cost of the training of the various provider groups, it actually becomes very clear fairly quickly that given the previous factors -- geographic distribution, cost of training, the profession itself -- the most cost-effective and efficient providers of primary eye and vision care in this province are optometrists, which is where the cost comes in.
Ms Lankin: I might give you an opportunity to continue on Mr Crozier's question. I remember well during the final days of RHPA the debates around scope of practice in optometry and ophthalmology and opticians. Boy, oh, boy, it was a real immersion in the world of eye care for me as the Minister of Health at the time. I think it was important to leave room for a growing scope of practice as some of these issues around refracting physicians and others got sorted out and obviously still need to be sorted out.
Dr Acs: The more things change....
Ms Lankin: I'd actually like you to continue on your answer, because I'm interested in the issue of practitioner distribution -- I use "practitioner" because I'm talking medical doctor and other health practitioners -- in the relationship particularly in your field of expertise, what the restriction on billing numbers and restriction on some of those services might mean for your profession, and whether or not we've got the right tools to deal with that.
Dr Acs: Optometry is unique in the three O's, if you want to talk about eye and vision care, and that is that we are very well, evenly and widely distributed throughout the province. The profession of optometry thrives in small communities, so that there isn't a community of under 5,000 in Ontario that doesn't have the services of an optometrist provided to them. Even the northern communities will have optometrists flying in to various isolated hamlets to do eye and vision care. So the distribution of optometry has intrinsically evolved historically to be very good, excellent, in terms of primary contact. If we are the primary eye and vision care providers, and we do provide 70% of the primary eye and vision care, we are poised and properly distributed to be doing that.
So the whole question of the restriction of billing numbers and where you can practise, when that first came up under physicians under the social contract, was a wake-up call to us to say, if we are an OHIP -- insured service and we have billing numbers and if it's happening to one group, then let's take a look at our group and make sure that 20 years down the road, as our profession is growing and being used by the public, we don't have an oversupply in one area and an undersupply in another, so our members don't look back on us and say, "Why didn't you see this 20 years ago and do something about it?" which is why that clause was put in there and said we all have to sit down, we all have to work together.
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There are solutions to be found and some tough decisions have to be made in terms of whether it is appropriate to train a physician for so many years of medical school and then to have that physician provide the services of a refracting physician where all they're doing is a refraction and they're not really doing primary eye care. Is it appropriate to be doing that and to allow the system to be paying for it?
Mr Bob Wood: I have a couple of questions. You refer to concerns about medical records. You may be aware that the privacy commissioner has expressed certain concerns to the Legislature about the legislation as drafted. If his concerns were met, would you then be satisfied with that respect?
Dr Acs: Honestly, I don't know what those concerns were. If they would be available, I would think so, yes.
Mr Bob Wood: The second issue I want to address with you -- and you made reference to what your profession has done about this -- you may be aware that the physicians have a plan that they think is going to fully address the question of underserviced areas. Do you think that plan is going to work and do you have suggestions for improving that plan?
Dr Acs: Boy, that's a tough one. Not having seen the plan, it's very difficult to start guessing ahead whether I think the plan would work. I can go back to what I know about optometry, and we've been very lucky and we haven't had to deal with this in the sense that we don't have overserviced or underserviced areas. But I know, human nature being what it is, individual practitioners who work individually like I do in a private office have a certain mindset and it's very difficult to move in certain directions unless they intuitively believe that that's what they want to do and that's where they're going to thrive and that's where they want to go.
I can imagine any kind of plan to redistribute things quickly, or even fairly slowly, would be very difficult and fraught with a lot of difficulties. You almost have to back up to year 1 med school if you want to make changes in those kinds of patterns of where people want to go and what they want to do.
Mr Bob Wood: You have a system that seems to have worked. What advice would you give the physicians in developing their plan? What principles would you apply to this?
Dr Acs: I think our system has worked because, as optometrists, we have always felt ourselves to be underdogs. We have always felt ourselves to be the lower guys on the totem pole and we're always chasing the big guys up there. So, in a way, when you're second, you try harder and you somehow make it work better because you have no choice. This is imposed on you, this is how you're going to do it.
Dr Kniaziew: Just a comment. Communication -- working as a team would help.
Mr Bob Wood: Your answer in essence to them would be communication and focus?
Dr Kniaziew: Correct.
Mr Bob Wood: I think we've actually got them focused on the problem. I'm confident, I might say, that this plan is going to work. I don't think there's going to be any necessity for doing anything further. The minister has made that quite clear. If this plan works, he has no interest in getting into the issue at all.
The Chair: Thank you, doctors. We appreciate your presentation this morning.
LONDON SOCIAL PLANNING COUNCIL
The Chair: Our last group for the morning is the London Social Planning Council, represented by Alice Kendall, the vice-president, and Gary Davies, the president. Good morning and welcome to our committee.
Mr Gary Davies: Thank you very much. I'm Gary Davies, president of the London Social Planning Council, and Alice Kendall is our vice-president. We were both elected to these positions last October at our annual meeting and so, for us, we are coming here as volunteers today. However, I think in the course of our presentation you'll discover that we both have other hats we wear and we'll be drawing on our experience in other places to bring to bear in our presentation today, which is in two parts actually.
The first part is some detailed comments on Bill 26 itself, which Alice will present, and then later I have some concluding comments about the bill and I would like to draw on a particular area of practice in health as it relates to planning because that's the interest of our planning council. Perhaps we can have some discussions after that. So, Alice.
Ms Alice Kendall: On behalf of the London Social Planning Council, I'd like to thank the committee for the opportunity to put forth our views and concerns regarding Bill 26. It caused us grave concern when the provincial government attempted to pass this piece of legislation with no public consultation. This action indicated blatant disregard for the democratic process valued by the citizens of this province. Our concerns have not been eased by the knowledge that the standing committee's report to the Legislature on January 29 has been allocated a time slot of 10 minutes. This is obviously an inadequate period of time to report on all the concerns expressed by groups and individuals across this province. We hope this does not indicate that our government is extending lip-service only to the people of this province.
Actions of the provincial government over the past few months have been devastating many individuals and families in this province. Dramatic cuts to social assistance benefits, regulatory changes that completely cut people off the financial assistance of last resort and the elimination of many support agencies have resulted in people in this province without the ability to provide basic necessities such as food and shelter. This has entrenched them deeper into the cycle of poverty.
We are aware that living in poverty causes increased health problems. Money saved by forcing people deeper into poverty will be quickly spent by the additional burden on the health care system, unless, of course, legislation is passed which makes health careless less accessible to those who require it more, legislation such as that which incorporates user fees, extra billing and reduced health care coverage.
Bill 26 should be rejected by all Ontarians who value a quality health care system accessible to all, no matter what their economic status. Reduced health care coverage, user fees, deregulation of drug prices and extra billing reduce access for middle-income families; it eliminates access to many low-income families. Thousands of families will be forced to choose between health care services or required medication and feeding their families. What kind of choice is this?
One such family residing in London is already desperately affected by the cuts to social assistance benefits. The provincial government had promised that disabled people receiving social assistance would not be affected by the 21.6% cuts. What they mean is that disabled adults receiving family benefits allowance will not experience the cuts; disabled children will.
This family includes a chronically ill two-year-old little girl who is dependent upon a respirator. She is tube fed and requires 24-hour day care. Her parents are struggling to keep her in their home with her two siblings. The love the parents have for their child can be easily measured by the sacrifices they have made to ensure their daughter is in the best possible environment with the best possible caregivers, her mother and father. The care of this child requires the parents to be on duty 16 hours a day and on call for the other eight hours, except on Sundays when they are on duty for 24 hours. These parents both have a background in nursing. They are trained to deal with her daily needs and are well aware of her medical needs.
The expense to this family of keeping their daughter at home with her family is enormous. The surgical supplies and diapers alone amount to hundreds of dollars per month. Her parents cannot take paid employment outside of the home; they both work full-time within the home.
These parents do not begrudge the money, time or energy required to care for their child. She is, after all, their little girl. Their stress is caused by the increasing prospect that they will no longer be able to maintain her health at home as they will not be able to afford to. To hospitalize this child would devastate the family, including this child and, incidentally, will cost the health care system thousands of dollars a day.
In a second family, a single mother of a child with environmental allergies survives on social assistance. This child too was hit by the cuts to the social benefits. His mother hopes that she can continue to live in the home she has customized to her child's specific medical needs. He cannot go out to play with neighbourhood children or attend nursery school. Contact with people outside of his controlled environment will make him ill and he will be hospitalized.
The mother secured accommodation with a fully fenced yard. This way her son can at least play outside without the danger of contact with others. She cannot secure paid employment outside of the home. Her child cannot attend a child care centre and, furthermore, an employer will not hire a person who must take her child to the hospital on a regular basis to receive drug therapy.
A third family, a London couple with three children, are now receiving unemployment insurance and a top-up from social assistance. This time last year they were both employed outside of the home. This time last year they lived in a comfortable three-bedroom home, had two cars, benefit packages from work, and enjoyed a two-week family camping trip once a year. Now this family lives in a cramped two-bedroom apartment, has one car which sits in the parking lot as it requires expensive repairs and cannot afford a family trip to McDonald's. In fact, since October 1995 they've had to access the food bank by the middle of every month when their money runs out.
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What will Bill 26 mean to these and all other families surviving on limited incomes? It will mean limited access to quality medical services and often no means of providing necessary medication. It will mean the choice between providing for their children's medical needs and providing other basic necessities such as food and shelter. It will mean that fiscal and budgetary reasons alone, dictated by government, will determine what medical services these children receive rather than a medically qualified health care professional. It will mean an American-style health care system where the experienced health care professionals are not available to treat their children's fragile medical conditions.
For cabinet to have the ability to make regulations which would allow fees for such things as accommodation and meals while in hospital, charges for necessary nursing services, for laboratory tests or emergency room visits, is an obvious and obscene barrier to health care for low-income citizens. We cannot allow a health care system to be created where a parent must look in his or her wallet before taking a child to an emergency room.
Charging a fee for prescription drugs to the people least able to pay -- seniors and those receiving social assistance -- simply means that they will not be able to obtain necessary medication and will become sicker. The families I have outlined today cannot afford to pay for medication. However, these children cannot afford to go without it. A family who cannot afford food in the middle of the month will not have spare money put aside for health care services or medications.
The ability to allow independent health facilities to charge fees over and above what is covered by OHIP is extra billing. It creates a system where the most experienced health care professionals are inaccessible to the low-income community.
Only qualified, expert medical professionals have the ability to determine what medical services are necessary. Giving cabinet the power to decide what services are to be insured by OHIP is incomprehensible. This will allow budgets to determine which child will or will not be treated.
Bill 26 eliminates quality, accessible and affordable health care for many Ontarians. It creates stress and turmoil for families who are attempting to raise healthy children. It creates a situation where parents will have to decide between food and medical services. Then, to add insult to devastating injury, it gives the Minister of Health the power to collect and have use of personal medical information. It takes the right to privacy from these and every other Ontario family.
As articulated by a co-worker, "Deny food to one child, you call it child abuse; deny food to 40,000, you call it deficit reduction." Change the word "food" to "health care" and you express the same sentiment.
Bill 26, if passed, will be responsible for the abuse of thousands of children in this province. We hear this government justify its actions because of its concern for our future children. Let us not forget the children of today. Do they not deserve access to health care services where a qualified medical professional determines that it is required?
Throughout the election campaign this provincial government promised no cuts to health care; you promised that user fees would not be introduced. We demand that this government demonstrates some care and compassion for the people of this province. Withdraw Bill 26 in its entirety.
Mr Davies: Thank you, Alice. I have some general follow-up comments to what she has said and then I want to go on and discuss a particular target population within the health care area.
First of all, I think it's important that a bill with such an impact be reviewed, and certainly it's good that this meeting and others across the province are occurring during the course of the month. There has been some concern expressed by some of our members about the transfer of some responsibility to the voluntary sector and in particular to the United Way, for example, and to the churches. I mentioned at the beginning that we speak with different hats and I've had quite a bit of experience with both those areas. They have no power, other than moral, to raise funds, so to transfer some of that responsibility is perhaps regressive.
However, having said all that, we firmly support the need for the province to live within its means and for agencies to live within their means. We try to live within our means as well, as agencies or as the social planning council, although they are certainly limited.
I don't know if it's been mentioned by others, but we can't forget the role of the federal government, which has been dismantling the Canada assistance plan. That has a spillover effect on the funding of many of the social and health programs in Canada. That has been one of the most, if not the most, significant piece of funding and social services legislation in this country in the last 30 years.
Some people earlier today talked about supporting the individual privacy of medical records, and we support the government in its intent, or promise at least, to change some of the provisions of the bill to make sure that happens.
Hospital restructuring is going ahead very quickly in London, as you know, through LACTHRC and the Victoria and University hospitals merger. Both of those processes have involved a lot of local participation, and it's very important to have local ownership as part of processes like that.
With respect to the operation of social planning councils generally in Ontario, and there are about 30 of us, two thirds depend for funding to a greater or less extent, mostly fairly significantly, on municipalities, be they regional or local governments or city governments. Certainly there will be some reduction in municipal funding and that is going to have some impact on the role of social planning councils.
Switching to the different letterhead you're looking at, another role I play in London is as the executive director of the social planning council. I thought I would take this opportunity to use the planning for services to the head-injured population as an example of where we're at with one particular target population as it relates to health services generally.
Some current facts: Every year probably around 12,000 new people are admitted to hospital or at least seen in medical facilities with a brain injury. Traffic accidents cause about 50% of these; younger males are the largest group affected. Probably a couple of thousand, 2,500 or so, people annually are left with significant lifelong problems in a number of different areas. You have a brochure from our organization that describes some of the difficulties people face. It's important to remember that brain cells do not heal. Doctors were in the room before. I'm sure they would back us up on that. Bicycle accidents have been a leading cause of acquired brain injury for youngsters.
Starting in the mid-1970s and through some of the efforts of the district health council here in London, a number of different studies have been done on the systems for services to the brain-injured. I'll use brain-injured and head-injured almost interchangeably here; it doesn't make a whole lot of difference.
It's been very hard to estimate the size of the population and some more work is needed here. Perhaps the most recent study, A Continuum of Opportunity for People in Ontario with Acquired Brain Injury, was completed in December 1994 by a very impartial, non-partisan group representing a number of agencies, government people from all across the province, involved agencies and individuals, academia, institutions and so on, and was submitted to the Ministry of Health in February 1995. To date, as far as I know, there has not been any action taken on this very excellent planning model. I will say a bit more about it later on.
One of the issues discussed in this report, however, was the fact that many people are being treated in the United States. Our movement in Ontario, the Head Injury Association movement, was very pleased to hear the minister's announcement in November, I believe, that about 75 people would be repatriated from the United States, not only to save some money -- and the current cost down there is around $21 million -- but also to ensure that they receive treatment at or as close to home as possible. In previous careers I have held, that has been a principle I strongly believed in, that if you have to receive treatment of any kind, you receive it in or as close to home as possible. We appreciate that, and certainly that was one of the issues discussed in that report.
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Another project which has been led by the Ontario Brain Injury Association is called CISL, the Caregiver Information Support Link. In the last few years it has been generating a lot of useful information about the nature and extent of the difficulties that people with brain injuries face, and also their families and their colleagues and co-workers and so on. As I say in my written remarks, this project is still in its infancy, and the information coming out will more usefully inform the planning process for this particular target population.
When the Minister of Health was here -- it might have been in this hotel -- in November 1995, he told the Ontario Public Health Association that "every effort" -- those words are in quotes in the media -- would be made to directing some of the savings from the merger of hospitals towards, again in quotes, "beefing up" community-based services as the hospitals downsize.
The comprehensive system laid out in this report gives an important role for the head injury associations in Ontario in both community support and in prevention. Logic would suggest that as a legitimate part of the service system, some of those funds saved from hospital changes might be diverted to the head injury associations or at least to some prevention and community support work.
I won't dwell at great length upon the insurance industry. We have made a submission, I believe, to the government about the OMEGA proposal; that's only car insurance. Another concern we have with respect to insurance is that very often the establishment of the cause of a brain injury is seen to be more important than the recognition of the fact that a person has certain needs that need to be met. I suggest it would be more useful if the primary effort could be devoted to offering treatment without delay and leave sorting out the responsibility for payment till later on. I know governments have some control over the insurance industry, but there needs to be some dialogue to sort out some of these difficulties. It isn't just for the patients, but their families often are facing some hardships as well.
I'm glad to see that Dianne Cunningham has come back into the room, because with my next point I certainly have to accord her some recognition for the role she played in bringing the bicycle helmet legislation, as we have called it, into force in the province. I have to confess, though, that we've got some disappointment that it did not extend to people over the age of 18, in spite of overwhelming evidence that mandatory use greatly increases compliance. Some of our medical colleagues in London have said that accident reduction could be at least 85% with helmet use. It has been mentioned that adults have some responsibility for looking out for themselves. I think that has to be weighed against the lifelong costs of treating a head-injured person, which may well exceed $1 million to $2 million currently.
Last October, a London Free Press editorial implied that "Cuts Without a Map," and that was the heading of the editorial, were dangerous. Without service plans, services could go anywhere. There is a little story in Alice in Wonderland where somebody says, "Where are you going?" The response is, "Well, anywhere." "Then I guess you'll get there." If you really don't have a plan, you won't know where you're going. There is a good plan in the Continuum report, and the editorial went on to say, "The Conservatives should not be so quick to throw away well-charted maps to greater savings." I think this applies with respect to this report. We'd like to have some response and dialogue on that, not just as a local head injury association but provincially speaking.
Our association covers a five-county area, Elgin, Oxford, Middlesex, Huron and Perth. There are approximately 680,000 people living in that area. We would have to consider them all members of our target population. Some of the estimating tools we use to estimate the target population have to be used with great caution, but probably there are between 1,000 and 3,000 people living in that area with the effects of head injury, and don't forget it spills over into families so there are effects on other people as well, and perhaps as many as 1,500 new people a year will receive a head injury in this area. The needs of these people and their families and friends and colleagues and coworkers and so on, considering the lifelong impact associated with brain injury, merit careful consideration using the planning tools we have, such as this report.
Those represent my remarks. Thank you for having us come this morning.
Mrs Boyd: Thank you both very much. One of the issues for us is trying to put into context the individual problems of particular associations that deal with specific injuries and also individuals trying to cope with the implications of Bill 26. We need to get a sense of what you as a social planning council think the dangers are of this kind of omnibus legislation and the lack of consultation in terms of an orderly planning process for health care and the determinants of health in our community.
Ms Kendall: I think this government hasn't recognized the impact at the ground level, the impact on individual lives this bill will have. We talk about deficit reduction, but at what cost to our communities, at what cost to our children, to families in these communities? We can talk about the future, but we have communities that exist today, and there has to be a balance.
Mrs Ecker: Your joint presentation illustrates very well the very difficult but, I believe, very necessary balance between a government trying to live within its means and at the same time provide services for those who need them.
The point about being able to repatriate those with brain injuries: We've been able to reinvest $12 million to bring back about 76 patients so far to Ontario, where we believe they will be cared for better. We've been able to do that because of the kind of restructuring we're doing in the system, so we can find savings in one area to bring forward in another.
One of the things I have heard from the communities within the Community and Social Services area is that one of the difficulties with getting some of that money to the front-line services is that there is a multitude of agencies. One suggestion that has been brought forward from individual groups in my area is that we have more direct funding to actual families, more direct payment to the individual or the family with the special needs rather than filtering it through an association or an agency. Have you got any comments about that suggestion that was made to us?
Ms Kendall: When we're talking about getting these resources directly to families, by the same token, they've cut benefits 21.6% and then said that to provide medication to your child, you have to pay a user fee. If somebody's child has an ear infection on the 20th of the month, the chances of them having any money to get the antibiotics to clear up that ear infection are just not going to be there. These families are already using the food banks and don't have access even to what you would consider a small user fee. It's a large user fee when you don't have it.
Mrs Ecker: But 140,000 more people have got a drug benefit plan now under the system.
Mrs Pupatello: Mrs Ecker is describing a health voucher on the head of individuals, much like the child care voucher. While in concept and theory that's wonderful, the reality is that even with the child care voucher, when you cut the value in half, you can't access good quality at the appropriate level. Whether it's health care you're now using as a voucher or child care, it's still not available at a quality level. That's the danger of that kind of approach, and I know your organization has looked into the critical area of child care.
With all the things you've mentioned about the reallocation going on in the London area, the minister is on record in the House as saying that savings from hospital restructuring will not go back to that community, so I'm just hoping you're not holding your breath for that. That is what has been said. We have tried to pinpoint the minister on several occasions and he simply has said no. That's on record. For any government members today to suggest that they're making a commitment to any local community to reinvest those savings is simply not on side with their own minister.
Mr Davies: I just have a comment about flowing funds to individuals versus flowing funds to agencies. From our perspective in London -- and I can't speak on behalf of the whole movement in Ontario -- we would regard community support and prevention as probably the two major flagship programs we operate, and in the area of community support the intent is to have people come together, not to remain in their homes. Our job is to facilitate the coming together. With respect to prevention, I mentioned that it's a job that has to be done with respect to almost three quarters of a million people whom we see, and it can't be done on a one-by-one basis either.
The Chair: Thank you very much. We appreciate your presentation and your interest in our process. We're recessed until 1 o'clock.
The committee recessed from 1201 to 1302.
LONDON AND DISTRICT LABOUR COUNCIL
The Chair: Our first presenter this afternoon, to represent the London and District Labour Council, is president Rick Witherspoon and Jim O'Leary. Welcome, gentlemen. You have a half-hour.
Mr Rick Witherspoon: First of all, Mr Chairman, I'm Rick Witherspoon, president of the London and District Labour Council. We represent something in excess of 20,000 members in the city of London and surrounding areas. As you will be aware, we made a presentation last week with regard to the general portion of the bill, raised our concerns with a number of specific areas and, of course, raised our concerns with the process that is taking place with regard to the hearings on Bill 26.
The reality is, our position at that point in time has not changed; we still think that the hearings should be expanded to allow those groups that have not been given the opportunity to make presentations, that they will be given that opportunity. Again, the reality is that the hearings are taking place across the province because of the actions that were taken in the Legislature to force these hearings to take place, and the unfortunate aspect of that is that it is still the government's intention to go back into the House with one more day of the Legislature and ram this bill through. The implications of it in general form, certainly in the area of health care, are going to dramatically affect everybody in the province of Ontario, and with the sweeping changes that the bill imposes, I think it is imperative that the current government take the time to listen to your constituents across the province and ensure that they understand the issues, and if in fact there are going to be amendments to the bill, that they understand those clearly.
I find it extremely difficult to understand that this government that has clearly said it is going to put amendments in place is still not prepared to let people know what those amendments are so that if we have issue with amendments, we could deal with those. The reality is, as I've said before, this is going back into the Legislature for one day, so nobody is going to have any opportunity to deal with the bill as amended before it is passed through the House.
The follow-up portion of the presentation today is going to be presented by Brother O'Leary, so I'll give him the opportunity to take over at this time.
Mr Jim O'Leary: I'm a medical laboratory technologist working at Victoria/University Hospital in London.
On behalf of the London and District Labour Council I want to express our utter disbelief that in this day and age a government would attempt to pass legislation that would take away the rights of its citizens and move us back to an age of inequality.
Not since civil rights were suspended with the imposition of the War Measures Act in 1970 in the fight against terrorists in Quebec has any piece of legislation attempted to undermine the democratic rights of its citizens. With the presentation of Bill 26 in the Legislature, Mike Harris has declared martial law on the health care system in the province of Ontario.
Such an approach to health care, however, should not come as a surprise. During the 1960s, when the Canada Health Act, which set up universal health care in Canada, was debated in the House of Commons, the Conservative Party of the day argued against it. Their preference was to let private insurance companies run our health care system for profit. Nothing seems to have changed in 30 years.
Bill 26 would create the Health Services Restructuring Commission. The legislation does not specify the exact powers of the commission, but provides that the commission can be assigned duties by regulation under terms and conditions determined by cabinet.
Does it mean that the communities we live in will have little or no say on the delivery of health care? Does it mean work done by district health councils will be substituted by bureaucratic decisions made in Toronto?
In fact, with Bill 26, 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. According to the bill, the public interest is defined as what is of interest to the Minister of Health.
We find it difficult to understand why, if this government is acting in our best interests, the cabinet have provided itself with immunization against any liability for damages arising in the course of carrying out its powers so long as they act in good faith. What has happened to one of the basic principles of democracy: allowing citizens access to an independent judicial system?
The bill would eliminate the requirement now contained in section 3 of the Independent Health Facilities Act that preference to operate independent health facilities be given to non-profit Canadian operators.
Under Bill 26, the minister can direct that a request for proposals be limited to one or more specified persons. This raises the real possibility that for-profit US health care providers will be licensed to provide our health care needs in the future. There will be no obligation to notify those who submit unsuccessful proposals or to give reasons for these decisions, with no right to appeal.
Without a tendering process, the door is open for the entrance of the American two-tier health care system, a system that costs far more than ours and leaves millions of its citizens without health care.
In tandem with the massive cuts to hospital services, the new legislation will allow the Minister of Health to handpick corporations or individuals to fill gaps created in the system with private clinics or organizations intent on profiting from the sick and the elderly. As I speak today, American corporations are poised to move in and mine this untapped resource. Do you think this is what the people of this province wanted when you were elected? I think not.
In the case of medical laboratory services, profit-making has cost the system dearly. It has been shown that the private sector medical laboratories are 34% more costly than their hospital counterparts. In fact, recent research proves that if hospital laboratories were allowed to compete fairly with private labs, the taxpayers of Ontario would save $106 million annually. Why would this government ignore this opportunity? Putting dollars into the pockets of corporate shareholders has priority over using the taxpayers' dollars to fund health care responsibly.
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The present act prohibits any person from communicating confidential information relating to a patient or former patient of a health facility, with narrow exceptions. The bill provides that, notwithstanding this protection, and for any purpose prescribed by cabinet regulation, the minister can collect, use or disclose personal information, and the minister can enter into agreements to collect, use or disclose personal information.
We are now living in an age of computer databases where people are becoming more concerned about personal privacy. What does this government want to do with this information? Will private insurance companies have access to this information? Will it allow them to determine who is insurable? Will this government sell this information to private companies to screen job applicants, or use it themselves for the same purpose? The Harris government clearly feels that economic considerations should override the rights of citizens to have a person's personal medical history held in confidence.
Proposed changes to the Ontario Drug Benefit Act and the Prescription Drug Cost Regulation Act will introduce copayments and deductibles for seniors and social assistance recipients.
All recipients of ODB benefits will now pay a minimum $2 charge per prescription. In addition, where individual income exceeds $16,000 or a family income exceeds $24,000, a $100 per person deductible per year will be instituted.
It also deregulates drug prices. Ontario will become the only province in Canada that does not regulate drug prices. Will this mean that you will go to your pharmacist and haggle over the price you pay for your drugs, as you do now with grocers over the price of your tuna? Where is it going to stop?
In 1970, the War Measures Act allowed the federal government to throw anyone in jail without a reason and without legal recourse. Bill 26 amounts to the same approach: martial law. Putting absolute power in the hands of cabinet sidesteps debate in the Legislature. It hides government actions from scrutiny and undermines the basic democratic rights of every citizen to be informed of not only what the government is doing but why.
A government which believes it should merge or close health care facilities, dictate to or overrule community boards, collect and use private medical information, has assumed dictatorial powers. In the interests of the citizens of Ontario, I hope everyone in this community will exert pressure on their MPPs to defeat this omnibus bill.
Ms Lankin: Thank you for your presentation. I have questions in a couple of areas that you've raised and one area that you didn't directly touch on in your brief. First of all, Jim, you talked about the role of the Health Services Restructuring Commission and you're quite right, there are no terms of reference, there's no mandate, there are no powers or limits on the powers set out, and there's no explicit connection to the work of local planning studies, often being led by district health councils around the province.
We've been urging the government to consider explicit amendments in this area that leaves us not so wide open to just the minister's decision-making, and actually links the work of this commission to implementing local planning reports and the consensus arrived at at a local level. I realize you'd like to see the whole bill defeated. Many of us think this needs a lot more time, and there are pieces of it that we could support and other pieces we couldn't. But if it proceeds, do you think that would be a useful amendment and do you have any comments on what should be contained in it?
Mr O'Leary: Absolutely. I think community boards and district health councils across this province have done an enormous amount of work over the past number of years. Restructuring has been happening in this province very quickly in the last two years in Sudbury, in Ottawa, in Toronto, in London and other places as well.
What this bill does, it could eliminate all this useful work that's been done with all the community input that people have to put into their hospitals. What we're afraid of with this bill is that the government can come along and disregard everything that's been done, all the work that's been done, and just impose its will for economic reasons only and not with the interests of the community in mind.
Ms Lankin: In addition to that concern, one of the other concerns I have is that any one partner in the community who may be dissatisfied with the end result of the community consensus, if they happen to be a powerful voice, has a pipeline to the minister and has the ability to sway the minister in terms of that decision. I think we've already seen that happen in a couple of communities. So that's an area we'll be working on in terms of amendments.
I have another question I'd like to ask you. You didn't explicitly talk about schedule Q, and that's before the other committee, and that's to deal with powers in fettering arbitrators' decisions in public sector interest arbitration. I raise it because in fact your employer was here this morning, and representatives from the board made a presentation. They talked about not only supporting the fettering of arbitrators' decision-making powers but they wanted it to be even stronger.
I wanted to raise this with you because I think it's important that people have a chance and government members understand why the arbitration system is there in the first place and the fact that this is a system attempting to replicate free collective bargaining. By imposing an ability to pay, I understand the hospital's frustration: It's like the government is a ghost at the bargaining table; it determines the amount of money and then the hospital is sort of stuck there.
But by entering into this world of ability to pay, the inevitable result I would see is that public sector workers are going to be asked to subsidize the cost of delivery of public services. I would say to you directly, as a laboratory technologist going back over the years in interest arbitration, and I'm thinking of the arbitrator Verity award, if it hadn't been for that process, of being able to take a fair look at things, the issue of equitable wages between the nursing profession and laboratory technologists could never have been dealt with. Could you share with us some comments on that section and perhaps provide the government members with some alternative views to what we heard this morning?
Mr O'Leary: I was quite surprised this morning. I heard Mr Dagnone, the presentation they gave from the hospital. They wanted to have a one-board arbitration, appointed by the government, that would sit permanently to determine these matters. That scares me. I don't think that would work.
What we have now is a system where arbitrators are agreed upon by the employer and by the union. I think we get a much fairer result because of that. That happened with Mr Verity's award, where they brought the wages that people in the hospitals were making up to the level that the community was making, that people doing similar jobs outside of the hospitals were making. At the time, they were grossly underpaid. At the present time, I think it's a more equitable solution. The changes that they've wanted, that the hospital even proposed this morning, surprised me, that they wanted to expand it even further than they did.
Ms Lankin: If you're in a collective bargaining situation and you know that the government has dictated the level of services the hospital must provide, so they must do a certain number of things with the money they're given, and the government also determines the amount of money the hospital gets, what are you going to be faced with across the table in terms of what the hospital is going to say to you and, inevitably, if you choose to go to arbitration, either party, to the arbitrator? What will it mean in terms of your ability to represent workers and to get salaries that are comparable to free collective bargaining situations where the right to strike exists?
Mr O'Leary: I think it destroys the whole arbitration process. It doesn't allow arbitration to take place the way it's supposed to at all; it wouldn't.
Mr Witherspoon: If I could, because I think your point is well taken, we did address this when we made the presentation last week. Of course the concern is that it defeats the collective bargaining process, particularly where the various criteria are put in place that are going to affect the arbitration process. Knowing full well that if you are using ability to pay as one of the criteria, the premise can be made, then, that we simply make sure that budgets don't allow for the funding to increase wages and in fact impose wage control in that fashion.
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Mr Clement: Thank you for your presentation. We heard earlier today from the hospital with which I believe you're associated, Victoria/University, about how they saw the restructuring of hospitals and they made an important point which I picked up on, which was they agreed that restructuring had to take place. They had some suggestions to us about how to balance the authority of the minister with the local area, and I want to assure you that if you read the Ministry of Health Act, the district health councils are still mentioned. They are still part of this legislation.
Read section 8.1 of the act, which has not been repealed, has not been altered, has not been changed by this legislation. The district health councils are still there. So if I tell you that, and if you could re-read the act, does that give you some comfort that the district health councils are still part of the process?
Mr Witherspoon: It doesn't give me any comfort because the reality is the legislation, in my estimation, supersedes what the health councils are going to do.
Mr Clement: Well, sir, I guess reasonable people are going to have to disagree, because if you read the act, section 8.1, which deals with --
Mr Witherspoon: I've read it.
Mr Clement: -- district health councils, it is still there. We haven't repealed it. District health councils are there to analyse and advise and plan. They still have that responsibility under the legislation.
Mr Witherspoon: And the minister has the ultimate authority to overturn those decisions.
Mr Clement: That is the case now, sir. Can I just deal with another part of your brief then. You state that the minister under Bill 26 can enter into agreements to "collect, use or disclose personal information." Did you know that under the old legislation the minister could enter into agreements to collect, use or disclose personal information?
Mrs Caplan: You have to make him tell the truth. That is absolutely misrepresentation.
The Chair: Mrs Caplan, Mr Clement has the floor.
Mr Clement: Subsection 2(3) of the Health Insurance Act, "The minister may enter into agreements to collect, use or disclose personal information relating to eligibility." It's in the old act. So who is telling the truth here?
Mrs Caplan: Mr Chairman.
The Chair: Mrs Caplan, Mr Clement has the floor.
Mr Clement: Who is telling the truth here?
Mr Witherspoon: I think the reality of the bill, and I'm not sure what you're reading in the old act, but --
Mr Clement: Subsection 2(3).
Mr Witherspoon: All right. And what's before it and what's after it and what does it pertain to? You know, it's no different than a collective agreement. When you relate to one section, you have to relate to 10 other ones to determine what you're going to do with it.
Mr Clement: No, I read you the old section, sir --
Mr Witherspoon: This one clearly says that you have the right to do that.
Mr Witherspoon: You can identify one.
Interjection.
Mr Clement: I'm just trying to correct the record. With respect to Ontario drug benefits, you've raised some important considerations for there. If I told you that 50% of low-income seniors, according to our estimation -- it's our estimation -- would be paying $32 per year or less for their drugs under our plan and that only 10% would be paying $110 or more, would that give you at least some comfort that the great bulk of seniors are not affected by this legislation deleteriously?
Mr Witherspoon: I don't have any comfort with this act at all. I don't have any confidence that this government is going to continue to do what's been done in the past. Obviously with this bill, with Bill 26, the government is intent on stripping people of the rights and the privileges that they have now.
Mr Clement: If I put it to you this way then, because this is the intention of the government, to restructure the health care system to deliver the dollars where they are needed because in this community, as in other communities we've heard about, the real needs of the community, in community health, in palliative care, in long-term care, there are lots of areas that do need more resources, but we need to find the money from somewhere. You know it doesn't grow on trees, so we have to restructure the way we deliver health care.
Mr Witherspoon: I could give you an example of resources here. The Laurentian Group in Sudbury of Doctors Bonin have approached the government with a plan to save, as I said, $106 million annually on laboratory services alone. That money could come back into the system. They approached the present government with the plan to do this and it ignored them.
The plan called for hospitals to be able to bill at two thirds -- not the full rate, at two thirds -- the rate that private laboratories now bill the government for their testing, and this would be a windfall for this province. There would be over $100 million that could come back into health care that could fund other areas that you're talking about and this government chose to ignore that.
Mr Clement: We're looking at all ways to fund. I do not make any apologies for the fact that we're looking at any way that we can deliver the services more efficiently. So I can assure you that that's the intention of this government.
But I guess my point is, we've got to restructure. We've got 9,700 empty hospital beds, by last count, in this province where we as taxpayers still pay for the heat, for the electricity, for the administration and then we've got other areas in our health care system that are crying for more resources. So don't you think we should at least give the minister the ability, even in a sunsetted and a time-limited fashion, to obtain some savings, make sure that we have a health care system that is efficient so that we can do the things that we have to do in the health care system and rechannel some of the money into the areas that need those increased resources?
Mr O'Leary: Let me ask you a question. Would you give someone the ability to have control over your life with no recourse to the courts, and this person would have absolute control over what happens to you? This is what this bill is trying to do.
Mr Clement: No, that's not true. Let me ask --
The Chair: Thank you very much, Mr Clement.
Mrs Caplan: Over the course of the last few days Mr Clement has been attempting to put forward a categorization of this bill which is absolutely incorrect. So I would like, if I could, to read a legal opinion into the record which I think will help to clarify for Mr Clement and the government that what they are doing is in fact not what Mr Clement says they are doing, and that your concerns are absolutely valid.
I'm just going to read it as follows:
"It has been stated" -- by Mr Clement -- "that section 21 of schedule H narrows the effect of section 29 of the Health Insurance Act. It might be so claimed because in section 29(2) of the Health Insurance Act it states that every insured person shall be deemed to have authorized a physician to provide the general manager with information respecting insured services for the purposes of the plan.
"In section 21 of schedule H, specific purposes are set out in subsections (a), (b), (c)." That's what you've been referring to, and he's nodding his head.
"However, such an interpretation would be in error because the reference to purposes of the plan in the Health Insurance Act 29(2) must be read in conjunction with section 10 of the Health Insurance Act which states that the purpose of OHIP is to provide for insurance against costs of insured services. Therefore, the actions of the act must be limited to those things which relate to the purpose of the plan, and only those, and therefore the information authorized must be for the purpose of providing insurance against costs and is therefore, not" -- and I stress "not" -- "personal health information.
"Furthermore" -- Mr Clement -- "such interpretation would also be in error because section 21(1)(d) of schedule H allows the minister" -- under your Bill 26 -- "to prescribe any other purposes. This therefore specifically and directly removes any limits on the information which may be collected. This would massively increase the purposes as stated in the Health Insurance Act presently in section 10."
That's what we've been saying to you. I know that Ms Lankin, also a former Minister of Health, will agree with this interpretation. You're absolutely wrong to suggest that those powers are already contained in this act. Bill 26 massively increases and enhances to the point where the Minister of Health has absolute control over every aspect of the delivery of health services and every right under this legislation to micromanage the system, to have access to patient records, for whatever purpose he would set out, and no one can sue him if they disagree with how he's used that information or disclosed it. And that's the truth. Now, withdraw. That's this law.
Interjections.
Mr Clement: I'll get my lawyer to call your lawyer.
Mrs Caplan: Well, you're a lawyer and you should know this. And to not do that is a clear misrepresentation of what is in this bill. You have to tell the truth here.
Mrs Pupatello: I just want to say, for your information, Mr Clement is attempting to do this in all of the communities he visits in an attempt to trip up those presenting. So we're glad to see that you certainly are informed as presenters.
I wanted to simply make the point that you stressed in your presentation about drug coverage and health service and what's going to be considered covered etc and available to all, and who really pays what no longer will be listed. Because at the end of the day, from your perspective -- and you're probably involved in contract negotiations -- when services become delisted they now become part of a bargaining parcel that you must go after for the employees who are part of your union. At the end of the day, as is the case in Kentucky, where there's a perception of cheap labour in the States, the reality is that in a state like that the companies have difficulty maintaining their good workforce unless they have great packages they can offer, especially health service.
Because we are now Americanizing our Ontario health care system, Chrysler, Ford, GM -- big business, I would submit, which this government assumes is on its side in this -- will end up paying the price, because for them to remain competitive, they now will have to pay for those services that are not being covered for individuals. It will become part of the bargaining process and that package. I'd just like your comment on that.
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Mr Witherspoon: The point's well taken. Of course I think, as representatives of workers, what manages to get legislated away we're certainly going to attempt to try to maintain on behalf of our members through the collective bargaining process.
Mrs Pupatello: And you compete and companies compete with themselves, within their sector as well. So if one offers, the other must offer and so on.
Mr Witherspoon: To a certain extent obviously. You've spoken about some of the major corporations, and I'd like to think that certainly the Big Three negotiations do have a spillover effect into other negotiations. If we're able to achieve those types of things on behalf of our members, certainly it sets a benchmark for other people to go after.
The unfortunate part we see within the whole process here is that we're now seeing a government that even though you do attempt to go to the bargaining table and put together a collective agreement on behalf of your members, the government wants to then have the power to overturn many of those decisions. So with the stroke of a pen, you can lose --
Mrs Pupatello: Even if it is a private negotiation --
The Chair: Thank you, gentlemen. We appreciate your being here today and making a presentation to us.
I'd just like to remind the members of the committee, our purpose in all the communities we go to is to listen to the people and to bring forth their concerns. I don't believe it's productive for us to get into long arguments with one another. That does not allow the people who come here to speak to be heard. I'd just like to remind you about that.
Mrs Pupatello: Jack, you keep your members in line and we won't have a problem.
The Chair: Thank you, Mrs Pupatello.
Mrs Pupatello: They have a responsibility when they sit there on the government side.
The Chair: Mrs Pupatello, I just made a suggestion.
ONTARIO COLLEGE OF FAMILY PHYSICIANS
The Chair: The next presenters are the Ontario College of Family Physicians, represented by Dr Lynn Nash, the president, and Dr Ralph Masi, the president-elect. Good afternoon and welcome to our committee.
Dr Lynn Nash: Good afternoon. Thank you for the opportunity to address you today. I'm a family physician providing full-spectrum care to my patients and I practise in Ancaster, Ontario. I'm also the current president of the Ontario College of Family Physicians.
With me today is Dr Ralph Masi, who is a family practitioner from Downsview who, as well as having a broad-spectrum practice in family medicine, has a special interest in multicultural issues. Dr Masi is the president-elect of the Ontario College of Family Physicians. I ask you not to look at Dr Masi's hands today. He called me in a panic on my cellular phone because he had a flat tire coming into London. He of course had all the written material in his car with him, so he had to change his flat. His hands are clean when he's in the office.
You should have the documents in front of you. Because there isn't an overhead today, the green sheets in your packet will be a substitute for any overhead presentation, and I will direct you to the appropriate pages at that time.
The Ontario College of Family Physicians is the provincial affiliate of the College of Family Physicians of Canada. It's a voluntary organization of over 5,200 family physicians across the province who are committed to the promotion and further development of the principles of family medicine within the province.
Membership with the college is voluntary. Certification with the college requires successfully completing certification examinations, a minimum of 50 hours of documented study credit annually and participation in ongoing continuing medical education. The Ontario college represents family physicians working in diverse areas, including the geographically isolated inner city, suburban and rural areas.
I'd like to talk a bit about the primary health care infrastructure in Canada. Canadians enjoy one of the finest health care systems in the world. One of the strengths of the Canadian health care system is its exceptional primary health care base. In 1990, in National Health Systems of the World, Milton Roemer studied the distinctive features of health systems in 68 countries. This work and others show that the characteristics of the Canadian system are consistent with those in other industrialized countries. Users of the Canadian system have shown the highest level of satisfaction of any of the health systems studied, and I would ask you to look at the second page in the document with the green cover. There is a graph there that shows the comparative levels of satisfaction with the health system.
Notwithstanding indications made by the Minister of Health in his backgrounder of November 30, 1995, the success of our health system is not simply a matter of money. Canada has had the highest cost satisfaction index of any developed country, and that graph is within your document today. The Netherlands, with the second highest, also has a strong, well-trained family medicine base. Why is it that many countries around the world are seeking the assistance of family medicine practitioners and educators to assist them in developing their own primary care systems modelled after the Canadian system?
The question of the need for reform is before us. As a society matures, there is merit to evaluating and re-evaluating our health care needs and to reshaping the system to better utilize existing resources. However, reform implies that we build upon current successes. Enacting sweeping legislation that virtually imposes government control by eliminating collective bargaining, due process and overriding the principles of natural justice is not the means by which a democratic jurisdiction can achieve meaningful and lasting reforms. Reforms cannot be motivated simply by the need for cost containment. Fiscal responsibility must be balanced with consumer and patient needs and the principles of care. These principles provide that primary care should be comprehensive, continuous, community-based and patient-centred.
We agree with the ministry objectives of achieving cost-effective use of health care services. However, solving problems relating to physician distribution and consumer and provider accountability requires goodwill and the buy-in of all consumers, providers and the government working hand in hand. In the long run, this will ensure the availability and the sustainability of a broad-spectrum health care for all communities in this province.
We've identified some of the long-term impacts of Bill 26 and we've identified a number of critical concerns arising out of the powers introduced by the proposed legislation. A number of these, such as the issues relating to obstetrics, the loss of patient-physician confidentiality and the abrogation of due process and natural justice, ie, arbitrary decision-making, no collective bargaining and no appeal mechanism, have already been addressed by others, and we will not dwell on those concerns but lend our voice to those others.
In the brief time permitted, we would like to focus on other issues which have not received such broad public attention. One of them is the politicization of health management. Traditionally, health care planning has been the responsibility of communities working to meet specific regional health needs. This has been a tremendously effective process which ensured that allocated resources would be utilized according to the priorities determined by the community itself.
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Under Bill 26 the minister will have the right to arbitrarily allocate and manage local community health. Accordingly, the emphasis on health management will be through the political process, rather than by local health planning. Do we want to create a system in which political lobbying determines funding and the delivery of health services?
With regard to physician distribution, in making decisions about physician distribution, we must ensure that the figures we base our planning upon are accurate. However, figures utilized in the government backgrounder are only very general estimates. The raw data fail to take into account such issues as type of practice, spectrum of care provided or even full-time versus part-time physicians.
Moreover, as Graham Scott pointed out, maldistribution is more a function of lack of support and backup. Rather than being assigned to rural communities where these problems remain to be addressed, over 65% of family medicine residents polled recently have indicated that they would emigrate to smaller communities in the US where these issues have been addressed. Clearly the problem is not a physical relocation.
We agree with those who recognize that no one works well under stress. By ignoring the underlying problems and enforcing redistribution through punitive measures like restricted billing numbers, you are creating a lose-lose situation in which neither the public nor the profession is well served.
What are the alternatives to achieve reform? Over the past several months several important initiatives to achieve sustainability, accountability and availability of health services have been undertaken. These include the Scott task force addressing rural and emergency issues, the Connell task force looking at funding and delivery issues, and many others.
Solutions are at hand that do not require the introduction of sweeping ministerial control. Solutions such as consumer selection or rostering or registration -- whichever terminology you prefer -- modified/alternative reimbursement mechanisms, identification of health targets and multidisciplinary approaches have all been tabled and thoroughly discussed to remedy in an equitable and just fashion the problems that Bill 26 purports to address.
The OCFP has been an active and willing partner, along with many other groups, in developing many of these solutions. In 1995 the Ontario College of Family Physicians published two documents: Bringing the Pieces Together and Beginning the Process. Both of these papers you have today. Both papers have been well received by the profession, the public and the government ministries, as responsible and practical proposals to achieve the needed reforms. To date, over 80% of our membership supports and agrees to the proposals for change outlined in these papers.
In summary, there's no question that there's much goodwill and many willing partners prepared to work together to effect the needed changes. Much has already been accomplished, and while there is much that remains to be done in terms of implementing needed reform, the broad, sweeping powers introduced by Bill 26 are counterproductive in the long run. Indeed, it is only through partnerships and collaboration that the success and the continuation of the high rating of our health system are likely to be maintained.
Thank you once again for this opportunity to speak with you. In the time remaining, we'd be happy to answer any questions you may have.
Mrs Ecker: Thank you for an excellent presentation. I appreciate the time you've taken and the work you've done to make sure you got here, flat tire or not. So thank you for some very excellent suggestions.
You make a suggestion in here about the fact that the profession now seems more prepared to look at things like rostering and alternative payments and issues of that kind. In terms of rostering, as I understand it, where you basically sign up with one physician and that is your physician, given the fact that we've seen, and physicians have told us, that one of the pressures they see in the system is people making use of walk-in clinics, for example, and then repeating the visit back to their own family doctor -- or the data also indicate that there's a lot of, I guess physicians would call it, doctor shopping going around. One of the statistics I've used before is that in one month 7,000 individuals in Ontario saw five or more family physicians in one month, which I think you would agree was a little excessive. What is the best way to ensure that consumers are, if you will, complying with a rostering system?
Dr Nash: Primarily through education of consumers, and certainly we'd like to see a lot of education of the consumers in this province go forward. There is no doubt that you get better health care if your health care occurs through a central either physician or clinic. I would put to those consumers or patients that moving around for different care is really not doing themselves a service in terms of their own health care needs.
I think also you have to educate the public about the concept of rostering. We did focus groups in the province with patients, and it was very clear they really didn't understand the term "rostering." That's why we've called it patient selection. Primarily they need to know they have choice, and we believe you that should have the choice of your primary health care giver, that that should be the central starting point.
Dr Ralph Masi: You should keep in mind that once the consumer selection process is in place, there is responsibility for physicians to be part of a network in which after-hours care is provided. But there would be a penalty involved for both the physician and the consumer for those who are seeking care outside their primary care source.
Mrs Ecker: As an organization that, if I say, has been sort of one step outside of the negotiations and some of the issues this government and previous governments have been wrestling with -- the family college is kind of a little outside some of that pressure -- would you like to give a comment about how you see the OMA-government negotiating process, how that has in the past met the needs of physicians and the needs of consumers?
Dr Masi: Basically, we feel we are members of the Ontario Medical Association. I don't think we believe that anybody's going to be well served by the profession being fragmented out into separate sections. We've been working with the OMA over the last number of years, and certainly much more so over the past year, to ensure that the voice of family medicine vis-à-vis primary health care gets through. We'd like to see that that voice is clearly and solidly heard in the process of negotiations, but we do believe that the best process is where one organization negotiates for the entire profession. We don't want to see splinter groups.
Mrs Ecker: One of the things the minister has been well aware of and acknowledged is that in order to get physicians into underserviced areas, there has to be a multifaceted approach. As many reports, as you note, have recommended, he has talked about the incentives through the education, through locums, through CME opportunities etc, and if in the last resort you needed some stick, the billing numbers would be the stick.
Can you elaborate on some of the comments you made in your report, since the committee's just seen it, that might address some of the underserviced areas challenges that so many governments have wrestled with over the years and none of us has managed to solve yet?
Dr Nash: I think it's going to take a great deal of time. We now have residents in the province in family medicine who are being trained in the north. It's very clear from that experience that they are staying in the north to practice once they become comfortable with their skills, because there's no question that if you're practising in a rural practice, you don't have the backup you have in the urban centres in terms of technology and specialists etc and you have to have a comfort level there.
I think that over time you will see more physicians choosing to be there because they're comfortable there. It's very clear that the people in those areas, the patients, would like to have physicians who are happy to be there, who want to be part of the community, as opposed to physicians who are only sent there because they have to.
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Mrs Caplan: Actually, I appreciate your answers to the government caucus, because I think you've identified the real crux of the problems of Bill 26. While you are an organization that has no official negotiating status, as was properly pointed out, the college of family practice is not only as well respected but you've had a relationship with the Ministry of Health and have been consulted on policy over the course of time. I know that because I consulted with your organization myself.
This report, Bringing the Pieces Together: Planning for Future Health Care, was printed in March of 1995. That was prior to June of 1995. It was prior to the tabling of Bill 26.
My question is, given the fact that this is out there, that your recommendations are very significant restructuring, were you consulted by this government as to what it was proposing in Bill 26?
Dr Nash: No.
Dr Masi: We've had a request in to meet with the minister and we have not yet heard back from the minister.
Mrs Caplan: He hasn't even met with you?
Dr Masi: No.
Mrs Caplan: I didn't expect that answer. I can't believe that he wouldn't have agreed to meet with you.
Ms Lankin: Elinor, you never ask a question you don't know the answer to.
Mrs Caplan: No, I must admit I'm surprised.
Your second report is out in December of 1995. That's just last month. I know that not only 80% of your members support this proposal, but I understand it is also supported by the Ontario Medical Association.
Would you like to see Bill 26 changed so that this became the model for primary care reform, or do you think that it should be done in a separate piece of legislation apart from Bill 26?
Dr Masi: I think the two processes are somewhat different. I think the changes involved in Bill 26 far supersede anything in terms of the focus of this, but certainly I think that the work represented by these two papers and the specific directions are not addressed directly. It bypasses it, and it kind of uses the push or the coercion approach as opposed to the partnership, which is there. It's evident; it's plain. We're willing to talk. You don't need the hammer.
Mrs Caplan: And Bill 26 is the hammer. If they were to withdraw those sections of Bill 26 which are most offensive and coercive, do you think there's a spirit out there where you could come together in partnership and implement something like this? Is that still possible if they withdraw those sections of Bill 26?
Dr Nash: I think it is. I have a great deal of optimism for the future of primary health care in this province, if we can build a partnership.
Mrs Caplan: What'll happen if they don't change Bill 26?
Dr Nash: If they don't change Bill 26, we know the physicians in this province will leave in droves. There's no question. Recently, a reporter said, "Well, is that sort of not just saying we will take our toys and not play any more?" It's the reality if you look at the numbers of physicians who are now being wooed to south of the border.
Dr Masi: Not only that, I think you're going to lose a tremendous amount of goodwill by people who are willing to work. You don't have to twist their arms, and once that starts happening, I think you'll start taking stands and I think you'll see more dissension and less willingness to work together.
Mrs Caplan: Well, I hope they've heard you, and I hope the minister will meet with you. In fact, I'm going to table a question, Mr Chairman, and ask if the minister will notify this committee of a date when he will meet with the college of family practice prior to the passage of Bill 26, which is contemplated on January 29. I think the committee would like to know the minister has at least met with these people, who have a very good alternative, and while you're drafting amendments and proposals, my request is, is the minister willing to meet with them, and will he do so prior to January 29?
Mrs Boyd: Thank you very much for your presentation and for all the work that's gone into the background materials that you provided for us. We heard Mrs Ecker say on behalf of the government that indeed these are problems that have been around for a long time and they haven't been resolved, and the implication was that they weren't being resolved because physicians weren't prepared to work on them. I think I hear, certainly from you and from other physicians who have appeared, a real resentment of this notion that all of a sudden martial law, as a former presenter said, in health care is required in order to get changes.
I think you know, and many of us know, because of the work that's been done before, what kinds of other supports physicians look for in these underserviced communities in order to find practice there attractive. Certainly the PCCCAR report and the Scott report and so on have detailed those. You don't detail them in your presentation, and I think it would be helpful to just name some of those, in view of the community members who are bringing forward their own ideas. What kinds of supports are lacking in underserviced areas that family physicians see as being more available in small and mid-size American cities that would encourage them to leave Ontario and go there to practise?
Dr Nash: I hear from many physicians who have looked at those smaller communities here that there's a lack of specialist support. If you look at many of the smaller communities in the US, they're able to attract their primary care physicians because they do have that physician backup, even when it is in a small hospital that may only have 100 beds or less than that.
I do think it's naïve, though, to look at it primarily in only a medical context. We now have many more physicians who are female practising. The majority of physicians have spouses who have a job or a profession, and it's not as easy to just pick up and go. I've heard many physicians recently say that indeed if they were mandated to go to one of these communities, much as they would like to, their families couldn't just go with them and it would mean actually for some stopping doing medicine. That's very sad to me when you look at the great resources that we've produced.
I think communities have to look at how they can attract physicians and their families. If you look at the successful communities out there, they attract the physician's family. If you're married to a teacher, they say, "Fine, we'll ensure that you have a teaching job." The US is doing that as well.
Mrs Boyd: So the multiplication effect, then, of all of the things this government is doing in Bill 26 and in other policies is going to impact very seriously on those things: effects on education, effects on the social services that are available, effects on the community services that are available, user fees in order to enjoy those community services; all of those will impact.
One of the questions that we asked this morning, one of the issues that we asked of University/Victoria Hospital, was even the lack of support for things like LARG*net, which has a great capacity to offer distance, immediate specialist advice to physicians in remote areas. Even ONIP, the program that funded that, has been cancelled.
So what we are doing is essentially saying on the one hand we're going to make physicians work someplace, and then on the other hand, with every policy that gets passed by this government, making it impossible to attract physicians to stay in our province and indeed in those underserviced areas. Am I right?
Dr Nash: Yes.
Dr Masi: I think we also have a concern that taking the approach of having the sort of backup "We will assign" will take the emphasis or the focus off the larger issues that are really the problem -- the family, the support structures, the working hours -- on the simplistic understanding that: "Well, we'll just assign people. That's all we have to do."
Mrs Boyd: Private industry is expressing the same concern, that if the quality of life, which is often the one thing they can use to attract people to move into the communities where they want to do business, is missing, they won't be able to attract people either. So this is a widespread concern, and one that you would find has great resonance with the larger population.
My last question would have to do with the question of retiring physicians and this issue of not being able to sell a practice if indeed you do retire or if indeed you move. I wonder if you'd comment on how that affects particularly family practitioners -- and their patients.
Dr Nash: There's no question that it affects both family practitioners and their patients. Family practitioners are very bonded to their patients. We have a relationship with our patients that occurs over years, and quite often, such as in my own practice, I have generations where I look after grandparents and grandchildren etc. It's very, very difficult just to leave those patients without any care at all. The impact in terms of physicians is that there are no physicians out there who would take over that practice. With the present constraints, I think you'd be crazy as a young physician to buy a practice, frankly.
The Chair: I must say, just as a little aside, you win the prize for the most musical interludes during your presentation, thanks to our chimes. Thank you very much, doctors. We appreciate it.
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LONDON LIFE INSURANCE CO
The Chair: Our next presenter is London Life Insurance, represented by Jim Etherington, the vice-president of corporate affairs. Obviously, Mr Etherington is not alone, so I'd welcome you all to our committee and ask you to introduce yourselves for Hansard, please.
Mr Jim Etherington: I am Jim Etherington. I'd like to also introduce Jim Connor, who is market manager of our employee benefit division, and the presenter today with me, Mrs Kim Noble, manager of health and dental products for the company. Although we're handing out copies of the Globe and Mail excerpts, this is a different Kim Noble.
Mrs Kim Noble: Mr Chairman and members of the committee, we're here today to address the changes to the Prescription Drug Cost Regulation Act, specifically the deregulation of drug pricing.
As background before I begin, you should be aware about London Life. London Life has over 4,200 health plans in Ontario which include prescription drugs as a benefit, we cover over 250,000 employees as well as their families in Ontario, and we pay over $52 million in drug claims each year to Ontario residents. We've incurred the same kinds of cost growth that the government has experienced on the ODB plan. We know the problems you're dealing with.
We support the minister's goal of controlling cost growth in the ODB program. We want to ensure that you're successful at doing that. We think that you need to make one amendment now and delay the introduction of the drug price regulation until at least the fall. Those are our two key recommendations.
If we read this bill correctly, the minister's intention is to encourage free enterprise and to allow competitive market forces to keep drug costs down. However, we believe without question that drug prices are going to increase. It could take six months to five years before the market forces start to kick in to have that positive effect on drug pricing. In the meantime, the immediate impact is on the non-ODB consumer, who represents 75% of the people in Ontario who purchase prescription drugs.
Let me refer back to the environment in the mid-1980s, prior to when drug prices were regulated, to help us understand why what was done was done. The reason for government intervention in drug prices from the very beginning was that the public believed prices were excessive and there were repeated calls to the government to do something. That was true in 1974. It was true in 1984.
Some members of the committee will remember the Gordon commission of 1984, which examined cost growth problems in ODB. The program had grown to an astounding annual cost of $350 million. Drug prices -- specifically the spread between the cost to the pharmacy and the cost to the consumer -- were the cause for public outcry. That's a very important point to keep in mind. The commission report said, "The Ontario drug delivery system operates to the benefit of all except the consumer and the taxpayer."
Just to reinforce those points, we did an on-line search of media coverage from a decade ago on this very subject. To refresh your memory, we brought along a small package of a sample of the articles from that time showing the tremendous public concern about drug prices. There are a lot to choose from. We just took a few to make a point. These are from the Globe and Mail during the period just before the Ministry of Health introduced the Prescription Drug Cost Regulation Act. So I'll quickly go through a couple of those.
From August 24, 1985: John Gordon, dean of the business school at Queen's University and head of the Gordon commission of 1984 said: "If we still believe in some sort of market economy, then the government had better start acting like it is a player. It seems that the government has just been rolled over by the other parties. And what really disturbs me is that it has not been representing the consumer and the taxpayer." That's the environment we were dealing in.
September 5, 1985: The Minister of Health, Murray Elston, said: "In theory the consumer exerts some pressure [to keep the total price down], but pharmacists have a self-imposed ban on advertising. It is somehow perceived to be a danger to the public's health if people know the price of prescription drugs."
Finally, September 24 of that same year: "The price of filling the same prescription in the Toronto area can vary by more than 100%, a Globe and Mail study of pharmacies has found.... Almost all surveyed pharmacies that charged the higher drug cost also charged consumers a dispensing fee above the legal limit."
The government of 1985 introduced the Prescription Drug Cost Regulation Act in response to legitimate public concerns. It seems prudent to consider these concerns when undoing that act.
We have come with a set of assumptions and with a set of experiences and history. The focus of our concern is on the non-ODB consumer who may or may not have insurance for their prescription drugs. Bill 26 will require the consumer to take on a new role, a role as a smart shopper, but this consumer will not have the tools to do that effectively. Who will be available to help the consumer meet this new role?
On the one hand you have the role of the insurer. At London Life, we believe our role is to act as an intermediary on behalf of employers who want to offer personal financial security to their employees. We have no direct relationship with employees. Everything we do is driven through employers and at the request of employers.
On the other hand is the role of the ministry. We believe, given the minister's responsibility for public policy, you have to understand the ripple effect of deregulation of prices. That will affect the 75% of the population that are not on the ODB plan. For example, this committee has already heard from some employers who plan to drop their prescription drug plan.
An insurance company cannot negotiate out of that. That is an employer decision. The end result is that all individuals will pay more out-of-pocket expenses for medicine and become candidates for the Trillium plan.
Given these two different roles, I want to ask the committee, who do you think is in the best position to make sure that drug prices do not escalate unnecessarily?
Maybe it's a good idea to look at what factors will drive the total price of a drug after Bill 26 is implemented. There are three things. First is the actual cost of the drug, secondly will be the markup by the pharmacy, and third will be the dispensing fee.
The dispensing fee has been posted and competition has worked so the consumer can make an informed decision. After Bill 26, the other two factors, actual drug cost and pharmacy markup, become variable, and they can vary from one pharmacy to another and from one plan to another.
Consumers cannot make an informed decision unless they know how their total drug price is going to be calculated. Therefore, they need to know exactly how their local pharmacy is going to set its price by the pharmacy posting its markup. We recommend this type of transparent pricing policy. And understand that it's not solely just on a receipt -- okay? -- that a consumer purchases the drug, comes home and later notices what the markup was. It's very important to stress that you need to know it at the time that you purchase the drug.
Purchasing prescription drugs is not like buying furniture. It's not where you can buy it today, take it home, comparison shop for a better price and then return it later. Drugs are not returnable. The consumer has one chance when they're purchasing the drugs, one chance to shop wisely. They need the information then to make the best decision.
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Without these consumer tools, we believe the impact of an unsuccessful implementation of Bill 26 will be felt by the non-ODB consumer, which again is 75% of the population.
We believe there are three parties impacted by this. First is the consumer. Consumers without information or tools to protect themselves from high drug prices will not become the expected market force that we need them to be to create competition. Consumer pressure needs to be targeted and focused in order to have an effect. They have to be able to compare the different elements.
Secondly, employees will be impacted. Drug plan costs will increase, resulting in employers either cutting back or eliminating their drug plans or passing higher premiums on to the employees. Understand that the employers will drive that. The bottom line is, though, there's more money out of an employee's pocket.
Finally, the third party impacted is the government. What you'll see, first, is a higher number of individuals become candidates for the Trillium plan. Secondly, you'll see an increase in public complaints. Finally, you'll have no more access to information than consumers do to understand why drug prices are increasing. You won't know where the problem lies, because in effect we've hidden the responsibility and the accountability for drug price increases. That's why we support a transparent pricing policy.
As I said in the beginning, I wanted to make two points. Number one, we strongly recommend a transparent pricing policy for all prescription drugs. Secondly, you're counting on London Life and other providers to become a negotiator in a way we've never done before. If you're counting on us to exercise a new market influence in a way we've never done before, if you need us to take on a role with manufacturers and pharmacists in a way we have never done before, if you need us to do those things, we're willing to do them. But we can't do them by January 30; we need more time. I can't imagine putting all of those things in place to be successful in less than nine months.
Our responsibility is very much like yours. We have to serve the public interest. We need the tools to do that. Thank you very much.
Mrs Pupatello: We talked to the district labour council for the London area. We talked about the changes in drug prices and services in health that now won't be covered, and that in fact that puts the onus on the employer, because it becomes a negotiated benefit. The likelihood is, too, that the employer can then in turn go to their insurer, such as yourself, and say, "I'm not paying any more premiums." It becomes a war among you and your competitors for who is going to provide the additional service coverage at a minimum premium to the employer.
I should ask the government members, I guess. In this, you know, free-for-all, pro-business stuff, how come you don't like that? I mean, you're business. You should appreciate this free-market glorious way to make money.
Mr Jim Connor: There are a couple of things you have to recognize in the 4,200 groups we represent. We represent from small groups right up to large groups. A large block of our groups are 3,500, and it can be down to three lives; in fact, they shrink down to two lives. In addition, the people we use to give counsel and advice to the employer cannot completely understand the whole drug mechanism the way it is, so we try in our dealings with the employers to keep the conversation about drugs, which Kim knows inside and out -- it's fairly high-level. Deductibles coinsurance is an area we work at. Dropping down to picking individual drugs at an individual level not only gets us into privacy issues, but is well beyond the scope of our distribution system. Those things we have to be sensitive to when designing plans.
Mrs Pupatello: I guess the simple answer to a simple question is that at the end of the day, with these changes in these services, it's going to be you who pays for them, because you won't necessarily have the ability to show the employer how he should pay. You're going to end up having to cover more and still try to maintain an optimum premium level.
Mrs Noble: Are you talking specifically about drug pricing or the other portions of the bill that --
Mrs Pupatello: I'm thinking of general services you are going to cover as an insurer.
Mrs Noble: We will give employers tools to decide if they choose to take on pieces that are no longer covered under an old --
Mrs Pupatello: So employers will pay.
Mrs Noble: We will give them the tools to decide which way they want to go. If they want to control their prices and keep them down, they may choose not to take on those pieces.
Mrs Pupatello: If they maintain the same level of service to employees as a benefit, the business will pay.
Mrs Noble: That's right.
Mrs Pupatello: Just so it's on record that the business will pay. For a party that is supposed to be in favour of business and not incurring additional cost on business, I would think this kind of bill is really bad for business.
Mrs Noble: I would just like to add that it may be the employee who pays. The cost of those premiums could go to the employee as well.
Mrs Caplan: Or they may have access to fewer benefits.
Mrs Noble: Those are the two things you play with: Do I keep my coverage the same and pay more, or do I drop my coverage and pay the same?
Mr Sergio: You have alluded to the financial aspect of the situation. The way it is presented now, what the minister wants to do with this proposal is to not only deregulate the drug business, but also to create two classes of people. How does the deregulation of drugs affect these two classes of people? You're going to have one that can afford it and one that cannot. You will have two people going to the drugstore to fill a prescription. One will be charged one price; the other another price. How does that affect?
Mrs Noble: That's what we're trying to say: Make the customer aware that environment is going to happen and put the tools in their hands to say, what am I going to do about that? That they ask some questions, understand what is being charged, and if they have the privilege of having an insurance plan, understand how their plan will cover that or not cover that.
Ms Lankin: I appreciate how in-depth your presentation was and the research work you did. This is terrific. I'm reading through these press clippings from 1985. I had forgotten some of this debate, so it's very helpful.
I came across a quote from Ed Mirvish. Honest Ed's was a big pharmacy player and was very low-cost, high-volume so they could have a low price. It actually says in here at one point their prices were so competitive that people came from as far away as Hamilton to shop at his pharmacy at Honest Ed's in downtown Toronto.
In the debate we've been having, I've been having a very hard time understanding this part of the bill. We've had the pharmaceutical brand-name industry come and say, "Right on." We've had the generics say, "It won't work." We've had the pharmacists express a lot of concern and caution. Generally, responses from the government -- and I understand what they're trying to do. They're trying to create competitive market forces and they believe that'll bring the price down. But in trying to determine who's going to drive that competitiveness, we realize that the large purchasers -- government, which is still regulated; large plans, where they have that ability, and I recognize your point about the time it would take; or large chains, say Shoppers Drug Mart -- have a capacity to bargain a price that small independent pharmacists don't, that small rural Ontario pharmacists don't, and, from the consumer point of view in terms of markup, where there's essentially a monopoly: one small-town pharmacist.
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We can't understand how there isn't at least the possibility that prices are going to go up, yet we keep getting assured of this, and we're told that the public will shop around. When you need drugs, many times it's because you're sick, and the idea of going from pharmacy to pharmacy to find the best price is a problem. If you have complicated medical problems, the flipside to how to save costs on drug plans is proper pharmacological education and pharmacological counselling, which means one pharmacist working with a patient and knowing the interaction of their drugs, their medication program and the diagnoses from the doctor and the prescription. These are the myriad questions I have.
As opposed to what we have now where basically drugs are essentially a one-price policy for the generics and the brand-names, do you see the possibility for differences in price in terms of what they're going to sell at to the pharmacies, and then differences in terms of the pharmacies' retail prices based on size of chain or location?
Mr Connor: We get different prices today with the pharmaceutical association and the manufacturers. We're the only one in this business with the end price of anything. They all ship it out their door, put a markup on it, and it may be different all over. We get a different price for the same drug today. We're the only ones who have that information because we pay the bill. There are different prices today for the same drugs. What you've got is some control in your mechanism to say it can only go this wide, but that's a 20% width. Think of it today. We experience paying through an employer a 20% difference in one price of drug to another, plus a dispensing fee.
Ms Lankin: Now, 20%'s a lot, so that spread's there. If competitive forces were going to work to bring costs down, why wouldn't they have at least reduced the possibility of that spread or the consumer shopping around? I guess it's the transparency issue you raised.
Mrs Noble: That's right. You don't know. There are three pieces to that, three things we know today. We can shop around, we can look on the log and say: "That pharmacist charges me $5. This one charges me $11. For the $11, I get 24-hour delivery, all kinds of things. It's worth it to me. Even if my plan only covers $10 of that, it's worth it to me to pay the extra." That's the only piece they have to decide on.
In the future there may be two other pieces, mainly the markup. If that independent, around-the-corner pharmacist charges 15% markup versus another place that charges 10%, but I'm getting 24-hour delivery, that's worth it to me. If I understand that my plan is only going to pay 10%, I make a conscious decision on that 5% to go with that pharmacist or not. But that's part of what competitive forces are all about.
Ms Lankin: What an incredible shift to the public, though, in terms of this competitive process. Wow.
Hon Mrs Cunningham: Thank you for your presentation and good afternoon. In your list where you talk about the transparent pricing policy, assuming that includes the markup and the dispensing fee, has this ever been a request by the insurance companies in the past? I've been through two rounds of public hearings in the last eight years on the overuse of medication, the cost of medication. Has this ever been a request or a suggestion?
Mrs Noble: To my knowledge, no, but there have been the drug regulations in place to control price, so there hasn't been a need for this.
Hon Mrs Cunningham: I think it's been an issue. Although the insurance companies haven't asked for it, many other consumers have asked for it over the years during different hearings. There's no doubt that people want to know what the dispensing fee is and what the markup is. I must admit I hadn't heard very much about the markup, but certainly the dispensing fee was extremely controversial during almost any hearings we've had on the cost of health care. That's why we are moving in this direction, because we feel that the cost of drugs is not only expensive to the public of Ontario, but we also think the overmedication of seniors is not effective for their proper health care. That's one of the solutions we've looked at.
You were asking for two things. What is the amendment you want?
Mrs Noble: The amendment is to provide transparent pricing, so therefore post markup, and indicate the actual drug cost as well as the dispensing fee.
Hon Mrs Cunningham: The second, of course, is to delay the deregulation piece.
Mrs Noble: The timing.
Hon Mrs Cunningham: And in the meantime, during this time of delay, if we want to sell this amendment to the government, what would be the three main messages with regard to the delay?
Mr Connor: If you don't delay it, you're going incur costs on your Trillium plan that you hadn't anticipated, because you won't have your negotiation done with the drug manufacturers. We're in the same situation. There would be variable pricing going on underneath the covers before you get a chance to get it in.
Hon Mrs Cunningham: But you're not here today to speak about deregulation per se. You're not against it?
Mrs Noble: No, we've not said that. We've said we need the tools make it successful and we've laid out what those tools are.
Mr Bob Wood: I gather from what you're saying that you favour the shift to the free market, that you have no quarrel with that. The invariable experience with true deregulation has been rationalization of prices and an overall drop in prices, the classic case being the deregulation of airlines in the United States; in 15 years air travel tripled and prices rationalized and overall went down. I gather you accept the validity of deregulating prices that ultimately will save money for the consumer.
Mr Etherington: What we would say is that if you're going to make it work, you have to put all the pieces in place to make it work right. What the bill is leading to at this point is a gap, and that gap is going to cause an increase in prices overall. As Mrs Noble pointed out, while there may be what you are anticipating that market forces will eventually kick in, it may not happen for three or five years, and in the meantime, people are going to have a zoo out there in terms of the cost of drugs.
Mr Bob Wood: I understand the transitional difficulties, but you accept the principle that a true free market will reduce costs to the consumers?
Mr Etherington: Yes, with all the pieces in place.
The Chair: Thank you for your presentation. We appreciate your interest.
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LONDON BATTERED WOMEN'S ADVOCACY CENTRE
RON WEXLER
RAFFAELE FILICE
The Chair: Our next presenters, representing the London Battered Women's Advocacy Centre, are Julie Lee and Cheryl Champagne.
Ms Julie Lee: Mr Chair, I'm also being joined by some copresenters that I'd like to introduce to you. I will make my 15-minute presentation, and then I'd like to make the rest of my time available to colleagues, Dr Ronald Wexler, who is a board member with the Ontario Medical Association, and Dr Raffaele Filice, from Diagnostic Imaging Associates. Just to ensure that all of us get an opportunity to speak, I'd like to ask that questions be held until the end.
I'm making my presentation to you today in good faith, assuming that my input will be given serious consideration. I begin by asserting this because I am concerned that my input will be dismissed because of some assumption that I represent a special-interest group. So let me be clear about what interests I bring to this table and what constituency I represent.
I am paid as a professional in this community to work to respond to the needs of women who are victims of violence in their most intimate circumstances. In order to do this work, I can't work alone. This is why I work within a community context which has a history of over 16 years where agencies, professionals, judges, lawyers, police, mental health workers, children's advocates and women's advocates all come together on a regular basis to collaborate in addressing a serious social problem. Together, our special interest is simply that violence against women in our communities must end.
None of us doing anti-violence work comes to the work from a perspective that simplemindedly defends the continued expenditure of public funds for the sake of protecting the budgets of agencies. Our principles of accountability, which are on record, demand that we ensure that any expenditure of valued and scarce resources be directed towards our ultimate goals, our special interest: ending violence against women. Certainly it's our hope that one day there won't be a need for an agency like the London Battered Women's Advocacy Centre, but we're not there yet. In fact, we'll be the first to celebrate when we arrive in a community and a society where we no longer require this service.
In order to achieve our goal then, what we require is a great deal of planning and foresightedness. We need to think in terms of the long run and not in simpleminded short-run issue bases. This is why I'm so concerned about this new piece of legislation and indeed concerned about the overall approach of your government to fiscal and policy management. Your approach to date has been extraordinarily narrow and shortsighted, and indeed your policies and cutbacks represent major setbacks, not just cutbacks, in the long-term project of ultimately ridding our communities of violence against women.
Let me be specific about what our communities require in order to reach our ultimate goals and deal with violence against women in our community:
(1) In order to shift bad attitudes about violence and sexism and to work in the area of prevention, our communities require support to provide education. Your government eliminated all funding for prevention and education through agency provision in October.
(2) Violence affects all peoples with all of their diverse cultural and lingual backgrounds. Therefore, we require support in order to ensure that women and men who do not speak English can access services and education. Your government eliminated funding for cultural interpretation services in the fall.
(3) In order to teach men who have been abusive to stop these behaviours, we require support from our government to offer professional counselling programs to abusive men. Your government eliminated Ministry of Community and Social Services dollars for batterers' counselling programs.
(4) In order to support abused women and their children to have a new fresh start in a life without violence in their lives, we require support for a transitional counselling and housing program, second stage housing. Your government eliminated all funding for the safety and counselling component of second stage housing through the province.
(5) Abused women require immediate and equitable access to a lawyer for advice and pursuit of justice. Your government has thrown legal aid services into a crisis in the last nine months because your Attorney General hasn't been paying the outstanding legal aid bills and because you have further constrained legal aid eligibility to low-income women. Abused women can no longer be assured that they will have due access to legal forums.
Finally, as I indicated earlier, in order for us to achieve our long-term goals, we need to be supported to come together to plan, coordinate and improve our strategies for ending violence. In the fall your government eliminated all funding for planning and coordinating bodies.
Prevention, education, treatment of batterers, transition programs for battered women, access to services in one's own language, access to basic legal services, planning, coordinating and collaboration -- all essential ingredients in the recipe for community-based, positive social change -- all which has been dumped aside by your government.
This bill further follows this path. It establishes a narrow and shortsighted approach to fiscal management. Ontario is in serious trouble when its government puts into place fiscal and legislative policy without considering the long-term goals of its people. Indeed, this legislation doesn't even take into account other important areas of concern related to the policy that you're setting. The best example of this contained in the bill is in your making vulnerable people's private case and medical records available to who knows who.
Is this government completely unaware of the ongoing national crisis with respect to the disclosure of abused women's private counselling records? It appears so, because you fail to take into consideration the full complexity of the matters at hand. You cannot continue to proceed in creating fiscally convenient policies without a full consideration of the interaction between legal and social issues.
Let me be specific about what I'm asking you to consider. In the last couple of years there have been increasing attacks on women complainants in violence-against-women legal proceedings in both civil and criminal courts. To be specific, defence lawyers are engaging in a strategy stridently named by themselves "whacking the complainant." Their strategy, actually documented and published in the Lawyers Weekly, is to subpoena all personal records, including diaries, of a woman complainant in order to shake her up -- this is their language -- in order to defame her character and credibility and to dissuade her from proceeding with her testimony in pursuit of justice. As soon as the records are subpoenaed from an agency that has been acting to support this abused woman, she is no longer in a situation where she can access those services, because her counsellor becomes a witness in a criminal proceeding.
The results of this hostile treatment of women victims are already being felt in communities across Ontario and Canada. According to research done in Barrie, Ontario, since this new strategy has become more dominantly practised there has been a 38% decline in the numbers of sexual assault victims coming forward for service. This is a serious decline, especially when you recognize that women are already overwhelmingly hesitant in coming forward for service. In fact, only 5% of victims are recorded, given national data, as coming forward for service. They're afraid of humiliation. They're afraid of stigmatization. Your bill further escalates this risk to battered women. Women's ability to come forward for help and support is now under attack from two fronts: in the courts and in the doctor's and counsellor's office. Where can women turn to for private, confidential, safe support when they've been abused?
In summary then, we're calling upon this government to immediately halt the approval of this bill until there is due and full consideration of the implications and consequences of this legislation and how it interacts with other important areas that are currently being debated and attempting to be resolved. Furthermore, you cannot begin to understand the full impact of this bill without ensuring that a truly inclusive and democratic process of consultation is undertaken. Given that principle, I'd like to ensure another voice that hasn't been heard is heard for the last part of my section. Thank you very much.
Dr Ron Wexler: Good afternoon. My name is Ron Wexler. I'm a physician who has practised anesthesia and intensive care medicine at University Hospital here in London since 1975. I am presently on the board of directors and on the executive of the Ontario Medical Association. With me today is Dr Raffaele Filice, who is a London radiologist and also holds an independent health facility licence in radiology.
First, I would like to thank Julie Lee from the London Battered Women's Advocacy Centre for so kindly offering part of her time to us this afternoon. I will try to keep my remarks brief and to the point.
The area I wish to explore with you today is the Independent Health Facilities Act and the changes that Bill 26 proposes to make to this legislation. I will first begin by outlining how the act originated.
The Independent Health Facilities Act was passed in 1989. It was originally designed to regulate the provision of private medical services that had a significant technical component in a non-hospital setting such as radiology clinics and outpatient surgery facilities. It provided a mechanism for the quality assurance of such facilities and also provided a way to fund the facility's technical costs, such as those required for equipment and staff. This became necessary following the passage of the Canada Health Act which prohibited the charging of any facility fees directly to patients.
IHFs, as I'll call them because it's easier, presently are thus only granted where a high technical overhead exists. Bill 26 would change these criteria to allow the Minister of Health to designate any private physician's office practice as an IHF. This is obviously a major change that has nothing to do with the original intention of the act.
At the present time, an IHF can only be shut down during the term of its licence for patient safety reasons. These facilities are then inspected every five years at the time of licence renewal, and the renewal of a licence can only be denied at that time unless, as noted, there's a safety factor during its existence.
The changes proposed in Bill 26 would allow the Minister of Health to revoke a licence at any time, not just at the end of the term, without a stated reason. There would be no appeal from this ministerial decision. The result of these two changes, the indiscriminate designation and the unappealable revocation, would lead to the minister being able to shut down any physician's private practice with no notice and no appeal. To my mind, this amount of power in the hands of the minister is unacceptable. The minister has not indicated why he feels that these extraordinary powers are necessary, and I for one cannot fathom it either.
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Bill 26 also determines by legislation that the minister can declare a service provided by an independent health facility to be nil -- that is, zero -- but does not remove that service from the OHIP fee schedule. This means that while there's no fee paid, there can be no charge rendered to the patient either, though if you provide the service, you don't get paid and if you don't get paid, you can't afford to provide the service. This bill also states that the value of an IHF licence has no value on transfer to another holder.
As you can imagine, these issues will make it very unappealing for individuals to hold IHF licences because they will never know for certain if they can afford to operate them, and if they cannot recapture any of their capital costs when they wish to transfer them, they will basically give up all of that investment. The cost to set up some of these facilities can exceed $1 million in some of the sophisticated diagnostic facilities, and the units may employ upwards of 20 people. We're not talking about small potatoes here. Every person presently holding an IHF licence will live under a continuous cloud of uncertainty, never knowing if tomorrow the licence will be arbitrarily revoked.
It is of some concern that with these changes Bill 26 also permits the minister to request a proposal from any specified individual. Presently, the Independent Health Facilities Act prescribes an open system that does not limit the number of applicants who may respond to a proposal. Why would we eliminate competition which provides the highest quality, most cost-effective services for the people of Ontario? These changes to the IHFA, the Independent Health Facilities Act, will without a doubt take us back to the days of open political patronage.
Finally, the Independent Health Facilities Act provides that the government give preference to Canadian citizens, landed immigrants or Canadian-owned corporations. Bill 26 removes this requirement, so that licences could be granted to foreign individuals and corporations. This proposal would have a negative effect, in many ways, on the Ontario economy. I feel that licences should be given to Ontario applicants, in particular Ontario physicians, who would be responsive to the clinical needs of their patients. Furthermore, the granting of licences to foreign operators would in fact cause Canadian dollars to flow out of the country.
I would now like to ask Dr Filice to comment on how he, as an IHF holder of a licence, feels that the changes in Bill 26 would in fact affect him.
Dr Raffaele Filice: From Dr Wexler's summary, it's not difficult to imagine the potential repercussions of implementing the regulations outlined in Bill 26. I am a radiologist practising primarily in an independent health facility. I have two offices and employ approximately 20 people.
Like most facilities, there is a sizeable capital investment. More importantly, however, is the fact that we provided health services with approximately 60,000 patient visits in 1995 in a professional, friendly, safe and efficient manner.
My staff and I are dedicated and proud of the work we do. Our facility has passed the College of Physicians and Surgeons of Ontario independent health facilities assessment for licensure, a quality assurance program with some of the most stringent criteria of any other jurisdiction in North America. The Independent Health Facilities Act has met its mandate of promoting excellence in the delivery of health care services.
The reasons for the proposed changes to the Independent Health Facilities Act, however, leave me at a loss. Why? I keep asking myself why the Minister of Health wants arbitrary and absolute power over such essential health facilities. Why does he want to be able to close them down with impunity? Why does the Minister of Health want us to work with this axe over our heads? How is this type of approach going to increase consumer confidence and create a climate for investment and job creation? This doesn't make sense to me.
You may have seen this document. Mr Harris was pushing this document. It's the Ontario PC Party's Common Sense Revolution. I thought this meant the application of common sense to governing. Instead, it's beginning to appear that the Common Sense Revolution actually means revolutionizing or redefining the meaning of common sense.
In conventional terms, common sense may be exemplified in the following ways. If your car breaks down, call a mechanic. If your house catches fire, call 911. If you have chest pain, go see your doctor.
The new PC Party definition or application of common sense might lead you to look at it this way. If your car breaks down, call a dentist. If your house catches fire, have a public hearing. If you have chest pain, call a bureaucrat.
Reforming health care by cutting doctors out of the process doesn't make sense. More government is not what we were promised in the Common Sense Revolution. A government with common sense is what we voted for, want and expect. Please reconsider what you're doing with Bill 26, or at least explain to us, the citizens of Ontario, what your reasoning is behind it and what your vision is for the future.
Ms Lankin: I appreciate the comments you've made with respect to changes under the Independent Health Facilities Act. I don't have any specific questions on that. My questions, actually, like yours, are of the minister and what it is he wants to do with these powers. But that's true of so many aspects of this bill. We do hear assurances from government members of what the intents are, but that isn't written into the legislation.
Dr Filice: It's not reassuring.
Ms Lankin: That and a quarter will get you the same.
I use this example a lot, but one presenter in Thunder Bay said it's like the government is asking us for a blank cheque, but they won't tell us what number they're going to write in before they cash it. I think that's a really eloquent summation of it.
I want to address the issue of patient confidentiality, because I think in Ms Lee's presentation she underscored that and I think it would be an issue of concern to you as practising physicians, given that the records are there in your office, what kind of effect this might have on what you keep on patient charts and/or on patients' willingness to share information with you. I'd appreciate answers from any of you.
Mr Clement has, day after day, tried to convince presenters coming forward that the new language actually narrows the ability of the ministry to use private information. However, it just seems that's absolutely incorrect. The old purpose for looking at any information was to look at the services. It was related to the services provided, to pay them, and it was under the purpose of the act. Now it's for the purposes of payment, for the purposes of monitoring and controlling, for the purposes of looking at broader health issues and for any other purposes.
There's the whole range of inspectors' powers, not to go in and look at accounts, which if you are looking at issues of fraudulent billing, which they say is the reason, used to be the process. Now you can go in and you can take the actual health records, the notations, photocopy them and take them back. In the past there was no provision for the minister or the general manager to disclose it to anybody outside of government, and now you can disclose it. And, by the way, now the minister and general manager are immune from any prosecution. Those are all new things.
Could you just tell me what it means, first of all, because I think, Julie, you did express the concern, but from your perspective as physicians, what it means in terms of patients and what they'll tell you and what you'll chart down, and your concerns. Then if there's any time, you could add to it, Julie.
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Dr Filice: To me, it's a double-edged sword. When you're in a confidential situation between patient and doctor or lawyer and client, whatever the case may be, your freedom to speak is enhanced by the very nature of that situation. Just like it would exacerbate the abused woman's situation, the same thing would apply when a patient comes to seek help from you.
The other thing that I see complicating the situation is that I have records on the patient. Technically, those records are the patient's, are about the patient, belong to the patient, and they have every right to determine what happens with those records. It's not really for me to decide. Yet the minister can come into my office and impose this on me, rather than at the very least going to the patient and saying: "Look, we're sequestering your records. How do you feel about that?" They bypass that whole thing.
So it certainly would encumber the patient-doctor relationship, and then also I feel, as a physician, that I am compromised by that arrangement. I would fight that.
Mr Bob Wood: I'd like to ask a couple questions of the doctors, and they relate to the question of cancellation of licences for IHFs. You would accept the proposition that if someone is not living up to the terms of the licence in the act, the licence should be cancelled. You have no problem with that, presumably.
Dr Wexler: I would accept a cancellation of the licence if it could be shown that the quality and safety of the services provided were unacceptable, of course.
Mr Bob Wood: So the issue that you really are bringing to us is, you don't like the way in which this is proposed to be done. You think it's too broad.
Dr Wexler: Exactly.
Mr Bob Wood: What I'd like to canvass with you is how you would repair that. For example, would you be satisfied if the legislation said it can be cancelled for non-compliance with the act?
Dr Wexler: I'm not sure what that means. Are you talking about the act? The regulations? When it comes down to a practice of medicine, I'm concerned about the quality of the practice of medicine and the quality of services. I'm not sure what nuances you're suggesting. Maybe you'd like to clarify for me some of the things you would consider as non-compliance with the act and then we can discuss it further.
Mr Bob Wood: Well, of course, there's non-compliance and non-compliance. It obviously depends upon the severity of non-compliance as to whether or not you'd reprimand a facility or actually --
Dr Wexler: I'm not sure. If I'm providing lousy medical care, yes, I'd better be shut down right away, real quick. If I'm providing good medical care in an appropriate manner, I'm billing appropriately for that medical care to the plan and I'm maintaining the various criteria that are required by the regulations of the act and the College of Physicians and Surgeons, ie, to maintain a quality assurance program, to keep proper records etc, then I would expect that the minister would not have the right, the power or anything else to shut me down.
I would expect that at the end of the five-year period, I would have a comparable physician from the college, as Dr Filice does on occasion, as my wife does in fact, go to the IHF that I own and have it reviewed carefully, intently. At that time, if my practice was up to snuff and everything met, I would assume to have another five-year extension of my licence. I would not want to be investing money, time and hiring people and never knowing, one morning, if I happen to say something in my public persona that offends the Minister of Health, he can pull the rug on me. I'm not interested in that. I'm sorry.
Mrs Lyn McLeod (Fort William): I appreciate both presentations and I do want to acknowledge our shared concerns about the privacy provisions or the invasion of privacy provisions in this bill, not only in doctors' offices but also in independent health facilities and also in the ability to not only access but disclose information in relationship to the drug benefit plan -- all without liability. We are certainly going to be pushing for amendments that would protect privacy in all those areas. We've heard similar concerns from HIV-AIDS patients and advocates concerned about whether or not they will come forward for voluntary testing.
I do want to come back to a question about the Independent Health Facilities Act, because it comes back to this whole question of the total control that government wants to exercise over the provision of health care in this province. You've raised all the questions we have not been able to get answers to either: why no reasons have to be given to close, what services are going to be shifted that are now provided only in independent health facilities that offer only insured services, what are going to be shifted out of existing facilities, why no RFP.
We're not in a court of law, and I'm going to invite you to speculate and make attributions, which I think you're allowed to do. I think it's a fair question, since we can't get any answers from the government as to what it intends to use these powers for. We've worried about Americanization, American companies coming in because the Canadian preference is lost. We've worried about whether this is a step towards much greater privatization, as we have a mix of insured and non-insured services delivered by one facility. You've suggested that there is also, because of no RFP, room for blatant political patronage.
The government has enormous powers in other parts of this act to control how many doctors, which doctors get to practise, where, who is an eligible physician. Do you see this as part and parcel of that, and what are your worst fears about where this may lead?
Dr Wexler: I have concerns about this. Like you, I have been speculating, had a few sleepless nights trying to figure out where this might be leading. I could speculate that by the minister having the right to designate a specific physician's office as an IHF, for example, and then turning around the next day and saying, "Now that you're an IHF, I'm shutting you down" -- and regardless of whether anybody would or wouldn't do it, guys, it's there, and if it's there, somebody some day will do it. I don't want to hear from anybody that, "Oh, we wouldn't do it, even though it's there." It's there, it's possible.
If you considered an area was overserviced, you can underservice that area very quickly by doing that. I thought that was kind of a neat trick. I don't know if anybody else came up with that little wrinkle or twist on it, but having worked it through, and worked it through actually with some of my legal colleagues, they say that would be perfectly possible to do. Of course, I wouldn't want to say that the minister or the Ministry of Health would ever do anything like that. Raffaele, do you want to comment on that as well?
Dr Filice: What we're failing to understand is that while there was clearly opposition -- and some of our Liberal and NDP members will remember that there was some resistance to the Independent Health Facilities Act when it was first implemented -- I personally am an assessor with the college and I assess independent health facilities. What has come to light in that experience is that the Independent Health Facilities Act is actually a good thing. The quality assurance that that has brought into effect has really had an impact, and the actual process itself is doing what it's meant to do. It's a slow, tedious process because it's fairly involved. It's a fairly involved undertaking to assess 900 or so facilities in the province, but it's happening.
What we're finding is a high degree of cooperation, actually a higher-than-expected level of quality of service out there. The ones that are below par are being asked to close, and that's why we don't need the Minister of Health arbitrarily deciding on a closure. The way the bill is now written, if the quality is not up to par, it will be closed. That's the process, and we can all live with that.
To me, it seems to be a power related struggle. Pure and simple, that's what it seems like to me. If he could just arbitrarily say, "You close," what else is that then? Gaining power over our future.
The Chair: Thank you for your presentations, and for sharing your time, Ms Lee, with the doctors.
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LONDON INTERCOMMUNITY HEALTH CENTRE
The Chair: Next is the London InterCommunity Health Centre, represented by executive director Shanthi Radcliffe and community worker Ted Town.
Ms Shanthi Radcliffe: Mr Chairman, we have agreed to share our time with another presenter, Margaret Gregor.
Mr Ted Town: Good afternoon. I'm a community worker at the London InterCommunity Health Centre, and with me are community worker Sarah Merritt and our executive director, Shanthi Radcliffe.
The London InterCommunity Health Centre is a multidisciplinary agency serving what's know locally as London east. Since our formation in 1989 we've evolved into an organization with deep roots in the community and a client base of nearly 3,000 in our medical roster, with many more accessing our other programs.
The area we serve was once a vibrant working-class neighbourhood, although in recent decades it has undergone a downward economic spiral. At the same time, it's become home to a growing number of recent immigrants and refugees. Consequently, our client base tends to experience various barriers to health care. Our mandate is to provide sensitive and equitable health and social services to persons with complex needs who have difficulties accessing other sources for a variety of reasons. We're committed to providing comprehensive primary health care while concentrating on local and personal empowerment.
Our staff, which includes social workers, mental health workers, art therapists, full-time physicians and nurse practitioners, are all paid by salary. This affords cost predictability and equitable care to all who come to us. We also offer various programs for immigrants and seniors as well as community gardens, English-as-a-second-language classes and an anonymous HIV testing clinic. Guiding us through all this is a philosophy of self-reliance. Our clients develop needs and issues related to the quality of life and health. We work with them to develop and provide services that meet those needs.
We're well aware of the current economic crisis facing the people of Ontario and we know that change is inevitable and necessary. We're concerned with the cycle of dependency that has developed over the years. We also know that there is a direct relation between wealth and health, that wealthier communities tend to be healthier communities. Personal and community empowerment can help break the cycle of poverty, dependence and illness.
The Mike Harris Forum on Bringing Common Sense to Health Care was released just over a year ago, December 2, 1994. One of the most striking aspects of this document was the unexpected common ground between the Progressive Conservative platform and the basic philosophy of the London InterCommunity Health Centre. Parts of this document could almost have been written by us. For example:
"Many of the access and affordability problems faced by our health care system could be resolved through a coordinated system of management, with health care professionals leading the way, working with government and incorporating community and consumer concerns.
"We believe that health care institutions and services should become more accountable to the people and their communities.
"Our commitment to a `patient-based' system also demands the empowerment of health care consumers and their communities, and a greater emphasis on mutual responsibility between the health care system and the public."
And finally, the stated goal of the health care bill of rights was to "empower the consumers of the health care system with the rights to proper care and to participation in decisions regarding that care."
The thoroughness of the about-face manifested by Bill 26 is astounding. Considering that many election promises were indeed fulfilled by the Premier of Ontario soon after taking office, we're even more puzzled by the change in attitude towards health care.
Mike Harris said, "The community will be important in letting government know what's needed." This is a noble sentiment, but we're not here today because of the government's commitment to public input. We're here because a lot of other people fought for the very type of public consultation Mike Harris called for before the election.
When a newly elected government cuts social assistance payments before the Legislature even convenes on the ground that the financial situation is far too critical to allow time for public discussion; when a government creates a document so sweeping and unwieldy as to be intimidating to anyone hoping to examine it properly and then times the introduction and first reading of that document to coincide with the financial statement occupying the time of the opposition and media; when a government only grudgingly allows public debate after a sit-in in the Legislature; when the time the government allows for those hearings is so short that routinely less than half those applying for presentation time can be accommodated; and when, after numerous criticisms and recommendations have been received, the government still insists the bill will be passed by the end of this month, serious concerns arise.
With what seems such a cavalier attitude toward public opinion, how can we put our faith in one person, in this case the Minister of Health, to determine what is in the public interest? How is this public interest defined? No doubt the minister, like many observers, has been struck by the sheer volume of participation these hearings have generated. How can we believe that one person has both the time to pore through that paperwork and the wisdom to sift through those recommendations, coming as they do from the entire range of socioeconomic strata, whether it's an Ottawa-born doctor concerned about being forced to practise in Smooth Rock Falls or a former psychiatric patient wondering how to pay for multiple prescriptions?
We're the first to recognize the current health care situation needs revamping, although we're less certain that money should be the driving force. The necessity and inevitability of change is not what concerns us most, however. What we're commenting on now is a bill that was never intended for public discussion and which by all accounts will become law within two weeks. How on earth can all the input from the public over the past month be given proper consideration and amendments to the bill be made in that length of time? If that isn't going to happen, then this exercise in democracy has been a hollow one. It's very disconcerting to think that these weeks of hearings have been moot, that they haven't told the government anything it didn't already know about determining what's in the public interest.
We're also concerned about what's not spelled out in the bill but what underscores it. We know much, but not everything, of what will happen if this bill is passed. We know when it will happen; the time frame is clearly spelled out. We know how it will happen, or at least how this bill provides for change to happen. It's the why that's causing us such concern.
We need to know why the government's access to private, personal medical information is being increased at the same time the public's access to government information is being decreased. We need to know why an amendment designed to combat health insurance fraud allows the Minister of Health to disclose this information to whomever the minister sees fit. We need to know why the government feels the need to enshrine its immunity from any sort of liability in the event of personal damage. We need to know why greater personal accountability is being demanded while government accountability is being eliminated. We need to know why the Minister of Health, in the name of fiscal savings, is allowing drug manufacturers to determine the price of their product, which the ministry will then pay.
The catch-all nature of the bill as it now stands makes an efficient study impossible. It's clear, however, that many of the fiscal savings it's intended to bring about may not happen. If anything, costs could escalate down the line.
The community health centre offers a wide range of services and programs designed to be preventive and holistic. While significantly different from programs offered at other health centres and hospitals, they provide an indisputable example of cost-effectiveness in health care. From its inception, the community health centre has created its services around the themes of community consultation and appropriateness. What follows are some specific examples of the services we offer and how they could be affected if Bill 26 passes.
"For too long, the public has been a silent partner in important health care decisions and has had to defer to politicians and administrators to manage Ontario's health care system. Now, there is a strong demand for more of a community voice in those decisions."
Mike Harris said that in 1994, but it has been part of our philosophy since we started operating. It is our clients who identify what they need in their community as well as in their health centre, and there is an ongoing consultation among clients, staff and board members.
Like Mr Harris, we emphasize "preventive care which can help people avoid becoming ill in the first place." We take things a little further than most, however. We know that a wide range of factors beyond what's traditionally seen as health care in fact have a significant impact on health. Commonly referred to as "determinants of health," these factors include self-esteem, employment and language fluency, to name a few.
Many of the programs we offer differ widely from those offered by other health services, but their efficiency cannot be overlooked. As an example, the SAFE -- Self Abuse Finally Ends- Canada program offers art and group therapy for women with a history of self-destructive or abusive behaviour, many of whom were frequent users of more traditional services. To give just one example, one client spent 76 days in hospital in a single year, with related social agency and police involvement at phenomenal cost to the system. One year later, after completing the SAFE program, the same person spent a total of two days in hospital, without using any ambulance, police or agency costs.
More than 300 people have been involved in SAFE since its inception five years ago and 25% of them have had no need to use other services.
To use another example, reiterated many times with slight variance in detail, another woman who was a sole-support parent with two children received $17,000 annually through family benefits allowance. Through the various programs we offer -- helping women to overcome language barriers or low education levels, teaching them self-reliance and job skills -- she found a $31,000-a-year job. Various levels of government are now receiving tax payments from this woman where before they paid social assistance benefits.
Our volunteer board is reflective of the many facets of the health centre, and each of our some 20 programs is directed by its own advisory committee of community members. They're all linked in an efficiently functioning whole by their belief in the centre's philosophy. We have, therefore, serious concerns about provisions in the bill which undermine the structure of autonomy and individuality, this gearing of services to community requests. Amendments to the Public Hospitals Act could effectively hobble local boards of directors and their relationships to the communities they serve. Boards could find themselves unable to make decisions and be confident of carrying them out. The Minister of Health would have the power to exclude members of the community from any real decision-making in the operation of the centre. This can only result in the disappearance of the spirit of volunteerism. At our health centre alone, we estimate some 30,000 volunteer hours annually. Clearly, we have a lot at stake.
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This goes against one of the most fundamental principles of our health centre, namely, that participation is critical to health. Powerlessness leads to dependency. Dependency is unhealthy. We know we're not alone in this sentiment; part of the rationale behind the government's recent cuts to social programs was to wean people from the cycle of dependency.
Once again, we have to wonder what became of the Progressive Conservative sentiments of not so long ago that, "True consultation only occurs when government not only listens to the people but hears what they have to say and responds to their concerns with action."
We return to the phrase "in the public interest" and the Health minister's determination of it. We can only hope that the Health minister, who no doubt has been watching these hearings, will recognize that a significant portion of Bill 26 is not in the public interest.
We believe that the concept of public interest is a dynamic one and that what may be seen as a benefit to one group is often detrimental to another. We are very concerned, therefore, that any definition of "public interest" take into account the huge diversity of Ontario's population: it must consider the influences of language, age, gender, physical abilities, economic status, culture, ethnic makeup etc; and that it be arrived at with due process and appropriate consultation.
We have serious concerns about sections of Bill 26 which "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."
These are dangerous waters. Health insurance inspectors and inspectors from the College of Physicians and Surgeons already have access to files when reviewing cases of health insurance fraud or medical misconduct. Those officials, from arm's-length bodies, are sworn to secrecy. The Health minister disclosing information to as-yet-unspecified parties, with no provision for appeal, is another matter altogether.
If patients cannot be guaranteed confidentiality, they are less likely to discuss their situation. In effect, each visit to a doctor would imply tacit consent to the distribution of their medical files. It doesn't matter if this fear is unfounded; it's the perception that's all-important. Patients with heart conditions, for example, or diabetes, may be unwilling to have their names end up in the files of a drug manufacturing company.
We're not suggesting a free-for-all with confidential files is in the offing, but the provisions in the bill are simply too vague. Again, even with official assurances that these powers will not be abused, with the absence of safeguards, that fear is there. Physicians can't treat patients who won't say where it hurts. Medical costs can only increase if the treatment is delayed. There is no fiscal saving to be found here, let alone any hint of the sentiments we heard in the health care bill of rights, which talked of the "right to treatment free of discrimination and which recognizes one's privacy, dignity and individuality."
The health centre also houses Options Clinic, an anonymous HIV testing site. More than 4,300 people have used the clinic's services since it opened in 1992.
Anonymous clinics were established to remove one of the most significant barriers to HIV testing for many people: the fear of identification, of being reported to public health boards. Anonymous sites are allowed to operate on condition they provide appropriate HIV education and counselling. Options Clinic staff offer prevention strategies and refer clients to appropriate medical and support services when needed.
Data from the AIDS bureau of the Ministry of Health show that more people test anonymously than through their family doctors. The data also show that because of the counselling that accompanies anonymous testing, people are less likely to become infected. Finally, HIV-positive people who are aware of their status generally change their behaviour and are less likely to infect others.
When early detection and treatment of HIV infection is compared with the estimated $100,000 required to treat a patient with full-blown AIDS, the fiscal savings attributed to anonymous clinics cannot be ignored. Furthermore, Ministry of Health figures put the cost of anonymous testing at $44, compared with $100 for a test done by a physician.
A perceived risk to confidentiality, however, is all it takes to keep people away. Time and again, Options Clinic staff assure people making appointments by telephone that the service is 100% anonymous. This concern is particularly prevalent whenever there is any talk of identifying HIV-positive people, whether by local health boards or blood donor clinics.
The perception of untouchability has to be maintained at all times. We cannot support any new access to records that might make even one person think twice about being tested. As surely as we're all sitting here today, this bill, with its provisions concerning access to and disclosure of personal medical records, will keep people away from Options and other anonymous testing clinics. The potential for horrific consequences, both in financial and human terms, is huge.
We have grave concerns as well concerning amendments which would "prevent persons from claiming compensation against the crown, the director or the minister for damages resulting from specified actions."
This immunity is astounding. We are unable to support a clause such as this without further explanation. Where are the data to support the assumption of so much mismanagement and fraud in our system that would warrant the unilateral removal of such basic rights as those of confidentiality and appeal? Is a wave of litigation foreseen on the horizon with the passage of this bill? We don't believe it's asking too much to want to know why this immunity is being enshrined in legislation, and, it's safe to say, neither would anybody considering a trip to the doctor. It's ironic that at a time when access to information is getting more difficult, one's own, most personal information is seen to be up for grabs.
One of the cornerstones of the Common Sense Revolution was "no new user fees," and if Bill 26 is passed as it stands, the Ontario Drug Benefit Act will no longer pay the maximum dispensing fee. The proposed dispensing fees can have wide-ranging ramifications for some people. A $2 charge means one thing to the person who needs only the occasional prescription filled; it means something else entirely to the person who may have several per day. In many cases, the people who need various medications the most are those who are on social assistance programs. Some of them are poor because they're sick, and some of them are sick because they're poor. But either way, the proposed copayments following on the heels of the welfare cuts will mean an overwhelming situation for many people. People may be forced to choose between paying for food and paying for medication. For those whose prescriptions must be taken with food, something else will have to be omitted. Some people may decide on their own which prescriptions they won't get filled this time.
Anyone who has had children or siblings knows that when one gets sick, others do as well. Often three or four people in the household will require the same medication, but doctors are not allowed to draw up one prescription for more than one person. Again, prescription fees could be prohibitively expensive in some cases, and the potential for serious health care costs further down the road cannot be ignored.
These situations contrast with Mr Harris's statement that: "A key way to contain health care costs and effectively manage resources is to invest in preventive health care. The best health care system is one that promotes wellness and prevents illness."
As Ms Lankin touched on about 30 minutes ago, we're unclear about the deregulation, whether a dispensing fee in fact is a user fee or a copayment. If it's the latter, will pharmacists be allowed to waive this fee? If they are, will it not work together with the proposed deregulation of drug prices to the advantage of retail giants who can afford loss-leaders and drive small pharmacies, such as those that are in our neighbourhood, out of business?
It's probably safe to say that if prescriptions and medications were easy to figure out, there wouldn't be a five-year program for pharmacists, so it's difficult to imagine how the Ministry of Health will be able to sort out what pharmacists and doctors are often at odds over: What constitutes an effective treatment? Medications still work independently of legislation, and due to what's known as the bio-availability of a drug, some people suffer allergic reactions to a drug which technically is designed to cure what ails them. If a similar but no longer interchangeable drug is on the pharmacist's shelf, it may not be available to that person due to the cost. So there's a dilemma here: A person can take the paid-for drug and get sicker, or that person can pay for the drug that works and get poorer. Either way, there's little chance of economic recovery here -- not at the individual level or at the governmental level.
In summary, the voluminous nature of Bill 26, with barely two weeks in which to secure the necessary documentation and develop this response, allows us only the opportunity to bring forward our key concerns. Encompassing all the items we've noted -- and others we've not, however -- is our deep concern that the acknowledged fiscal imperatives are driving us towards a structure of health care that is both disjointed and ultimately destructive. The principles of the Canada Health Act have provided a vision of health care based on equity that every survey has shown to be highly valued by Canadians. Indeed, some even define their national identity by it. By what values is Bill 26 guided besides that of deficit reduction? When the headlong rush to cost-cutting is over, what will the delivery system look like? As institutional health care downsizes in the name of community-based care, which incidentally is also being decimated, what becomes of the patient who is faced with a six-month waiting list for needed service at every level?
Our recommendations, to sum up, are:
That Bill 26 be divided up into individual packages, each specific to its own particular area of concern. These sections can then be more accurately studies by those people they'll affect.
That the time frame in which the bill is to be studied be extended to allow a more accurate measure of the public interest.
That any consideration of public interest take into account the huge diversity of Ontario's population, and include appropriate consultation.
That Bill 26 enshrine provisions to ensure that the public is a key player in determining local health care priorities, in keeping with the spirit of the Common Sense Revolution.
That provisions to retain the autonomy of local boards be included in Bill 26.
That any amendments to the Ministry of Health Act ensure that patient confidentiality will be breached.
That the provisions prohibiting the public from seeking compensation for damages be clarified or deleted as they stand.
That the amendments to the Independent Health Facilities Act be removed.
That the provisions in the bill introducing copayments for prescription drugs be deleted.
That the provisions allowing the deregulation of drug prices be deleted.
Finally, that the provisions of Bill 26 respecting health care services be amended to ensure that the health care goals expressed in the document Bringing Common Sense to Health Care are not nullified. We thank you for your time.
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Mrs Margaret Gregor: I would like to express my appreciation to these people for sharing their time at this hearing.
Good afternoon. My name is Margaret Gregor. I'm the elected executive vice-president of the Brant-Haldimand Liberal Association and I'm also active as a director on the board of the Oxford Provincial Liberal Association. However, I am speaking today as a non-partisan citizen concerned with the democratic civil rights and liberties of Canadian Ontario citizens. I'm also concerned about the rights and privileges of physicians and medical personnel who serve and care for us.
As the member of a family whose father served in the First World War and sent four sons to fight for cherished freedoms in the Second World War, I am very concerned about the powers that this government is proposing to take over in Bill 26. The more I study this bill, the more concerned I am that the arbitrary control and authority placed in the minister's powers are to be allowed to pass unquestioned. Surely if our individual rights and freedoms were fought for and bought at such human sacrifice, it behooves us to protect and defend these rights now.
Regarding the health issues, and this has been spoken of, confidentiality of information between doctor and patient is not only a privilege but a right that cannot and should not be denied.
Individual choice of physicians and surgeons to practise where they choose is also a democratic right and privilege as long as they are providing legitimate service and care. Decisions regarding adequate servicing of doctors in all areas in Ontario should be a matter decided by the government in partnership with the Ontario Medical Association.
Phrases such as "without prior notice" and "imposing, ending or extending moratoriums" regarding control of numbers of eligible doctors in certain areas have possibilities of extreme power over physicians' lives and decisions, both in their family lives and practices.
I have strong objections also to schedule H, page 112, subsection (1.2), which proposes creation of "different classes of persons" with "different entitlements...relating to each class," establishing "different requirements, conditions or restrictions on or relating to each class". Such statements as these are surely in strong opposition to our Charter of Human Rights and Freedoms, and I am surprised they have not been spoken of more fully in these hearings.
In many cases, as I read this Bill 26, I note that there are few, if any, opportunities to dispute or challenge a person's rights with regard to this bill.
Schedule I, page 118, subsection 1(4) says, "If a right or obligation is designated under this act, a decision, ruling, award or order made in a proceeding relating to a dispute about the right or obligation shall be of no force or effect." So no challenge is possible.
Mr Chairman, ladies and gentlemen of this government committee, I not only suggest, but appeal to you that this Bill 26 is seriously flawed. This act should be completely revamped to live up to our rights and privileges in a democratic society.
I might add that someone, Terence Young, suggested to me that sundowning was suggested, as some of these rights might come into force and then be moved away. I don't believe that privileges that are allowed under this type of bill are going to disappear. It's something like the GST; once you've got it, it's forever with us.
Sources referred to in Bill 26: I would like to refer to these in order to prove that I've spoken honestly.
Part I, Health Insurance Act. Subsection 2(4.1) of the act, page 91, "The minister may...collect, use and disclose personal information concerning insured services provided by physicians, practitioners or health facilities.
"(4.2) Information may be collected directly" -- and this is the phrase I dislike -- "or indirectly under subsection (4.1)."
What does this refer to? It could be almost anything.
Schedule H, page 103, subsection 29.3(1), "The minister may, by regulation, fix or vary the number of physicians...who may become eligible physicians in an area after the date on which this section comes into force. The minister may do so" -- underlined -- "without prior notice.
"(2) The Minister may, by regulation, determine from time to time the areas of Ontario that are oversupplied with physicians....
"(6) The minister may impose, end or extend a moratorium" -- preventing more eligible physicians in an area, underlined -- "without prior notice."
Section 29.4:
"(7) An exemption may be made....
"(8) The minister may designate a person to exercise his or her powers" to decide such exemptions.
I am very much against one person deciding an exemption for such broad powers.
Schedule H, page 109, subsection 40.1(1), "An inspector has the following powers....
"5. To inspect and receive information from health records or from notes, charts and other material relating to patient care and to reproduce and retain copies of them.
"7. To remove material described in paragraph 5...for the purpose of copying it....The material must be promptly returned to the person apparently in charge" -- I certainly don't like that quote -- "of the premises from which the material is removed." It could almost be the caretaker.
Schedule H, page 112, and this is my own statement: I have strong objections to this section and I am very much surprised that this has not been debated more. This is put under "Classes" and certainly is against any democratic principles I have understood.
"(1.2) A regulation may create different classes of persons...and may establish different entitlements for or relating to each class or impose different requirements, conditions or restrictions on or relating to each class."
"(3.1) A regulation may exempt a class of persons or facilities from the application of a specified provision of the act or regulations."
In other words, those to whom they wish to apply this act, they may do so, and if they wish not to apply this act, then they don't. I don't see the justice in that.
Schedule I, page 118, section 1(4), and this is underlined:
"If a right or obligation is designated under this act, a decision, ruling, award or order made in a proceeding relating to a dispute about the right or obligation shall be of no force or effect."
In other words, you have no appeal to the courts.
To speak in summary, I'd like to read a letter written to the Brantford Expositor by Dr Robert Eddy. I have his permission to read this letter. I feel that it is a concise way of finalizing my submission.
"Is This What the Citizens Want?
"One newspaper used to have an important logo at the top of its editorial page -- something to the effect of `not proposing or submitting to arbitrary measures.' I always admired that quotation.
"Currently, I and my profession" -- and this is Dr Robert Eddy speaking -- "are being subjected to arbitrary measures. I am writing this letter as a citizen, protesting not just on behalf of my profession, but on behalf of all citizens of this model democracy of ours.
"As thinking people, doctors are aware of the country's and the province's economic situation, and aware that we must share the financial burden of its correction. We have done so and continue to do so.
"My protest is not an economic one. The arbitrary measures to which I am protesting are the following in Bill 26, the" ominous bill -- "omnibus bill." I beg your pardon. "Ominous" is probably a good word, right?
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"The limitation of doctors' licences granted in the province, without the advice of the Ontario Medical Association.
"The restriction of geographical areas in which a doctor may practise, without the advice of the Ontario Medical Association.
"Decisions about which medical services will be provided in which facility, without the advice of the Ontario Medical Association.
"The ability of a government official to seize medical health records of patients from doctors' offices without a warrant.
"The government arbitrarily deciding which medical procedures, services and tests will be covered in the health plan, without the advice of the Ontario Medical Association.
"The government arbitrarily deciding which medical services are necessary, without the advice of the Ontario Medical Association.
"The government's arbitrary termination of existing agreements with the Ontario Medical Association.
"My profession is willing to handle the problems of distribution of Ontario physicians, the problem of the luxury utilization of resources, and the other problems which involve the profession. We would like to do it in a partnership way with the government so that our expertise might be available.
"But instead we are being told to submit to arbitrary measures.
"The character of your province's medical profession may be permanently changed by this legislation."
I would like to add that I feel that it will, and probably already has, by the exodus of so many physicians already from our group. Is this what we as citizens want?
The Chair: Thank you very much for your presentation. I've been quite generous to allow you to at least read the letter at the end, as far as time goes. We appreciate your being here.
PERSONS UNITED FOR SELF HELP LONDON
ACTION LEAGUE OF PHYSICALLY HANDICAPPED ADULTS
The Chair: Our next group represents PUSH, Persons United for Self-Help, Bonnie Quesnel. Good afternoon and welcome to our committee.
Ms Bonnie Quesnel: Thank you, Mr Chairman and members of the committee. I'd like you to note first that I'm sharing part of the time with another group, called ALPHA, the Action League of Physically Handicapped Adults. It's another organization that is involved with people with disabilities. Let me begin.
Persons United for Self-Help is an organization which has long been committed to working for the advancement, integration and achievements of people with disabilities. We, better than most, understand the complications and difficulties which are faced by people caught up in a health system that has lost its humanity and accountability. Ontario as a whole has not yet been exposed to the second-class and bureaucratic health care that we who have disabilities know so well. The general public does not yet comprehend the "least for the most and the best for the rest" type of service provision. We do; we have known it for some time.
PUSH has already begun to see a class structure infiltrating our health care system. This is partially attributable to previous cuts and anticipation of the government's November budget. It is openly reflected in the marginal availability of timely, accessible service. It is also reflected in the insistent demand for "Do not resuscitate" notations on our files prior to taking our temperatures. Several PUSH members have recently sought medical support for correctable conditions; for example, hernia, bronchitis and bowel obstruction. They were all asked for this DNR designation while receiving treatment. Would you able-bodied, working individuals have been asked for this? We think not. Assumptions about your value and merit have been processed and it is believed that your life is worth living, saving and investing health dollars into.
The new human valuations and devaluations that will transpire within the sacred white halls are awesomely fearful. What happens when the new experts, those who decide who will get the survival care versus who is made "politely" comfortable, are no longer accountable to anyone? Change can be made by a few but will impact upon many. This legislation would deny an alternative prospect -- an avenue of appeal -- to everyone. Is an election every five years going to be our only recourse? Is this protection enough for those who are vulnerable and lack the money and/or machinery to prevail?
How often have we heard the words "quality of life" applied to a person who dared to get old or a young adult born with one or more disabilities? Their health needs shrink under a magnifying glass of some anonymous expert reciting positions on quality of life. Able-bodied and employed served first; all others to the rear. This is the essence of triage, omnibus style.
People with disabilities have experienced being marginalized and ignored by powerful decision-makers for many years. We have been victimized before by those who told us to trust them, that they knew what we needed. What you propose now is worse. We have the insights necessary to warn you of the problems in this Bill 26.
History reveals that in times of fiscal restraint it is those with the least perceived power who suffer most from the scapegoating devices. It reminds one of being on a whitewater raft ride where everyone ultimately falls into the void. Three have lifejackets and survive to tell others of their awful peril. The others could not afford, or were deemed unworthy of receiving, lifejackets -- and they do not come back. No one will ever hear their tales of true horror. This is what the current omnibus legislation will achieve in our health care system. This bill increases vulnerability and hostility towards people with disabilities -- those without lifejackets. It will encourage the health care system to identify people with disabilities as an expensive burden, a stereotype used extensively in the past. It simplifies the route for politicians and bureaucrats -- some of them with the lifejackets -- to forget about our humanness and our contributions, to see our rights as vexatious irritations, just like the wild white water. This easily adopted perspective will lead to the loss of our vital rights.
Let us take a look at some specific items outlined in the bill.
Schedule A, disclosure of salaries: This is only reasonable if it applies to the profit sector as well as the non-profit sector. This becomes an even more important consideration when one hopes that more for-profit services are getting involved in health services. It is impossible to compare any kind of service efficiencies when only one segment of data is available. Certainly long-range planning demands maximum data collection from all involved sources.
Schedule F: Will the minister's and his government's definition of "public interest" include all Ontarians? In the name of proper management of the health care system, will people with disabilities and others from the lower levels of your hierarchy be institutionalized, warehoused or denied service? If this is not your intent, then provide us with avenues of appeal and redress, with specific guarantees. Don't ask us for blind trust, knowing that our experience has shown the error of such action. Blind trust is something we have run out of. We need commitments and we need them now.
We would also like to know just what is an independent health facility. Will the unknown definition of this section lead to a two-tiered health care system as exists in the United States? We know that the American health system is not cheaper or accessible. In fact, it's been proven to be an expensive disaster.
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We also know who suffers most in the American system -- the disabled, the elderly and the poor. Why would we try to replicate failure? Caution lights are flashing throughout our community. Our raft is about ready to overturn and we are the people without lifejackets. Any change of this magnitude should be studied and reviewed more carefully before implementation.
Schedule G: We believe that deregulation of drug prices has nothing to do with deficit reduction. Whom does it serve? In whose public interest is it being put forth? Why is it here? This concept is truly a violation of those who struggle daily to make ends meet. It dictates that there will be one standard for the government and another, more costly standard for the public. To some, such will have no impact. To others it becomes a life-and-death issue. Again we ask, in whose public interest is it?
Further, the copayment user fees for prescriptions will directly contradict promises made to Ontario prior to election day. These fees cannot be afforded by people with disabilities, seniors or the poor. Is this the intent of this government?
Schedule H: Fees, fees and copayments. Nothing is to be deemed necessary, therefore nothing must be paid for. No anaesthetic to numb surgical pain, no morphine to dull cancer's agony, nothing. The minister will decide who gets what, how much and when. Such discretionary power raises fathoms of ethical and moral obligations and questions.
Perhaps this approach would not be so frightening if we people with disabilities knew that our needs were being included in the plan. However, we're like Cinderella watching our stepsisters going off to the dance, knowing that we are only part of the cleanup crew, our portion consistently being leftovers. We have little reason to think that this time will be different. We cannot face another bout of white water without the safety of a lifejacket of commitment from the provincial planners such as yourselves.
Other: By amending three separate pieces of legislation, Bill 26 shreds away our right to privacy and dignity. In days gone by, when citizens shared information and later found it was abused and misused, there were avenues of remedy to access. Omnibus dismisses our security rights flatly. Absolute access to all of an individual's records are for arbitrary reasons is an endorsement which decries logic. No government could possibly want to invade its citizenry so fully. Surely this is not the KGB.
With information technology progressing at warp speed and technical experts scrambling to safeguard their data, we in Ontario are being asked to yield all. We are to go without the lifejackets, drifting while others invade and violate our personal information, deciding when or if we can get back into the boat. This is wrong. No explanation will justify such abuse.
My conclusion is this: We know that good leadership weighs risk against outcomes before committing to a system overhaul. This is a difficult position when one recalls that the legislation we are here to address is supposed to be a housekeeping document, not a reform document.
We know that it's difficult to anticipate all of the impact implications of this omnibus planned actions. However, it is foolish to pursue action when gaping flaws are already apparent. This is no time for political posturing. This is not the kind of bill that demonstrates conservative progress. We need the reflective concern and common sense that you assured us would be ours. Anything less will not be good enough, and I thank you for your time.
Dr Shirley Van Hoof: Patti's going to say a word.
Ms Quesnel: Okay. This is Patti. She's the chair of ALPHA.
Ms Patti Doolittle: Hi. Good afternoon. I'm the chairperson for ALPHA and we're a subcommittee of the southwestern March of Dimes.
First of all, I'd like to thank you for southwestern for allowing us to have this presentation time during your speaking time. Also, thank you to Ontario March of Dimes for helping us prepare both written and oral presentations.
The background of ALPHA: The Action League of Physically Handicapped Adults has been fighting over the past 25 years. We have worked to improve the quality of life for persons with disabilities. This includes all aspects of life that affect all people. After all, we are people too with extra challenges. ALPHA believes that Bill 26 threatens the right to live with dignity for all vulnerable citizens, including children, the poor, the unemployed and the sick and/or disabled.
Now I'd like to turn over the presentation to Dr Shirley Van Hoof.
Dr Van Hoof: Thank you very much, Patti. I'd like to present an overview.
ALPHA finds few redeeming features in Bill 26 and would prefer to have it withdrawn. The next best thing is to have the bill presented in pieces, with substantial consultation with the affected parties on each section. A full assessment of the effects of the proposed changes must be undertaken before any part of this bill is passed. The rush to pass this legislation is scary.
Themes that pervade the document include (1) Increased powers given to a single person and taken from boards or other groups of people; (2) immunity; and (3) lack of appeal process.
We need more than one set of thought processes to tackle complex issues, as all of us have blind spots or soft spots that may unduly influence decisions. Boards were developed over time as a cooperative way to make decisions so that the biggest, strongest or most financially endowed do not infringe on the needs and rights of other citizens. Any time one person can close facilities and open others, withdraw services and cover others, corruption is just waiting to happen. To hand absolute power to one person is inviting an abuse of that power and should not be done.
Immunity for harm done to people or property is ludicrous. If in Bill 26 powers are being used "in the public interest," as stated so many times in this bill, then why the emphasis on immunity from repercussions when Bill 26 is implemented? In recent times, persons in power have been held accountable for their actions. This government will be held accountable for the impact of its legislation. Ferdinand Marcos of the Phillipines and Nicolai Ceausescu of Romania were both held accountable. Unfortunately, families that give up a child to the children's aid society or place a loved one with a disability in an institution because their resources have been decreased by Bill 26 are changed forever.
Lack of an appeal process gives decision-makers absolute power, which must be avoided. I'd like to quote from a letter from Lord Acton to Bishop Mandell Creighton, April 5, 1887, which said, "Power tends to corrupt and absolute power tends to corrupt absolutely." I think that's very relevant here.
Even the best and most thought-out legislation in the past has been found to have areas which need revision that could not have been anticipated until actually put into practice. To eliminate an appeal process would totally eliminate this valuable feedback and practical working experience.
Under discussion since this government took office in June 1995, persons with disabilities have been hurt in many ways, and Bill 26 will increase the disadvantages to which we are exposed.
Under health, the present status: Decreased funding has increased waiting times for doctors' appointments, decreased fees to laboratories for home services at a time when people are remaining at home when quite ill, questions by health professionals to persons with disabilities which are inappropriate, and you've already heard the DNR example. Some persons with disabilities are being denied treatment for a broken limb, pneumonia and other ailments. Some physicians today refuse to accept patients with certain conditions, MS, for example. In smaller communities this may effectively mean a person with a disability does not have access to routine medical care. Such service cuts are discriminatory and cannot be tolerated.
Given these present realities, this proposed legislation would further marginalize persons with disabilities.
Under transportation: A 6.2% decrease in funding began in 1995 and is still in effect in 1996 and 1997. Bill 26 will give municipalities further powers to alter funding, implement user fees and change whatever they wish without consultation.
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The critical issues. Under health:
1. A universal public health care system is crucial. A two-tier system is not acceptable.
2. With the addition of multiple copayments, the poor must choose between food, rent, medicine and assistive devices. Exceptionally high costs for basic medical and essential living expenses for persons with a disability is readily substantiated. To even consider copayments for prescribed medications for persons with disabilities would clearly be intolerable.
3. Using age as a criteria for health care is discriminatory. Not only the old and young but certain categories could be targeted.
4. Allowing the "manager" and not the person's physicians to decide what is "medically or therapeutically" -- again not defined -- necessary is unacceptable. This would seriously jeopardize the doctor-patient relationship and not utilize the knowledge and experience of the physician.
5. Coverage of treatments can be changed even retrospectively. Life-saving procedures may be delayed while clarification of coverage or family guarantee of payment is received. This is also totally unacceptable.
6. Cost and whether doctors will be paid will now be part of the decision-making process, which will result in the Americanization of our health care system.
7. If drug costs are unregulated, costs will increase to consumers. We've heard today that they may decrease after five years, but in the meantime what do we do? We pay through the nose. This does not address savings and restructuring as Bill 26 purports to accomplish.
8. The confidentiality of patient records under this legislation is not protected. This is considered sacrosanct and the legislation must be amended to guarantee such confidentiality.
9. Any limitations which will govern how and where physicians may practise in the future, as noted in section 29.4 will again further reduce the opportunity and availability of medical care for persons with disabilities in many communities.
Other issues:
10. Sweeping new powers to municipalities with no need to consult the public will hurt many citizens, especially the disadvantaged:
Transportation: I talked about the 6.2% cut, which remains until January 1998.
Education: Reductions in funding to adult and post-secondary education and the power to decrease or eliminate junior kindergarten and kindergarten.
User fees: A regressive form of taxation for necessities such as garbage collection and recreation facilities.
11. The amendments to pay equity legislation is a step backwards for women, combined with decreased support for child care, battered women's shelters, homes for unwed mothers and the repeal of the Employment Equity Act. If women are affected, women with disabilities are further penalized.
12. Decreased environmental protection standards, whether at mine sites or for garbage incinerators, are unacceptable.
In summation: Bill 26 encourages the attitude that those who have bear no social or economic responsibility for the other citizens of this great province. Citizens have repeatedly supported funding for education, health care, the poor and the disabled and yet Bill 26 potentially decimates all of these. To repeat the opening comments, ALPHA beseeches the provincial government to repeal Bill 26 or seek further consultation on the broad range of sweeping powers this legislation represents.
Thank you for the opportunity to present our concerns and we await the results of these hearings.
Mr Steve Balcom: I'll be addressing the questions.
The Chair: Oh, we've got one more person to talk, have we?
Mr Balcom: No. I'm going to be addressing the questions.
The Chair: Okay. Beginning with the government. Sorry, Mrs Johns. I got a little confused there.
Mrs Helen Johns (Huron): That's okay. Thank you very much for your presentation, all of you. It's nice to see you again, doctor, and it's always interesting what you have to say. In a short time, I don't exactly have a question. I just wanted to say that I recognize a couple of things that you've said.
I, as a person in Ontario, feel that I've been without a lifejacket also for the last few years as debt has increased. We have been unable to get it under control and it's wreaked havoc with the debt and the amount of money we have for all social programs, so I understand that.
I recognize that you said you feel your plight has been getting consistently worse for a number of years and it just continues to be worse.
I want to just comment about the age factor. I know this is a technicality when you have so many important things that you say in the bill, but since I have no time -- the age factor was in the previous bill and it's in this bill also, so it's not something new coming out with this age differential. If you'd like to make any comments on that. Do I have any time, Jack?
The Chair: No, you don't.
Mrs Johns: Sorry.
Mrs Pupatello: If the group doesn't mind, I'd like to address just initially the comments to the Conservative member.
Mrs Johns, really, all of us are surprised. That you would even consider comparing the lifejacket of the Ontario debt on your shoulders to what some groups in Ontario suffer from is unbearable and unacceptable to come from government, and you're going to have to withdraw those remarks. You cannot for a moment compare that you personally have had any suffering, given where you come from, in comparison to what some groups have in terms of disadvantages in Ontario.
Mrs Johns: We can't afford the health care that these people need because people have overspent in previous governments.
The Chair: Mrs Pupatello has the floor.
Mrs Pupatello: The reality is that the bill that is being presented today is simply going to make it worse for many people in Ontario. That is completely unacceptable, and I submit that most people in Ontario agree with me on this. That is unbelievable. Perhaps you'd like to make a comment.
Mr Balcom: I am sitting here shaking my head personally in disgust -- mostly in disgust, mostly in bewilderment at the politicized nature of the issue that you're dealing with. We live it every day, 365 days a year. And you're right, I am greatly insulted, because there's no comparison. That's about all I have to say.
The Chair: Thank you very much. Ms Lankin.
Mrs Caplan: Apologize.
Mrs Pupatello: You should apologize. You should be ashamed of yourself.
Ms Lankin: I want to specifically address one thing Mrs Johns said on a technical nature. She did mention that the issue with respect to discrimination of services based on age was in the old act, and I sort of sigh with weariness at this because we've been over it so many times.
She knows well that in the old act that was provided for in a context of regulation powers that was covered by a clause that said all of this had to be done in accordance with the Canada Health Act, which meant, for example, things like breast cancer screening programs for women over age 55. There are some things that have been prescribed by age but in that context.
This government has taken that age provision, moved it out, put it in another part of the act which is not under the protection of that clause saying that the government has to do it in accordance with the Canada Health Act. If that's not what they intend, they'll have to amend that, but it's not correct to keep saying to people it's the same as it was before.
I'd like to leave the last few seconds to you. Any comments you would like to make and message you would like to give to this government with respect to this bill?
Dr Van Hoof: Repeal the bill. Like I just said, withdraw it, because there are no redeeming features in this bill for us. And to say that you have to cut costs at our expense and you're sorry, I don't believe you. As you get your Porsche out to drive, I don't feel sorry for you. You cannot reduce the deficit on the backs of the poor and the disabled. That is not the Canadian way.
The Chair: Thank you very much. We do appreciate your being here this afternoon and your presentation.
We're going to take a three-minute recess.
The committee recessed from 1558 to 1605.
The Chair: Okay. The three minutes are up. We're back in business.
JAMES ROURKE
The Chair: Our next presenter is Dr James Rourke, who is a rural family physician. Welcome, doctor, to our committee.
Dr James Rourke: Thank you very much. I guess everyone's here who's coming.
Just as a brief note of introduction, I'm a rural family doctor from Goderich, Ontario, and I've had the joy of practising in rural practice for the last 16 years there. I've also been involved in teaching students and residents in our practice and residents for the last approximately seven years. I've been involved in the educational end of things. I've been involved in doing some research on the rural practice both in Ontario, Canada, and around the world, and involved in various policy-producing groups and chairing several of those for the Ministry of Health, the Ontario Medical Association and the Ontario Hospital Association.
I also had the privilege last year to travel to Australia for six months and be heavily involved in their rural practice difficulties and their approach to rural practice, and I've been involved with the World Organization of Family Doctors in preparing a policy statement for them on training doctors for rural practice.
So that's the perspective I'm trying to bring to this, to point out the need for rural health care and the need for some action. I understand that's part of the reason why this bill has been developed, to try to address those needs. I'm not going to comment on whether this bill is the best way to address those needs, but I want to highlight what the needs of rural practice are.
What I've done for the committee members is prepared a brief that I hope you have in front of you. Do you have a brief in front of you?
Mrs Pupatello: We're getting more copies made of the presentation.
Dr Rourke: Just to start by highlighting the need to address rural health care, I would tell you that 2,497,000 people live in rural Ontario as defined by Statistics Canada's definition of "rural" as up to 10,000 people. That's 24.8% of the Ontario population.
The health care for that 24.8% of the Ontario population is under jeopardy now, it is getting worse and not better, and it's time for some action. Basic medical care needs for the rural population of Ontario include local access to a family doctor, access to emergency medical care within a reasonable time and distance, safe obstetrical care as close to home as possible, special aboriginal and first nations health care needs, psychiatry services, access to other general specialty services such as internal medicine, access to specialized care by outreach clinics, and access to secondary and tertiary care centre resources. Each of these is under serious threat at this point in time, and there has been little action done to address those over the last 10 years.
I put in some definitions of rural practice so that people can understand what rural medical practice is and how it differs from city practice. There's a vast difference. Some of those differences include the large population-to-doctor ratio and the fact that family doctors in rural areas are called upon to do many things that in urban areas family doctors don't do, but that are done by specialists. Those include hospital care of all sorts, including a lot of obstetrical care, emergency care, doing anaesthetics, minor surgery and sometimes major surgery.
There's limited and distant specialist backup and a very small number of rural specialists. There's difficulty securing relief for holidays or education. I also want you to know that recruitment retention, of course, is more difficult the further away you go from the larger urban centres and that a lot of the recruitment retention difficulties are part of spousal and personal and children concerns as opposed to professional concerns.
I'm going to talk briefly about our progress to date and then I'm going to talk about what needs to be done and the need for the government to act on this at this point.
Overall, progress has been poor. There is a worsening situation for the provision of safe obstetrical services in our province. That's gotten worse over the last seven years. The problems of rural health care have now reached a crisis proportion, not only for rural emergency services but most rural health services, as indicated by the independent Scott report. I'm sure you're all familiar with the Scott report, but one of the good things about the Scott report was that it wasn't done by a rural doctor, it wasn't done by a politician, it wasn't done by a rural hospital administrator, and Scott called the shots the way they were. I think it's received widespread acceptance as this reflects the reality of today's rural practice crisis.
Just to draw your attention to the crisis, let's look at the marked urban-rural maldistribution of doctors. I'm going to talk about family doctors as if they're not non-specialists, because the data we have are for non-specialists. This is 1994 data from the Ontario physician human resource data centre.
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For the province, there's one non-specialist for every 1,100 people. In Metro Toronto there's one for every 836 people. In London it's one for every 983 people. But if you go up to the more rural areas, even just up the road where I live in Huron county, in Bruce county -- that's not very far away -- it's one to 1,400 people.
Let me tell you, it should be the exact opposite, because I'm only a 60% family doctor, like most of my colleagues. Some 40% of my time is spent doing hospital-based medicine. So compared to the office-based family doctor in the city, I can only do 60% of the office-based time that they can provide. So the ratio should be different. There should be more of us per population in the rural areas instead of less.
Let's just flip over to emergency care for a second. I'm not going to spend a lot of time on that because Scott has addressed that, but I will indicate that the current government has made the first initiative in addressing this rural emergency care crisis that's been with us for a decade now and getting worse as it goes along by implementing at least part of the Scott report this past Monday, which was the sessional payments, basically a salary payment for rural doctors.
In addition to that, we need more rural doctors because the ones who are there are burning out even if we do pay them properly to do the work. But at least this government has started. This problem has been fumbled by the medical association and the hospital association and the previous governments for the last five to 10 years. It's a litany of failed negotiations where all the parties have agreed to the need to address the problem, yet somehow they weren't big enough to come together to resolve it. So at least we're moving on this one.
There's a need to move in other areas: obstetrical care. I will tell you that fewer small hospitals are doing obstetrics now than they were seven years ago, as I've just completed a 1995 study and compared that to 1988. Of the hospitals that are now still doing obstetrics, there are fewer family doctors doing them. There are fewer family doctors doing GP anaesthesia, and less availability for emergency anaesthesia, less availability for Caesarean sections in those small hospitals that are doing obstetrical care. Women's health care, including obstetrical services, has gotten worse in the last seven years. We are not making progress; we're going backwards.
Let's talk about psychiatry. It might be interesting for you to know that the population of northern Ontario is greater than the population of Ottawa-Carleton. In northern Ontario there are 49 psychiatrists. In Ottawa-Carleton there are 252. The population-to-psychiatrist ratio in Ottawa-Carleton is 2,851 to one. In northeastern Ontario it's 22,000 to one. If we go up the road to Huron county it is 20,000 to one. In London it's 3,600 to one. These are vast inequities in distribution. We need to address those vast inequities so that the rural person gets their fair share of the health care dollar, so that they get a fair chance to access the kind of health care they require, the same as very other person.
Imagine for a moment: If psychiatry services were population-based funding and psychiatry services received the same amount of per-dollar funding in northern Ontario as they did in Ottawa and the fees were prorated, we'd soon see a shift of psychiatry services, I'm sure.
Medical education: Every study around the world indicates that medical education is one of the keys to getting doctors into the country. How well are we doing at medical education? Well, primarily it remains urban-centred and urban-oriented. We made a few steps forward, but if we look at people particularly from northern Ontario, they do a three- or four-year degree before they get into medical school in a university, usually in southern Ontario. They then spend four years in medical school, then two to five years in specialty training. After that, they spend a 10-year time in southern Ontario, and then we expect them to go back up to northern Ontario? They've already met spouses who have a professional career down in Toronto or somewhere else. It just doesn't make sense. We have to do more of their training in northern Ontario and rural Ontario, and we have to develop that now. There are proposals in front of the government now to do that. It's time to act on them.
Post-graduate training for family medicine: Again there are some northern and rural programs, but the number is far too small for the needs. Some family doctors to go to rural areas need third-year training positions such as for GP anaesthesia. They've been tremendously limited by the previous governments in Ontario. There simply have not been enough positions put forth to supply anywhere close to the needs for this. Is it a surprise that we have a shortage of GP anaesthetists? No it's not.
One of the positive things on education has been the OMA-Ministry of Health continuing medical education agreement for rural doctors that was started by 1993 with the NDP. That has been a very positive thing for rural doctors and we'd all like to see that continue because it helps fund us to get out for the kinds of education we need.
I'll talk briefly about rural practice support programs, the Ontario underserviced area program: very limited targets and little improvement over many years. Twenty years ago the amount of funding they provided in that might have been an inducement for doctors to go to a rural area; 20 years later the funding has stayed the same. It simply is not as attractive as it was. It's not a surprise it isn't.
The locums program by the Ministry of Health-OMA under the 1993 agreement again is a success, but it's too small.
Coordinated rural health strategy: Other countries and jurisdictions around the world have developed a coordinated rural health strategy in the last five years. Australia has, Alberta has, closer to home; British Columbia's developing that now. We haven't even got that far in Ontario. It's long overdue. We haven't given it the thought needed, so it's not a surprise the problems haven't been solved.
In summary, the problems are multifactorial. Major education, recruitment and retention initiatives are needed and require significant resource reinvestment. We are cutting back on funding to hospitals and universities. The total health care dollars are supposed to be kept the same, according to this government's plans, and therefore there's money to be reinvested. Let's reinvest it where it's needed: in rural health care. How do we do that?
In the next part of the brief I've outlined the key points we need to address and how to do them, in a brief I sent to Helen Johns November 24, 1995. Things haven't changed a lot since then; that's only two months ago.
Under education, we need to provide rural-oriented medical education at all levels. There are proposals in front of the ministry right now in answer to the minister's letter to be considered to do that. One would include more training in northern Ontario, which is a really important idea. Other jurisdictions have done this kind of thing. In northern Norway they've successfully trained more doctors, and guess what? More of them stayed in northern Norway. These things have been proven to work. We need to get on with them now, and this bill or whatever legislation comes forth have to address these problems.
We need to do more specialty training in rural areas. One of the proposals in front of the minister is a University of Western Ontario multispecialty rural training unit, and that is the exact kind of thing the minister asked for in his letter to the Council of Ontario Faculties of Medicine.
Let's go past education to recruitment and retention. The Scott report provided an excellent assessment and provided initiatives. Under the Scott report he recommends a lot more than just a salary report for doctors doing residency work. He recommends community facilities. Is it any surprise that a doctor graduating these days does not want to go to a small town, buy or build an office, hire his own staff and then find out a year later that he can't stand the place and he can't sell his $250,000 investment? No, it wouldn't be a surprise that they don't do that. But in communities that can provide facilities, a turnkey operation, they are going to be more likely to go there. If we can provide a guaranteed income, a contract position, we'll be able to attract more doctors to those communities.
These things are possible, they've been shown to work; it is time to get on with them. They've been almost negotiated with former governments and this government under the contract positions in the 1993 agreement, but little problems kept cropping up and they were never quite completed. It's time to complete the negotiations and get on and address the problem.
Significant sustained incentives are needed for rural practice. It's not enough to just get people there. We don't want a doctor coming and lasting for two years and in a 10-year period having five doctors turn over. We want one doctor to stay for 10 years. So we need to look at how to retain them, and we need a significant funding shift allocation to do that.
I've talked about specific areas. I'll just highlight one particular item, the CMPA premium. There's been a lot said about getting rid of the Canadian Medical Protective Association premium for doctors, and there are a lot of good arguments for getting rid of it, but I can assure you that if we take away for doctors in rural areas who do anaesthesia and obstetrics, we will take away anaesthesia and obstetrics in rural areas.
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I don't care whether the CMPA premium is paid or there's some other subsidy or inducement given for that, but you can't take it away and not provide some bonus for doing that kind of work. I like doing obstetrics; it's part of the joy in my practice. Right now, basically we do it for close to nothing because you have to do so many deliveries to pay for the costs. If you take that away, we'll be having to pay to do obstetrics. I don't think many doctors are that altruistic. We can't take that away without having it collapse unless we substitute some bonus for doing those activities, specifically obstetrics and GP anaesthesia.
Other potential future distribution measures: Regional population-based funding would make a tremendous difference to physician allocation and distribution. For example, if you funded psychiatry for northern Ontario at the same per capita basis as you do for anywhere else, the other places would find less funding for their multitude of psychiatrists and there'd be a plethora of funding for the northern Ontario psychiatrists. We could apply that same kind of concept to funding other primary health care services such as family physician services.
Primary health care reform may also be helpful. Billing number restrictions may not have the result expected. Studies in the United States show that physicians recruited to areas because of return of bursary service or other restrictions tend to stay fewer years than people attracted to those areas. They tend to do less work when they're there, less satisfactory work, and they get out as quickly as they can. Billing number restrictions may not get the right doctors to the right places. A far better population-based incentive would be much better than billing number restrictions. However, that may be necessary to at least move the people out of the biggest, most overpopulated doctor centres.
Specialists linked to hospital privileges has both an upside and a downside and has to be carefully entered into, but it may have some beneficial effects for the rural areas in terms of getting doctors to come to areas where privileges are available.
Just to close, there's also a need for providing some rural health research. In Australia, they have come to the realization that you can't solve the problems of rural health care in Melbourne or Sydney. We can't solve the problems of rural health care with policy-based planning and research centred in Toronto, Ottawa and London. We need to have some strategically placed rural-based health care research policy and planning development, so that policies and planning and strategy are based on the needs and the issues important to rural practice and the rural health care of Ontario. Unless we do that, we'll continue to sit and come up with solutions that no longer work.
A typical example of solutions that don't work is when several years ago the government went to a two-year licensure for doctors; you had to have two-year licensure or you couldn't get your licence or finish the specialty program. Educationally this was sound, but one of the spinoffs was that it eliminated all the doctors from moonlighting in residency training in all the small towns in Ontario, which had been the salvation for the small-town emergency departments. We took that away and we got the crisis in emergency health care in small towns because the central planning body didn't quite think through the ultimate effects of that and didn't make compensatory adjustments in their planning.
My final point for rural health strategy in Ontario is that it should include and should start immediately with better education for rural doctors with more rural-oriented education, better working conditions for rural doctors to get more doctors in rural areas, and more equitable funding for the rural population so they are provided with the basic health care services they need in the rural and northern areas.
Mrs McLeod: Thank you very much for your presentation. I think your last comment about things that are not carefully thought through applies to much of Bill 26. A good example of that is the CMPA rebate withdrawal, which looked like a politically popular thing to do, but government simply hadn't looked at the impact. As I told the committee last week, I have a bias because my husband has been a practitioner in a northern Ontario community for 30 years, does obstetrics, is delivering the babies of the babies he delivered, and would now have to deliver at least 46 of those babies free of charge before he started to see any return. Obviously, that creates concern.
I appreciate that you've presented a very positive set of constructive suggestions. I wish this forum was about receiving positive suggestions. I have to tell you, I don't believe it is. I believe this is a finance bill, as it has been presented by the Minister of Finance. Although the government talks about redistributing the dollars, the only financial statement we've had from that Minister of Finance takes $1.5 billion out of health care for deficit reduction. The Minister of Finance has not given us any financial statement that puts the money back in.
If this were a forum about how we manage the challenges in health care, you've given us a blueprint to deal with recruitment and retention that we could build on very quickly to begin to address the problems. There have been things tried that are working, but there hasn't been a comprehensive approach. There's a 67% retention rate in the northern residency training program, which I think is a real success story. But this bill is about control and quotas and powers to decide who practises where, and I would like to ask you two questions.
First, there's concern about the ability of the Minister of Health and the ministry to work that program effectively, even if you believe in it. We heard in Sudbury, which is trying to get an underserviced area designation, that ministry data included three dead physicians and one retired family doctor who gave 'flu shots to his neighbours as full-time practising physicians, and that's why they're not an underserviced area.
Do you have confidence in the Ministry of Health's ability to handle quotas and determination of who should practise where, and do you think at the end of the day that Bill 26, hand-in-hand with coercive billing numbers, will make recruitment more difficult because more people will leave this province?
Dr Rourke: I have not been impressed in the past with the Ministry of Health's ability to micromanage health care and physician placement, for the exact reasons you gave. I'm probably as close to the data as anyone, and it is impossible to get accurate statistics; it just does not exist in a close enough way to micromanage it. Therefore we need broad incentives, broad actions, rather than micromanaging where this town gets a doctor, this town doesn't get a doctor. That just cannot work.
In terms of Bill 26's ability to do that, I have concerns that it gives a lot of power to one person's discretion rather than to groups and individuals, without recourse. But either Bill 26 or something has to be done to address the problems, and we can't go back to the way things have been done before. Action is needed now. If this is one way to get action, then that needs to be done and maybe amended to take out the sore points.
Ms Lankin: Thank you very much, Dr Rourke. As government members have pointed out and as you pointed out, this problem has been around for a long time, and a number of governments have attempted to deal with it. I recall in early 1992, when I became Minister of Health, a crisis, as it was presented to me, in terms of underserviced areas and looking for solutions to it. The very proposal we see before us in this bill in terms of billing numbers was brought forth through the ministry policy proposals to me. We explored that and the response was overwhelmingly negative, and I came over a period of time to understand why and to understand that was not the way to go.
There wasn't a consensus on a lot of what needed to be done. There were ideas. We moved ahead with the northern residency program, the CME, little pieces of it, but in terms of a more comprehensive solution really undertook the processes through PCCCAR and Scott, and I agree with you that it is past time for action to implement the recommendations of those reports.
My concern about the elements of billing number restrictions, as set out in this bill -- and it's not that other governments haven't tried to use it as a gun to the head to get solutions. This bill's going to be passed in a week and a half with those measures in place, and doctors in northern Ontario, where we were last week, told us they are already beginning to relocate their billing numbers and their practices to southern Ontario, or from rural to urban, in order not to be caught by the bill, if that section is implemented, and be frozen in place. Are you aware of this in terms of rural doctors' practices? Is this a phenomenon that's really happening?
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Dr Rourke: Rural doctors have been among the prime candidates for recruitment from the United States because of their multiple and varied skills. There are two concerns with the billing number restrictions. Pity the poor doctor who has been in rural practice for 10 years, has done his job, he's done it well and because of life-cycle reasons he now wishes to relocate to a more urban centre for children's education or whatever. And you have the doctor who spent his 10 years in urban Ontario and billing number restrictions come in that then prevent that rural doctor, who's done his dues, from moving to the city yet do nothing to the urban doctor. That's why I'm not in favour of billing number restrictions but more in favour of recruitment and retention initiatives that are significant.
An example of those are those in Quebec, where there's a tremendous differential in payment for physicians setting up in Montreal versus Sherbrooke versus Chicoutimi. That seems to have some effect on us to work. Other incentives that are used in Quebec include a significant salary component for GP anaesthetists to make it worth their while.
I think those things are more effective, more likely to work in the long run, and if we make it financially unpalatable for people to set up initially in the city, then some who really desperately want to do that will do that, and that's okay. But I think we have to apply population-based funding more to those things and then that sort of levers the blunt instrument of billing number restrictions, which I am not convinced will achieve the effect that's desired by the government.
Mrs Johns: Thank you for being here, Dr Rourke. As usual, I learn lots every time I talk to you. I want to thank you for being here, because it legitimizes what I've been saying about a two-tier health system, people having doctors in urban Ontario and not having doctors in rural and northern Ontario. Sometimes I know people think I have holes in my head when I say that, but I appreciate the numbers that back up that process.
The minister has said that he will not implement billing restrictions if your professional bodies come up with an alternative that allows people in rural and northern Ontario to have access to doctors. Can you tell me how long it would take to implement the kind of things you're recommending? I know there are different levels so there are different time frames, but when could you see that, through the normal course of your recommendations, we would have adequate doctors in rural and northern Ontario and what do you perceive we should do in the meantime to solve the problem?
Dr Rourke: That is the major problem, the time lag. If we start an educational process that's centred more on rural and northern Ontario, we're talking a time lag of eight to 10 years to get an output at the end of that. If we're talking a time lag of putting in some funding and recruitment incentives, such as recommended in the Scott report, from a funding point of view, that can be instituted immediately and can have an immediate effect. I think for financial funding-type arrangements to have an immediate effect there needs to be not only a bonus for rural areas but a compensatory offset in urban areas. The numbers are small enough that the offset would not have to be that great to make a significant difference, but I would suggest in the order of what happens in Quebec is perhaps a reasonable incentive package. I think that can work fairly well.
There are other things that we can put into place that will have a lag time. That's an immediate one, could have an effect within a year or so. The intermediate ones are building the infrastructure. For example, the contract positions and facilities for rural doctors could be put into effect to work within about two years to have some beneficial effect there by building the kind of turnkey operations. I would say many hospitals now have lots of room because we're not keeping many people in hospital any more, and they would be the ideal location to develop rural clinics to attract doctors to work into. Those would take about two years to have an effect.
What can we do immediately? The question of whether you close off certain very oversupplied centres for a short time has been raised, and that has potentially negative effects as well as positive effects but would have certainly helped some people move out into the rural areas.
The Chair: Thank you, doctor. We appreciate your presentation here today.
Ms Lankin: While the next presenters are approaching, I just wanted to mention into the record that legislative research has provided us with some background documentation in answer to questions raised by the other subcommittee on issues of ability to pay. I've mentioned to government members a few times that I would urge them to read the Johnson commission, and I didn't have a citation for that. I would point out to you that while the full Johnson commission report is not contained herein, it is referred to in the research summary, and in the appendices, the third-last article, by Martin Teplitsky, it gives actually some quotes and quite a bit of overview of the issue of both arbitrators' treatment of ability to pay and the Johnson commission rejection of that in the 1970s. I would really urge the government members to take a look at this. I think it's an excellent document.
The Chair: Thank you, Ms Lankin.
CHATHAM AND DISTRICT LABOUR COUNCIL
The Chair: Our next presenter is from the Chatham and District Labour Council, Buddy Kitchen, the president, and David Frain, a member. Welcome, Mr Kitchen.
Mr Buddy Kitchen: Hello, Jack. How're you doing?
The Chair: I'm fine, thank you.
Mr Kitchen: Long time no see.
The Chair: You have a half-hour to use as you see fit.
Mr Kitchen: Okay. As a background, the Chatham and District Labour Council consists of 25 affiliated unions representing approximately 12,000 members. Our members come from both private and public sector workplaces. We were chartered by the Canadian Labour Congress in 1958 and have been representing the views and interests of working people in this area since. The elected officers of this labour council are not full-time positions. Although we are not confined to geographical boundaries, our organization considers the boundaries of the county of Kent to be the same. Politically, we are represented by the MPPs of Chatham-Kent and Essex-Kent.
Bill 26 is so encompassing in its contents, two sets of hearings are being held. Because this labour council represents workers in the health care industry, we made an application to appear before the subcommittee dealing with health issues.
It should be noted the labour council applied to the clerk of the committee requesting an appointment to appear before the subcommittee on general issues in either Windsor or London, the closest geographical locations to us. We were accepted and made a presentation at the January 8 Windsor hearings.
This labour council offers no apologies for making a second presentation. We have no more vested interest or influence than any other organization or citizen who made application. We simply applied for both committees and were accepted by both committees.
As an introduction, the Chatham and District Labour Council is pleased to participate in the hearings on Bill 26, the Savings and Restructuring Act.
However, we must make it absolutely certain we oppose much of the content of this omnibus bill. More importantly, we object to the undemocratic process with which it is being forced on the citizens of Ontario. This labour council is of the opinion the window of opportunity which allowed a bill of this magnitude to be introduced lies squarely on the shoulders of the federal Liberal government and the implementation of the Canada health and social transfer. Bill 26 reaffirms our position this provincial government is autocratic and undemocratic.
These hearings are not being conducted as part of the democratic process. We are of the opinion these hearings are a result of relentless pressure by the public to be consulted and unprecedented parliamentary disobedience by the opposition parties which embarrassed the government, and for that, we congratulate them.
We question this government's integrity to implement any of the recommendations brought forward not only to this committee but the other committee as well. My proof for this statement comes from viewing the December 22, 1995, health hearings on the parliamentary TV channel.
Frances Lankin, MPP, tried unsuccessfully to introduce a motion to extend the length of the hearings outside of the Toronto area. It was already acknowledged before leaving Toronto that there were more applications for submissions than there were time slots. A very generic amendment requesting the government House leaders be advised of this information was then voted down.
This confirmed to me the government members are here to pay lip-service to the people of Ontario and conduct these public hearings but at the same time will toe the party line regardless of the information brought forward.
This act is very far-reaching in terms of content and scope. The fact it creates three new acts, totally repeals two acts and amends a total of 44 other acts verifies this. Bill 26 is over 200 pages. The compendium provided with the bill is said to be a foot thick.
Given the number of acts created, repealed or amended, and given the significance of all other issues involved, the process should allow for the democratic input of all concerned. However, we feel that with the new powers this bill will give to certain ministries within this government, certain sectors of this province are intimidated from making a presentation for fear of reprisal once this bill is implemented.
More importantly, given the number of groups and individuals who applied to appear before this committee and were not successful, and given the fact other groups and individuals are making multiple presentations, serious consideration must be given to improving the selection process to ensure all people have access to be heard. I believe, Jack, you said that in an interview on CSCO radio last weekend.
If this committee can agree with our assessment that groups and individuals are being heard for the second time at the expense of people not being heard at all, then you should have no problem agreeing with our recommendation that these hearings be extended so all people have a chance to be heard.
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The Savings and Restructuring Act includes substantial changes on many issues. I would like to touch on some which are pertinent to our organization, as they would affect our members as individual citizens or as a member of an affected group.
Before dealing with specifics of the legislation, I feel it is important to make reference to the individuals whose job it is to draft, promote, debate and vote on this important piece of legislation.
The MPPs' ability to understand the legislation: I raise this issue with the greatest sincerity. There are presently 130 MPPs in the Legislature. These are the individuals who were duly elected by the people they represent and ideally are answerable to them.
Of the people elected in the last election, 71 MPPs are sitting in the House for the very first time. The Tory government has 59 members new to the Legislature and provincial politics. My MPP from Chatham-Kent, Jack Carroll, is one of them.
Would it be wrong to assume an individual such as Jack Carroll, who had no previous political experience, hasn't the ability to accept the following changes in his lifestyle and do merit to a job he is still getting used to?
Mrs Johns: He is doing merit to it. You're doing a good job, Jack.
Interruption.
Mr Kitchen: Some people say that it would be better to be quiet and let me assume you're ridiculous than to open your mouth and let me prove it.
Events such as opening constituency offices in Chatham and Toronto and hiring staff for each, familiarizing himself with his constituency because he doesn't live in it, familiarizing himself with Toronto because he is going to live and work there part-time, learning the rules and regulations of being an MPP, meeting with his own caucus and being assigned duties within, see to the day-to-day responsibilities of his constituents, attend civic functions on behalf of the government, attend the opening of the Legislature in September, meet with and listen to the concerns of protesters at his office on a weekly basis, start dodging the protesters at his office on a weekly basis, be in the Legislature to debate and vote on new, far-reaching legislation such as Bill 7, meet and try to rationalize to the Chatham city council all the provincial funding cuts, appear on radio debates with local detractors of the Common Sense Revolution, give his maiden speech in the Legislature, try to maintain some semblance of family life, chair the general government committee hearings on Bill 26 etc, etc, etc.
Ms Lankin: And they say the life of an MPP is glamorous.
Mr Kitchen: And highly underpaid.
It is probably safe to say Jack Carroll and the other 70 new MPPs are still feeling their way along in their new jobs and are apt to make the usual mistakes rookie MPPs make until they become familiar and experienced in the ways of government. In a December 18, 1995, Chatham Daily News article regarding him chairing the hearings on the controversial bully bill, Carroll said he expects to hear from "regular opponents of Conservative policies, such as union leaders and social activists." Which categories did Ministers Wilson and Leach fit into when they made their presentations?
I have written letters to my MPP, the Minister of Labour and the Premier concerning various issues. Some letters have gone unanswered, some letters have been responded to four months after the fact and some letters have been referred to the minister involved, only never responded to. This again shows how extremely busy all members of this Legislature are.
I've made phone calls directly to the Minister of Economic Development, Trade and Tourism's office when funding cuts for the proposed ethanol plant in Chatham were announced, only to receive no response from that ministry.
It is conceivable to understand that government backbenchers and rookie MPPs could be ill-informed as to the content of this bill, but one would assume government ministers would have working knowledge of this bill, particularly if your ministry was one of the ones so adversely affected.
After the bill was introduced in the House, Municipal Affairs minister Al Leach was hard-pressed to explain direct taxes at the municipal level. He offered his resignation if he was wrong in his interpretation. According to some experts, he is dead wrong.
The charade goes on. During the first day of public hearings on Bill 26, Minister Leach again denied a suggestion the ability to impose direct taxes at the municipal level means a new class of sales tax. He said the language was just "legalese." According to a Windsor Star article of December 19, 1995, here is what happened next:
"When pressed by NDP leader Bob Rae, Leach asked for help from ministerial staff. The seat beside Leach became a musical chair as one bureaucrat after another attempted to assist Leach as he struggled to explain the bill."
The Ministry of Health is another ministry which will receive new, far-reaching powers. One can raise issue with the fact the Minister of Health will be able to control a health care delivery system which is the envy of the world, dictate in certain aspects of it, yet holds no medical degree nor comes from a medical background.
To conclude this section, we feel the elected officials who vote on this ominous piece of legislation are inexperienced and lack the knowledge and expertise to evaluate this bill at this time. They don't know their job yet and they're still making mistakes in the day-to-day workings of the basic MPP job. Having only sat in the Legislature approximately three months since being elected, their time has been quite busy dealing with the legislation before them. The MPPs, including the ministers who should know, are ill informed about the content and intent of this bill. If the larger staff an entire ministry has cannot explain the pertinent sections to that minister, as was the case with Minister Leach, is it conceivable the average MPP, without the expertise of the ministry's staff, be able to comprehend the entire bill?
The Chatham and District Labour Council recommends to this committee that, at the very least, this act should be broken down into its various components and debated as such.
One also must question who is in control of the direction this government is going and who is really calling the shots. I have been told by my MPP he would not vote against government legislation even if it was bad for our riding.
This scares me when I read a London Free Press article on December 16, 1995, entitled, "`Whiz Kids' With Inside Track to Harris Raising Resentment." This article talks about "the unelected insiders, highly influential...who advise the government on policy and how to implement it." I wonder how much of this pertains to Bill 26. It scares me to think that they could impact a bill of this magnitude when I read the following quotes:
"Politics is strictly just one big game to them. I'm speaking of Alister Campbell, Mitch Patten, Tom Long and Leslie Noble.
"It is this outside group...who are saying: `Ram this stuff. Do it.'"
"There are too many people with too much input who have never even been elected dogcatcher in their life. They have no constituency to answer to," said a Tory backbencher.
"They don't understand the democratic process," a Tory MPP said.
Reference has been made to this committee that this bill is a power grab which will put the power in the hands of the ministries and thus the hands of the unelected bureaucrat. If this is the attitude of the unelected power brokers of this government, something has to be done to stop them.
Freedom of information: Bill 26 amends two separate acts concerning freedom of information and the protection of privacy. In essence, these amendments will make it harder to gain access to documents and easier to deny access. One should offset the other, not reinforce it.
Schedule K is the section which gives the Minister of Health new powers to obtain confidential health information and give it to whomever he chooses.
Allow me to share this information with you: I am a recovering alcoholic. I received treatment at Westover Treatment Centre in Thamesville, Ontario. I've been sober since receiving treatment in April 1993. You now know this information about me because I've told you, not because some Minister of Health obtained it from my files without my consent.
As a recovering alcoholic, I must tell you, to some anonymity is an important part of their recovery. Anonymity, much like protection of privacy, once it is breached, can never be recovered.
Pensions: The amendments to the Public Service Pension Act and the OPSEU Pension Act facilitate the privatization and downsizing of government employees. If the government lays off the thousands of employees it says it is going to, they will have the authority to deny full pension benefits to those people. Employees should be entitled to all money owing them, particularly if that money come from pension sources.
We understand that when the government tried to make the same changes to the pension acts by regulation last summer, they were beaten in court by the Ontario Public Service Employees Union and their actions found to be totally illegal. We find it ironic to see a government which campaigned on MPP pension reform and is still struggling with how to achieve that, suddenly become pension experts when their employees are involved.
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We recommend to this government that rather than legislating pension changes to your employees, become a responsible employer and enter the changes into the collective bargaining process. Make the pension plan part of the collective agreement, subject to the members' approval. After all, this will allow members of the plan an opportunity to democratically vote on changes to their plan, much the same as you will when the changes to your pension plan are brought before you.
Municipalities: Section 33 of the bill makes privatization of public utilities such as hydro, water, sewer and, in some municipalities, transportation services much easier. Disregard the fact it was the taxpayers who paid to install and maintain these utilities over the years, and disregard the fact that proper market value could probably never be found, but you cannot disregard the fact the amendment takes away the requirement to hold a municipal referendum. What could be more anti-democratic?
Conservation authorities have had their funding slashed 70%. This bill will now limit the levies they can charge the municipality. This means their source of income will primarily be the decreased provincial funds, whatever voluntary municipal funds are available and increased user fees. This can only lead to the shutdown of many of these authorities. It would be sad to see these areas, which were developed by local residents for local residents, shut down. But the question must be asked, what becomes of the assets?
Restrictions on arbitration: Despite the fact that of those affected by these amendments to the five different acts, this labour council represents only hospital workers, we must oppose the significant interference with the independence and integrity of the arbitration process. This legislation could force arbitrators to cut wages of these workers or, worse yet, consider whether fire, police, school and hospital services should be reduced. This places the wrong decision-making power in the wrong hands.
Health care: The Chatham and District Labour Council believes in the five cornerstones of medicare spelled out in the Canada Health Act. We also endorse the Canadian Health Coalition's Ten Goals for Improving Health Care. A copy is included in this package.
We oppose the changes to the Ministry of Health Act which create a Health Services Restructuring Commission. One would assume this is designed to provide a cover for the government on unpopular decisions like hospital closings. We oppose changes in the Independent Health Facilities Act which we argue set the tone for American for-profit companies to take over more of Ontario's health care.
We oppose changes to the Ontario Drug Benefit Act, the Prescription Drug Cost Regulation Act and the Regulated Health Professions Act, 1991. As advertised, this introduces copayments for seniors and social assistance recipients. It also deregulates drug prices. When the Drug Interchangeability and Dispensing Fee Act takes effect, Ontario will be the only province that does not regulate drug prices. There is no reason to believe deregulated drug prices will go down.
We oppose the implementation of user fees of any sort. Some will say the implementation of such violates the Common Sense Revolution. Our studies reveal user fees do not deter abusers, so to implement them as a policing agent for abuse is ridiculous.
We also see user fees on prescriptions as a punishment for being sick. Jack Carroll, MPP for Chatham-Kent, sees this differently. Despite the fact he is not a doctor, in a December 1, 1995, Chatham Daily News article, Carroll said the reason behind the user fee is to ensure the drugs are absolutely necessary. He is quoted as saying, "It causes us to think, `Do I really need this?'" The need for a prescription should be determined by a trained professional, not by the whim of a newly elected politician.
The implementation of user fees could lead to the closure of small, independent pharmacies, as larger chain-store-type pharmacies have the capability to absorb or discount the fee. The Physician Services Delivery Management Act treats the doctors like the Leamington mushroom workers who were decertified with the repeal of the Agricultural Labour Relations Act. It voids the Ontario Medical Association's agreement, strips the OMA of any negotiating rights and says any judge's ruling, decision, award or order to the contrary "shall be of no force or effect."
It seems when this government has problems with groups or organizations, the easiest way to deal with the problem is to legislate them out of existence rather than sit down and endeavour to reach an agreement.
In conclusion, Bill 26 represents a large power grab and redistribution of power for Ontario politicians. There is an attempt to centralize power into the hands of the ministers of the crown. When that happens, the power really lies in the hands of the unelected bureaucrats, not the duly elected officials. As pointed out, the unelected power brokers of this government can't be trusted by their own people.
In this case, what happens to the principles of democracy? They become sacrificed by a few for the benefit of a few. The government holds no constituency. They answer to themselves and democracy stopped when the ballots were cast. It is because of these actions that the Chatham and District Labour Council holds the government of Ontario in disgust as a government that cannot be trusted and a government that refuses to consider all the residents of this province when setting policy.
Ms Lankin: Thank you, Buddy. You didn't read the next line, which was, "Respectfully submitted, Buddy Kitchen." I'm sort of tempted to offer to substitute for the Chair and to let him say a few words. I think it might be entertaining for all of us.
Mr Kitchen: My quotes are backed up by newspaper articles.
Ms Lankin: Yes, we saw that here, and that's very helpful. You are frank and forthright, as I've always known you to be, and I appreciate your sense of humour, but these are very serious issues that you've raised.
I was speaking to some folks in Toronto who were talking about their analysis of the government's approach. Bill 26 was but one example of it. You touched on it in the end. They identified three things. One was a divide-and-conquer approach. Yesterday in Windsor we had these brochures, which I notice the government's not handing out today, that said, "Ten Great Things About Bill 26 the Vested Interests Don't Want You to Know." So you're a vested interest. Why are you a vested interest? Because you oppose. If you were here agreeing, then you wouldn't be a vested interest; you'd be ordinary folk.
The other things is perpetuating myths. I have to tell you I hear it over and over again in terms of some of the things the government argues around aspects of this bill.
But the third thing, and a really troubling thing, is this issue of transfer of power. I see it in many actions that the government has taken, and you've addressed it specifically within this bill. I'd like you, if you could, to comment on those aspects in terms of the balance in communities and the role that groups representing workers play and what it's like when you're called a vested interest, and this transfer of power that we see in this bill and other actions and what it means for ordinary working people in Chatham-Kent.
Mr Kitchen: Vested-interest groups, special-interest groups -- we've heard them all. It seems like if you're minutely opposed to any direction this government has taken, you're automatically a special-interest group. I would suggest that, given the makeup of this government, they are a special-interest group of themselves -- and there's no doubt about that. Given the direction that their policy is taking them right now, it is serving only one special-interest group, and that's not the majority of the people of Ontario.
With letters to the editor of the Chatham Daily News, there was a letter written by a Dr Evans recently that more or less said, by and large, "We were the ones who supported you in the last election and now you're passing legislation that's even opposing us." Where do the special-interest groups stop when they're not even listening to their own supporters? There's only one vested-interest group that's being promoted, and that's this government.
Mr Kitchen: I really scares me. It scares me when I read these articles on the power brokers --
The Chair: Next question, Mr Kitchen.
Mr Kitchen: Pardon me?
The Chair: Next question. Mr Clement.
Mr Kitchen: Oh, okay.
Mr Clement: Sorry to interrupt you. Did you want to finish your sentence?
Mr Kitchen: I've already been interrupted twice now, so that's fine; go ahead.
Mr Clement: Okay. Can I interrupt you by just suggesting that I appreciate your comments? Certainly I've been around this table now for two and a half weeks. It should come as no surprise to say that not everyone has agreed completely with the government's position; in fact, quite the opposite in certain cases, and yours is one of those. But I respect your position, and it's important in a democracy that the government continue to be exposed to your point of view, so I thank you for bringing your message to this committee.
I've noted all your criticisms of the bill and I thank you for that. I wanted to get to some solutions to the situation in which we find ourselves. I noticed your reference to the Canadian Health Coalition, Ten Goals for Improving Health Care. I'd like you to turn to that, if you could. I just want to get an expansion of your opinions about these particular items. For instance, number 6 is, "Ensure fair wages for all health care providers." In your opinion, how is the best way to get to that? Do you think unionization is part of the answer or is that irrelevant to the issue? How best to allocate the resources, which are scarce by any standards, to help the health care providers?
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Mr Kitchen: I'm not necessarily saying that unionization is the answer to everything, if that's what you're trying to get to.
Mr Clement: No, I'm just asking you.
Mr Kitchen: All we're saying is that health care providers be paid a fair and decent wage for the work that they're doing. If you read what it says here, it's "being shifted on to poorly paid workers in the community and unpaid family caregivers in the home, most of whom are women." I don't think you could disagree with that, could you? "Health care reform should not rob communities of `good jobs' and contribute to the development of a low-wage economy. Wage parity with existing institutional jobs recognizes that fair wages and decent working conditions contribute to a quality of care."
Mr Clement: Absolutely.
Mrs Pupatello: I had an interesting conversation, Buddy, with London Life this morning. They were here. I see on your shirt you have "CAW." You are a member of the CAW. We were talking about where the costs are really going for anything that's going to be delisted in terms of health service or drugs. I want to get your opinion, you either agree with this or not, and that is that anything that's going to come off in terms of a drug that is still required or that your employees are going to want as a part of their package, any kind of health services that are going to come off as a result of this or as a result of the minister's decision, is going to be wanted by your employees and asked for and negotiated for the next time you get into contract talks with the Big Three or whomever. Your success rate in terms of negotiation is probably one of the best in North America. The likelihood of your getting that kind of coverage is probably good, that it would be extended.
That was the problem with London Life, because they recognize that. What's going to happen is that eventually they, as the insurer for the employer, are going to have to encompass additional drugs that are not being covered for now. They'll have to include that as a part, without raising or changing the premium, or the individuals simply don't get it and they pay for it themselves. So we're just shifting the cost burden on.
But in the case of a powerful private union like the CAW, the likelihood is that you'll be able to cover that, in which case that cost moves directly to business, and this bill indeed is bad for business because it has in it the ability to move the cost to the employer.
Mr Kitchen: There's a lot of truth to what you're saying, but let's not fool ourselves. Because a workplace is represented by the CAW, that doesn't necessarily mean that it has a negotiated drug benefit plan. Many of the plants that CAW represents do not necessarily have a negotiated drug benefit plan. Other ones that --
The Chair: Thank you, Mr Kitchen. We appreciate your attendance here today.
Mr Kitchen: Oh, boy, I've been cut off by better.
LONDON-MIDDLESEX TAXPAYERS' COALITION
The Chair: Our last presenter for the afternoon is the London-Middlesex Taxpayers' Coalition, represented by Jim Montag, the president, and Robert Metz.
Mr Jim Montag: Good afternoon. I am Jim Montag and with me is Robert Metz. We both represent the London-Middlesex Taxpayers' Coalition. We are here today to offer our assessment of the medical portion of Bill 26.
Ontario's cost for health care is slightly more than $17.5 billion. The direct payment to doctors alone is $4 billion. The cost of health care for Ontario is the single biggest government expenditure. This is more than what Ontario spends on social services and the entire education system. Clearly something must be done to control this expense and to prevent any cost escalation.
I quote from the November 1995 Fiscal and Economic Statement by Ernie Eves, Minister of Finance: "The government is committed to maintaining health care spending while aggressively eliminating waste, duplication and inefficient practices. Health care will focus on direct care for those in need and on preventative care." This is a commendable goal and we wish them success.
If we don't control spending and reduce the deficit, we may be faced with an alternative solution. That would occur when the International Monetary Fund and the world bankers do it for us. Their cuts would be much more severe than any plan by our government. We need only look to New Zealand for an example.
You have heard and will hear from many groups protesting the government's proposals to control the cost and to remedy the weaknesses in the system. These are mostly self-interest groups with their own agendas. I really can't believe that they have any other than their own interests at heart.
For example, doctors would have us believe that they are deeply concerned with patient confidentiality if patient records are examined by inspectors. However, I believe their real concern is that examination of patient records would enable inspectors to investigate billing practices.
The Ontario Medical Association is seldom regarded as a union. However, it is one of the most successful unions that we have. It has consistently worked to prevent competition and to keep costs high. Once a very powerful lobby, this medical union has lost a considerable amount of its influence when faced with increased control by the government. Obviously, they resent this. With reference to their oath, I wonder if some of the medical profession is confusing the word "Hippocratic" with "hypocritic."
I see nothing wrong with doctors being required to work in remote localities for a few years after graduation. Even bank managers have to work in small communities at the start of their careers.
Many medically intensive treatments recommended by doctors for their patients are not utilized by the doctors themselves when they are afflicted with the same illness.
The drug aspect of Bill 26 will, for some, mean a $2 prescription fee and a $100 annual cost-sharing payment. This appears to be a user fee, and we agree with this concept. These minimal user fees do little harm and go a long way to prevent abuses. We also agree with the plan to no longer pay for more expensive drugs if a less expensive alternative is available. This is plain common sense and something we all do with comparative shopping.
Most of the funding for research and development is directed towards medically intensive treatment and very little is spent on prevention. We believe that a research dollar spent on prevention is better than a dollar spent on treatment.
If I talked about all of the weaknesses in the medical system that I'm aware of, we would be here for a long time. We feel that the provisions of Bill 26 will go a long way to assist the government in its efforts to correct the system.
If Ontario is required to pay all of the expenses for a medical care service, then surely it must have the right to control, regulate, direct and investigate the system. When health care and treatment are free, ways must be found to control the unlimited demands placed on a limited service. After all, he who pays the piper calls the tune.
I would now like to call on Robert Metz for his portion of this presentation.
Mr Robert Metz: In September 1989, Canadian doctor Dr William E. Goodman described Ontario's health care system to an association of American doctors in the following way: "In economic terms, it is an open-ended scheme with closed-end funding. In other words, the potential demands are completely unrestricted, but the money to pay for them is not. It's like giving the public a no-dollar-limit, no-responsibility-for-payment medical credit card, an open invitation to unlimited abuse by both patients and doctors."
In 1992, Canada's provincial health care ministers attending a conference in Banff, Alberta, concluded that Canada's national medicare system would be bankrupt by the year 2000. It is now 1996, and despite its shortcomings, socialized medicine continues to be highly popular in Canada and is even gaining popular support in the United States.
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As Dr Goodman explained in 1989, most people don't understand its long-term effect on their lives, their liberties, their access to first-class medical care or even on their pocketbooks. All they know is that they had to pay nothing out of pocket at the time and place of actual medical service, at least initially.
The vast majority of Canadians had and still have similar difficulties in associating free benefits on the one hand with massive increases, taxes, public debt and inflation on the other. They do not understand that their rapidly decreasing access to first-class medical care is an inevitable consequence of these free benefits. Fortunately, we now have a government in Ontario that is acknowledging the latter reality. "Health care dollars will focus on direct care for those in need," says Minister of Finance Ernie Eves's 1995 Fiscal and Economic Statement.
If this is indeed the direction being pursued by this government, we applaud it. We would remind the government that the public clamour surrounding its new focus in funding does not indicate true need but is simply a predictable result of past governments undertaking to cover everyone for everything regardless of cost.
It is interesting to note that the very concept of directing health care dollars to a specific target, be it the needy or some specific medical procedure, violates the principle of universality. But if we are sincere about our desire to help those in need, universality must be abandoned in favour of a multi-tiered system. Given this government's commitment to aggressively eliminate waste and inefficiency, perhaps it's time to stop for a moment to consider how utterly wasteful and tragic our political commitment to universality is. Under universality, we all lose. As taxpaying citizens, we're forced to support a myriad of social programs invariably justified to help those in need. However, under universal medicare the concept of directing help to those in need is completely abandoned. Universality precludes helping just those in need; it's for everybody.
How can we expect to help those in need when we commit ourselves to squandering billions of dollars on providing free government services to all? Who's holding up the safety net if everybody's inside it? Clearly, universality is no friend of the poor, needy or the disadvantaged. The truly needy have absolutely nothing to fear or to lose by cuts in government spending or by a government that wants to focus its spending specifically on them. For them, such a change would be a win-win situation. Yet you have been faced by a myriad of special interest groups, each insisting that the needy will become victims and lose out by such an approach. "We must protect our universal social programs at all costs," they insist, and in so doing, they offer themselves as prime examples of how the needy get pushed out by the greedy.
One look at the vast majority of the groups that have been permitted to speak before the standing committee will paint a picture that's worth a thousand words. I have a list there before you, but I will not read the entire list. I will just focus on a few, for example, Association of Ontario Health Centres, Canadian Union of Public Employees, the Medical Imaging Clinics of Ontario, Ontario Public Service Employees Union, Ontario Nursing Home Association, Toronto Conference of the United Church of Canada, York Region Coalition for Social Justice, Mytec Technologies Inc, and on and on.
Though all of these groups claim to speak for the needy in some way, the real thing they all share in common is a desire to continue their existence at the public trough. Despite their sentimental pleas and display of concern for the needy, I'd be willing to bet that each and every one of these groups is absolutely committed to the doctrine of universality.
In keeping with the theme of increased efficiency in government health care spending, we would propose for your consideration some of the following alternatives and options to assist in your efforts to get the most value for these health care dollars.
(1) Reintroduce some form of extra billing and user fees. With any form of medical insurance, whether public or private, payment for small claims is also highly inefficient. For example, with car insurance, those insured expect to pay a deductible for small and/or routine matters. In this way, we can rest more assured that more funds will be available to cover the costs of catastrophic illness that might otherwise lead to financial ruin. That is the whole purpose of insurance: a common sharing of major expenses without wasting funds on minor and routine services.
(2) Eliminate government funding for many elective procedures, from cosmetic surgery to abortions, which should be paid for on a user-pay basis or by a private insurance plan.
(3) Insure the patient, not the system. By this I mean that patients should receive copies of all medical billings relating to their claims on the system and that they should authorize them before payments for their services are rendered.
When I was covered by a private dental plan, my dentist was not permitted to remit a claim to the insurance company without first getting my authorization on a claim form that specifically outlined the procedures performed and the amount being charged. It's only common sense, and it goes a long way towards preventing fraud before it happens.
It must be said in conclusion that fundamentally the London-Middlesex Taxpayers' Coalition supports a totally private medical system, with government assistance directed only to those in demonstrable need. However, our preceding comments and suggestions acknowledge that this final and ideal option is not within the purview of Bill 26, nor within the mandate of this government. Nevertheless, we urge you to avoid painting yourselves into a funding corner with no options by preparing yourselves for the inevitable future. We hope our suggestions perhaps, in addition to offering alternatives within the current government medical monopoly, plant the seeds for future debate and consideration of this most worthwhile final option.
Mrs Ecker: Thank you, gentlemen, for an interesting presentation. Having come in to listen to the tail-end of the Chatham and District Labour Council and hearing yours, I think we can truly say that this committee has heard both extremes and a wide range of opinions in between in terms of suggestions and recommendations for the health care system.
One of the things you talk about is insuring the patient and not the system and having patients receive copies of medical billings and stuff. One of the concerns that has been highlighted is misuse in the system, and when I use the term, I use it very generally to include not only any misuse that might be occurring by providers but also misuse by consumers. One of the figures I have is that, for example, in one month 7,000 individuals in Ontario used five or more family physicians, which most people would agree is a fairly serious, interesting use of the system.
How do we get at this sort of consumer use or misuse of the system in the most appropriate way? You've mentioned one suggestion about receiving copies of all medical billings and things of that kind. Are there other suggestions you have for how we might look at that concern?
Mr Metz: Unfortunately, within a medical monopoly, you are kind of backed into a corner, because you have this unlimited demand on limited resources, so what the government is forced into trying to do right now is to limit the demand as well. The only way you can do that is pretty much by doing what Bill 26 suggests right now. That's the inevitable outcome and the inevitable result of adhering to this principle of universal socialized medicine that pays for first dollar right up front.
It's an unaffordable system and to suggest alternatives within it is very restrictive. However, if we were in a multi-tiered system, you would have a situation where, for example, the government would concentrate its resources on the people in need. A fact that's very overlooked by most Ontarians today is that before we had socialized medicine in Ontario, which was 1967, 82% of Ontarians had private health insurance that covered their basic health care needs and would include costs for catastrophic illness. If the government was really concerned about making sure that everyone was insured, they would've concentrated on that 18%, but instead they sold us a plan for 100% of the people.
We have to get back to more user fees. We have to deregulate the medical industry, the research industry. There are infinite options if you're talking about options within a free market system. But if you're talking about options within a government monopoly, you get one.
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Mrs Ecker: You also suggest eliminating government funding of many elective procedures. How would you suggest that kind of activity should ever take place? The difficulty, and one of the things we've certainly given a commitment to, is that the decision about medically necessary is a physician's decision, and you're wandering into territory which many people would say is inappropriate to discuss in this kind of debate. Many of the people who have come forward to this committee would reject quite strenuously what you're suggesting. Do you think that is feasible?
Mr Metz: I agree with you that what is to be determined is medically necessary is definitely a decision between a physician and the patient. However, what is to be covered by insurance is a decision made, normally, by an insurance company, and the person who is getting the insurance claim knows in advance what he's covered for and what he's not covered for.
I think we're talking about two different decisions. It's a misnomer, almost, to be saying we're here talking about health care. We aren't at all. I dare say Jim and I don't know too much about particular medical procedures and that most people around this table do not either. The issue we're talking about here is money and funding and economics, and how to get money into the health care system we have. Unfortunately, government is blocking ways of money getting to the system by banning things like extra billing. On the face of it, it seems ludicrously absurd that we would prevent people who are capable of doing so from giving money and pouring more money into the medical system.
Mrs McLeod: I acknowledge that I come with a different perspective than you bring to the table, right off at the very beginning. I don't know what special-interest group you'd like to slot me into, but I am absolutely, unapologetically committed to the doctrine of universality as you have described it.
I appreciate that in your brief you have underscored, for those of us committed to ensuring that the best is available in health care regardless of ability to pay, how that commitment is going to be challenged by the provisions of Bill 26. I also agree with you that unfortunately we're not here to talk about health care, even though this bill radically restructures our health care system. This is about money. That is also what I have been saying for about 10 days on the road.
Having declared my own bias, however, I'd like to ask you some questions about your sense of the bill from your own perspective, whether you would have concerns. Before I do that, because you note that you see nothing wrong with doctors being required to work in remote localities for a few years, I want to mention the fact that I'm a northerner. I come from northern Ontario and have been involved in recruitment and retention of physicians for a long time. I've just come away from a full week of hearings across the north, and there's nobody in northern Ontario who wants doctors who have been forced to work in northern Ontario. We think there are better ways.
I'd like to ask you a couple of questions, so I hope we have time. You've touched on the fact that you don't have a lot of concern about the access to doctors' records in the name of dealing with fraud. This bill provides significant access to patients' confidential medical information. To be very specific, whereas in the past the general manager of OHIP was able to look at a doctor's billing records and challenge the billings and then refer to the Medical Review Committee to say whether this was medically necessary, this bill now allows the minister to send investigators right into a doctor's office. Those investigators can look at not only a doctor's billings but his charts and notes on patient care and the patient's condition, can take those out of the office, copy them, can then disclose them for reasons the minister deems to be in the public interest, and there is no liability for misuse of the records, no liability to either the inspectors, to the Minister of Health, to the staff members, or to any other individual, and I'm quoting the act directly. It's one of those things you end up having committed to memory.
I'm wondering if you don't feel those powers are somewhat excessive and a grave violation of right to privacy and go far beyond what is needed to deal with concerns about inappropriate billing.
Mr Montag: No. I really don't agree with that. Many other government branches have those powers. The income tax department has the same power to go into a business, to take out the records, to examine them, so why should the medical profession be different? If we're dealing with a government that has to pay for the system, they certainly should be able to police the system. I trust the government, that it's not going to disclose my income tax records to other people. I think I would trust the government commission that it would not disclose medical records to other people.
Mrs McLeod: Some of us become concerned when the government in its own legislation sees the necessity of absolving itself or anybody that works for it from any liability for inadvertent disclosure or misuse of confidential information. Confidentiality is held inviolate by others who had access to confidential information.
Mr Montag: They do that for every group that has investigative powers. They absolve the police departments. They absolve the RCMP. They absolve the income tax department. You can't sue them.
Mrs McLeod: I think you'll find that the privacy commissioner feels the powers go far beyond what are granted anywhere else.
The Chair: Thank you, Mrs McLeod. Ms Lankin's turn. I presume Ms Lankin. Is it Mrs Boyd?
Ms Lankin: No, I'm just --
Mrs McLeod: Speechless. A rare thing.
Ms Lankin: I was thinking about your response to Mrs McLeod about the privacy of information. I wonder if I could come at it this way.
What I know about you two gentlemen, your political affiliations with the Freedom Party, runs counterintuitive to what I think you believe in, so I'm a bit perplexed. What is it about the current system of review of doctors' billings and the financial information -- which in fact can already be done; you can go in and look at the billings and the financial accounting in a doctor's office -- what is it that's not sufficient to deal with the problem?
Mr Montag: I'll simply state that I think it's totally inadequate to police this system with the current system.
Ms Lankin: But your response to Mrs McLeod -- and I'll give you time; I won't use up all the time. I'm just wondering if you actually realize that we're not talking now about the financial billings and what the services are in the billings and checking that out. That's one thing. We're actually talking about the doctor's notations about what you said as a patient and what was wrong with you and the nature of the bug you caught or the disease you caught or the mental problem or the home problem you discussed. Those are the records now that you couldn't look inside before; you could look at the services provided in the billings and check that out. Why do you support the Minister of Health seeing that information?
Mr Montag: We already are doing that with regard to the dental system, and they're doctors as well. When you go to a dentist you authorize treatment and the dentist prepares a bill, and it says clearly on the bill what the treatment was and you have to sign that and then either they send it in or you send it in. This disclosure is already there in dentistry.
Ms Lankin: I think you're confusing a couple of things, or maybe I'm not being clear enough. The idea that a patient would sign off the billing or something like that, that's one suggestion you made and that's something the government could consider. I'm asking you why you specifically support this government taking steps to open up the confidential part of patient information inside the doctor's record -- not the billing, not the accuracy of whether the service was done, not the financial account, but the actual personal health information. Why is that necessary for the Minister of Health to have and to be able to disclose? Why do you support that?
Mr Montag: Like I said, it's already done in the dental industry. The records are there.
Ms Lankin: No, it's not. I'm sorry. You're talking about the billing information, the code of that billing.
Mr Montag: I was talking about medical records as well. A dentist keeps medical records and this is on the bill, what the procedure was. I just believe it gives the government more power to find abuse and fraud in the system. It gives them a total record.
Ms Lankin: I think we understand something different about what is actually happening in the bill, and that's fine; it's a very complex bill and there are different thoughts about what's contained within it.
This is not meant to be a facetious question, but I'm interested in the way you've labelled every other group that's come forward as a vested-interest or a special-interest group. Do you exclude yourselves from that definition?
Mr Montag: Not really. The taxpayers' coalition has an interest. We are interested in accountability for our tax dollars. We are much against the waste of tax dollars and we are interested in accountability, and that's been our purpose from the very start of our organization. We're not against taxes; we know we have to pay taxes. We ask for a service and we have to pay for it. But we've found that in many areas these tax dollars were squandered, and this is our main concern. We feel there are many abuses in the system, and with this bill the government is asking for certain powers to correct the abuses in the system.
The Chair: Thank you very much. Our time is up for this afternoon. We appreciate your attendance here this afternoon, gentlemen, and your interest in our process.
Mrs McLeod: I apologize. I've been in and out of the committee this week, and I'm not sure whether there's been a pattern of acknowledging when a written brief has been presented by somebody who was not able to make an oral presentation.
The Chair: We have not done that, but --
Mrs McLeod: May I? I happen to notice that there is one written brief which has been tabled by Mr Keith Oliver. I just feel that when somebody has gone to the effort of tabling a written brief, we should note for the purposes of Hansard that that brief is available to anybody who would like to read it.
The Chair: Thank you, Mrs McLeod.
We stand adjourned until Kitchener, our next port of call.
The committee adjourned at 1730.