Legislative Assembly of Ontario

1997 ANNUAL REPORT, PROVINCIAL AUDITOR
MINISTRY OF HEALTH

CONTENTS

Wednesday 11 March 1998

1997 annual report, Provincial Auditor: Section 3.10, public health activity

Ministry of Health

Ms Sandra Lang, Deputy Minister

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

Dr David Mowat, director and chief medical officer of health, public health branch

Dr Brent Maloughney, physician manager (acting), population health service, public health branch

STANDING COMMITTEE ON PUBLIC ACCOUNTS

Chair / Président

Mr Bernard Grandmaître (Ottawa East / -Est L)

Vice-Chair / Vice-Président

Mr Richard Patten (Ottawa Centre / -Centre L)

Mr Marcel Beaubien (Lambton PC)

Mr Gary Fox (Prince Edward-Lennox-South Hastings / Prince Edward-Lennox-Hastings-Sud PC)

Mr Bernard Grandmaître (Ottawa East / -Est L)

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

Ms Shelley Martel (Sudbury East / -Est ND)

Mr Richard Patten (Ottawa Centre / -Centre L)

Mr Peter L. Preston (Brant-Haldimand PC)

Mr Joseph N. Tascona (Simcoe Centre / -Centre PC)

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

Substitutions / Membres remplaçants

Mrs Marion Boyd (London Centre / -Centre ND)

Mr Tim Hudak (Niagara South / -Sud PC)

Mr Gerard Kennedy (York South / -Sud L)

Also taking part / Autres participants et participantes

Mr Erik Peters, Provincial Auditor

Mr Ken Leishman, assistant provincial auditor

Clerk / Greffière

Ms Donna Bryce

Staff / Personnel

Ms Elaine Campbell, research officer, Legislative Research Service

The committee met at 1042 in room 228, following a closed session.

1997 ANNUAL REPORT, PROVINCIAL AUDITOR
MINISTRY OF HEALTH

Consideration of section 3.10, public health activity.

The Vice-Chair (Mr Richard Patten): Let me welcome you today to this standing committee on public accounts session. We have the deputy minister and Mr Mowat and Mr Sapsford. Welcome. We understand you have some initial comments before members pose questions to you.

Ms Sandra Lang: Yes. First of all, let me say that we are pleased to be here today to talk about the Provincial Auditor's recommendations regarding public health. It's also gratifying for us that the auditor has, by and large, expressed satisfaction with the progress we have made as it relates to the recommendations.

It was noted in the report that our branch has introduced significant initiatives, which I'm going to be outlining in a few moments. The recommendations of the report are valued by us and we have prepared action plans. In fact, we have addressed the concerns outlined in the report, and I'll discuss most of those actions with you today.

First, though, I'd like to just take a few minutes, if I could, to outline the role of the ministry and the public health branch in defining standards for good health and monitoring compliance in the province.

The most significant role of the ministry under the Health Protection and Promotion Act is to set standards for public health, monitor and enforce them. We believe it is absolutely necessary to establish clear, specific guidelines to ensure consistent delivery throughout Ontario, to provide municipalities with the necessary understanding for the provincial expectations and to provide for effective monitoring and enforcement.

The public health branch provides leadership and support to Ontario's public health system through comprehensive consultant support services to the local boards of health. The branch also provides advice to the ministry's senior management and the minister and staff on public health issues. It provides a provincial epidemiology service and response to control outbreaks of disease. It manages the transfer payments that we still have for public health, and the branch maintains a comprehensive database for planning for population health at the ministry and local levels.

We think it's important for the committee to understand the context in which the ministry directs its efforts towards supporting the health of Ontarians. There are two major components for maintaining good health for our citizens in the province. One component deals with health promotion and disease prevention, and that entails educating and equipping people to take more responsibility for their own health.

The ministry has initiated many significant activities to support this objective. Our heart health program is a specific case in point. This is a partnership between the ministry, public health units and the communities they serve to take action against three key preventable risk factors -- poor nutrition, inactivity and tobacco use -- linked with heart disease and cancer. Our heart health investment of $17 million that was announced recently has been spurring major local initiatives. For instance, for every dollar of funding we provide, our community partners provide $2 worth of in-kind contributions. To date, local communities have committed $11.5 million in resources towards matching this requirement.

The human costs of heart disease and cancer are immeasurable, but the treatment is not. Heart disease treatment costs some $2 billion annually. Cancer treatment runs another $1 billion.

Complementing heart health is the Ontario tobacco strategy, a comprehensive, province-wide effort to reduce tobacco consumption. It tackles the prevention of tobacco use, especially among children and teens. It's also aimed at protecting people from secondhand smoke and supporting smokers trying to quit. The tobacco strategy activities are carried on in partnership with such agencies as the Lung Association, the Cancer Society and the Heart and Stroke Foundation.

The minister recently announced four new initiatives to further the aims of the tobacco strategy and indicated our commitment to enforcement of the Tobacco Control Act. They include funding for pilot testing of a telephone protocol service for a toll-free quit smoking telephone support line at the University of Waterloo; funding for the Commit to a Healthier Brant project in Brantford, which will help disseminate resources to the tobacco strategy partners such as health units; funding to the program training and consultation centre at the Ottawa-Carleton regional health department to assist local health units to launch education campaigns; and funding to the Ontario tobacco research unit for a variety of anti-smoking efforts.

Alcohol and drug abuse are also tackled at the community level through our focus community project, geared to abuse prevention in 11 at-risk communities. Focus directly supports the health promotion and disease prevention component of the provincial substance abuse strategy.

Health promotion and disease prevention are also catalysts for our overall strategy for children. That includes such interministerial initiatives as our preschool speech and language services for children; Healthy Babies, Healthy Children; Better Beginnings, Better Futures; and the Best Start programs -- all aimed at giving at-risk youngsters a better start in life and eliminating costly health and social problems before they take root.

Twenty million dollars goes to the preschool speech and language program, with the program being phased in to serve more and more children so that those awaiting service and those over two years old will have access to service.

Healthy Babies, Healthy Children is a prevention/early intervention program designed to give youngsters a better start in life. Currently, $10 million is being invested to improve their health and life prospects. Better Beginnings, Better Futures is yet another investment in the futures of our children. Best Start, a funding partnership between business and government, uses community-based approaches to develop innovative disease prevention programs.

Women's health promotion and disease prevention motivated the government's investment of about $24.3 million over four years to the Ontario breast screening program.

Those are just a few of the examples of the ministry's health promotion and disease prevention efforts. These and other efforts will continue to increase as Ontario's health system focus shifts from illness to wellness.

The second major component of the ministry's plan is to deal with the setting of standards and monitoring for compliance. The Mandatory Health Programs and Services Guidelines for public health provide goals, objectives, requirements and standards for equal access, health hazard investigation and program planning and evaluation. Mandatory program standards cover chronic disease and injuries, infectious diseases, sexually transmitted diseases and vaccine-preventable diseases and family health.

Since January 1998, public health has been fully funded by municipalities. However, the province continues to provide funding for vaccines. Immunization programs will remain mandatory for boards of health to provide, but the province will retain responsibility for the purchase and distribution of vaccines to the boards of health and health professionals.

Further, we have required boards of health to perform key tobacco control enforcement activities under Mandatory Health Programs and Services Guidelines.

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It's important to us that public health programs be consistent and accessible to all Ontarians. However, we also want municipalities to have flexibility in delivering mandatory public health programs as long as the provincial standards are met, and municipalities will have the discretion to deliver extra services as they see fit.

Now I'd like to address some of the specific issues raised in the auditor's recommendations relating to how the ministry will ensure that the public standards are maintained.

Under the amendments to the Health Protection and Promotion Act, the province has the authority to set provincial standards and monitor compliance and to enforce mandatory public health program standards, and this will be done by the ministry.

We have two key strategies for ensuring the maintenance of public health standards. First, we will continue to provide program consultation, selected information systems, disease surveillance systems and other supports to assist boards of health in providing effective and efficient programming.

We also have a strong legislative scheme to ensure the ministry can enforce program standards. The ministry will be monitoring compliance with the standards through some routine monitoring of boards, and ministry assessors are able to exercise a range of powers to gain information on programs and health units and are able to direct boards of health to correct deficiencies in programming.

A variety of sanctions can also be used if other means have not been able to bring improvements. Sanctions include the charging of boards of health or municipalities or both under the Provincial Offences Act, or the ministry can provide the program and bill back the municipalities.

A monitoring project steering committee and its subcommittees are actively working on the development of a comprehensive system for monitoring compliance with the program standards. The framework will be ready this summer, and reporting is expected to begin by the fall.

In the meantime, existing information systems are being used to assess program standards. The ministry assessors are available to review programs flagged for non-compliance prior to the complete establishment of the enhanced monitoring system.

To ensure the provision of public health programs and services to protect the health of the public, amendments to the Health Protection and Promotion Act clearly specify the statutory role of the local medical officer of health. The medical officer reports directly to the board of health on issues relating to public health concerns and programs; public health staff report directly to the medical officer, who is responsible to the board for the management of public health programs.

In terms of where we are in completing audit recommendations, well over 50% have been completed and the balance are under way. With regard to time frames for completion of outstanding recommendations, the main pending items are the completion of the monitoring system, expected to be done in June, and the revision of the RDIS, currently under way with completion expected next year.

The policies and procedures for control of vaccine expenditures will be finalized by this April.

There are a number of key areas where we are moving with specific actions this year, and I'll outline a few examples for you.

We will be monitoring compliance by boards of health with our program standards. We are looking now, as we are thinking about the business plan, the estimates for the ministry, at how we will include these results in our annual reporting to the Legislature.

An immunization record information system has been developed and is operational at the public health branch. It provides immunization data on coverage of all children in licensed day nurseries and pupils in schools.

With regard to tuberculosis control, the ministry is working with the federal government to improve the tracing of immigrants under surveillance. A federal discussion paper was released in early 1998 and our public health branch has provided a response to the recommendations in that report to improve the tracking of such people.

Immunization coverage achieved in recent years compares favourably with targets established in our Mandatory Health Programs and Services Guidelines. Influenza coverage in long-term care facilities approaches the target of 95%. Pneumococcal coverage is expected to approach the 70% target upon completion of the three-year catch-up implementation of the program, scheduled to finish a year from now. The three-year phase-in is due to the limited availability of the vaccine.

With regard to tobacco vendor compliance, the ministry is committed to the enforcement of the Tobacco Control Act and has required boards of health to perform key enforcement activities under the Mandatory Health Programs and Services Guidelines.

Targets for sexually transmitted diseases have been defined and published in the Mandatory Health Programs and Services Guidelines. The collection of data on results of case management and contact tracing at the ministry level will be improved when the existing reportable diseases information system is redeveloped.

In conclusion, I'd like to give just a few examples of the overall success of our health promotion and disease prevention efforts.

Measles have been virtually eliminated in Ontario following the completion of an immunization campaign in 1996. Anywhere between 2,000 and 5,000 cases had occurred annually prior to that campaign. That number dropped to 22 cases in 1997, and those occurred among children who had not been immunized with two doses.

Ontario has the most comprehensive hepatitis B immunization program targeted at teens. Thanks to school immunization programs, we should see a substantial reduction in this disease.

We have the broadest pneumococcal immunization program in any Canadian jurisdiction, having completed the second year of a three-year phased-in program for seniors and those with high-risk medical conditions. A million Ontarians have been immunized in the last two years.

Provincial rates of gonorrhoea and syphilis have declined dramatically in the past decade, from some 9,500 to 2,300 for gonorrhoea and from 1,500 to 300 for syphilis. This is thanks to the provision of the necessary drugs for treatment of these sexually transmitted diseases.

There has been an 11% decline in diarrhoeal illness due to food-borne bacteria since the implementation of a systematic method of inspection of food premises. The Minister of Health's hazard analysis critical control procedure involves the inspection of hazardous foods from delivery to service in a food premises.

The number of Ontarians treated annually for exposure to rabid and suspected rabid animals has dropped by 50% to 60% since 1995. Our ministry staff works with professionals from other ministries and agencies responsible for animal health to control this disease and that has resulted in a significant decline in rabid animals.

We are proud of Ontario's track record in the areas of public health and we will continue to ensure our standards are maintained.

Mr Peter L. Preston (Brant-Haldimand): I was shocked to hear we were not doing a monitoring of the mandatory immunization programs. I know that in my area it's been going on for 15 years. If kids don't get it, they don't go to school. You get a letter and it says, "Bring the yellow card or don't turn up." That's been going on for 15 years and I found out today that even though it is mandatory, it is not being done in some areas.

I was happy to hear you say there was going to be a program put in effect by this summer to make mandatory things mandatory. We're going to audit municipalities to make sure the mandatory items are mandatory?

Ms Lang: Yes. Perhaps, Mr Preston, what I can do is ask Ron Sapsford, who is our ADM responsible for this area, just to give you a bit of an update on the state of our work with the steering committee and the intentions for the monitoring systems.

Mr Ron Sapsford: Since the passage of the legislation regarding amendments to the Health Protection and Promotion Act, as part of that the new standards and guidelines are part of the regulatory framework, and included in that of course are mandatory immunization programs. That will be a requirement for public health units to provide, and through a monitoring of those standards, through some of the information systems the deputy referred to, we will have a linkage in the ability to monitor that.

As well, where that information gathering raises questions or flags, then the ministry staff, or assessors, as they're called in the legislation, will be able to directly monitor that at the local level and work with health [failure of sound system] framework for the ministry to participate in the monitoring and ensuring these standards are upheld.

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Mr Preston: When I hear "mandatory" I hark back to a gentleman I knew in Peru. You have to be in the army in Peru and I said, "Is service mandatory?" "Yes, mandatory but not necessary."

I want to make sure. Is September too early to ask for a report back on who is complying with the mandatory legislation as far as immunization is concerned, and who isn't?

Mr Sapsford: Is September too early?

Mr Preston: You're starting it in the summer. Is September too early to ask for a report on what's happening?

Mr Sapsford: We expect the data to begin to accumulate this fall so it would take some time to provide those responses.

Mr Preston: January?

Ms Lang: Perhaps, Mr Preston, I can ask Dr Mowat to respond to that, because on the immunization side I think we can say yes, but I'll ask Dr Mowat to comment on that.

Dr David Mowat: The situation is a little complex. It is indeed true that in order to be eligible to attend school in Ontario, a child must be immunized or have a valid medical exemption or a documented conscientious objection. For many years now the health units have reported, through our computerized information system, the proportion of their children immunized at various ages.

In 1996, with the decision to have a massive measles immunization campaign, it took all the resources available to the health units to do this one-time catch-up very large measles campaign. Because of that, they were not able to pay their usual attention to the school entry documentation, so we found for that one year that a lot of the data from the health units were missing.

However, in previous years we have achieved -- one health unit achieves coverage measured in senior kindergarten of 98.54%. Other health units, on the other hand, could be as low as, say, 75%. Overall, at two years of age in Ontario for, say, diphtheria, it's 85%; for measles, 95%. These are good figures. They could be better and we could have more uniformity across the province. We're satisfied that now we've got over the measles hump and they're able to devote their usual resources to the routine childhood immunization, they'll be reporting much better in this year.

Mr Preston: We've been receiving yellow cards and letters every single year, because I have a turnover of kids in my home. So I know there are some health units that are checking every year, regardless of the problems. I know that. I want to find out why others aren't. Is September fine for a report on immunization records, or January? I'd like to have a report back about what's happening and why it's not happening.

Dr Mowat: In relation to the school year, it takes some health units some months after the September start of school to get the class list and to send out letters and so on, so January is a better time of the year.

Mr Preston: Could we ask for a report in January on what immunization is taking place, and if not, why not?

Ms Lang: Certainly.

Mr Terence H. Young (Halton Centre): Thank you very much. With regard to page 166 in the auditor's report, "Sexually Transmitted Diseases," can you please tell me how the sexually transmitted disease program works, when boards of health are required to have appropriate case management?

It says here that the program, "includes identifying, tracing and referring the sexual contacts of individuals who have been diagnosed as having a serious sexually transmitted disease." Can you please tell me what diseases are included? For instance, is hepatitis B included in that? Is tuberculosis included in that? What diseases are included in that program?

What does that mean? What actually happens when the attending physician conducts contact-tracing to the public health authorities, and then what do the public health authorities do? We've seen cases, for example, where a promiscuous individual who has AIDS spreads it to other people intentionally. What I'm wondering is not just with regard to AIDS but with regard to a number of other diseases. What are we doing to prevent that from happening? How does this program work?

Ms Lang: Perhaps I'll ask Dr Mowat to answer the question, given the specific nature of the program.

Dr Mowat: The sexually transmitted diseases that would be of interest would be syphilis, gonorrhoea, genital chlamydia, HIV -- hepatitis B is very often regarded as a sexually transmitted disease although we don't specifically do that. It may involve tracing sexual partners. When a report comes either from a physician, from the health unit's own STD clinic or from the laboratory, it's the staff's duty to interview that person to find out the likely source.

Mr Young: So could you tell me what happens? The doctor notifies the local health unit --

Dr Mowat: Or the laboratory.

Mr Young: -- or the laboratory, and they notify the local health unit.

Dr Mowat: Yes.

Mr Young: Then tell me exactly what they do, please.

Dr Mowat: The health unit, if they have the name, address and phone number of the patient, will contact the patient or will obtain that information from the physician, if that's the only information available. They will interview the patient and they will explain to the patient that if they have not already contacted sexual partners, they may do so themselves or the health unit staff will contact the sexual partner. When they contact the sexual partner, when they're able to find them -- and of course some of these contacts are of a casual nature, such that it is not possible to trace the partners -- they will inform them that they have been possibly exposed to a sexually transmissible disease. They will not mention the name of the patient. They will answer their questions and encourage them to go to a physician for testing and for treatment.

Mr Young: If you can't find the partner, there's nothing you can do about that, I suppose. Are there any sanctions for the doctor or the laboratory or the individual if they don't carry out their responsibilities within that chain of events?

Dr Mowat: The laboratory reporting is 100% in Ontario.

Mr Young: It's 100%?

Dr Mowat: Yes.

Mr Young: Are there any sanctions, though?

Dr Mowat: It's a requirement under the Health Protection and Promotion Act that they report, but there are no sanctions.

Mr Young: Does that include hepatitis B on that reporting?

Dr Mowat: Yes, indeed, all reportable diseases. There's a list of reportable diseases, which can be changed from time to time.

Mr Young: What about the doctors, are there sanctions there?

Dr Mowat: Physicians do not report reportable diseases themselves very often. However, in many cases they know they have sent a specimen to the lab. It comes back to them positive. They know the lab has sent it on to us. They may not consider it worth their while to report it also.

Mr Young: If a person does know who the partner was and contacts them -- it's their choice. The laboratory gives them a choice: "You can contact your partner or we will." Is that how it works?

Dr Mowat: Yes, but the public health nurses use their own good judgement as to whether to trust the word of that person.

Mr Young: Because of privacy-related things, I imagine, and just embarrassment etc, sometimes they don't contact the person. Is there anything to follow up to make sure that person is contacted? The person could be walking around with a disease.

Dr Mowat: That's right. The public health nurse may say, "Go ahead, we've accepted you have notified your partner," or, "Go ahead and notify your partner," but may check on that later, or they may elect to do it themselves because they want to be very sure the notification has taken place.

Mr Young: With regard to actual sexual health programs, how do you intend to enforce the reporting of the mandatory program guidelines?

Dr Mowat: At present there is a committee and a number of working groups, in fact seven working groups, working on different parts of the mandatory program guidelines. There is one working group around sexual health. They are considering ways which are both reasonably comprehensive, but also practical, in which the ministry could require reports annually from each health unit showing the extent to which they have complied with mandatory programs. That process will be ready in June.

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In the meantime, however, there are other means of bringing to the attention of the branch a failure to comply with the guidelines. There may be a complaint or we have our various information systems which we currently have in place. If, for example, in a previous year a large health unit had reported, putting all the sexually transmitted diseases together, 300, and this year we're only getting five reports, it's a red flag and we would call that health unit and ask for an explanation. If the explanation is that they no longer run their sexual health clinics or they no longer have a nurse collating the information on reportable diseases, then that would be a case to be investigated by the assessors.

The Vice-Chair: I'm sorry, we have to move along. You might want to continue your line of questioning afterwards. We're already 13 minutes past, so we'll give the other caucuses the same time.

Mr Gerard Kennedy (York South): Welcome to the committee. I'd like to ask a general question to the deputy, if I might. We understand that you're looking at the future direction of the ministry and so on. How do you see public health as part of any future implementation of a prevention strategy now that implementation is sitting with the municipalities? Can you incorporate public health as part of your plans or do you have to use just loosely coordinating mechanisms like the type that are being described?

This is not a philosophical question; it's a practical question. How will public health have a role in terms of making sure that we have an integrated health approach at least in the future now that it is sitting with the municipalities? I wonder if you have some comments on that.

Ms Lang: Sure. I think it's quite fair to say that we would see public health as being a critical component of any future directions for health. We have a tremendous infrastructure in this province through the municipalities and the provision of public health, and the requirements for them to maintain that infrastructure in terms of the responsibilities they have for our mandatory program guidelines.

We also have the benefit of a significant commitment on the part of many local governments to ensure that we continue to invest in early intervention and prevention strategies, so we would not exclude the expectation for municipalities and their local boards of health to be a very significant player in the strategies for prevention.

In addition, I think the ministry, if it proceeds with additional investments in prevention, would look very closely at the potential for the infrastructure that's available to us through the boards of health for the delivery because of their local awareness and the appreciation they have of their local communities. They have a very strong network of services at their disposal for using education strategies or early intervention strategies. I think we would clearly want to make sure that the public health community is very much a part of our prevention initiatives.

Mr Kennedy: I appreciate that response. I think it's something that many people would agree with, that it makes no sense to have an approach that doesn't include a public health level in terms of an integrated approach to both prevention and some of the detection things that can happen at the local community level.

I guess that brings us to the focus of what the Provincial Auditor is talking about in his report, and that is the accountability. We're told about some areas of accountability difficulty in the past fiscal year. I just cite one statistic, for example, around immunization in terms of those in day nurseries. There is an effective reach of 44%, based on some of the statistics provided.

Those are some fundamental jobs that we think would be front and centre in the responsibilities of public health. I guess the concern we have here in the future is, how are you really going to make sure that even the existing mandates of public health are carried out? I have specific questions in this regard.

Do you have enforcement staff in place today monitoring and interacting with municipal councils as they go through their budget deliberations? In most parts of the province at least boards of health are being directed to cut their allocations or their actual expenditures. Is there some coordination taking place? Do you have the monitoring staff who are making sure that these aren't being done in a way that would be inconsistent with an accountable delivery of the mandated systems? Are those in place now?

Also, with respect to the mandatory guidelines, could we in this committee get a copy of the final edition of the mandatory guidelines? In addition, how are those being implemented? They've gone through their fourth and final draft I guess fairly recently. Have those been accepted wholeheartedly by your municipal partners and what, if any, is the process in making sure that those will find early recognition and acceptance among municipalities? Again, we're in the budget-setting period of what for many municipalities is a changed look for their local public health activities, so I'm wondering very specifically, how are you pursuing those things to ensure that the role of public health is upheld?

Ms Lang: I'll provide some general comments and then I'll probably turn it over to Mr Sapsford to elaborate. I think you had six or seven questions there, if I can keep track.

First of all, the ministry has in place and has identified ministry assessors who are part of the public health branch who are mandated in law to be available to monitor and ensure compliance. We are quite prepared to make ourselves available to local municipalities to assist them with their review of budgets as they are now going forward from the local boards of health to ensure that, as they look at those budgets, they're looking at them with a view to ensuring that they have sufficient resources to comply with the mandatory guidelines.

We have also been working very closely with our municipal partners, both through the boards of health and through AMO, to ensure that the guidelines are practical and are going to allow us to achieve the maintenance of the standards that I alluded to earlier that we are quite proud of as a province. We will continue to work with AMO and we actually have a process in place with them to ensure that they work with us as we review the degree to which we have seen compliance with the standards and we are quite prepared to work with them on making adjustments if there is sufficient evidence to suggest that adjustments are necessary.

Maybe I could ask Mr Sapsford to elaborate a little bit more on the state of our discussions with AMO and the other processes we have in place to get to the achievement of a comprehensive monitoring system.

Mr Sapsford: Some of the concerns expressed by municipalities on the implementation of the standards and guidelines resulted in some discussion which clearly led to an agreement that we needed to continue the discussion around implementation issues. Given that this is the first year, we're starting a process with both AMO and the association of local boards of health to create a process to discuss implementation issues.

As the deputy said, as far as the specific cases with individual municipalities are concerned, ministry staff are available for consultation on specific program areas. We intend to work with the municipalities in that fashion.

Mr Kennedy: I'm looking for a little higher level of specifics perhaps. How many staff are actually currently deployed, monitoring the decision-making at the municipal level? How quickly would you be able to act if a municipality somewhere in the province decided to limit severely or drop what you would consider mandatory programs?

Ms Lang: I'll ask Dr Mowat to give you those specifics.

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Dr Mowat: There are 20 staff within the public health branch who have been appointed as assessors within the meaning of that term in the act. We are monitoring what is happening with budgets and budget requests throughout the province. We're receiving calls, we have sent out a survey, and we are collecting that information at the moment because now is the time when boards of health are looking at their requirements. If we do receive a request that the ministry should provide assistance in equating budget requests with the standards set out in the mandatory guidelines, we will provide that assistance.

Mr Kennedy: I don't want to quibble, but the premise for our discussion here today is a couple of examinations by the auditor around accountability about whether the province can really monitor the achievement of public health objectives. When you say "if assistance is requested by the local boards of health," I guess I'm looking for when some independent decision-making and monitoring on the part of you and your assessors will come into play. In other words, those boards of health will be, as they have been in the past, controlled by appointments by municipal council. The difference this year is that that majority will be looking with some fairly sharp pencils because of the overall effects of downloading and so on.

What I'm wondering is, would you not, I would think, make your own independent assessment of whether or not those measures are taken and not wait for a request for assistance, but rather be fairly proactive to ensure that somehow, with the best of intentions -- and I'm not implying otherwise on the part of municipalities -- but somehow, given their pressures, that public health doesn't go off the rails in a number of communities in this province?

Ms Lang: As Dr Mowat has indicated, we have sent a survey out to the municipalities so we know the state of their discussions with their boards of health on budgets, and if, in the course of that, we determine that there are areas where there needs to be some assistance, we're certainly going to make ourselves available and we might interject ourselves. But the boards of health may also be able to move quite smoothly through the budget process in many places, one would hope, depending on the degree of compliance they have had over the years with the standards and guidelines. Some of the boards are seeking additional resources because some municipalities in the past have reduced budgets, and we know that. We will be monitoring those ones in particular. So I think we have the mechanisms in place and are quite prepared to make ourselves available or interject ourselves where we identify a problem.

On the question of monitoring for compliance, as we are developing this comprehensive system, Dr Mowat also indicated that we have a capacity through our existing information systems now to be able to identify when things aren't quite working the way they should be working in terms of compliance. So there are some trigger mechanisms we use now and have used in the past to identify where there are problems and make ourselves available to those boards and those municipalities.

Mr Kennedy: I probably will come to some of those monitoring and trigger mechanisms later on, but there's one question that I'd like you to touch on for us. Your basis now for enforcement -- you can't withhold funding or you can't make that the point of discussion. You have a system of being able to effectively take municipalities to court. Is that a fair way to express the ultimate power that the assessors have, that if they don't comply, they are subject to the possibility of fines, that form of enforcement? Because this is a new system and it relates very germanely to what the auditor is talking about, how easy will that be to use? What kind of time frame would have to take place for you to actually use the enforcement mechanism provided in the legislation?

Ms Lang: I think we have a couple of means at our disposal. Certainly that is the ultimate one, and having some experience with the courts, I recognize that it may not move quite as quickly as perhaps we would like. But we also have the capacity in law, as I understand it, to provide the programs directly and bill back the municipalities. I think it's our hope that we can use whatever means are necessary to ensure the continuity of public health programs.

Mr Kennedy: Because I have one minute more, I just want to know, for example, for needle exchanges or some of the sexual health programs which may or may not fit the definition of some of the mandatory guidelines, will you be stepping in to provide those programs if they are dropped or diminished by local health authorities?

Ms Lang: I would suggest that if they are not part of the mandatory health programs, that would become a discretionary decision on the part of the local municipality.

Mr Kennedy: Okay. I'll leave that and pass on.

Mrs Marion Boyd (London Centre): Thank you very much for coming. I'm going to continue with this questioning because I didn't hear a response to Mr Kennedy's request for the fourth iteration of the mandatory guidelines.

Ms Lang: Oh, sorry. Yes.

Mrs Boyd: One of the things that drives me a little bit nuts about the way all this change in the health system is working is that you change it, you devolve it, and then you discuss what the mandatory guidelines are going to be and how they are going to be developed. It seems to me that it's quite backwards for this process to have gone on this way. Before you even have decided on the changes in terms of mandatory guidelines, you've already devolved it, so if there is a slip between what was mandatory before and what you are now calling mandatory, that will be a loss of programs to communities.

On top of that, although you assure us you have mechanisms to deal with this, I can tell that all of us are equally sceptical. Since you had the lever of funding before and yet we saw municipalities not obeying mandatory programs, you cannot be surprised that we are sceptical and that the citizens in the communities we represent are sceptical.

You said that if they are not doing it, yes, we could take them to court, but that would take a long time, and then you said we would step in and deliver the programs. With what? Do you have the staff to step in and deliver programs? I don't think so.

Ms Lang: A couple of responses to that. One is that in terms of the final edition of the guidelines, they should be made available to you and I will ensure that they are made available.

Mrs Boyd: Today? We need them today because it's very hard for us to talk to you unless we know what the changes have been.

Ms Lang: The answer is yes. We will get them to you.

The second part of the question relates to the compliance and how we would ensure that those programs are delivered. I guess we would look at a number of options. The ministry does have public health officials as part of our employee base and we could potentially use those, but we could also talk to our other public health units to determine the extent to which they could make themselves available in an interim way to assist where we have a municipality that's not playing in the sense of complying with the standards. So I think we would look at whatever means are at our disposal to make sure those services continue to be provided.

Mrs Boyd: Let us take the example of sexually transmitted diseases, since Mr Young started us on this, and say as Dr Mowat suggested that you noticed that the reporting had been 200 or 300 cases, I think you said, in the past six months, and in this six months you look at the reports and you see five cases. What would you do in that circumstance? What would your process be? And who is looking at these reports? Are you really telling us that you look at reports month by month to see whether compliance is happening? I don't believe that, but if you are, would you tell us what the process is?

Ms Lang: I'll ask Dr Mowat to answer that.

Dr Mowat: These reports are transmitted electronically to the ministry weekly and are in fact run off and scanned. That's how the ministry needs to do this to ensure that on almost a real-time basis there is nothing going missed out there. We also need to spot where there would be a slight increase in cases in one health unit and a slight increase in another health unit which, put together, would be significant. So we do look at these very frequently.

If we determined that there had been a great dropoff in cases, say, of sexually transmitted diseases, obviously the health unit would be contacted and an explanation sought. Were they to say, "We used to run four clinics a week but we have cancelled them," then we'd need to draw their attention to that section in the mandatory program that said you have to run clinics up to a certain level. Ultimately, they would be assessed, a report would go to the minister and the minister would issue a notice to comply with the mandatory programs. If there was a failure to comply with that notice issued by the minister, they would be subject to prosecution.

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Mrs Boyd: You say that the mandatory guidelines indicate the number of clinics that health units are required to provide.

Dr Mowat: That is correct, the number of hours of clinic time to be provided according to population of the health unit.

Mrs Boyd: That's interesting to know. How has compliance been in the past?

Dr Mowat: The number of hours is a new introduction in these revised guidelines. We have information on the number of hours of clinic time provided in the various health units in the past, and there was a range. We have picked a mandatory level that is within that range, so obviously some of them would have to do a little better and others are currently exceeding the guidelines. Taken as a whole, it's a continuation of what the health units were doing previously even without the guideline.

Mrs Boyd: Is that comparable to what is recommended by World Health Organization standards and standards across the world?

Dr Mowat: I'm not aware of any applicable World Health Organization standard in this respect.

Mrs Boyd: That surprises me. I thought there were recommendations that had come forward in terms of the tracking of sexually transmitted diseases. No?

Dr Mowat: Are you referring to the tracking of sexually transmitted diseases or the hours of clinics? I'm sorry. I did not understand that.

Mrs Boyd: The way in which we determine whether we have issues around sexually transmitted diseases in various populations.

Dr Mowat: In terms of the provision of clinic hours, it should be remembered that these are one component of a comprehensive health care system that is available through family doctors and other primary care providers. So we are not the sole provider of these kinds of services.

With respect to standards of follow-up of sexually transmitted diseases, there are indeed standards published by Health and Welfare Canada, and our mandatory programs are consistent with those standards.

Mrs Boyd: When you described how you determined the level of clinic hours, for example, you were talking about there being a range of hours, and then you sort of came up with a number that would be higher than some are offering and lower than others. Mr Sapsford made some comment about it being necessary to have a lot of flexibility because municipalities have different capacities and have provided services differently in the past.

It makes us all very nervous in the area of public health to hear words like "flexibility" in mandatory programs. Flexibility in mandatory programs is what all of us have been asking about. What does that mean? If a program is mandatory, doesn't that mean everyone should be kept to a particular standard, not that we should develop a means of having flexibility that would enable, quite frankly, what we're concerned about: local politicians who are depending on a regressive property tax base taking the lowest possible level of protection for their population base? Is the flexibility there, because they may not have enough money, to provide the same level as they ought to be providing?

Ms Lang: Perhaps I'll ask Mr Sapsford to answer that question.

Mr Sapsford: My reference to flexibility, Mrs Boyd, was not related to the standards themselves but the mechanisms they use to organize the staff and provide the service at the local level. There are some opportunities, and municipalities have identified them, in the way the programs are organized between public health perhaps and social service provision, where there are some advantages in providing those programs in a more coordinated fashion, to have the flexibility to do that. But the standards themselves and the program requirements under the mandatory standards are not flexible in that sense. It's more in how they deliver the services locally, where they may offer services jointly as opposed to separate, entirely divorced programs.

Mrs Boyd: That then raises another issue. If they are offering them jointly, would the people offering those services still be subject to all the confidentiality issues and have the same expertise as a public health nurse? I would be very uncomfortable if I thought what you just said meant that a welfare officer in some municipality was the person responsible for doing some of the reporting in public health that has been done by professional health care providers.

Mr Sapsford: No, I'm not suggesting that.

Mrs Boyd: What kind of program might be offered jointly?

Mr Sapsford: I'm speaking more about not the direct service provision but the administrative structures that support the program delivery, some of the administrative overhead program costs that are associated with every program. So it's those areas I'm speaking to, not in terms of public health nursing being provided by welfare workers.

Mrs Boyd: If that were done, the whole issue that arose when the first iteration of Bill 152 came out around the ability of the medical officer of health to have control over his or her own budget and to have control over the personnel delivering and monitoring that budget, how would that be affected if you are permitting joint delivery of the services?

Mr Sapsford: The medical officer's role extends to the direct provision of the public health services, the direct delivery side of it. There were questions related to the administrative management of the programs at the municipal level. Again, that was where municipalities were asking for some flexibility with respect to their role. But it's very clear, and this statute makes it clear, what the specific role of the medical officer is with respect to the directing of direct public health programs. That continues.

Mrs Boyd: Whether the administrative function is actually done by a staff member of the medical officer of health or not? Any of us who have run programs have occasionally run into situations where someone who is nominally in charge of a program finds they are unable to ensure the program is delivered properly because there is a bureaucratic block somewhere in between.

I think that was what medical officers of health were very concerned about: Will they have the ability if in fact the municipality administrator says, "This is a priority. All the staff in this administrative area are going off to do this task that the municipality deems to be most important," and the medical officer of health says, "Hey, hold it a moment. I have all these administrative things that need to be done, these reports that need to go out" -- I mean, we're talking about little municipalities. There may be one person doing all this stuff. Who wins?

Mr Sapsford: Administrative support is an important issue, and there are many ways of providing it. To the extent that administrative support is required to produce reports, as you're saying, which is part of the compliance process for the standard, the municipalities will have some flexibility as to how that's done. That doesn't change the requirement that there be sufficient administrative support to ensure that there is compliance, that reports are submitted. We're looking at the output of the process, not how the output is specifically achieved in areas of administration. We're going to monitor and ensure that the output is achieved as opposed to focusing on the details of the means.

The Vice-Chair: Thank you, Mrs Boyd. Your time is up. Mr Sapsford, I wonder if I might ask if you could speak up just a little bit. It's difficult to hear you. Mr Beaubien and Mr Hudak.

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Mr Marcel Beaubien (Lambton): Ms Lang, you mentioned that the role of the Minister of Health is to set the standards, monitor them and enforce them, and also that one of the roles of the public health program is to promote health and disease prevention. One of the programs you mentioned was the heart health program. Some of the difficulties, they attributed to that particular program were poor nutrition of people, inactivity and smoking.

I recall reading a report not too long ago where apparently 51% of young adults today suffer from poor nutrition or will say they are not in good physical condition. Am I imagining things, that we have not been monitoring the program or enforcing the program? What is wrong with the program when over half of the young adult population is not in a healthy position?

Ms Lang: I'm going to ask Dr Mowat to take that question.

Dr Mowat: That is truly a difficult question to answer. It is not the case that there are well-known, effective, easy to put into place, cost-effective interventions out there which people are wilfully not using. The fact is that the science is in its infancy and that above all we are talking about human behaviours, human behaviours upon which there are any number of influences, including peer pressure, advertising, various images created in the marketplace. These are extremely difficult to tackle. Witness the fact that there are similar problems in almost every other jurisdiction in the developed world of exactly the same nature. You're quite right to say that this is a problem about which we ought to be concerned and obviously one where we must continue to find new knowledge about how best to tackle these issues and to continue to deliver programs to address them. However, based on recent experience, I think we will have to be satisfied with very modest and slow progress.

Mr Beaubien: To take it a little further, am I correct to assume that the smoking population among young adults today is approximately 30% to 35%?

Dr Mowat: That is correct.

Mr Beaubien: Yet we have had anti-smoking programs for, what, 20 or 25 years, and I think the records show that 20 to 25 years ago about 30% to 35% of young adults smoked. So we have spent money, time and effort and basically we haven't moved, we're in a vacuum. Has anybody really assessed the program? Maybe we're not providing the proper program. Looking at it from a business point of view, if I were in the business world and I spent 25 years doing something, but 25 years later I'm still facing the same situation -- any comments on that?

Dr Mowat: Yes. I don't think it's the full story to say that we've had programs for 20 or 25 years and nothing has happened. Two things have happened. The programs have changed over the years because we've learned. Unfortunately, we've learned rather more about what doesn't work than what does work, but I think progress is being made. Second, things weren't static: We were in fact reducing those teen smoking rates and there was a reversal at the time of the reduction of cigarette taxes, so I think we would have been about five or six points lower than that.

Mr Beaubien: If I may interrupt, the reason we were successful was because we had made it so cost-prohibitive. Is that the way we should regulate? At least that's how I take what you're telling me, that maybe by making it cost-prohibitive we would be more effective.

Dr Mowat: I can only comment that the science shows that young people especially are sensitive to the cost of cigarettes. About a 10% increase in the cost will lead to a 14% reduction in consumption.

Mr Tim Hudak (Niagara South): I want to follow up on some questions of my colleagues about the mandatory guidelines, whether it's a cart-before-the-horse type of issue. Perhaps you could explain to the committee where the mandatory guidelines that are to be released -- we'll get a copy later today -- came from. Are they out of the blue? How different are they from what we've had in the past?

Mr Sapsford: The mandatory guidelines are really the end product of a number of years of work in the public health community. Prior to the new legislation and the mandatory standards, there was a series of documents, or guidelines, as they were referred to, in a number of areas of public health: immunization, sexual health, food premises inspection. So for a number of years, the public health community has worked with guidelines that guided the work at the local level.

These guidelines have been developed by the Ministry of Health, sometimes with standards developed at the federal level, in consultation with the public health community. They were published in 1989 as the guidelines, and subsequently there were additional programs put into place, the tobacco control as one example. In 1997, when the mandatory standards were put in as regulation, it was really a compilation of that history of work that has gone on in this province for many years, and that formed the basis of the mandatory programs and guidelines standards.

Mr Hudak: Do you think it basically captures what is standard practice for the average board of health across Ontario?

Mr Sapsford: That's correct.

Mr Hudak: It shouldn't be a surprise to municipalities, so when we get this report later in the day or when we do get it, will it be shocking to municipalities or should they know what's in those guidelines already?

Mr Sapsford: No, certainly not. As I said, this represents the standard practice in the field at the moment. In many cases in the mandatory standards, you'll see reference to services should be provided according to this specific program guideline which was developed in 1993 or 1992, so the mandatory standards make reference to existing protocol and procedure in the field.

Mr Hudak: The Niagara region, where I am from, has suggested that the guidelines are in fact an unfunded mandate. That's what they say. They say they will have to hire, I forget the number, but somewhere between 30 and 40 full-time equivalents, because they say that these guidelines are new to them, that there's a whole bunch of new programs in there. Is that a fact, or what is the explanation for the difference in opinion between the region and what the ministry is saying?

Mr Sapsford: I can't comment on what's new to them. Certainly it depends on the area you're talking about but, as I have said, in each of the mandatory program areas, the current standard is based on the current practice that has been developed in this province for a number of years. I don't know whether Dr Mowat has a specific comment.

Mr Hudak: I'll rephrase. If the municipality says that the mandatory standards are an unfunded mandate, is that because there is a vast array of new programs in the standards or may it be the case that that municipality hadn't been living up to the current level of standards as they existed up until 1998?

Dr Mowat: When the standards were introduced in 1989, there was additional funding made available by the ministry over three years following that introduction to enable individual health units to come up to the standard. Most took advantage of it but not all. Perhaps those who did not take advantage of that funding at that time would not be in a good position now, and even for those who were in compliance with the 1989 guidelines, some things may have happened since. They may have had their budgets cut. They may have a stable budget but a massive increase in population to serve. All of these are explanations of why there might be some difficulty now.

As to whether there are massive new programs, there are a few small things added because there is new science, because issues arise where I think any prudent person would wish to take action to protect the public. On the other hand, there were several areas where intervention was felt to be less cost-effective, which were deleted from the guidelines, and it was the committee's opinion that those deletions more than outweighed those few small additions.

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Mr Hudak: I notice the auditor as well had flagged, on another topic, the "Medical Service Undertakings" I believe the title is, for immigrants or refugees who had inactive tuberculosis. The auditor had called for bettering the monitoring of those individuals, but I understand that this is an area of shared responsibility and that the federal government, through Immigration, would be required to record some data when they enter the country. Can you help explain to the committee what the role is between the federal government and the province on these MSUs?

Dr Mowat: The issue of immigration and tuberculosis is an important one, because the prevalence of tuberculosis in certain places in the world from which many people immigrate to Canada is extremely high.

The way the system is supposed to work is that they would be screened by a chest X-ray before entering Canada. Many of them will have an abnormality, and it is probable that is old, healed tuberculosis which will give rise to no trouble. However, we know that a certain percentage of them over the space of, say, five years will turn into active tuberculosis, which could infect other people.

The intent is to follow these people, to monitor them medically, to pick up any problems. The role of the federal government is to document these cases as they come in and to forward the documentation to the relevant Ministry of Health, and, in our case in Ontario, we then forward it to the health units. The health unit can make sure they have a family doctor or a clinic and they do get seen. The problem has been in the past that a very high proportion of these notifications are untraceable, usually by virtue of an incorrect address -- people move, people do not follow up with the monitoring.

There has been a large conference of all provinces and territories and the federal government to try and address this in a recent report on immigration. There are a number of actions that might be taken. One is to have provisional immigration status conditional upon complying with medical follow-up.

Mr Hudak: My last question, before I pass it on to one of my colleagues: The government has an admirable record, as the deputy minister had said in her presentation, on vaccination. For example, you talk about measles virtually eliminated across the province, a comprehensive hepatitis B program, pneumococcal vaccinations for seniors. I imagine you're addressing the auditor's concerns, in fact the presentation said, by setting up the mandatory standards for boards of health to achieve to continue this rate of success.

To put this in perspective, could you describe to the committee how this was addressed in the past? Was it in a haphazard way? What kind of monitoring systems were in place and what is the ministry's plan to improve on that? What options do we have to make sure that we continue to monitor and to achieve that level of success for vaccinations across the province? For example, is there any scope in working with the OHIP billings on vaccinations for people other than children?

Dr Mowat: Yes, indeed, it is true that we need to find more effective and cost-effective ways of ensuring that we can document immunization. We do in this province have a very strong law, the Immunization of School Pupils Act, which controls immunization upon entry to school. However, that does not address the many children younger than that who do not attend a licensed day care centre. Their own family doctor may know, but of course people move family doctors and it's sometimes difficult. Also, we have no way of tackling the adult immunization.

Indeed, one obvious way appears to be to derive this information from OHIP claims. We have in fact run a pilot with OHIP around pneumococcal and flu immunization. Those data have been collected and they're currently being looked at to determine whether this is a practical, doable way of following an immunization status.

The Vice-Chair: Thank you, Mr Hudak. I gave you guys 15 minutes. When we come back, Mr Kennedy, you can start. Let me suggest 15-minute rounds when we come back at 1:30. We'd ask you, Deputy, if you could rejoin us with your staff at 1:30 this afternoon. Thank you very much.

The committee recessed from 1156 to 1333.

The Vice-Chair: The floor is over to the Liberal caucus, but first I'd like to introduce Mr Ken Leishman, who is the assistant Provincial Auditor. The Provincial Auditor had to depart because of a death in the family. We welcome Mr Leishman this afternoon. We had moved on to 15 minutes with the government side so, Mr Kennedy, if you'd like to proceed.

Mr Kennedy: I'd just like to come back to the discussion we've been having concerning enforcement. I wonder if I could ask specifically of the chief medical officer of health: You indicated you have 20 people who are identified as assessors. Would those be new staff that you've added for these responsibilities? I understand you had about 39 staff before. Are these an addition in terms of your office, or are these people simply designated under the act and using those powers?

Dr Mowat: No, all 20 are current permanent staff of the public health branch. It was our feeling that for assessors to do their work properly they would have to be people who had a substantial knowledge of the content of the mandatory program, so we are using staff who are, on the whole, program consultants in the branch.

Mr Kennedy: What I'm wondering, and I'm sure you can address this directly, is when we have a different dynamic in terms of public health -- we don't know exactly which way it will break, but there are certainly concerns -- what used to be possible because the province funded if not all then most of the programs, appreciating that those programs would take place, has now been put into an enforcement and regulatory mode only on the part of the province. I just wonder if you could comment.

We've had some other people -- I'll just make some non-political references, so we can be clear that this concern is widely shared. On the part of Duncan Sinclair, I attended a meeting in November in Kingston where he said this download was just plain stupid, that it was going to reduce the quality of public health. We had Richard Schabas at the same event saying that, all in all, he did not believe public health could be sustained as it was in the past, even though he did say there were positive things that had developed.

You can respond to those comments, if you wish, but given the enlarged concern that exists out there, is there not a requirement for you to have some additional capacity to ensure, particularly in the transition stage but I suspect on an ongoing basis, that there is compliance with these very detailed guidelines which we now happen to have a copy of for the first time?

Do you have the capacity to ensure that these can be lived up to, and particularly that those transition decisions on the part of municipalities can be monitored, if you effectively only have the same staff as you had under what many outside experts are saying was a completely different scenario than the one you're being asked to manage now as chief medical officer of health for the province?

Dr Mowat: First of all, we do not expect we would have to have the branch staff devote large portions of their time to a constant, detailed oversight of what is going on in the health units. We do not believe that will be necessary, because it is most probable that the vast majority of health units will make very conscientious efforts and will achieve a high degree of compliance with the standards.

Furthermore, we have designed the overall monitoring and enforcement system in such a way that it should not require an overwhelming burden upon ministry staff; it should not be a very expensive exercise. It's the intent that, using a routine monitoring system which builds upon some of the information systems we already have in place, supplemented by reports in a fairly straightforward format from health units, we will be able to identify potential problem areas. It is only in those circumstances that the assessors will be required to start their work, so I believe this is quite doable with the resources we have available.

Ms Lang: Mr Kennedy, if I could just comment as well, I think it's important for the committee to understand and appreciate that with the exchange that has taken place as the result of Who Does What, the branch staff are no longer required to spend endless hours dealing with budgetary matters. Their time can be freed up to deal with the compliance monitoring functions that are now significantly part of their role as part of the legislative change.

Mr Kennedy: I just want to be clear: Are we talking about branch staff or medical officer of health staff, or is there a distinction in this case? You are also in charge of the branch in a formal sense. Is that correct?

Dr Mowat: Yes.

Mr Kennedy: I'd just like to ask a related question on your role and your independence, because you have some statutory independence, if I'm not mistaken, under provincial statute in terms of your oversight of public health in this province. We heard earlier, I believe, the deputy minister reference the independence of the medical officers of health in certain areas. That was changed after an approach by the OMA. At least, there were some amendments made to clarify that independence. But you'll appreciate we're looking in this new system at whether there are approaches being made currently by the municipalities to change that.

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Is any consideration being given to changing the role of the local medical officers of health or even at the provincial level? Is that under consideration by the government at all?

Ms Lang: I think the regulations that were approved as part of the act are very clear, and I'm not aware that the ministry has any plans at this point in time to alter those regulations. I think we attempted to ensure in those regulations that it was quite clear what the role of the medical officer of health is and will be in the management of the public health system. We're not contemplating any changes. I know the municipalities, in various meetings with us, certainly have an interest in us exploring other possibilities, but we're not entertaining those at the moment.

Mr Kennedy: In what circumstances can you foresee yourself acting in your independent capacity over this new system? I wonder if you could just elaborate a little bit on what that role is. You're not just a line person in the ministry; you also have a responsibility for public health in this province. Does that role change at all under the new arrangement? Do you see an extra onus on you in terms of being able to ensure public health now that you don't have the direct connection? Is there anything on that you'd like to -- because I would like to know if we can expect from your office a slightly different outlook, or do you think it's business as usual?

Dr Mowat: I think it has always been the case that my predecessors have been able to give voice to their professional concerns and to obtain a hearing. I don't think it's realistic to expect that the chief medical officer of health can demand a certain course of action without respect to all the other considerations that have to be brought into play at that time.

In terms of making clear statements about threats to health and a warning about the need to take action against particular diseases or health hazards, it's my understanding that has never given rise to any difficulty and I do not see any reason why that should alter in the future.

Mr Kennedy: Do you see any reason that the medical officer of health should report directly to the Legislature as was suggested by the auditor, that we should receive a report from you about the risks and opportunities for enhancing public health in Ontario?

Dr Mowat: I believe that matter is currently under consideration within the ministry.

Mr Kennedy: Would either Ms Lang or Mr Sapsford care to comment on that?

Ms Lang: My own view is that the medical officer of health needs to be accountable to the minister of the crown who is responsible for the health of the province. We have a responsibility, through the mechanisms currently in place with estimates and business planning, to account to the Legislature. So it would be my view that the work and the responsibility for public health should be included in the minister's accountability to the province and to the crown for health.

Mr Kennedy: Just to be clear, it would not seem, then, that a great deal of consideration has been given to an independent report or scrutiny of public health matters as distinct from -- your point is taken around the line responsibility for budgetary matters. Is that correct?

Ms Lang: I guess I would like to clarify your question. Are you suggesting that we should give consideration to, or asking if we are giving consideration to, the role of the medical officer of health in being an independent body reporting to the Legislature in the same way that the Provincial Auditor is?

Mr Kennedy: The Provincial Auditor raises it as a practice in other provinces. I don't know that the full statutory requirement would need to follow. The two questions raised by the auditor are the effectiveness of the programs in terms of reaching objectives in public health and their efficiency and his suggestion, at least somewhere in his text, that that information could be related directly to the Legislature. I think it particularly apropos, at least for brief consideration here, because we are going to have a more disconnected system. There is no question in my estimation that you won't have the smooth interaction. There will be all kinds of reasons for local health authorities to not smoothly interact with the province. We set ourselves up for a lot of different potential.

Even with the smoothest implementation -- let's say that might be limited to the transition phase; it might be on for longer -- it certainly requires us to know, to be able to test on a regular basis, how much information is really being collected, how much in resources is allocated for us to know where public health initiatives are. That's just one element of it and I wondered if that was at all under consideration, had been ruled out or was something you would consider.

Ms Lang: The direction and the recommendation from the Provincial Auditor was that the ministry consider reporting directly to the Legislature, not the medical officer of health. That's my understanding of the recommendation. As I said in my opening remarks, the ministry is currently considering that in the context of our business plan and our performance indicators in our accounting to the Legislature for the use of ministry dollars. That's very much under consideration at the moment.

Mr Kennedy: I just wonder whether you could comment about the topic I opened up with in my question, which was about the future of health care. How would you ever effectively introduce new programs in the public health domain if they were deemed to be necessary for the purposes of an integrated health system? How could you make them occur with evenness across the province under the system we have today? We're looking at problems we've had in the past, but we're also understanding that there may be much potential in terms of what we can do for prevention with health education and so on. How would that happen under this new system? How do you see that occurring?

Ms Lang: I think there are a couple of ways it could happen, and there are examples of it happening now. I reference the Healthy Babies, Healthy Children program, for example. If the province deems it's necessary to introduce additional programs that are required for public health and see the public health community as the deliverer, the province has the option of developing those policies and ensuring those programs are created, and then making the determination on the financing. Nothing precludes the province from looking at additional resources to finance provincial programs that will be delivered through public health.

I would suggest the other mechanism that's available to us, as we work with the municipalities and the public health community, is to review the effectiveness of the sciences -- Dr Mowat talks about it -- and the effectiveness of the guidelines. We learn through research that there are other ways of doing business, and then perhaps we sit down and talk about alterations to the program guidelines to deal with new knowledge and new ways of providing service.

Mr Kennedy: I'm just curious because even right now you have Thunder Bay saying they can't administer vaccines properly because you paid for the vaccines but the special programs that used to pay for the administrative cost of it don't exist any more. They've made that point emphatically to you. Earlier today we had reference to the fact, in my honourable colleague's question around monitoring what's happening in schools, that in effect that program was cannibalized because there was a provincial initiative for -- I can't remember if it was hepatitis B or measles, but that took away from the effectiveness of local public health, and that was under a more integrated system.

What you seem to be saying is that we're disentangled but we could tangle up again in terms of having the province fund more local programs, that that's an open possibility. I'm just wondering, though, whether you would acknowledge that there might be some difficulty in the effectiveness of such programs given those practical realities.

Currently we have a public health department in Thunder Bay saying they really worry about administering their vaccine programs. We've had the past experience under the old system of having shifting resources. Would you really be able to deal with them if they're under duress with their local budgets, and how would you be able to make sure they're really doing that kind of spending with the dollars?

Ms Lang: I think we would utilize what we have available to us in our policies and our legislative framework. The expectation is that the local public health units will comply with the mandatory standards and guidelines, that the appropriate resources will be available to ensure those programs are delivered, and that if they are not able to do that then we would have to resort to the sanctions and the measures we have available to us by either asking somebody else to do it and billing the municipalities or using legal means. I think our expectation and our responsibility as a ministry is to ensure that there is in fact compliance with the mandatory standards and guidelines.

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Mr Kennedy: The whole nature of that compliance -- the terms used today have been things like "identified" and "requested" and so on. Is there anything by way of status reports within your ministry? How will you or Mr Sapsford know, for example, how the first phase has gone? Are there indexes you'll be following, building on the current information system? Will we have to wait for a year to find out that public health will have deteriorated in this province and then we bring into play these mechanisms? Just to give it a real world thing, how are you kept informed, how is the minister kept informed about how this is unfolding, this new world for public health services in this province?

Ms Lang: As Dr Mowat indicated, we are putting in place the monitoring process through the steering committee and that will be our vehicle for ongoing monitoring and status reporting. But in the interim, as a ministry, we have internal performance management and program requirements. Reporting is necessary when there are issues that need to be dealt with. So Dr Mowat, as the chief medical officer of health, has an obligation to advise when there are problems. As we are, as a ministry, dealing with the Who Does What implementation, we are obliged to report on the progress we're making and the effectiveness of that as part of an overall government desire to monitor the Who Does What implementation.

Mrs Boyd: This accountability issue obviously is the most important one we all have, so, if you don't mind, I'd kind of like to get pretty clear what the lines of accountability are. Who is the employer of a medical officer of health?

Dr Mowat: The board of health employs the medical officer of health.

Mrs Boyd: Who comprises the board of health?

Dr Mowat: The board of health can either be an autonomous board of health, in which case it will have a majority of members appointed by the participating municipalities and may, in addition, have one or more order-in-council appointees, or it may be the council of a region. We are currently working on implementing the new clause in the act as amended, allowing some other councils to function as boards of health.

Mrs Boyd: In what circumstances would there be order-in-council appointments to a board of health?

Dr Mowat: Up to now, it's been fairly routine that most boards, as opposed to councils functioning as boards, have had order-in-council appointees. It is probable that in the future fewer will be appointed. Many municipalities have made representation that they would prefer an all-municipal council.

It's the government's position that it should retain the right to appoint order-in-council members and would probably do so if the board wished to have those members appointed, or if the board was felt to be experiencing some difficulty in complying with the standards and that the appointment of other members might assist them.

Mrs Boyd: Then basically we have a situation where the medical officer of health is the employee of, and reports to, the board of health, which in many cases is made up of municipal councillors, certainly the majority of municipal councils, even where there are order-in-council appointments?

Dr Mowat: Correct.

Mrs Boyd: Okay. So really the boards of health are the creatures of the municipal councils, right?

Dr Mowat: Yes.

Mrs Boyd: If the municipal council decides -- I'm just reading where you say here, on page 2 of your standards and guidelines, under 4:

"Capacity: Are we able to do it?

"It should be within the capacity of the local board of health, working with the community, to provide the program (ie, reasonably compatible with the current or achievable resources and skills of the organization.)"

It goes on to say: "The cost of an intervention must be considered. This should include an assessment of the costs and benefits of a program as well as its impact, both positive and negative, on other programs in terms of monetary costs, opportunity costs and other effects."

Essentially if a municipal council decided that it was not reasonably compatible with its current or achievable resources to offer a program that is supposedly a mandatory program and that it costs too much, the benefit wasn't enough and it costs too much, what is to prevent them from ordering their members of the board of health to order the medical officer of health not to offer that program?

Dr Mowat: That's in fact a misinterpretation of the document. What the board of health must comply with are the requirements and standards under each of the mandatory programs. They state what programs and services must be delivered. The preamble section, from which you read, is, as the title says, an introduction to the standards which explains where the standards came from. The four principles which are laid out there -- need, impact, appropriateness and capacity -- are mentioned there to illustrate how the mandatory program advisory committee arrived at the standards which come in the body of the text. They are what guided the production of the standards, but the standards are what must be complied with. It is not permissible to reinterpret those four principles again and apply them to the standards. For example, with respect to capacity, it is the intent that, taken as a whole, the new mandatory programs should be no more onerous than the old mandatory programs, and therefore we can expect that the capacity to deliver them should be present.

Mrs Boyd: Okay, then that takes me back to the question Mr Hudak asked. He asked why he was hearing in his area that municipal councils feel these new standards are going to be onerous. The answer, as I understood it from you and Mr Sapsford, was that when these standards that were in effect before January 1, 1998, were put in place in 1989, the ministry provided additional funding to municipalities that wished to have it in order to put into effect the mandatory programs. I understood your answer to be that some municipalities didn't take advantage of that.

My understanding of the issue Mr Hudak was raising, then, is that obviously some municipalities weren't offering mandatory programs and are now saying, "I don't care whether I was supposed to be offering them from 1989 on; I don't have the capacity to do that." We certainly are hearing that argument from municipalities. I understand that in the northwest we're hearing very strong arguments from municipalities about their inability to afford to meet these minimum standards. Is my understanding incorrect? Did I not hear you say that, that some municipalities may be in difficulty now because they didn't have the 1989 standards in place? Is that what you said?

Dr Mowat: It may well be that there will be more difficulty for some health units to achieve or maintain the standards in the new mandatory programs. I think that flows from our certain knowledge that immediately before these standards were introduced, there was a range of per capita expenditures by public health units across the province, from which I think we can deduce that for a variety of reasons -- any one or more of many reasons and things that have happened between 1989 and 1996, some of which were in the control of the boards of health and some weren't -- that capacity may have been eroded to some extent in some health units. Notwithstanding that, we believe, and it was the intent during the revision of the mandatory programs, that taking the province as a whole, the provision of the new mandatory programs should not present an additional financial burden.

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Mrs Boyd: But even when the provincial government had the major cost-sharing role in the provision of mandatory public health programs, there were some boards of health that were not providing those programs? Is that what you're saying?

Dr Mowat: That's correct.

Mrs Boyd: Then what on earth makes you think that when they have to pay for them all by themselves they're suddenly going to fall into line?

Ms Lang: I think I would argue that the government, through its legislative scheme, has introduced mechanisms that weren't there previously for enforcement, such as the capacity to offer the program and bill the municipalities or to use the legal means of the Provincial Offences Act. Those are strengthened mechanisms that were not there previous to the legislative changes that have been put in place to deal with the requirements of the government to monitor and ensure that there is compliance.

Mrs Boyd: A medical officer of health is the employee of a board of health, which is the creature of the municipal council. What recourse does that medical officer of health have to fulfil his or her mandate to protect the public health of the community? What would they do if they found that their capacity to carry out their duties under the act was being stymied by a board of health and a municipal council? What could they do -- without getting themselves fired, obviously.

Dr Mowat: As a result of the discussions around Bill 152, the amended Health Protection and Promotion Act states very clearly now, which was not the case before, that the medical officer of health has the right of access to the board. Because he is in day-to-day charge of public health activities and the delivery of public health programs and services, he is in a position to know what is going on, and I suggest in the discharge of his or her duties would present to the board -- this is in an open meeting -- a statement of where the deficiencies are with respect to achievement of the standards set out in the mandatory programs. In addition, if assessors are appointed, the assessors have the right to question any employee of that board, and employees must answer and answer truthfully. So I think there is a number of options open to a medical officer of health in those circumstances.

There will be reports, through our monitoring system, to the Ministry of Health, and the medical officer of health will be involved in drawing up those reports, and of course it will be required that those reports do in fact reflect the true situation.

Finally, the provision in the former act continues that both the appointment and dismissal of a medical officer of health requires the approval of the Minister of Health, and this clause was originally put in there so that a medical officer of health should have no fear about bringing forward any such matters into the public domain.

Mrs Boyd: In other words, you think that will protect a medical officer of health from local reprisals?

Dr Mowat: That was the intent of the clause as originally placed in the act, yes.

Mrs Boyd: I certainly have heard many of the medical officers of health say that they have grave concerns about their capacity to actually carry out their duties under these circumstances because of the kinds of pressures that are going to be on municipal councils, given the extraordinary burden that has been placed on the property tax by the downloading and very real concerns that there will be choices made that may not have an immediate effect but in the long term would have an effect. It's going to be very hard for a medical officer of health to convince a board of health that something that is an appropriate preventive or health promotion action that isn't going to bring any kind of relief to that municipality but may bring relief down the line to the health ministry's budget -- it's going to be very hard to convince them to spend local dollars on something which is not necessarily going to have any payoff.

To say that it's open and the public can attend, the public is the taxpayer that the government is so worried about, and they may share those concerns that there's no local payoff and why should they be carrying the burden which should have been borne by the provincial or federal government.

Mr Preston: We've said a lot about downloading or transfers or cutbacks or what have you. This is maybe an observation to you but a question to the auditor. With the federal government, the federal Liberals, taking $2 billion out of our budget, what thought has been given to reducing payments to self-interest groups?

We gave $25,000 to the Citizens For Local Democracy. I'm not picking on them, but it comes to mind. That was to fight amalgamation, which we tried to put in. That $25,000 and like amounts to other single-interest groups could go a long way to helping the health industry do some of the jobs it has to do, including the monitoring of the standards. Has there been any thought given to reducing grants to single-interest groups and putting the money towards helping groups that are really concerned with everybody?

Mr Ken Leishman: I think you would have to ask the Minister of Health that question. That's a policy-type question that we don't deal with.

Mr Preston: This is not money the Ministry of Health gives out; this is money that all kinds of ministries give out to self-interest groups. It's a policy decision to give it to any particular group, but is it a policy decision that we continue to do that or is it not a recommendation from the auditor that we can't afford to do that any more?

Mr Leishman: If we were ever to get into an audit of grants such as that, we may or may not have recommendations. But not having done an audit like that, all I could say is that it's up to the individual ministers and the Premier.

Mr Preston: We can't afford to find out that kids have been immunized but we can pay for parades against what we're doing. It doesn't sound reasonable.

The Vice-Chair: Mr Preston, the auditor is there not to set policy; he's there to audit programs once they're in place.

Mr Preston: I understand that, but they do make recommendations and I wondered if that was ever one of them, because we did lose $2 billion to the federal government that is coming out of these programs.

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Mr Beaubien: I'm going to go back to a question I asked this morning. If we refer to the Mandatory Health Programs and Services Guidelines that you provided to us late this morning, on page 14 and 15, reading from item 4, it says, "The board of health shall work with community agencies and groups and health professionals to provide information and education on the benefits and methods for quitting smoking including community smoking...." and it goes on. In 5 it says, "The board of health shall contribute to the reduction of the secondhand smoke exposure to the public...." and it goes on.

Number 7 says, "The board of health shall work with municipal recreation departments and other community partners to promote and increase access to regular physical activity for people of all ages."

Then number 8 says, "The board of health shall work with community agencies and groups to promote access to sufficient, safe, nutritious and personally acceptable food for people of all ages."

I'm going to go back to what we talked about this morning under the public health act. You want to promote health promotion, you want to promote disease prevention, but some of the difficulties with the heart problems we have in Ontario and probably in Canada are poor nutrition, inactivity and smoking. If we look at the four points I referred to under the guidelines, which are administered by the public health, and possibly to follow up on Mrs Boyd's comment, it is difficult to get results today. This morning you referred to the fact that it's a social problem: health, activity, smoking, whatever. I tend to agree with that, yet it's under the guidelines, the jurisdiction of the Ministry of Health, the public health. My question is, is this in the wrong place? You've been working at it for 20 or 25 years and the results are not there. If it's a social problem, why is it under the Ministry of Health?

Dr Mowat: I did express the difficulty of tackling these problems. It is well known, of course, that these problems originate with health behaviours of individuals but also the social and physical environment. I don't think that's quite the same as saying it's a social problem.

As to the issue of who should have responsibility for these, the fact that these very important health problems, very prevalent and serious health problems, are addressed in the mandatory guidelines by no means precludes other actors from becoming involved. Of course there are many voluntary agencies active out there, and health providers, physicians, hospitals and workplaces, that also share that concern about heart disease and are active in this area. In fact one of the thrusts of the heart health funding is to enable health units to take a leadership role in bringing all of these actors together.

Typically one of these heart health programs would involve the health units, the Heart and Stroke Foundation, various voluntary groups concerned about perhaps bike paths and exercise, availability of good food for the poor, and get them to work together to have a greater impact. In fact, I believe there is evidence that when there is a comprehensive program which addresses its message to the public through a number of channels, attempts to change the social and physical environment to make these health behaviours easier to do, it can have an impact. Dr Moloughney, if you'd like to come to the front, there are examples in the literature, are there not, of comprehensive heart health programs which have produced impacts?

Dr Brent Moloughney: Certainly the whole model and approach with heart health has been something that's been going on in this country for over a decade.

The Vice-Chair: Can I ask you to introduce yourself for Hansard, please.

Dr Moloughney: I'm sorry, I thought Dr Mowat had done it. It's Dr Brent Moloughney, and I'm with the public health branch as well.

The Canadian heart health initiative has been a federal-provincial partnership, as well as with the third sector in terms of non-governmental organizations, particularly the Heart and Stroke Foundation, which has been going on for over a decade trying to model, what are the most effective ways of promoting heart health in our country? We've gone through a number of phases, and I'm quite pleased to say this province has been one of the leaders nationwide. Many of the other provinces, some of which I've worked in as well, have looked to this province in terms of best approaches.

A fundamental aspect of the approach has been one of partnership. That is why, when you are reading through the requirements in this section, there are those statements of working with others. Public health isn't alone in trying to accomplish these things and needs to, at a community level, work with other organizations to have the most benefit. Anyone who has ever been involved in, say, working on local bylaw development for secondhand smoke, the only way to accomplish those sorts of important initiatives is through those partnerships.

I think the evidence now and the recommendations by expert groups is that you definitely need those partnerships occurring at local levels, regional levels, provincial levels and in fact nationally and now internationally through the World Health Organization collaborative centres to have those partnerships, because no one agency can do this alone.

Public health, though, has the set of skills, knowledge, abilities and linkages to have a very key role in dealing with a wide variety of issues, particularly heart health, which is why the ministry decided to ensure that public health units were in a key position and the receiver of funds in the current heart health project that was announced earlier this year.

Mr Beaubien: Let me concede that public health certainly plays a key role. I think as someone pointed out, under the new bill there might be some legislative enforcement mechanism, but the reality is, as Ms Boyd pointed out, that the medical officer of health does come under the responsibility of the local district health board. Even though we may have these legislative and enforcement mechanisms in the bill, we have not been very successful in the past in enforcing and regulating the programs we had in place. How are we going to do that in the future and who is going to be responsible for the output results? Who is going to measure that?

Dr Mowat: The fact is that all the health units in the province applied for and received funding through the heart health initiative from the public health and health promotion branches. There are many examples across the province over the last, say, 10 years of some high-profile and innovative, comprehensive programs -- Brant, Ottawa and others -- that I think have made good progress against cardiovascular disease.

As to the question, who is going to measure this, obviously measurement is not easy but one of the fundamental skills of health units -- and they employ staff with these particular skills -- is to measure morbidity and mortality and the health of communities. That's a very important role. In fact, there is a mandatory program which requires health units to be aware of the needs in their particular area and, as much as is possible and reasonable, to evaluate the impact of their programming.

Mr Young: How much time do we have?

The Vice-Chair: You've got three minutes.

Mr Young: Okay. We can come around again, at any rate.

In future, if there were any similar outbreak to the recent meningitis outbreak, how would you intend to pay for the cost of dealing with such an outbreak, the vaccines etc?

Ms Lang: I would suggest that in that circumstance the ministry certainly was there to assist in whatever way it could. The government will continue to pay for vaccines, there's no question about that. If we are faced with an extraordinary circumstance that means there's undue hardship on the part of a municipality, then I think on a case-by-case basis we would take a look at that and determine whether there has to be some additional assistance provided.

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Mr Young: We've had a recent spate of problems -- serious problems and some less serious, I suppose -- of waits in emergency departments of hospitals. I've done some inquiries in my own community, and one of the problems is that we pay doctors on a fee-for-service basis, which works sometimes, and sometimes it doesn't serve us very well. If a doctor is waiting in an emergency department that isn't busy, the doctor is making no income, so naturally is disinclined to wait around. A hospital often will have just one doctor there, and if the waiting list fills up and it gets to a certain critical mass, then they'll call another one in.

The problem is the waiting list. What initiatives are you making towards at least dealing with it in emergency departments, paying doctors on salary to make sure we can keep the waiting periods in emergency departments down?

Ms Lang: We have a couple of programs in place at the moment. One is called an alternative payment plan, where we negotiate with doctors and hospitals for the establishment of an alternative payment plan that allows for the necessary coverage in those emergency departments to cover that requirement. We also introduced a year ago, as I understand it, a special stipend to provide hospitals with funds to make available to the doctors on call to deal with the requirements for emergency caseload.

Mr Young: So why are we having these problems?

Ms Lang: We actually have a task force under way at the moment to help us understand and get a much more specific factual report on that, but there are a number of circumstances that would suggest that the problems are related to what seems to be a significant prolonged problem with an influenza strain that we can't quite understand. That apparently happens every year about this time, but this one seems to be hanging on much longer than traditionally. We also have some reason to believe that some of our hospitals are not making the necessary accommodations for that kind of increased caseload in the emergency department by looking at their elective surgery requirements.

We're hoping that when the task force reports, we will be able to introduce, with the cooperation of the hospitals, the necessary measures to make sure there is emergency response and emergency capacity. We're also quite hopeful that this influenza problem will dissipate fairly quickly.

Mr Kennedy: The reference made to hospitals -- you raised a question. I'm wondering, does the ministry recognize that the problem at hospital emergency rooms is province-wide? Do they understand that it is not just Toronto or the GTA? Is that acknowledged by you?

Ms Lang: We're aware that there is significant strain on emergency departments across the province, yes.

Mr Kennedy: Is there an effort under way by the ministry to deal with the problems in those other areas? The task force doesn't have that mandate as far as I'm given to understand. What would those efforts be?

Mr Sapsford: The first task was working with OHA region 3, which is the greater Toronto area, to do some preliminary data analysis and survey work on trying to identify the specifics of the problem. The understanding of some of the other areas -- Ottawa, Hamilton, London and Windsor, to name a few -- would be that we would take the results of that preliminary analysis and then begin working in those areas of the province as well.

Mr Kennedy: I'll add to your list. Thunder Bay has some of the better statistics, and they have what they call corridor admissions. They have to have a category for putting people in the hallway rather than in beds. They're up fourfold over the last two years.

I'd also like to ask you about the influenza idea, because we're here on public health business principally. I'd like to know how influential the medical officer of health believes the impact of this season's influenza -- I understand there was a mismatch of some of the influenza vaccines with the actual strain, and I know that's not a fault thing; that can happen. I wonder if you could clarify for us, in your role as medical officer of health, how impactful that has been this year versus some of the other factors that are being cited by different people.

Dr Mowat: I'm not able to give you an estimate of the impact of influenza versus other factors on the activities of emergency rooms, because that is not my area of expertise. I can tell you, however, that it has indeed been a severe year for influenza. The reports are well up on last year even though we expect further activity to continue, so it may well be we have twice as much influenza this year. Furthermore, a high proportion of the cases are at the upper end of severity.

Influenza in a young, fit person is to some extent an inconvenience. It makes you feel dreadful. You lose work, which is important, of course. But in the frail elderly, it can make them very sick indeed, such that they would require to be seen in an emergency room, possibly admitted, which is why that is the target group we aim immunization campaigns at, and indeed we have quite a good coverage in this province with influenza vaccine.

The influenza virus can mutate and does mutate normally very slightly, if at all, so that the vaccine preparation which contains the three flus you are most likely to come up against works pretty well. Unfortunately, this year we had a new strain, A Sydney, which appeared much too late to be incorporated into the vaccine, and the correspondence between the A in the vaccine and A Sydney was fairly slight. Many people who might have escaped influenza altogether did get influenza, and of those who caught it, a lot of them were quite sick. So indeed there's no question that we had a severe influenza season, and that would unquestionably give rise to a large increase in the demand for medical care.

Mr Kennedy: I'm intrigued that you say the actual impact of influenza on emergency wouldn't be something you would monitor, that you wouldn't be receiving reports from hospitals. I'm just curious about that part of your statement. Would you not be kept informed, particularly if it was seen to be having a very strong deleterious effect on the health system in addition to the people who are infected?

Dr Mowat: We do have monitoring systems in place throughout the province, and they are the monitoring systems that we consider to be the most sensitive and that give us the earliest indication of influenza problems. They are absenteeism levels in school, absenteeism levels in selected workplaces and reports of influenza-like illness from nursing homes. Those are the ones that we use, and we are satisfied that this gives us a timely and sensitive indication of influenza activity, as well, of course, as our reports from the laboratory. We are aware that large numbers of people with influenza turn up in emergency rooms. What I'm not able to tell you quantitatively is the effect upon those emergency rooms.

Mr Kennedy: And those data would be used by the institutional branch to advise and warn hospitals of the potential impacts? Does that level of coordination exist?

Mr Sapsford: Specific advice to hospitals about that?

Mr Kennedy: Yes. If it is being monitored by public health, would it not then follow that you would issue information bulletins, whatever, to the hospitals to let them know that you have an increased incidence taking place? Does that happen as a matter of routine?

Dr Mowat: The influenza information we compile every two weeks is faxed out to health units. If there's a particular issue, a sudden flare-up of activity, then it will be faxed more frequently to health units and those health units are then able to provide that information immediately to hospitals and physicians within their jurisdiction.

Mr Kennedy: Was that being done in the first few months of this year and does it continue today?

Dr Mowat: Yes, it was.

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Mr Kennedy: I want to ask a question of Mr Sapsford. Last year, when you joined the ministry, there was some confusion about your status as the person now in charge of, I believe, institutional health as well as population health. At that time the deputy minister indicated that you were on a secondment. Is that still your status today or are you an employee directly of the Ministry of Health?

Mr Sapsford: No, I'm on a three-year secondment.

Mr Kennedy: I just wanted to verify it because we were promised at that time some details of that secondment which haven't arrived. I think it's germane because there is some question about what the overall approach and the vision of the ministry is going to be, community versus institutional health. I think there are proposals coming to beef up the institutional sector. But just for the record, you're on a secondment from Toronto Hospital. Is that correct?

Mr Sapsford: That's correct.

Mr Kennedy: I understand, from the deputy minister last year, that there are specific clauses that you're subject to around confidentiality and so on that protect a potential conflict of interest. There was an offer at that time to make available to us those clauses so that we could know how the ostensible conflict of interest, being in charge of all hospitals as well as the community section of health care, would not conflict with the fact that you're receiving your stipend from Toronto Hospital. Is it possible to receive that information?

Ms Lang: I'm not sure what information was promised to you, Mr Kennedy, but I have two concerns. One is, I'm not sure this is an appropriate line of questioning in the context of today's meeting. Second, I think it's fair to say that the terms of employment and conditions for employment are within the guidelines of the government for ensuring confidentiality, so I'm not sure that it's appropriate to go into any further details of a private employment relationship.

The Vice-Chair: Mr Kennedy, I'd suggest that if you want to raise that, maybe in our closed session you might bring that up.

Mr Kennedy: Are we going to have an opportunity for a closed session in committee?

The Vice-Chair: In committee, yes.

Mr Kennedy: Okay. Relevant to this question, within the public health field there are people who have raised this issue to me as a concern. In other words, what is the background, who is calling the policy decisions? Public health was downloaded against some significant objections. We're here today to discuss some of those implications as well as the ability of you as the ministry to be able to monitor what happens to public health. I'm asking that as a matter of clarification, which was raised in estimates. I know it's a different committee, Mr Chair, but I just believe it would be helpful if we knew that that potential for conflict wasn't there.

The only question I have is, are secondments a usual practice within the ministry in the senior ranks? Are there other examples of that? Is this just a normal thing or is it unusual, in your estimation, Deputy?

Ms Lang: In my experience across government there is a value in trying to blend the expertise that exists within ministries with the expertise that exists in the broader public sector, and I for one would be, and have been, very much a part of having secondments come in from various parts of the broader public sector to enhance our understanding and our front-line knowledge. It is in fact something that is in place and in practice in various ministries across government. I can assure you that I personally think it's a very valuable thing to do, in addition to our capacity to consult with those who are in the front lines providing service now. The more we can bring in the expertise and share that expertise between ourselves and the broader public sector, the better, as far as I'm concerned.

Mr Kennedy: I'd like to ask about the specific staffing taking place in the Ministry of Health. We touched on it earlier. I wonder if it would be possible to share with us just how this transition period is being handled. Is it possible to make available to this committee the deployment of staff in terms of how those assessors will operate? Will they be full-time assessors? How will that structure be compared to the structure you had before?

There was reference made that these are people who were previously working on budgets and liaising with individual public health units. Is it possible to get us a staffing structure, or is that ready and available yet in terms of how they are going to function -- will they be, for example, regional assessors; will they be set up on that kind of basis? -- and some idea that we can draw from that about the capacity you're going to have?

Dr Mowat: We would be able to provide you with the org chart for the public health branch and indicate those members of the staff who have been appointed as assessors. This whole process of monitoring and assessing is one that is under development right now and, as we have said, we intend to have it fully operational by the end of June. We are working on exactly how the assessors would work, but it's quite clear that they would work within their area of expertise. If we have, for example, the consultant who looks after tobacco issues and we had a health unit where there was reasonable cause to believe that the tobacco mandatory program was not being properly implemented, then we would call upon him to undertake that assessment. It's our belief that it does require knowledge and experience in how programs are actually delivered in the field and in-depth knowledge of the particular mandatory program to undertake that assessment.

Mr Kennedy: Bear with me perhaps in the persistence of this. Your predecessor said everyone should be watching very carefully what happens to the public health system over the next few months and the next few years. That's what we really want to understand, where you're going to go with your changed ability and also your outlook. Who are you and who are you looking at in terms of making this happen?

The mechanism that you have in the legislation, I just want to maybe touch back on that. If your assessors tell you there's something wrong, you're not able to make arrangements, how ready will you be to go in and run the programs? How ready will you be to take a municipality to court? Can you give us some concrete indication? I know that these are new provisions, but the likelihood that these would be used within a three-month time frame, a six-month time frame -- how severe would the conditions have to be for the province to use the only means they have, which are fairly heavy duty, to make the municipality comply?

Ms Lang: Clearly what we would want to ensure is that we are working quite collaboratively and closely with those boards of health or municipalities to rectify and correct the situation, which would be our first line of involvement, and to assist them with whatever support we could to get them back into compliance and draw on the resources of other public health units, if that would assist in fixing that.

Using the potential we have for consultation and persuasion and support would be the first approach one would take. I would assume we would not be using the more heavy-handed legislative tools at our disposal unless we were of the view that there was a serious public health risk.

Mr Kennedy: I will ask you on my next round, because I think it's up, but I'd like to know your definition of what a serious public health risk is, because we have cited back to us from the minister, or the government certainly, that there are mechanisms in place that people will be protected. You cited them earlier, but obviously those only work if there is a good and likely way where those are going to happen. Otherwise municipalities, as they stare down their fiscal decisions in the next number of months, will believe that these things will never get used and they won't have that effect of telling them the province is serious about the standards they have to have in place in their communities.

Mrs Boyd: I'd like to ask, if you can tell me, whether there are any of the programs that you have funded in the past that you'll continue to fund. For example, you funded 100% of some of the programs that were considered to be of provincial interest previously. Others were cost-shared. Is there anything left that you'd fund 100%?

Mr Sapsford: The only part of the public health piece are the costs associated with immunization. There were other provincial programs, some of which were offered by health units as special programs. Some health units offered speech-language therapy for children and the health unit was used as the vehicle for providing that service. Those funds continue as well. In the public health envelope, the only 100% funding remaining is the cost of immunization.

Mrs Boyd: Not all the costs. You're talking just the vaccine costs?

Mr Sapsford: Just the vaccine, that's right.

Mrs Boyd: So Healthy Babies, Healthy Children is not funded 100%?

Ms Lang: Yes, that one is definitely funded 100%.

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Mrs Boyd: And Better Beginnings?

Ms Lang: Better Beginnings is funded 100%. That one, as you know, is funded through three different ministries.

Mrs Boyd: Your share remains the same as it was previously.

Ms Lang: Yes.

Mrs Boyd: As I go through these mandatory health programs, it strikes me that I continue to have concerns about whether municipalities are going to agree to fund some of the things that are supposedly required here. I'll just give you some examples, and I'd really like a response.

In sexually transmitted diseases, for example, one of the requirements on page 44 is: "The board of health shall provide or ensure the provision of appropriate case management. This shall be accomplished at a minimum through" -- and under that, section e is "provision of condoms." In the family health area, one of the requirements that is there -- perhaps it's reproductive health, I'm not sure which one -- is the requirement on page 26 that:

"Activities Associated with these clinical services shall include as a minimum:

"b. contraception counselling, provision of prescription and other contraceptives at cost and/or free for clients in financial need."

Back again under "Sexually Transmitted Diseases" on page 45, under number 5 where it's talking about injection drug users:

"The board of health shall ensure that injection drug users can have access to sterile injection equipment by the provision of needle and syringe exchange programs as a harm reduction strategy to prevent transmission of HIV, hepatitis B, hepatitis C and other blood-borne infections and associated diseases in areas" -- I emphasize this -- "where drug use is recognized as a problem in the community."

Again, back to the issue: If you have a municipal council that has taken a position against contraception in any form and says it will not use locally raised taxes to pay for the provision of condoms or of contraceptives or of needle exchange, what will you do?

Dr Mowat: I believe that a reading of the mandatory programs, together with the act, provides the answer to that question. Clearly there is a legal obligation upon the local board of health to comply with all the provisions of the mandatory program document, including those provisions you mentioned. Therefore, were they to fail to conform, they would be subject to the whole process of assessment and the sanctions as have been described previously.

Mrs Boyd: If a municipality were to say, as I hear only too frequently municipalities say, "Intravenous drug use may be a problem in other communities, but it's not a problem in my community," who could override that perception that intravenous drug use is not a problem in a community? There's no minimum standard here to say when it's a problem. Is it a problem if only 10 people per 100,000 are intravenous drug users? What is the standard?

Dr Mowat: I think it particularly addresses the number of successful injection drug programs, needle exchange programs, currently in operation --

Mrs Boyd: How many are in operation?

Dr Mowat: At least five, I would say -- across the province where they can demonstrate by the number of needles they in fact exchange and by the number of regular clients they have that they are meeting a need. At a minimum, I suggest that there's quite clearly a demonstrated need in those cases.

Mrs Boyd: We've got a chicken-and-egg problem here because if you don't have a needle exchange program, you can't prove how many needles you exchange. Having gone through this process in my own community, where there was a strong public reaction against a needle exchange and it required very strong action on behalf of the medical officer of health and the AIDS committee to ensure that program continued, I have real concerns, certainly about the expansion of this.

We know drug use is prevalent all over. If you only have five programs -- actually I thought you only had three but maybe you have five -- in place when the province is paying the full cost, what do you really think are the chances of an expansion of this program which has certainly been shown to be a very effective harm reduction program in other jurisdictions?

Ms Lang: It would seem to me, and this is my view, that if the kind of evidence that you're indicating was available in London, where there was significant public pressure to look at a needle exchange program --

Mrs Boyd: No, they didn't want a needle --

Ms Lang: I understand. But you also had a constituency that was arguing for it, and presumably that constituency had some information that would justify and support the need for some kind of intervention. If that information were made available to the medical officer of health and the ministry, then I think we would be in a very good position to suggest that municipality had a problem and therefore must comply with the requirements of the standards.

Mrs Boyd: I must tell you I really think this document is much better than the initial document that came out with the suggestions around what would be mandatory programs. Having said that, I am glad to see there clearly has been some listening to very concerned medical officers of health around some of the things that were missing in the original document. I'm very pleased that through this process this is much improved to what we saw earlier on.

Ms Lang: Thank you.

Mrs Boyd: Having said that, I am very pleased to see this. I know from feedback from some of the medical officers of health that they are greatly relieved, that this is a much better process than they had thought it would be, and that they themselves have some sense that at least the people in the ministry have come to appreciate how difficult their political position may be. That was not true in the beginning and I think there has been a real learning experience about that. I'm pleased to see that.

It's not clear to me what is happening in the unorganized territory around this. I wasn't clear in the download document what happens in unorganized territories around the provision of public health services. Previously you were providing those, were you not? What happens now?

Ms Lang: I don't think we were providing them directly. Perhaps Dr Mowat could comment on this.

Dr Mowat: The unorganized territories are all part of one or other health unit. There are several health units which have both organized and unorganized territories within their boundaries. Previously the ministry paid 100% of the costs for providing services in the unorganized territories. After January 1, 1998, the ministry is continuing to pay 100% of the costs attributable to the unorganized territories as an interim measure.

Mrs Boyd: Until what time? Till what date?

Dr Mowat: I'm not aware of the details of that.

Mrs Boyd: I understood that the Minister of Health had announced $11.5 million to sort of do a transition, but I wasn't sure whether that had to do with the unorganized territories or what it had to do with.

Ms Lang: The unorganized territories is over and above that. The unorganized territories will continue to be financed by the province until such time as the ministries of Municipal Affairs, Northern Development and Mines, and Finance work out the taxing arrangements for unorganized territories.

Mrs Boyd: So you're on the hook for quite a while I guess.

Ms Lang: My colleagues are wrestling with that one, fortunately, not me.

Mrs Boyd: Because it is a big issue and not just in public health. It really is something that I think a lot of people don't understand, how big an issue that is for the municipalities that feel they're carrying the freight in those areas where they lie in the middle of or on the edge of unorganized territories, and it really creates some difficulty.

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On the dental program for children in need, I know there has been some considerable concern expressed by the Ontario Dental Association around how those programs are going to be delivered, that the agreement that had been there in terms of the Ontario Dental Association and its provision of dental services for children in need was not necessarily going to be continued. I wonder if you could give me some information about that.

Dr Mowat: There are two dental programs, really. There's CINOT, the children in need of treatment program, which is provided through health units. The actual work is done by private dentists and the money is disbursed through the health unit. That program is administered by the health units. There is another program, which I believe addresses children in receipt of family benefits. That is the program that is administered by the Ontario Dental Association. I'm not aware of any intent to change either of those administrative arrangements.

Ms Lang: However, it doesn't mean we can't look at the potential. As the government wrestles with services for children, one of the challenges we're faced with, as you well know, is the extent to which we can consolidate those efforts. There is a strong belief that children in need should continue to get appropriate dental health.

Mrs Boyd: The Ontario Dental Association has made a fairly good case for the fact that a consolidation under their auspices might get you the best and widest kind of service, because they're well known for going well beyond what they're paid for in that program.

Ms Lang: Actually I've had some representations from that association, and if they can make the business case, that's not something I would turn my eyes away from. Certainly, my colleague in the Ministry of Community and Social Services is as keen as I am on looking at how we consolidate some of these functions. So if there is a business case and if we can ensure a continued level of service for dental health for children, we would look at those opportunities for sure.

Mrs Boyd: It has the added advantage of having a very large and fairly powerful professional group quite intimately concerned with the health of children in the province. It might have a couple of payoffs in other ways.

Mr Young: I'd like to ask the chief medical officer of health or perhaps the deputy if you can estimate the cost of treating sexually transmittable diseases in Ontario.

Ms Lang: I'm not sure. Do we have the ability to do that?

Dr Mowat: Sexually transmitted diseases are by and large treated by family physicians; some are treated in emergency rooms; some are treated in public health clinics. As to the drugs used to treat them, a prescription may be given, or in the case of public health clinics, some of those drugs may be provided free. It would be difficult to track the cost of those drugs. I'm not aware of an administrative mechanism to actually find those costs. What would be necessary, I believe, would be to mount a study which would estimate, would find from, say, OHIP data the number of cases, and then form estimates of the range of costs for each type of STD and then calculate it.

Mr Young: That would be helpful. For instance, someone said earlier that it's about $1 billion we spend on cancer treatments, and about $1 billion on heart disease.

Ms Lang: No, $2 billion.

Mr Young: Oh, $2 billion -- thank you -- on heart disease.

What is the most reliable way of preventing sexually transmittable diseases?

Dr Mowat: Reliable in theory or reliable in practice?

Mr Young: In practice.

Dr Mowat: In practice the most reliable way, I believe, is to educate people to avoid infection through either abstinence or the use of condoms.

Mr Young: Is using a condom a reliable way to prevent the spread of AIDS or hepatitis B?

Dr Mowat: It reduces the probability of spread greatly. It is not --

Mr Young: Is abstinence a reliable way?

Dr Mowat: Of the spread of HIV?

Mr Young: Of sexually transmittable diseases.

Dr Mowat: Yes, excluding transmission through, say, drug use or transfusion, that kind of thing. Abstinence as a means of reducing the transmission of, say, gonorrhoea or chlamydia or syphilis obviously is a completely effective method of doing so.

Mr Young: I'll tell you why I'm asking. I've looked through the section here on sexually transmitted diseases beginning on page 44, on infection and control on page 40, on sexual health on page 25, and I only find the word "abstinence" once in 50 pages of narrative guidelines for our municipalities. The word "abstinence" is used under sexual health only in one context and that is as a method of contraception.

Dr Mowat: That's correct.

Mr Young: It's never mentioned with regards to sexually transmittable diseases and neither is monogamy. We don't know the cost, but certainly we know the cost is huge to our health care system, without even talking about unwanted pregnancy. Why are we not asking our local health units to counsel people and make sure people are aware that the most effective way to prevent sexually transmittable diseases is abstinence?

Dr Mowat: Speaking as a former medical officer of health, I can assure you that the public health nurses who are involved in these issues are well aware of the role of abstinence in the prevention of sexually transmitted diseases. It is not down here, as you point out, in that context. It doesn't mean to say it doesn't happen.

Mr Young: Doctor, what I'm saying is we're all aware of it, and yet unwanted pregnancies are as high as or higher than they've ever been and sexual activity among our youth is as high as or higher than it's ever been. We've had these education programs since the 1960s and it's obviously not working. I'm suggesting that if we want to reduce some of these costs and if we want to avoid these problems, we should talk about this. If we're going to get our public health nurses and others to talk about it, we should put it in the guidelines.

Dr Mowat: I can assure you that to my knowledge, in all of the health units that I'm familiar with, abstinence is indeed presented in the context you've mentioned. It may not appear in the mandatory guidelines. This is not a program manual. It sets out some requirements. I agree with you, it might well have said abstinence in the context -- it just didn't. I feel confident that, in practice, in the health units abstinence will be presented in that context.

Mr Young: I would like to see it in the guidelines, but I'll change the subject.

There's an excellent section here on page 19 on the Ontario breast cancer screening program. It's related to catching cancer early and prevention with regard to cancers contracted by women. I'm wondering, are there any initiatives or any guidelines for the public health units to help identify or prevent cancers which might be contracted by both men and women, or primarily by men, like prostate cancer?

Dr Mowat: The issue of detection of prostate cancer is one that I think we can characterize at this point in time as controversial. I know there's a lot of prostate screening going on in the US. The experts in the US and in Canada often disagree on the most effective approach to screening cancer, certainly around the details. There are a number of studies going on. Health Canada is involved in looking at this. I know Cancer Care Ontario is undertaking a comprehensive look at all kinds of cancer screening: the two that we commonly use, mammographic breast cancer screening and pap smears for cancer of the cervix, and also prostate cancer and colorectal cancer screening.

The consensus of opinion still is that for a variety of technical reasons, which I could certainly go into details on afterwards, the current technology available is not reliable enough and is likely to give rise to an enormous number of difficulties. Taking the population as a whole, even though it is admitted that there will be cases where cancer of the prostate will be detected early and there will be a favourable outcome because of that detection, as a population-wide screening instrument, the consensus of scientific opinion in Canada right now is that it is premature.

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Mr Young: Cancer affects men, women and children as well, and treatment of cancer costs us right now about $1 billion a year. What are you doing, if anything, in addition to what this breast screening program has initiated, to address prevention or treatment of other forms of cancer, for instance, more surgery, because cancer surgery saves lives, and other therapies?

Ms Lang: Perhaps I could ask Mr Sapsford to talk about that in the context of --

Mr Young: Maybe I can put it in context for me. Heart disease has a very high awareness and some of our heart surgeons are the busiest ones around. It's a disease that primarily white males who in many cases have a lot of money have. It gets a lot of attention in our system, but cancer doesn't a lot of the time. Cancer affects a broader sector of people more often; I think it's probably the plague of the 1990s. I'd just like to know what we're doing to deal with it and to help prevent it.

Mr Sapsford: The issue of breast screening in this document is based on fairly convincing research over a number of years about the benefit of breast screening methods. Some of the criteria here in terms of the age of women who should be screened on a routine basis are based on fairly solid research evidence. As Dr Mowat indicated, some of the other forms of cancer have less convincing statistics. So when one decides to put a screening program into place, it needs to be effective based on solid research.

As for other initiatives in cancer research and development of programs and services, that role in this province has been assigned to the newly created Cancer Care Ontario, the former Ontario Cancer Treatment and Research Foundation. That organization has as its mandate work around both research and the effective application of cancer treatment intervention. They work through a series of nine regional centres across the province and are now actively working on assisting other elements of the health care system -- surgeons who operate in general hospitals -- to develop standard application of treatment methods. The work of their scientists, the work that goes on at CCO is translated into clinical guidelines which are set as the standards for cancer treatment. They work through these regional centres to communicate that information to the broader health care system.

Mr Young: You say we have five syringe exchange programs in Ontario. Do you have any idea how much money we spend in Ontario -- I realize they are municipal programs -- to provide free syringes to addicts?

Dr Mowat: I would have to go and find that information for you.

Mr Kennedy: I want to turn to the budgetary concerns, because of our public accounts responsibility. I wonder if you can refer to the report we received in estimates, the extract from the briefing book. I don't know if you have a copy of what we have. In broad strokes, then, what parts of public health expenditure will still be made by the province, to be explicit? I know you had an earlier question about parts of this. In addition to the programs that were mentioned in terms of 100% funding, are there any other public health programs the province will participate in post-Who Does What? How much, if any -- I guess you can only speak to the year that's passed -- provision has been made for your enhanced enforcement role in the budgetary outlays of the department? Just so we can know how well resourced you are and what residual public health programs there are coming from the ministry.

Ms Lang: We have not made provision in our business plan for additional public health programs. We have also not made any provisions for reductions in our current staffing associated with the public health branch.

Mr Kennedy: So that means only the programs that were discussed before are the ones the ministry has any funding participation in, is that correct?

Ms Lang: That's right.

Mr Kennedy: Coming back to the mechanism we were talking about, the definition of -- I'm not sure if you said "public health crisis," but on what basis you would use what you referred to earlier as the new enforcement mechanisms, I wonder if you could elaborate on that for me as specifically as possible. Obviously, in putting that in the legislation, its use must have been contemplated. I'm wondering under what circumstances you would actually take them to court, implement those programs. I think you talked about a public health urgency or a public health emergency. I really would like to see what anticipation there is on the part of the ministry of the use of that mechanism, because it tells us a little bit about how the municipalities will react to you in the next number of months.

Ms Lang: Dr Mowat will comment.

Dr Mowat: I believe the term used in the legislation is "imminent threat" to health. Because the enforcement mechanisms and the sanctions available generally in the act require the use of the courts, obviously there would be the passage of time before those sanctions might be put into effect. For that reason, the other clause was added, saying that where there is an imminent threat to the health of the public anywhere in the province, instead of going through the procedure of assessment, issuing a notice of non-compliance and then taking action thereafter, the minister may act immediately to take action against that threat.

There are a number of ways this might be done. If it were, for example, a matter of issuing an order causing somebody to do something or cease from doing something, then the chief medical officer of health could issue that order in that particular area. If it were a matter of providing a program, again the chief medical officer of health could take over in that health unit and order the staff to provide that program, or other means of providing the program could be put into effect.

It is meant to be used where there would be, say, an environmental or infectious threat which might quickly progress to be a hazard to health. But this would only, of course, be necessary in the extremely unlikely event that the local health unit did not take the appropriate action in the first place. It would seem to me that there is a very remote possibility of this happening, but merely because of the very serious consequences were it to happen, then obviously it has to be addressed up front.

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Mr Kennedy: I appreciate and I'm listening carefully to the language you're using in framing that. I just wonder what it means for programs, whether it's family health or chronic disease prevention, whatever, where you wouldn't establish imminent danger, just that the community is going to be less healthy because the municipality is determined that either it won't implement the program or it won't have enough activity to meet your standards in the program. I wonder what besides an ongoing wrangle we can look forward to to ensure that community does indeed meet its obligations under the mandatory guidelines. How do you reconcile that with imminent danger to health?

Dr Mowat: Imminent, to me, means that it is going to happen, the serious and possibly irreversible consequences would happen before one could go through the regular process. Notwithstanding that failure to provide family health or chronic disease programs may have a serious effect, it is not the case that a delay of days or weeks in bringing those programs up to the standard would be of material consequence. Therefore, the standard provisions allowing for assessment, for the minister to issue an order and, if the order is not complied with, then either prosecution or direct provision of the program could take their normal way. I believe that to be consistent with the approach in legislation generally, that one tries to have an approach where there are checks and balances and rights of appeal and so on which are in our regular process, but where there is an emergency then one can act more quickly. That's, as I see it, the structure of the legislation.

Mr Kennedy: Coming back then to what you call the regular route, that would be the court route, I guess, the regular process, where you would apply under the court to have them comply and if they were unwilling then you could seek remedy in terms of fines, cost replacement and so on. Given the time that takes -- have you anticipated what an application under that kind of provision might take? Let's say you're determined, the municipality is equally determined, you've reached an impasse. What length of time might that take to enact? Have you anticipated that part of the mechanism?

Dr Mowat: That determination is part of the work that's going on at the moment.

Mr Kennedy: I wanted to ask about a specific matter. I understand that there are provisions that used to be under environmental legislation which have now been passed on to municipal inspection services, particularly to do with roles that public health used to do in inspecting sewage and so on. I'm just wondering if you would comment on that. Do you monitor that transfer now that it's gone outside the domain of public health workers? Could you tell me about that?

Dr Mowat: Yes. It was the case in the past that health units, which generally are governed by the Health Protection and Promotion Act, acted voluntarily as contractors to the Minister of Environment in inspections pursuant to part VIII of the Environmental Protection Act. That refers to private sewage systems and land divisions. As part of the Who Does What process, that responsibility was transferred to municipalities, which now have a greater choice of how they wish to address those activities. They may, for example, incorporate that work into their own building department or they may indeed decide to continue that contract with the local health unit. It's my understanding that certainly at this stage, with the change coming into effect on April 1, a great many municipalities have chosen to continue to use the health unit, at least for now.

Concerning the ministry's role and responsibility with respect to those private sewage systems and of the local health unit, many of the issues around part VIII, private sewage systems, refer to the regulations under EPA, which provide specifications for private sewage systems. This is the way it has to be done, and the inspection says it's done according the regulations. That's one issue. A second related issue is, is it a hazard to health?

The way it will be in the future is that the municipality will be responsible for the compliance with the detailed provisions of the EPA and its regulations. If, however, the system malfunctions in such a way as to present a hazard to health, the local health unit may still take action, as it has the authority to intervene where there is a hazard to health, and that term, "hazard to health," is defined in the Health Protection and Promotion Act.

In that respect, although the public health system doesn't have direct responsibility for the EPA, part VIII, if there is impact on health, notwithstanding, they can become involved.

Mr Kennedy: I guess you may acknowledge that a number of your colleagues, in terms of people in public health around the province, do see, though, that they won't be in the same position to acknowledge the hazard by not being exposed to it; they do see some risk there, as I do. The language we're using here, "if something is identified," "if it presents" -- the proactivity part of this is gone in terms of public health being exposed, but I appreciate knowing that you don't share apprehension of risk at this time.

One other specific question: Is the survey that you indicated earlier had gone out to municipalities an effort to try to get an idea of the baseline of services being provided by municipalities, or does that information already exist within the branch or within the ministry in terms of what is being provided? I'd like to know the status of that.

Dr Mowat: The survey that's recently gone out is a very short one to ask what is happening to budgets and to the staffing complement, as much as it's known. That may be an approved budget or it may be simply a request. It's to give the ministry a picture of what the perception is out there of what the requirements of these mandatory programs would be.

Mr Kennedy: Would the results of that survey, which I think you indicated was under way, be something that could be shared with the members of this committee, something we could know in terms of what the impacts are going to be?

Ms Lang: There are two kinds of results. One is, what is the current budget request? Certainly we could prepare that and provide that to the committee. What might be more important to the committee, though, is, what is the actual budget result after the municipalities go through the process they go through? We're at your disposal in terms of what would be useful to the committee.

Mr Kennedy: I asked that in the context of our discussion here. How does the province have oversight, especially with these new challenges?

The final question, which just needs a very brief answer, is, does the ministry object in any way to a continuing involvement by the Provincial Auditor's office in monitoring these mandated programs, even though there isn't an outlay of provincial dollars? We talked about this in our in camera session, and I am wondering if there is a point of view on the part of the ministry to that question. It is, according to the auditor, ambiguous about whether he would have that responsibility, but there is another review taking place of the auditor's functions.

Ms Lang: I'm not sure I fully understand the nature of the question and I'm not sure I'm the person to answer the question. If the Provincial Auditor is suggesting that he would like to move beyond the scope of his authority, I'm not sure I'm the person to be responding to that question, so perhaps someone can help me understand the question.

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Mr Kennedy: There's simply a concept of value-for-money audits and the idea that the auditor has a responsibility not just to see that the money is accounted for but that the objects that the province is seeking through its legislation and through its funding are achieved. That received approval from this committee some time ago, and it may be subject to some change.

I just wondered whether there's any objection on the part of the ministry to the continued oversight of the auditor, who has already done two reports on public health.

Ms Lang: The ministry has no objection to the Provincial Auditor carrying out his responsibilities.

Mrs Boyd: Speaking of the Provincial Auditor, let's go back to the report in terms of some of the concerns that were raised. I realize that always the response of a ministry to the Provincial Auditor occurs some months before these hearings, and I would really like to have a bit of an update on where exactly you are. Many of the responses are rather vague in terms of time lines.

I actually was very pleased to see the kinds of questions the Provincial Auditor was asking about the vaccine-preventable disease program, because quite obviously this is the program that can help the public understand the whole issue of disease prevention. Probably it's one of those things that is most important. Going through the report of the auditor, there are a number of places where the recommendation from the auditor is about monitoring. How do you monitor, how do you ensure that immunization is taking place and how can this monitoring be made more effective and more available?

For example, there are several places where you talk about having a joint process between public health and provider services, because many of these vaccines are delivered by primary care physicians or, soon, nurse practitioners. One of the issues really is, what are we looking at in terms of time frame? On page 158 of the auditor's report, you have responded to the auditor by saying that the pilot project that began in June 1997 was expected to be completed by December 1997. Is it completed? What were the results? Will that pilot project be extended to all providers? Since there must be a billing code for giving an immunization shot, it ought to be the kind of information that could be gathered and be available, given the cost of this program.

Dr Mowat: Yes, indeed, the pilot did take place and the data were gathered. They are undergoing analysis now. Our conclusion at the interim stage is that this is another of those things which sounds very straightforward in principle but one would be amazed how many little glitches can come out. To do this, of course, we had to change the billing system, because currently, apart from this pilot, physicians do not identify which vaccine has been given. We had to work with OHIP to find a pilot method of bringing in an identification for the particular vaccine. There have been some difficulties around that, so we don't think we're now at the stage where this would be ready to go. It's quite tricky, actually. But we'll continue to analyse those data.

Mrs Boyd: If I were the auditor, I wouldn't be very happy with that response, and I'm not very happy with that response, because this is the kind of information that you need to have available. Given the cost of not being sure that immunization is being done, it's a pretty serious matter to be sure that it is in fact being done. I would certainly urge the ministry to be able to answer this question in the affirmative by the time estimates come around because I think it's a pretty good question in terms of accountability. I would hope you would have a work plan and a timetable by which this kind of monitoring could be in place.

That goes for some of the other monitoring, for example, the wastage of the vaccine, which also seemed to be quite of concern to the auditor. I would have hoped, with the assurance of the ministry that they would be able to deal more effectively with that and lower the wastage amounts, that there would be some way of measuring that success for the ministry.

I'm interested in page 161, the vaccine purchasing issue, because this issue of a value added award component to the purchase of vaccines and the dollar amounts noted by the auditor really sends up warning bells in my head. Your response was that you are in the process of developing administrative controls so you can separate the cost of the vaccines from services.

First of all, what kind of services were these that were being value added, and second, where are you at with developing the control process?

Dr Mowat: The control policies -- I now have the third draft with us. This is something that has to be developed between the public health branch and the supply and financial services branch. That is almost complete. It's in the third draft. That will be available within a few weeks.

Regarding the nature of value added services, purchasing a number of vials with liquid in them is obviously an essential part of an immunization program, but it isn't everything we need. We sometimes purchase, depending on the program, additional services. That could be a hotline that the manufacturer will run for inquiries from the field, if we don't feel we're able to handle that, perhaps temporarily. It could be promotional materials, particularly, say, during the measles or the hepatitis B immunizations, when the decision was made to proceed with the campaign, and with a limited amount of time to get a campaign up and running it's felt to be more effective and timely to purchase those materials from the manufacturer. It could be additional help around tracking adverse effects and so on. So it could be goods or it could be services, either an inquiry service or consulting services.

Mrs Boyd: But I understand from the auditor's report that you had no recordkeeping system to keep track of these things and that you really couldn't explain to the auditor where these costs actually were. The auditor says on page 161: "The branch does not have a formal recordkeeping system to track value added awards. We reviewed two contracts issued" -- just two -- "in June 1996 which totalled $610,000 in value added awards." That's a lot. "From our view of available correspondence, we determined that approximately $300,000 remained to be utilized by the ministry."

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Dr Mowat: There were tracking systems in place within the branch to follow the expenditures on these value added items. Unfortunately, there were at that time, I believe, inadequate procedures for communication between the public health branch and the supply and financial services branch, which operates the government pharmacy which actually orders and disperses the vaccine. We have now proceeded to put in place, that is, this protocol, procedures as recommended by the audit branch in the ministry, which will enable us to track much more closely and effectively those value added services.

Mrs Boyd: I want to ask you about the tuberculosis control issue, because I think this is an emerging serious problem. It's one that has a lot of concern in a lot of places. I mentioned to the auditor when he was here this morning that I have a little bit of concern around the sole emphasis on immigration as a tracking issue, when we know that tuberculosis is a major problem within Canada on many of our northern native reserves, both Indian and Inuit reserves, and that people move back and forth between the reserves, some of which may be in Ontario and some of which may not -- I think most are not that have a high tuberculosis problem.

The tracking of those individuals may be just as important an issue as people who are coming in from outside the country as well as those who leave reserve areas and come to our cities. I certainly know, working with the street nurses, that they have great concerns. They believe there is a growing incidence of tuberculosis but no mechanism for mandatory testing and tracking among street populations in urban areas.

I just really want to get some sense from you about whether our current guidelines are sufficient, particularly because I know that the chemoprophylaxis kind of effort to reduce the possibility of a recurrence of TB is not a particularly pleasant process. It's one that people don't like to go through. There are side effects. People often fall out of the program as a result. It's not clear to me what answers you have for those kinds of concerns.

Dr Mowat: The mandatory program on tuberculosis control in the new guidelines has been extensively updated in light of recent recommendations, mainly at the federal level or through federal-provincial conferences, and I believe now is very explicit about the responsibility of health units to pay very close attention to the control of tuberculosis. Having said that, it's my personal experience in the field that this is something that certainly all the health units I was familiar with took very seriously in any case. This is to them a very important basic public health practice, and my impression was they were already doing this very well.

We have introduced in here, for example, the new standard, the generally accepted standard now, of directly observed treatment or DOT, and that's set out in a protocol. That means that, given the reluctance of some infected persons to take their medications, we really have to be quite emphatic about assuring ourselves that they are taking their medications. As you know, they have to take them for a number of months. We have also strengthened the section on tracing and investigating contacts of cases and the section on the follow-up of those who are tuberculin-positive but without active disease.

I agree with you that there are a number of high-risk groups, immigrants, homeless people, first nations people among them. These are well known in the public health community. Large urban health units in particular I believe have had a good record of programming to try to reach these people. It is never easy and we're never going to achieve 100%, but I'm satisfied that we are doing fairly well in the tuberculosis area. There is clearly a growing awareness of how risky it is and of the disastrous consequences should multi-drug-resistant tuberculosis gain a foothold in Ontario. TB is taken very seriously by the public health community.

The Vice-Chair: Mrs Boyd, you have one last question.

Mrs Boyd: The last issue I have to raise, because I raise it all the time, is the one big disappointment I have that both in the child health area and in the injury prevention area there is no mention of child or woman abuse, which is the injury prevention issue.

It has long been a concern that this is not part of mandatory public health involvement. In some communities public health departments have been very involved, given the kind of morbidity and mortality rates they have seen from so-called accidents, which we all know very often mask abusive situations. But I know in the child health issue, and given the work that is being done by the Ministry of Community and Social Services, particularly given Healthy Babies, Healthy Children and Better Beginnings and all the rest of that, it is a glaring omission that we not be always monitoring child abuse and woman abuse as a fairly serious public health issue and ensuring that public health units are working with other service providers in their community, including children's aid societies, women's shelters and other advocacy groups.

Much of our health dollar actually is being spent in these areas. It is a major prevention area, and I must tell you that in my community having the committed involvement of our public health unit has been a tremendous benefit to our integrated response. I feel very sad that it isn't there as part of the mandatory program.

Mr Young: If I could comment for 10 seconds on that, I think we have, Mrs Boyd, an opportunity here, now that social welfare and day care and public health and public housing are all being delivered at the municipal level, to improve services to people in need and to coordinate them and integrate them better to address that issue, for one.

Mrs Boyd: That may be, but does it belong with the regressive property tax base to do that? I don't believe so, and I think that's one of the big problems with this whole area, because the benefits of this don't accrue at the municipal level.

When it comes to those hard services that municipal taxpayers see as affecting their property values and these soft services which save us huge numbers of dollars in other parts of our budget, it's hard to convince taxpayers and municipal politicians that their dollar spent is being spent in an appropriate way, and that is going to be the struggle with this whole issue. There is not going to be an immediate reward for the prevention issues in public health.

That's why there has been so much opposition to the download of public health issues to the municipal level. It has very little to do with the kind of outcome that property taxpayers look to from their municipality. It's going to be a struggle for all of us to ensure that the education that's necessary for those public officials at the municipal level continues and that they become as committed as we know medical officers of health are to the expansion of prevention and promotion programs, because that's where the big savings are going to come from in our health dollar.

The Vice-Chair: Deputy Lang, Dr Mowat and Mr Sapsford, thank you very much for joining us today. We appreciate your diligence and found it very instructive.

The committee will move into closed session for a few minutes to discuss the report.

The committee continued in closed session at 1540.