1999 Annual Report,
Provincial Auditor: Section 3.08, Cancer Care
Ontario
Dr Kenneth Shumak, president and chief executive officer, Cancer
Care Ontario
Mr Jeffrey Lozon, deputy minister, Ministry of Health and
Long-Term Care
Dr Richard Schabas, head, division of preventive oncology, Cancer
Care Ontario
Dr Tom McGowan, coordinator, radiation therapy program, Cancer
Care Ontario
Dr Les Levin, special adviser to the minister on cancer
issues,
Ministry of Health and Long-Term Care
Mr Naresh Khosla, vice-president of Finance, Cancer Care
Ontario
STANDING COMMITTEE ON
PUBLIC ACCOUNTS
Chair /
Président
Mr John Gerretsen (Kingston and the Islands / Kingston et les
îles L)
Vice-Chair / Vice-Président
Mr John C. Cleary (Stormont-Dundas-Charlottenburgh L)
Mr John C. Cleary (Stormont-Dundas-Charlottenburgh L)
Mr John Gerretsen (Kingston and the Islands / Kingston et les
îles L)
Mr John Hastings (Etobicoke North / -Nord PC)
Ms Shelley Martel (Nickel Belt ND)
Mr Bart Maves (Niagara Falls PC)
Mrs Julia Munro (York North / -Nord PC)
Ms Marilyn Mushinski (Scarborough Centre / -Centre PC)
Mr Richard Patten (Ottawa Centre / -Centre L)
Substitutions / Membres remplaçants
Mrs Lyn McLeod (Thunder Bay-Atikokan L)
Mr Dan Newman (Scarborough Southwest / -Sud-Ouest
PC)
Also taking part / Autres participants et
participantes
Mr Erik Peters, Provincial Auditor
Clerk pro tem / Greffier par intérim
Mr Douglas Arnott
Staff / Personnel
Mr Ray McLellan, research officer, Research and Information
Services
The committee met at 1045 in committee room 1,
following a closed session.
1999 ANNUAL REPORT, PROVINCIAL AUDITOR
MINISTRY OF HEALTH AND LONG-TERM CARE
Consideration of section 3.08,
Cancer Care Ontario.
The Chair (Mr John
Gerretsen): Good morning, everyone. I'd like to call
into session the standing committee on public accounts to deal
specifically with section 3.08 of the 1999 annual report of the
Provincial Auditor dealing with Cancer Care Ontario. I understand
this morning that we have two delegations with us, one from
Cancer Care Ontario and the second from the Ministry of Health
and Long-Term Care. You will be given an opportunity to make a
presentation first. If you can keep that as short as possible,
we'd appreciate it. Then we'll go into rotation, starting with
the government side, in asking questions of either one of the
delegations. If before speaking you could identify yourselves,
we'd greatly appreciate it. It would make it easier for Hansard
as well. Good morning, gentlemen. You're Mr Shumak?
Dr Kenneth
Shumak: Yes. Good morning. I'd like to introduce my
colleagues, Dr Richard Schabas and Dr Tom McGowan, who will be
with me representing Cancer Care Ontario.
Thank you very much for
inviting me to appear before your committee and giving me the
opportunity to provide Cancer Care Ontario's response to the 1999
report of the auditor. We welcomed the report when it was
released in the fall and I'm pleased now to have the opportunity
to speak to the auditor's findings.
I hope to make you aware of
some of the work Cancer Care Ontario has undertaken and some of
the progress we've made since the auditor's report was released
in improving the province's cancer services. Let me start by
saying that the many challenges we currently confront in the
cancer system did not happen overnight. Accordingly, a sustained
effort is going to be required to address them adequately. But
today I'd like to assure you that a solid foundation has been
laid. If we can continue on this path, I'm confident Cancer Care
Ontario and our many partners will be able to build a sustainable
system that will provide all Ontarians with timely, high-quality,
accessible cancer services.
I'm going to focus my remarks
on four key areas today: radiation treatment, the Ontario breast
screening program, cancer prevention and the memorandum of
understanding that has recently been signed between Cancer Care
Ontario and the Ministry of Health. I'll try to go through my
remarks reasonably quickly so that there will be an opportunity
for questions either in my remarks or in the report or about
cancer services generally.
In the material I've
pre-circulated there are a number of handouts and I'd like to
draw your attention to the first, in which you will be able to
see what I believe is self-evident, that the importance of cancer
as a health problem in this province is increasing.
If we look at that particular
figure, you'll note that the impact of cancer on death rates in
this province continues to rise. This is in contrast, for
example, to the death rates from ischemic heart disease. This is
a very important point that I wish to stress, that we continue to
have an ever-increasing burden of cancer in this province, and
until such time as we can prevent cancer or find ways to cure it,
we are going to be faced with this particular issue. More than
45,000 people, perhaps closer to 50,000 Ontarians, are diagnosed
with cancer each year. That is about one in every three Ontarians
who will have cancer at some time in their lives.
Unfortunately, cancer still
kills about 23,000 people in this province each year, and our
rates, as I've just shown you, are increasing. It's mainly
attributable to the aging of our population. As you can see from
that graph, most other health problems are either stable or
diminishing. If you turn to the second overhead, one of the
issues that the system has faced is that although the number of
cancer cases that we have seen in our regional centres, to use
that as an example, has steadily increased over the last decade,
until very recently there was not a commensurate increase in the
resources provided to meet the needs of the increased number of
patients. I'm pleased to say, again as seen in this graph, that
that picture is beginning to change.
Cancer is a very complex
disease and for this reason cancer patients require services of
many different health care providers in many different settings.
Before 1997, when Cancer Care Ontario was created, we did not
have a mechanism in this province to coordinate all the different
types of services that an individual cancer patient can require.
Similarly, there was no mechanism to establish standards across the province to ensure that
all Ontarians have access to the same high-quality services
regardless of where they live.
The third page on the handout
illustrates the general structure, the general approach that
Cancer Care Ontario has taken. As you can see in this schematic,
we run our operation through a provincial office that sets
standards and deals with province-wide programs, but this is
implemented and we get information back from eight different
regions across the province. It's very important to look at the
chart and to see the various participants in Cancer Care Ontario.
I would submit that this approach is the secret to being able to
get a handle on cancer and how we're going to deal with cancer in
this province. All of the stakeholders are brought together in
this mechanism.
It's very easy and so far in
my own remarks I've focused on treatment. I've talked about
treating patients. But cancer prevention, screening to detect
cancer earlier than it might otherwise be detected, supportive
care for patients with cancer, education about cancer and
research into cancer are all important strategic priorities of
Cancer Care Ontario.
Just to give you a little bit
more on the structure of the system, most hospitals in the
province do deliver some type of cancer care. However,
specialized cancer care is essentially concentrated in nine
facilities across the province. These nine centres are the
exclusive providers of radiation treatment in Ontario. Eight of
the nine facilities are regional cancer centres funded and
managed by Cancer Care Ontario. The ninth is the Princess
Margaret Hospital, which is operated by the University Health
Network. Again I want to stress that all of these centres, in
addition to having treatment programs, also have programs in
supportive care, prevention, screening, education and
research.
As I said, I want to give
some attention to radiation treatment. We are aware, of course,
of the issues that are confronting us with regard to radiation
treatment. The fact is that at the present time cancer patients
are experiencing waits for radiation treatment that are
excessive. I'd like to discuss for a moment how this has
happened.
During the past decade there
has been a growing gap developed between patient need for
radiation treatment and the resources available to meet this
need. The need increased because the population aged and because
radiation was being used, and has been used, to treat more and
more types of cancer. Just to give you one example of the kind of
change-in-practice pattern that makes it difficult to predict
exactly what amount of resource we will need, until the late
1980s, if a women presented with early-stage breast cancer the
standard treatment was mastectomy. That changed and, instead, the
standard treatment became removal of a lump, followed by
radiation. That single change in practice obviously had a
tremendous impact on the need for radiation treatment in this
province. I could give you a similar story about prostate cancer
and so on, but I think that example serves to illustrate it.
The key problem that we're
facing at the present time is staffing shortages. There have been
budget constraints over the past decade by successive provincial
governments that essentially meant that little money was
available to cancer centres and hospitals to hire the staff we
need and also, and very importantly, to maintain internationally
competitive salary levels. Complicating the staffing situation
was a significant delay in the startup of a new training program
for radiation therapists, the people who actually deliver the
radiation therapy.
At the time the audit was
conducted, 32% of patients were receiving their radiation within
the four-week standard recommended by the Canadian Association of
Radiation Oncologists, and at that time there were 1,600 more
patients who needed radiation treatment than we could treat in
the acceptable time period. We have made some inroads. Currently,
instead of 32%, 40% of patients are treated within the four-week
standard. This has resulted from a dual strategy of aggressive
recruitment of radiation treatment professionals and also patient
re-referral. As a result of this strategy, during the last year,
although the increase from 32% to 40% is modest and is not as
much as we would like, the important point that I want to stress
is that the cancer centres in this province have been able not
only to do that but also to meet the 3% annual increase in the
demand for radiation treatment as a result of the predicted and
evident increase in the incidence of cancer.
So the situation has been
stabilized, despite that increase in burden of disease, and some
improvement has begun. The net impact of this, although it's not
as much as any of us would like, has been to begin to reduce the
number of patients in the backlog by 200, by comparison with the
time the auditor did his report.
These improvements came about
and were facilitated by the minister's acceptance of the report
of the task force on radiation treatment. That resulted in a
$15.5-million allocation of new funds to Cancer Care Ontario and
just over $4 million to the Princess Margaret Hospital.
Furthermore, and importantly, funding for radiation treatment is
no longer subject to a ceiling but will increase by formula as
the number of patients increases. That enables cancer centres to
hire new staff as caseloads grow and to maintain competitive
salary levels.
A new, expanded training
program for radiation therapists opened in September 1999.
However, because training of radiation therapists takes several
years, we have had to, and have allocated funds to, recruit staff
from elsewhere. In 1999, despite an international shortage, we
were able to recruit 40 radiation therapists from abroad. Six of
these people are now working in Ontario, and very recently the
federal government has committed to speeding up the immigration
process for the others. I want to inform the committee that these
additional 34 therapists have the potential of further reducing
the number of patients in the backlog by 350. So this is a very
significant contribution.
With respect to the physical
facilities to treat cancer patients, we have received approval
for three new regional
centres in Kitchener, Oshawa and Mississauga, which will open in
2002, a new cancer centre in St Catharines, a satellite centre in
Sault Ste Marie and expansions at existing centres in Sudbury,
Windsor and Hamilton.
I believe that, given time,
these initiatives taken together will improve the availability,
accessibility and timeliness of radiation treatment services in
Ontario. In the meantime-and it's very important to stress
this-it is essential that we continue to have the ability to
re-refer some patients who require radiation treatment,
preferably to northern Ontario but also to the United States.
Cancer Care Ontario's target is to eliminate re-referrals within
18 months. That is a target. It assumes that clinical practice
patterns will remain constant and that we will continue to be
successful in our drive to get radiation therapists and other
radiation professionals to come to Canada.
As a physician who treats
cancer patients, I want to make it clear that I personally
understand how difficult re-referral is for patients and for
their families. But I also want to make it clear that I believe
this is an appropriate and effective interim approach. It helps
the patients who elect it as an option, and it helps other
patients because it helps control and actually reduce the waiting
list.
I'm aware that there has been
some concern with regard to how patients who are re-referred feel
about this program. I won't go through the details of the patient
satisfaction survey; they are appended to the material. Suffice
it to say that the summary statement is, as you'll see, that the
great majority of patients are very pleased with not only the
care they have received but also with the quality of the
experience, as good as it can be under the circumstances. It's
not optimal. We know we can do better, and we are working
together with the Canadian Cancer Society and other supportive
care experts to try to improve on that side of it, which perhaps
is the weakest component of the re-referral enterprise.
Before I move on to the
breast-screening program, it's important to acknowledge that
there is a significant issue with regard to travel and
accommodation costs for patients who are re-referred for
radiation treatment. I'm aware that there are members of this
committee from northern Ontario for whom this is an especially
important issue. I just want to say that our current
reimbursement practice in Cancer Care Ontario is that indeed we
have funds available to cover the costs of travel and
accommodation for patients who are re-referred. We see this as an
exceptional and temporary circumstance, as these patients would
not normally have to travel long distances for their
treatment.
The ministry has provided us
with the resources to cover the costs but, as I said, we
acknowledge that travel for radiation treatment within northern
Ontario is an issue. For this reason, Cancer Care Ontario's board
of directors has established a task force to look into this
issue. We are waiting for the task force recommendations and, as
the principal adviser to the ministry on cancer, we will make our
report available to the ministry when it is completed.
1100
I would like to turn now to
the Ontario breast screening program, another major area of
discussion in the auditor's report. By way of introduction, I
want to point out that mammography remains the best method to
detect breast cancer early, when it is easiest to treat. We are
very fortunate in this province to have the OBSP. I believe it's
one of the best programs in the world. We offer screening to
Ontario women between the ages of 50 and 74. Ultimately, our hope
is to screen 350,000 women each year, that is, 70% of the target
population.
At present there are
approximately 250 facilities that conduct mammography in Ontario,
and 55 are part of the OBSP. This means that most Ontario women
receive breast screening outside the organized program. One of
our key objectives is to increase the number of facilities that
are affiliated with the program.
You may ask why we think it's
important that facilities join the OBSP. There are three key
reasons. First, the minimum standard for participation in the
OBSP is accreditation by the Canadian Association of
Radiologists. OBSP provides assistance to prospective affiliates
to meet this standard. Unfortunately, at the present time, only
one third of mammography sites in Ontario outside of the OBSP
have this accreditation. Second, the OBSP continually monitors
and evaluates the performance of its sites to ensure a continuing
high standard of operation and service. Third, and importantly,
the OBSP offers comprehensive breast screening, which includes
not only two-view mammography but also clinical breast
examination by a specially trained nurse examiner as well as
education in breast self-examination.
When the year 1999-2000 is
finally over, we expect that the OBSP will have screened 125,000
women at 60 sites, a 25% increase over the previous year.
We have had some other
improvements since the release of the auditor's report. These
include the implementation of an enhanced data collection system
to monitor the effectiveness of the OBSP; improved protocols for
informing radiologists and radiology coordinators about cancers
missed at screening; and quality control procedures to monitor
screening outcomes at each screening centre are now in place and
the information is being distributed to staff, as is appropriate,
for their analysis and follow-up.
Because there was some
concern about guidelines for screening women who are at high risk
for breast cancer-there is controversy about this-we have
established an ad hoc group to give us guidance on the role the
OBSP should play in this area.
Finally, the OBSP has been in
existence for 10 years, and we plan an independent evaluation of
the program by a panel of outside experts to give us an external
validation of the strengths and areas for improvement within our
program.
The OBSP offers screening to
women at average risk every two years. I want to take a minute to
talk about this, because it's important in terms of understanding
the auditor's comments about missed cancers. Cancers that
are diagnosed between the
two-year screens are called interval cancers. There are two
groups of interval cancers: those that were in fact visible on
the previous mammogram but were not detected-and are missed
cancers-and those that were not visible on the previous mammogram
and are truly interval cancers.
Radiologists have always been
informed about cancers missed at screening. As I previously said,
we now have improved protocols for this area. It's very important
for us to continue to monitor interval cancers to make sure we do
as much as we can to eliminate missed cancers. For that reason,
all X-rays from women who have developed interval cancers are
carefully reviewed by our chief radiologist and a panel of
radiologists. Any cancers that are missed are discussed with the
original reading radiologist.
When the auditor's report was
done, OBSP data from 1990-95 were reviewed. During this period,
the OBSP detected 1,759 cancers out of 216,000 screens. Of the
216,000 screens and the 1,759 cancers-with that in the
background-there were 304 interval cancers. That rate of interval
cancers compares very favourably with other programs around the
world. Only 68 of these interval cancers were actually missed
cancers. Therefore, 3% of all the cancers that developed in women
who were screened by the OBSP were missed cancers.
There is a study in the
literature that was published in 1998 in which the OBSP rate of
missed cancers was cited and is lower than the rates in British
Columbia, Australia and Southern California. This gives you some
idea by some yardstick of the quality of our program.
Just very quickly, to try to
conclude, with regard to cancer prevention, I don't want to give
this short shrift, so please bear with me for just a couple of
minutes. A very important part of our mandate is to make cancer
prevention an integral part of Ontario's cancer control system.
It's a fact, as we've all read in the media, that issues around
cancer treatment still tend to dominate public debate. So I would
like to take this opportunity to inform the committee about some
of the prevention initiatives that have been undertaken since the
auditor's report was prepared.
These important initiatives
include establishing a media network for the Ontario tobacco
strategy; we have developed a provincial network on diet and
cancer; and we have undertaken an initiative to examine the links
between physical activity and cancer. John Garcia, Cancer Care
Ontario's director of prevention, has recently been appointed to
oversee the implementation of the Ontario tobacco strategy.
Importantly, occupational and environmental exposures to
carcinogens were identified in the CCO strategic plan as explicit
areas that require attention. I expect that these areas will
emerge as priorities in the primary prevention plan for the
upcoming year.
Finally, I just want to
allude to the memorandum of understanding. The auditor's report
noted that there was a need for a memorandum of understanding
between Cancer Care Ontario and the Ministry of Health and
Long-Term Care. I'm pleased to report that in the fall of 1999 we
did sign this agreement.
The memorandum of
understanding codifies Cancer Care Ontario's role as the
principal adviser to the ministry on all matters related to
cancer. It sets out all of the accountability, all the
operational guidelines, and it gives us the opportunity, I
believe now, and the ministry the opportunity to work together to
try to ensure that we deal as effectively as possible with the
problems that we currently face and, very importantly, that we
don't lose sight of the future and that we plan for the future to
try to minimize the problems that we'll have with cancer in the
future and also, of most importance, that we can begin to change
our focus into thinking about preventing cancer.
With that, Mr Chair, thank
you very much.
The Chair:
Thank you very much, Dr Shumak. Next we have the deputy minister,
Jeffrey Lozon.
Mr Jeffrey
Lozon: Good morning. The Ministry of Health is pleased
to meet with this committee today.
Ensuring that all Ontarians
can rely on quality health care has required a modernization of
our health system to meet the needs of an aging and growing
population. A strong Ontario economy has made it possible for the
provincial government to increase health care spending by $1.5
billion since its 1995 commitment of $17.4 billion. In fact, the
government is planning to increase funding by another 20% over
the next five years to meet future needs. In 1998-99, our actual
operating expenditures totaled $18.9 billion.
This year, the Ministry of
Health and Long-Term Care budget is expected to be approximately
$20.6 billion, over one third of the budget of the province of
Ontario. Funding for cancer services forms an important and
growing part of that funding envelope.
The ministry understands the
comprehensive approach required to control cancer and therefore
we fully support the mandate of Cancer Care Ontario and will
continue to work with Cancer Care Ontario to meet the needs of
Ontarians. The ministry also understands the necessity of
providing high quality service to cancer patients across the
province and recognizes the high standards of existing services
currently provided by the dedicated staff in our health care
system.
In April 1997, the Premier
and the Minister of Health announced that the then provincial
cancer agency, the Ontario Cancer Treatment and Research
Foundation, would be replaced by Cancer Care Ontario, or CCO, as
the agency to expand the service delivery role of OCTRF and to
work with stakeholders in the province to develop provincial
standards and guidelines to coordinate cancer services. These
services cover the full gamut of cancer-related activities,
including prevention, screening, diagnosis, treatment, supportive
care, education and research.
The ministry is pleased to
appear before the committee today reviewing the Provincial
Auditor's report on his findings regarding Cancer Care Ontario, a
schedule 3 agency of the Ministry of Health and Long-Term
Care.
We take the findings of the
auditor's report seriously and are pleased to have this
opportunity to respond jointly with Cancer Care Ontario to any questions
you may have.
1110
The Provincial Auditor's
report is based primarily on information collected by the
Provincial Auditor from February 1998 through September 1998.
Although the report was not tabled until November 1999, the
Ministry of Health and Long-Term Care was aware of the work of
the Provincial Auditor throughout the audit. The ministry has
therefore been able to work closely with Cancer Care Ontario in
order to address the recommendations of the Provincial Auditor as
quickly as possible. Today I am pleased to inform the committee
of the important progress which has been made, and I will focus
my comments specifically on the recommendations which the
auditor's report directed to the Ministry of Health and Long-Term
Care.
The first recommendation made
by the Provincial Auditor was that to clarify CCO's role and
responsibilities and the ministry's expectations regarding CCO's
administration, the ministry should expedite revisions to the
Cancer Act and establish a memorandum of understanding with
Cancer Care Ontario.
On November 8, 1999, a
memorandum of understanding between the Ministry of Health and
Long-Term Care and Cancer Care Ontario was signed. The purpose of
this memorandum is to:
(1) set out the operational
accountability and the financial, auditing and reporting
relationships between Cancer Care Ontario and the ministry;
(2) set out the roles of the
minister, the deputy minister and the ministry and the board, the
chair and the chief executive officer of Cancer Care Ontario;
(3) set out the
accountability framework among the minister, CCO, the deputy
minister, the board, the chair of CCO, the ministry and the CEO
of Cancer Care Ontario; and
(4) set out the extent to
which specific directives approved by Management Board apply to
Cancer Care Ontario.
In March 1999, the Ministry
of Health and Long-Term Care signed a separate memorandum of
understanding with Cancer Care Ontario which permits the transfer
of data for cancer surveillance purposes to Cancer Care Ontario
while protecting patient privacy.
The ministry believes that
these arrangements address the intent of the Provincial Auditor
in this recommendation, and we will review the need for a new
Cancer Act as these memoranda of understanding become
longer-standing and more fully developed.
Two recommendations of the
auditor were in relation to radiation treatment. Cancer Care
Ontario, in conjunction with the ministry, should develop and
implement a long-range planning and funding process that
integrates equipment and staffing requirements for radiation
therapy and should implement a plan that provides the most
cost-effective radiation treatment equipment for patients.
The ministry agrees with the
Provincial Auditor's observations concerning the necessity to
link human resource and capital planning. We are willing to meet
this challenge which has presented itself in Ontario, other
provinces and internationally for many years.
I am pleased to inform the
committee that the ministry and Cancer Care Ontario have taken
the following steps to ensure a linkage between human and capital
resource planning for radiation treatment in the future.
The ministry has agreed to a
volume-linked, cost-per-case funding formula for the delivery of
radiation services at Cancer Care Ontario and the University
Health Network/Princess Margaret Hospital. In essence, this
allows these organizations to plan for and treat incremental
numbers of patients with confidence that government funding will
be provided to cover their costs. We are currently working from
an estimate, provided to the ministry by the Task Force on Human
Resources and Radiation Therapy, as to the amount of this cost
per case while we await recommendations as to the precise, exact
cost coming from the joint policy and planning committee, a
partnership between the Ministry of Health and the Ontario
Hospital Association. This committee report is expected in the
fall of this year. In the meantime, both Cancer Care Ontario and
Princess Margaret Hospital and the ministry have agreed that the
interim funding per case is satisfactory.
The ministry has provided
significant infrastructure support for training programs in
radiation therapy and physics. The ministry and Cancer Care
Ontario formed a joint cancer human resource planning committee
in November 1999 to ensure that training programs are geared to
provide sufficient staff to deal with these problems in the
future. The committee is also reviewing innovative strategies to
deal with the immediate problems of staffing shortages.
The ministry requested that
Cancer Care Ontario regional council for the GTA produce a report
on human resource and capital requirements for the four radiation
treatment facilities in this region once the new centres in
Oshawa and Mississauga become operational. The ministry is
extremely pleased with the quality of this report and will use it
as it develops the preconstruction operating budgets and plans
for human resource requirements over the next three years.
The ministry has established,
in conjunction with Cancer Care Ontario, a schedule for the
replacement of radiation equipment throughout the province.
Because of the understandably
high interest in and importance of this matter, I would like to
further inform the committee regarding other steps taken by the
ministry to provide for present and future cancer treatment in
Ontario.
During 1998-99, the ministry
committed almost $40 million in additional funding to
increase capacity and access for radiation services in Ontario.
New spending included $1 million allocated in June 1998 for the
operation of two new treatment machines in London and for
expanded services in Hamilton and Windsor; $15 million was allocated to expand
services, including radiation treatment, chemotherapy, new and
expensive drugs and supportive care; $1.4 million was allocated
to the Princess Margaret Hospital at that time to increase
radiation treatment capacity; $15.5 million of this new funding
was invested to train additional radiation human resource
personnel.
In December 1998, Minister
Witmer appointed a task force to identify immediate and long-term
human resource requirements for radiation oncologists, radiation
therapists and physicists, and to make recommendations to the
ministry and other relevant stakeholders on how to meet these
requirements. The Task Force on Human Resources for Radiation
Services Report was received in February 1999. As a result, the
minister established a training program for radiation therapists
at the Michener centre, and the first ever formal physicist
training program in this country.
Cancer Care Ontario has also
received funds for salary and workload adjustments for staff
involved in the delivery of radiation therapy and additional
funding for recruitment programs. So far, Ontario cancer services
have achieved a net gain of 54 radiation therapists, two medical
physicists and 12 radiation oncologists as a result of this
aggressive recruitment campaign.
The ministry provided $4.4
million in one-time funding to the Princess Margaret Hospital in
May 1999 for equipment upgrades to increase patient capacity.
In June of last year, the
ministry announced $153 million for the development of new
radiation treatment centres in Kitchener, Oshawa and Mississauga,
planned to be operational in 2002, plus a new centre in Sault Ste
Marie, expected to be operational in 2004. This funding also
includes expansion to the Hamilton, Windsor and Sudbury cancer
centres. Planning for a new cancer centre in St Catharines is
underway.
In March 1999, the minister
approved the re-referral of consenting breast and prostate cancer
patients to other cancer centres in Ontario and the United States
to offer patients an alternative option while capacity builds
within our own system. The cost of this program is expected to be
$23.1 million for one year.
The ministry is aware of the
heavy emotional burden which travel for radiation therapy places
on Ontario patients, and for this reason we will continue to work
closely with Cancer Care Ontario to address this matter. Our
first priority is clearly to provide quality treatment as close
to home as possible, and this has been the key principle
underpinning our planning for delivery of radiation. If this is
not possible, we need, through Cancer Care Ontario, to allow
patients access to radiation services elsewhere in the
province.
In regard to the Ontario
breast screening program, the Ministry of Health and Long-Term
Care continues to provide support for screens and Cancer Care
Ontario's co-ordinating activities. The ministry is committed to
working with Cancer Care Ontario to develop and implement
strategies to increase the participation of women in the age
group of 50 to 74.
In response to the Provincial
Auditor's concerns regarding quality assurance within the
program, the Ministry of Health has requested a review of the
Ontario breast screening program, which Dr Shumak has already
referenced.
In regard to Cancer Care
Ontario's development of an effective cervical screening program,
the Provincial Auditor has recommended that the ministry should
facilitate access to appropriate cervical screening information
and develop protocols to use data for statistical purposes while
safeguarding the privacy of patient information. As you may know,
the ministry has invested over $3.6 million over the past three
years to develop a cervical screening program, which is being
coordinated by Cancer Care Ontario. I am informed by Cancer Care
Ontario that the official launch of this province-wide program
will be in June of this year. This program has developed
provincial guidelines for screening, testing and follow-up with
stakeholder participation and education videos for women and
physicians. A strategy for dissemination and implementation of
guidelines has also been developed. The program has worked with
public health units to develop a clearinghouse for educational
and promotional materials for general and specifically targeted
populations. It will implement a social marketing campaign, a
cervical screening registry and increase accessibility to
screening.
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The Ministry of Health and
Long-Term Care is currently engaged in broader initiatives to
develop a laboratory information system and associated standards
for the sharing of laboratory information between its funded
agencies. When established, this will provide Cancer Care Ontario
with the necessary test results to permit CCO to follow up on
high-risk patients and to facilitate biannual recall of patients.
The ministry will continue to work with Cancer Care Ontario to
develop a provincial data capacity within this provincial
initiative. Meetings between the ministry and Cancer Care Ontario
are ongoing in this regard.
The Ministry of Health and
Long-Term Care endorses the recommendations made by the
Provincial Auditor in his section dealing with managing
resources. The ministry believes that the memorandum of
understanding which was signed between the ministry and CCO in
November 1999, through provisions of a clear CCO mandate and
through its requirement to comply with Management Board
directives on acquisition and purchasing, establishment of
subsidiaries, conflicts of interest and the requirement for
strategic operating and business plans, provides the appropriate
framework to respond to the Provincial Auditor's concerns.
In conclusion, the ministry
is grateful for the insights of the Provincial Auditor and the
stimulus he has provided for making important changes as we
together face the enormous challenge posed by cancer. We have
indeed established an effective and cordial working relationship
with Cancer Care Ontario toward this end.
The Chair: We have about 36 minutes
left until the 12 o'clock recess. I'm suggesting that we split
the time evenly, about 12 minutes for each caucus, and we start
off with the government caucus today.
Mr Dan Newman
(Scarborough Southwest): I want to begin by welcoming
Cancer Care Ontario, Dr Shumak, and the ministry's Jeff Lozon
here today before the public accounts committee.
My question is for Dr Shumak.
I think it's internationally recognized that there is a shortage
of radiation therapists throughout the world. I know the Minister
of Health and Long-Term Care and the ministry have been very
aggressive and active in recruiting radiation therapists to
Ontario.
In your presentation today,
you said, "Staffing shortages are at the root of the current
problem."
Dr Shumak:
That's correct.
Mr Newman: I
was looking through some press clippings that appeared yesterday.
It says here, "Techs Blocked at Border," where it appears that
the federal government, through its immigration policies, is not
allowing radiation therapists to be available to the people of
Ontario. I quote from that article. It says, "Twenty-eight
radiation therapists are now wading through a lengthy immigration
process, while Ontarians with cancer continue to be sent outside
the province for treatment." That's quite a serious comment. I
think the Premier has been very clear on this issue, Dr Shumak.
He said, "They transfer hockey players back and forth ... within
24 hours," and he said that radiation therapists are "a tad more
important" than hockey players. I would agree with him.
The Minister of Citizenship,
Culture and Recreation, Helen Johns, wrote a letter to the
federal Minister of Citizenship and Immigration, Elinor Caplan,
this week, asking her to speed up the process so that we could
get more radiation therapists in Ontario. She said that this is
"yet another example of the serious problems with your
immigration policy" that are affecting the health care system
here in Ontario.
I ask you today, what has
Cancer Care Ontario done to augment and enhance the effort of the
ministry to attract more radiation therapists to Ontario?
Dr Shumak:
I'll deal first with the last part of your question. We have had
a very aggressive recruitment strategy. We have recruited a total
of 40 radiation therapists from outside of Canada, including five
Canadians who we are repatriating and 35 other radiation
therapists. This is against the background of international
competition for these people, because there is an international
shortage. So that's what we're doing about it. We have certainly
been working as diligently as we can through the immigration
process and in fact have a full-time staff person who has been
involved in doing this, along with the other aspects of the
recruitment inititiative.
I'm pleased to say that
just a couple of days ago I received a telephone call from
Minister Caplan in which I was assured that whatever blocks there
were will be dealt with. I'm not sure what the details will be,
but hopefully this is a sign that we will be able to-our numbers
are 25 people who are simply waiting for approval, and as soon as
the approval comes then these people will be able to work in
Ontario and will help us to reduce the backlog that I referred to
before.
The Chair:
Is that in addition to the 40?
Dr Shumak:
No, that's 25 of the 40. Maybe I can just clarify that in
addition to the immigration issue, which obviously we have to
deal with, there's also an issue different from the hockey
players. In this instance, we've got licensure issues and
competence issues. I'm sure members of the committee will support
the position we've taken, which is that as desperate as we are to
have more radiation professionals, we can't compromise our
standards, and therefore, in addition to getting past the
immigration issues, there's also the need for individuals to
prepare for re-examination. That takes some time. That's why not
all 40 are ready.
Mr Newman:
I hope the immigration roadblock is removed, that the minister
keeps her word, because she too represents a riding in Ontario
and it affects her constituents as well.
The Provincial Auditor also
raised a concern regarding the quality assurance measures of the
Ontario breast screening program. What has Cancer Care Ontario
done to address those concerns?
Dr Shumak:
What I'd like to do, to give you the details rather than an
overview of the sort I presented in my remarks, is call on my
colleague Dr Schabas, who can speak to the specific quality
assurance measures that have been taken.
Dr Richard
Schabas: Let me just reiterate the point that Dr Shumak
made, that the Ontario breast screening program operates and has
always operated a program of very high quality, demonstrable by
the outcomes of screening. We have cancer detection rates,
interval cancer rates and other quality measures of outcome that
favourably compare with those across Canada and indeed around the
world. We certainly welcome the comments of the auditor in
identifying ways in which we can improve on the quality
assurance. We're always striving to improve our quality. Because
cancer screening is so important, quality must be of the utmost
importance, and that's why we regard Dr Shumak's remarks about
the issue of screening outside the organized program as so
important.
But indeed with specific
reference to the recommendations of the auditor, we now have
established better links with the registered persons database and
through the Ontario Cancer Registry to improve our ability to
monitor the cancers that are found within the program and to
identify and follow up on interval cancers of all kinds. We have
established a routine protocol of review of the interval cancers
with our radiologist-in-chief and with panels of radiologists,
and we've established a routine protocol for informing those
radiologists who were the original readers of the interval
cancer, particularly the missed cancer, screens. We've also
developed a routine protocol for identifying the results of
screening, the cancer
detection rates, the interval cancer rates, the missed cancer
rates on a radiologist-by-radiologist basis and on a site-by-site
basis. I think those were the key recommendations of the auditor
and reflect a shared commitment we have with the auditor to
continue to improve the quality and to make sure that we know and
can demonstrate how high our quality is.
Mrs Julia Munro
(York North): I certainly appreciate the opportunity to
hear the remarks you have provided for us today. My question
comes from the whole area of prevention and the question of
promoting prevention, because as we look into the figures that
you have provided for us, it's clear that everyone in Ontario has
a vested interest in finding various methods to look at
prevention. I notice that the Ministry of Health provided $17
million to heart health and also the announcement of $19 million
for the Ontario tobacco strategy. I wonder whether or not you
could comment in more specific terms on the role you see Cancer
Care Ontario playing in that field of prevention.
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Dr Shumak:
I'd like to just make some brief overview remarks and then again
I'll ask Dr Schabas to comment in more detail.
Cancer Care Ontario has
recently completed its first revision of its original strategic
plan. The original strategic plan was clear in having one
explicit goal about prevention. We have certainly reinforced that
and adopted that role again in our new iteration of the strategic
plan and, I think importantly, have recognized very clearly some
specific initiatives that we intend over the next several years
to focus on. They include initiatives in tobacco and
environmental and occupational carcinogens, diet and
exercise.
As I mentioned in my
remarks, we believe it's crucial for us not to be too consumed by
the crisis of the day, as important as it is. We obviously can't
ignore that. We must, through all this, begin to plan for how we
can change things in the long term. So we're very committed to
prevention.
Maybe I can ask Dr Schabas
to give you a few more details about the plans.
Dr
Schabas: I have just a few brief comments. I'd refer you
back to the graph that Dr Shumak presented at the beginning of
his remarks which shows a steady increase in cancer deaths, and
indeed that reflects a steady increase in new cases of cancer,
and I suggest to you there are really three key messages to take
away from that. The first message is, obviously, the steady,
inexorable demand on treatment services, which have been
discussed already by Dr Shumak and by Mr Lozon. The second
message is that we need to do things differently, that clearly we
cannot continue to sustain that kind of pressure. The third
message, if we look at the other lines on the graph, particularly
for heart disease, is that we can do things differently, because
we've done much better with heart disease. A lot of that
difference has been because of more effective measures in the
area of prevention.
Cancer Care Ontario's role
in prevention is a new one. We only received funding approval for
our prevention unit last February and hired the staff beginning
in June, so it's certainly early days. But through our strategic
plan we've identified strategic priorities. Tobacco, diet and
physical activity are at the top of that list, because those are
the major preventable causes of cancer in Ontario. We've also
identified an interest in occupational cancer. We've requested
funds so that we can improve our surveillance of occupational
cancer so that we can develop an effective strategy to deal with
that. Indeed, we're also looking at issues related to
environmental pollution. We have a very small project underway to
try to develop some strategic directions in that area.
But I think if we want to
really make a difference in the long term, if we don't want to
continue to have these meetings year after year and talk about
the pressures on the treatment system, we have to put more
resources and more efforts of all kinds, including public policy
efforts, into primary prevention and into cancer screening.
The Chair:
Thank you very much. That's 12 minutes. Mr Maves.
Mr Bart Maves
(Niagara Falls): Pass.
The Chair:
OK. Mrs McLeod.
Mrs Lyn McLeod
(Thunder Bay-Atikokan): I'm sure you're aware there's a
number of questions we're going to want to address over the
course of the day, both to Cancer Care Ontario and to the
ministry. I appreciate the fact that you both in your opening
presentation addressed one of the key concerns, which is waiting
times for radiation. That is an issue we want to return to,
including the issue of recruitment of professionals and whether
we're making much progress in catching up for the regrettable
decision that we've made to cancel the training programs that
were being done before there was any alternative training program
put in place. If that decision hadn't been made, we might well
not have been trying to deal with recruiting professionals from
abroad. But I'll return to all of that this afternoon.
I want to lead with a
different issue, because one of the things that concerns me
overall, as we look at the auditor's report and read the
concerns, is that part of the history of cancer care is that
we're constantly trying to catch up with something that maybe we
all should have been able to see coming.
There's a statement in the
auditor's report that there is-he's looking at systemic treatment
wait times. The language is perhaps a bit technical, but can I
just understand before I proceed that that is access to
chemotherapy through medical oncology. The auditor notes that
there is no national or provincial standard for systemic
treatment wait times and that CCO plans to address this
issue.
In your strategic report,
Dr Shumak, you say, on the issue of adequate access to timely
care, that timely access to quality care requires adequate
resources at each step. There's a rather alarming statement made
on the next page: "Insufficient resources lead to crises in
access to care. Potential crises loom on the horizon in areas
such as systemic therapy, surgery, diagnostics and palliative
care, again, just as in
the current crisis in radiation treatment, due to the critical
shortages in trained professionals."
Before I come back in the
afternoon session to the concerns we have about the crisis in
access to care for people needing radiation treatment, I want to
ask you whether or not we are looking at a serious crisis. What
are the dimensions of the crisis, particularly starting with
systemic therapy or access to medical oncology and chemotherapy
treatment? What are the dimensions of the problem that you're
identifying? Is anything being done to deal with it? What needs
to be done?
Dr Shumak:
I'd be pleased to respond to that question. The statements you
cite are indeed statements that we strongly support. It's
essential that we try to prevent problems before they happen.
There are warnings on the horizon about each of the areas you
cited, that unless we plan very carefully we run the risk of a
similar problem to the one we're having with regard to radiation.
The way Cancer Care Ontario has approached this is that for the
past year, once it became clear that this is a serious problem,
we've had a task force that has worked diligently. I want to
clarify that in contrast to radiation treatment, in which all the
treatment is delivered within the regional cancer centres, the
issues with regard to systemic therapy, with regard to diagnosis,
with regard to surgical oncology, are more complex because those
services are provided throughout the province. So it's extremely
difficult, and there are far fewer national standards, as you've
cited.
This task force report is
in its final draft stage. Once it's completed, we will be
developing the case for what we believe needs to be done in
response to these issues and taking it forward to the ministry.
The ministry is aware of this problem, and on an interim basis in
our operating plan for this year we did request some funding,
because even before we could quantitate it specifically we knew
that we needed some resources, and we did obtain some resources
to deal with it on an interim basis. But the long-term solution
will require a lot of effort, not just in systemic therapy but,
as you point out, in surgical oncology and in the diagnostic
area.
I would like to suggest
this is one of the advantages of a structure such as Cancer Care
Ontario because we can bring together all the players. In the
systemic therapy task force we have members of the community,
oncologists, pharmacists, all the people who can help us to
identify the issues.
Mrs
McLeod: I appreciate that, and that puts Cancer Care
Ontario and the task force in a position that the auditor wasn't
in, because as the auditor explained in his report, they didn't
have access to a lot of data on the waiting times for
chemotherapy.
I'm not sure how legitimate
it is for me to ask you this next question, but I'm going to
anyway, and you can say you won't answer it. Has the task force
been able to acquire data as to the range of waiting times for
chemotherapy that currently exist and, if you have, how that
would compare to any waiting times that you might use as a
benchmark, even though I appreciate that at this point there is
no standard?
Dr Shumak:
One of the problems with the approach to systemic therapy is that
waiting times may not be the best indicator of the situation,
because in contrast to radiation, where, as bad as it is, waiting
times can actually occur, when a patient presents requiring
chemotherapy treatment, in many instances it's really quite
urgent. Generally, instead of having lengthy waiting times, what
happens is that the system just gets more and more stressed. The
systemic therapy task force analysis deals more with the stress
on the system. We have people who are seeing more patients than
we're comfortable with. We're concerned about staff retention
because of stress rates.
The waiting times really,
as I say, are still relatively brief because it's really
analogous to emergency medicine-not quite, but obviously people
have to be seen, and that's the way it's happening. There are
certainly anecdotal examples of people who've had to wait longer
than we know is appropriate, but it's hard to get good data, and
as I say, I don't really think it reflects in the same way as
these other measures I've referred to.
1140
Mrs
McLeod: The analogy was that emergency care might not be
the most fortuitous one to use because we've seen the problems
we've had with emergency care over the past winter and fall.
I guess then that whole
issue of staff, which is what you've addressed as being the
problem that could create the crisis-medical oncology, what is
our situation? If people are seeing too many patients, that has
to affect quality of care, even if they're currently able to see
them immediately.
Are we facing a current
shortage of oncologists? How soon will this shortage of medical
oncologists occur? If it's now, what's being done in order to
change the training system, increase the residency positions to
be able to deal with the shortage of, in this case, I guess both
medical and radiation oncologists?
Dr Shumak:
We're certainly doing everything we can to recruit medical
oncologists and, as well, to make sure that the medical
oncologists who have trained in Ontario remain in Ontario. One of
the issues for us always is, for all such professionals, that
there are opportunities for them elsewhere. So our focus is on
that.
In addition, we have had
ongoing discussions with COFM, the Council of Ontario Faculties
of Medicine. This has been an ongoing problem over many years, to
ensure that our needs are properly integrated with the needs of
all sorts of medical specialists.
One of the recommendations
that may come out of the systemic therapy task force might be to
have separately funded training positions for medical
oncologists, funded through Cancer Care Ontario, which would not
be the way the current system is funded. But it's perhaps a bit
premature to table recommendations. As I say, this is still in
the final draft stage. But you have put your finger on a key
issue; there's no doubt about it. We believe that staffing shortages will be just
as important in this field as in radiation.
Mrs
McLeod: The same thing will hold true, then, in surgery.
If I have time, is the task force looking at waiting times for
surgery for cancer patients, given the fact that we are seeing
problems with acute-care beds and surgical beds and lack of
anaesthetists in order to do surgery? Are you starting to see
long waiting lists for surgery for cancer patients?
Dr Shumak:
The task force for systemic therapy is not looking at that, but
we have formed a division of surgical oncology in Cancer Care
Ontario and one of its projects is to do just that, to try to
gather data on waiting times for patients who have cancer who are
waiting for surgery. There is a dearth of data in our system and
I think we recognize that this is a priority. At the moment,
there is nothing I can report. This is extremely preliminary.
Suffice it to say that there are waits that are longer than we
would like and that's why we think it's an important issue to
deal with.
Mrs
McLeod: Have I exhausted my time?
The Chair:
Two more minutes.
Mrs
McLeod: I won't have time in two minutes to get to the
ministry questions that I have on budgets, so I'll return to
those later. But on the question of-I'm hesitating because I know
there will be areas that are confidential information. But is the
issue of staff shortages and the need for Cancer Care Ontario to
be in a position to recruit the people they need, whether it's in
radiation oncology or whether it's in medical oncology-and I'm
not sure that would be specifically your budget-have you been
able to estimate what you believe the staffing needs are in those
areas and make a submission to the ministry? If you have, is it
possible for us to know what the gap is between your estimate of
staff needs for oncologists and what we currently have?
Dr Shumak:
As I alluded to before, the situation with regard to radiation
therapy is in some respects the model that we'd like to develop
in systemic therapy. As you recall, we have a per-case funding
formula, which enables us-as the volume increases, we have the
resources. Provided that the adjustments are made, as the deputy
referred to, to make sure that the per-case funding is
appropriate, then we will not be in this position again.
At the present time we have
no such approach in systemic therapy, but one of the
recommendations that we may make, and this will obviously require
extensive discussion with the ministry, is that we look at this
kind of approach with regard to systemic therapy. Because in the
absence of that, what we're left with is that the current staff
see all the patients who come, to the best of their ability, and
we do run the risk of getting into the problems I described.
We are beginning to develop
staffing standards in medical oncology in terms of the number of
patients it's reasonable to expect medical oncologists to see. We
know that at the present time our medical oncologists are seeing
significantly more than these standards, based on recommendations
from other provinces, where similar-
Mrs
McLeod: Can you give us figures?
Dr Shumak:
Yes. In general, the typical figures in our own studies and in
other provinces are that a medical oncologist should see
approximately 140 new patients per year. That's a reasonable
workload. At the present time, our figures in Ontario, at least
within the Cancer Care Ontario system, and I can't give you the
data for the people working in the community, are over 200. So
there is an issue.
During the time that we
were developing the detailed report, just speaking about budget,
we made a request of the ministry in our 1999-2000 budget
submission for $3 million in addition for systemic therapy to
enable us to recruit, and we received the $3 million.
Ms Shelley Martel
(Nickel Belt): Thank you for coming to see us today. Let
me start this way. I understand that CCO is managing the
re-referral list for patients who have to travel to other centres
for cancer treatment. Is that correct?
Dr Shumak:
That's correct.
Ms Martel:
When did that process start?
Dr Shumak:
It started back in the spring of 1999.
Ms Martel:
Patients have gone to Buffalo, Detroit, Cleveland, Sudbury,
Thunder Bay and Kingston as part of this initiative?
Dr Shumak:
That's correct.
Ms Martel:
Is it true, then, that when they travel, 100% of their travel
costs are covered?
Dr Shumak:
So far I'm able to answer all your questions, but because I can
see that you're getting into more detail, the person who is most
able to speak to the details of the re-referral project is Dr
McGowan. So I'm going to refer you especially to Dr McGowan.
Dr Tom
McGowan: For the purposes of travel and accommodation
for patients travelling in the re-referral program, we arrange
travel for patients and we pay for that directly. If they drive,
we pay them the mileage. We pay accommodation costs when they are
in another city, and we pay that directly. We provide them with a
per diem for food.
Ms Martel:
I just want to be clear: 100% of an airplane ticket would be
covered. Is that correct?
Dr
McGowan: Yes.
Ms Martel:
And 100% of a bus ticket?
Dr
McGowan: If that's their route of travel, yes.
Ms Martel:
And 100% of a train ticket, if that was required. For someone who
drives, what is the price per kilometre that you pay?
Dr
McGowan: I can't tell you that. I think it's around 30
cents. It may be a bit less than that.
Ms Martel:
Would that be for the total number of kilometres travelled or
just for travel from the home to the cancer treatment centre?
Dr
McGowan: It would be their travel from their home to the
cancer centre that they're going to.
Ms Martel:
What I'm getting at is, is it for one-way travel or for return
travel? You pay the entire kilometres?
Dr McGowan: If they drive from
Hamilton to Buffalo, we pay their kilometre charge from Hamilton
to Buffalo and then return.
Ms Martel:
So back is covered as well.
Dr
McGowan: Yes.
Ms Martel:
Okay. Is it true that at a recent CCO meeting there was also a
possibility floated that costs for a companion, a spouse, a
partner would also be paid to allow that companion, spouse or
partner to visit the cancer patient while they were getting
treatment somewhere else?
Dr
McGowan: We had discussed that as a possibility.
Ms Martel:
Was that possibility accepted or rejected?
Dr
McGowan: We decided not to pursue that.
Ms Martel:
Can you tell me whose idea it was to fund 100% of the travel,
accommodation and food costs for cancer patients who have to
travel?
Dr
McGowan: That was an idea that was presented by Cancer
Care Ontario.
Ms Martel:
So it was Cancer Care Ontario's idea to do this, and you've
presented this to the Minister of Health?
Dr
McGowan: Yes.
Ms Martel:
Can you tell me why this decision was made?
Dr
McGowan: Because we felt that in the extraordinary
circumstance of a re-referral from the cancer centre they should
have been treated at to another cancer centre, we should not
institute a financial barrier to care.
Ms Martel:
OK. Can you tell me how many patients have received treatment
through this mechanism so far?
Dr
McGowan: It's approximately 800.
Ms Martel:
It's 800. And all have qualified for 100% reimbursement of the
costs that they have put in-
Dr
McGowan: People sometimes request other costs that we
don't cover: telephone charges, certain things like that. They
have qualified for the costs that we're covering, which is, we
pay for the flights and the hotels.
Ms Martel:
How are patients reimbursed?
Dr
McGowan: We pay these costs directly and for the mileage
charge we submit them a cheque.
Ms Martel:
So they would submit a claim to CCO and you would pay them
directly.
Dr
McGowan: For their mileage charge and their per diem for
food, yes.
Ms Martel:
And for air travel?
Dr
McGowan: No, we pay that to the airline.
Ms Martel:
OK. How much has been spent to date to pay all of these
costs?
1150
Dr
McGowan: I don't have that figure with me. Do you have
that figure?
Interjection.
Dr
McGowan: It's $2.3 million.
Ms Martel:
So $2.3 million has been paid to date for reimbursement? I
thought the deputy-
Dr
McGowan: Not for reimbursements for-to cover these
costs, and all of that has been reimbursed directly to the
patients we pay, to the airlines or the hotels.
Ms Martel:
So $2.3 million reimbursed directly to patients. Can you tell me
how much money has been reimbursed in total to patients and to
airlines as part of this program?
Dr
McGowan: Again, $2.3 million is the total cost. I don't
have the split between accommodation, travel and per diem for
food.
Ms Martel:
Can you tell me what would be the average cost per patient that
you would be reimbursing?
Dr
McGowan: The total cost per patient is of the order of
$5,000.
Ms Martel:
How many people remain on a waiting list who may have to use this
same mechanism? Do you have any idea?
Dr
McGowan: Our rate that we're sending patients for
re-referral is of the order of 20 to 25 per week. We anticipate
that we would need to continue to re-refer patients. Our target
is 18 months. That would be dependent, of course, upon
recruitment efforts, ability to increase the-so it's a target and
we're doing our best to reach that target. The rates will
probably drop from 20 to 25 a week as we get closer to the
target, as fewer and fewer patients will be qualifying.
The Chair:
Could you sit a little closer to the mike?
Dr
McGowan: Sure. The target is 18 months. We're currently
sending about 20 to 25 a week. We expect that rate to drop. There
may be a very small number that continue to travel within Ontario
until the new cancer centre is open. Some of these projections
are hard to be firm on because we treat 25,000 patients a year.
Of those 25,000, only 800 travel. So the vast majority are
treated and continue to be treated at the cancer centre close to
where they live.
Ms Martel:
Can you tell me, Dr McGowan, who is paying for these costs?
Dr
McGowan: This is funding that's paid by Cancer Care
Ontario for these costs, and our funding, as you know, is
received from the Ministry of Health.
Ms Martel:
Let me just clarify. Is this funding that came out of your base
budget?
Dr
McGowan: No.
Ms Martel:
Is it funding you received from the Ministry of Health?
Dr
McGowan: Yes.
Ms Martel:
So the Ministry of Health is flowing you the funds to pay for
this program?
Dr
McGowan: Our programs are predominantly funded by the
Ministry of Health, yes.
Ms Martel:
I want to be very clear about this.
Dr
McGowan: I know this is probably a nuance you're getting
at. I'm just personally having trouble following the nuance.
Ms Martel:
Let me start again. The money that you're paying these patients
for their 100% of costs is not coming out of Cancer Care
Ontario's base budget?
Dr
McGowan: No.
Ms Martel:
So it is money that has been flowed particularly for this effort
by the Ministry of Health?
Dr
McGowan: Yes. This is funding for this program.
Ms Martel: So special
allocations?
Dr
McGowan: This is funding for this program, yes.
Ms Martel:
So it would be probably dishonest or false for someone to suggest
that in fact the money paying for this is coming from Cancer Care
Ontario or the Canadian Cancer Society, for example?
Dr
McGowan: Well, it's not coming from the Canadian Cancer
Society.
Ms Martel:
At all?
Dr
McGowan: No. This is not funding that's coming through
the Canadian Cancer Society. Cancer Care Ontario is managing this
as one of the programs we manage and run, and it's funding that
we receive from the Ministry of Health.
Ms Martel:
I just want to be really clear. You're saying to this committee
that none of this money comes from the Canadian Cancer
Society?
Dr
McGowan: No, it does not.
Ms Martel:
Absolutely not?
Dr
McGowan: We're not getting funding from the Canadian
Cancer Society for this.
Ms Martel:
And it would probably be false, dishonest, for someone to suggest
that this program is being paid for by Cancer Care Ontario,
because in fact the money is being flowed from the Ministry of
Health.
Dr
McGowan: Of course, the money that we spend
predominantly comes from the Ministry of Health.
Ms Martel:
It's a special allocation that you're getting for this
process.
Dr
McGowan: This is an allocation we're getting for this
program.
Ms Martel:
Over and above your base budget?
Dr
McGowan: Yes.
Ms Martel:
The reason I'm asking is that Anna Watson, who lives in Fort
Frances, Ontario, received a letter dated September 22, 1999. She
wrote to the Minister of Health to complain that she is a cancer
patient from Fort Frances, that she has to travel to the Thunder
Bay Regional Cancer Treatment Centre, and that her costs to do
that are not covered 100%. In fact, she only gets kilometre costs
one way, from Fort Frances to Thunder Bay. She gets no allowance
for food, which she has to purchase at the hospital while she's
there for treatment. She gets no allowance for accommodation if
she has to stay on the weekend because she can't stay at the
lodge in Thunder Bay on the weekend; you have to stay in a hotel.
So as a result, seeing what was happening to southern Ontario
cancer patients, Ms Watson wrote and wanted to know why the
Ministry of Health was not paying these same funds for northern
cancer patients. She received a reply that said, "Cancer Care
Ontario and the Canadian Cancer Society are paying the expenses
for cancer patients who travel to northern Ontario for
treatment." That was signed by the Minister of Health, Elizabeth
Witmer.
The reason I asked you the
question is because I think it is dishonest of the minister to be
writing to people and telling them that the costs that southern
Ontario patients are having covered are being borne by Cancer
Care Ontario or the Canadian Cancer Society. Do you agree?
Dr
McGowan: Perhaps I should answer.
Ms Martel:
Anyone who wants to answer, and I would ask the same of the
Ministry of Health.
Dr
McGowan: For the patients who are travelling for any
treatment to the cancer centre that is the one they should be
travelling to-so people in Barrie going to Toronto-there is a
travel program that the Canadian Cancer Society runs. They have
volunteer drivers. For the patients who are travelling from their
home to a cancer centre that is not the one closest to their
home, we felt that we should fund it as we've recommended.
Dr Shumak:
If I could make a couple of comments, first, just to pick up on
what Dr McGowan has stated, the confusion here I think is because
the Canadian Cancer Society does have elements, as Dr McGowan has
referred to, of supporting patients in shorter trips. I can only
surmise that was probably what the minister was referring to.
Ms Martel:
Oh, I don't think so.
Dr Shumak:
With regard to Cancer Care Ontario, does Cancer Care Ontario pay
for this program? The answer is yes, we do pay for this program.
I just want to stress what Dr McGowan said. Although I take the
nuance that you're driving at, that it is a special allocation,
it is still a program that is administered through Cancer Care
Ontario.
I'd like to take the
opportunity to speak to the overall issue.
Ms Martel:
Before you get there, if I might, Dr Shumak, because I'd like to
add to this-
The Chair:
One more minute.
Ms Martel:
It's not only the Minister of Health who is doing this. Last
week, my staff spoke to the manager of the northern health travel
grant in Sudbury about this issue. The manager at the northern
health travel grant in Sudbury told my staff that they were
disappointed that there was so much misinformation about this
issue being raised and that in fact it was not the Minister of
Health or the Ministry of Health that was paying for this program
to allow southern Ontario patients to have 100% of their costs
covered, that it was the Canadian Cancer Society and Cancer Care
Ontario which were paying.
I don't think there's any
confusion. What we have here is the Minister of Health and the
ministry I think deliberately misleading northern Ontario cancer
patients who are writing to say, "Why can't our costs be covered
too?" That's a legitimate request that they are making, because
they're having to travel to receive cancer care. It's the same
for people in Pickle Lake who have to go to Thunder Bay, or Red
Lake who have to go to Thunder Bay, or people in New Liskeard who
have to go to Sudbury, or from Elliot Lake to Sudbury. Why aren't
their costs being covered 100% by the Ministry of Health too?
The Chair:
A final comment, Mr Lozon.
Mr Lozon:
I'll be brief. First of all, I apologize. I forgot to introduce
my colleagues who are with me. Dr Les Levin is a special adviser for cancer services,
appointed directly to the Deputy Minister of Health's office at
the end of 1998. Beside him is Dr Colin D'Cunha, who is the chief
medical officer of health for the province of Ontario.
First of all, a couple of
points of clarification: The re-referral program for Cancer Care
Ontario for cancer patients was set at $23.1 million and that was
inclusive of the full costs of the service, including the travel
grants that were the subject of the last questions.
The other point I'd like to
make is that there are other programs of the Ministry of Health
that may apply here. One is the northern health travel grant,
which is perhaps the basis upon which the reimbursement is being
provided in certain sets of cases. I'd be quite prepared to talk
about the northern health travel grant and explain what it is in
the fullness of time.
The Chair:
Thanks very much. Your 12 minutes are up.
Before we recess, I'll just
use the Chairman's prerogative to ask one clarification of a
comment that's been made a number of times, and that is, you
stated that the per-case funding has increased on a per-case
basis. Are we talking about all of the cases, including those on
the waiting lists, or just those people who are currently being
serviced by the system?
Dr Shumak:
The per-case funding refers to the cost of treating a patient
within one of the cancer centres, whether it be one of the cancer
centres run by Cancer Care Ontario or the Princess Margaret
Hospital, so it's the actual treatment. The costs associated with
maintaining the waiting lists and so on are part of the special
program that the deputy referred to with re-referral.
The Chair:
Thank you very much. We stand recessed until 1:30 this
afternoon.
The committee recessed
from 1200 to 1335.
The Chair:
I'd like to call the meeting back to order. We'll start the
questioning for 20 minutes with the government side.
Mr Maves:
Let me just start off by congratulating both of our presenters
this morning for excellent presentations, very thorough and quite
informative.
I was going through Dr
Shumak's presentation. On the second page you stated: "Before the
creation of Cancer Care Ontario in 1997, there was no mechanism
to coordinate all the different types of services that an
individual cancer patient can require. Similarly, there was no
mechanism to establish province-wide standards for care." I'm
just curious: Did the Ontario Cancer Treatment Research
Foundation not do any of those functions at the time?
Dr Shumak:
The responsibility of the OCTRF was primarily to manage the eight
regional cancer centres of the OCTRF. There was also a role they
had with regard to, for example, launching the OBSP. They also
had a role in planning for provincial research. But what they
didn't have was any mandate whatsoever to coordinate the-without
trying to make this pejorative, there's the formal system, the
informal system, the organized and the unorganized. The formal,
organized system is the Princess Margaret and the eight regional
cancer centres. The rest of the province, which delivers more
than 50% of cancer care, never was under the jurisdiction of the
OCTRF. The important point in the formation of Cancer Care
Ontario was to try to ensure that all parts of the province, all
cancer services within the province could be coordinated for the
first time. That was the sense of that statement.
Mr Maves:
One of the things you talked about on page 3 of your report was
difficulty maintaining "internationally competitive salary
levels." I'm just curious: What are they here, what are they in
our neighbouring states in the US, what are they in other
provinces?
Dr Shumak:
In terms of the details, I'm going to defer to Dr McGowan, who
may have these figures.
Dr
McGowan: The three main professionals are radiation
therapists, radiation oncologists and physicists. For radiation
therapists, the top of the range of our salary rates is of the
order of $55,000, which is nationally competitive. It's a little
bit less than the BC rate but it's nationally competitive. In the
United States there's a dollar-per-dollar match, so there's the
exchange rate difference. For physicists, we've recently raised
the salaries so that the top of the range-the dollar-per-dollar
rate is the same as it is in the States, which is just over
$100,000 for physicists. Again, there's the exchange rate
difference. That's very competitive nationally. For radiation
oncologists, there is a very big difference in the salary rates
between Canada and the United States. Those are well-known
differences, and I think there's no point in really dwelling on
that. But nationally the salary rates for radiation oncologists
in Ontario are very competitive, are among the best in the
country.
Mr Maves:
For each of those in the Canadian comparison you said we're
competitive. Are we in the top three? Are we below only one or
two provinces?
Dr
McGowan: I would say for physicists we're at the top,
for radiation therapists we're probably number two and for
radiation oncologists, I'm sorry, I can't quote the ranking but
we're in the top few.
Mr Maves:
The other thing I was interested in is, "Currently, 40% of
patients are treated within the four-week standard." We've had
some chats about the four-week standard. How many of the other
provinces-and I don't know if this is for the Ministry of Health
or Cancer Care Ontario-have adopted that four-week standard?
Dr
McGowan: The four-week target from the point of referral
to the start of treatment is the standard that has been endorsed
by the Canadian Association of Radiation Oncologists, which is
the medical professional body of radiation oncologists in the
country. This is a standard that has been promoted
nationally.
As far as I know, Ontario
is the only province which has formally endorsed this as the
target. All other provinces are working to keep their waiting
lists as short as possible. There is informal, at least at the
ministry level, agreement with that outside of Ontario. Within
Ontario we have formal agreement that that is the target we want
to reach. I don't know
if there's any other province that-
Mr Maves:
So we're leaders in endorsing that.
Dr
McGowan: Yes.
Mr Maves:
How long has that been the standard that has been put forward by
the Canadian Association of Radiation Oncologists?
Dr
McGowan: At least five years.
Mr Maves:
When did we adopt that?
Dr
McGowan: At the start of 1999.
Mr Maves:
The next question I have is, 40% of our patients are treated
within the four-week standard in Ontario?
Dr
McGowan: Yes.
Mr Maves:
Are there any other provinces, then, if they don't have that same
standard, that are matching that, improving that? Where do we
stand in comparison with some other provinces?
Dr
McGowan: There are differences in the way the statistics
are captured and reported in the other provinces, so it's more of
an apples-and-oranges comparison, the numbers they report. They
sometimes report, rather from the date of referral, from the date
of consultation, which is a different point in the process.
I can tell you that Quebec
has sent patients down south; Manitoba is sending patients down
south. I know the waiting lists in BC are long. This is a
national issue, but as far as where we rank on a benchmark in
using that specific definition, I can't tell you exactly. A
number of the other provinces have longer waits. Certainly Quebec
is longer and Manitoba is longer.
Mr Maves:
There was a goal set by Cancer Care Ontario that by the end of
March 2000 we'd be at 50% of patients treated within the
four-week standard. Is that the end gain or do we then have a
2003 goal for 75%, or is there not a need to have 100% seen
within the four-week standard?
Dr
McGowan: You're right in the implication of the
question. This is a process that takes a couple of steps. We
could not move from the status we had in the fall of 1998, of 32%
within four weeks, to immediately moving to 90% in four weeks.
With the four-week target we wouldn't see 100% of patients, but
we are aiming at 90% eventually. What we've set as the interim
standard is 50% in four weeks and 90% within eight weeks. We had
set that target for the cancer centres. That of course is
completely dependent upon recruitment and having the staff in
place to treat the patients. So once we've reached the interim
target, we would then move to setting targets to reach the full
standard of 90% within four weeks.
Mr Maves:
The aggressive recruitment of radiation treatment professionals
that you talked about, and we had a little discussion about some
of them waiting to get into the country and whatnot, where are we
finding most of the ones we've recruited, and how are we going
about that recruitment?
Dr
McGowan: We're recruiting through advertisements. The
person who is coordinating the hiring for us is currently in
Australia, attending a conference there and recruiting people.
Most of our applicants have come from Australia, New Zealand,
South Africa and England. That's where most of the recruits have
come from. So we go through a process of advertisements and
attendance at conferences. We had someone attend a conference
that was in Scotland who presented a presentation we have that
outlines cancer care in Ontario, outlining the radiation
treatment facilities, including the Princess Margaret Hospital.
We're doing the same thing in Australia and we do this at any of
these professional conferences that take place.
Mr Maves:
We talked about other provinces adopting the four-week standard
and 40% getting treatment here. Have those countries adopted a
similar four-week standard? Is it different there? How are they
doing measured against that four-week standard?
Dr
McGowan: In England they have had a similar problem with
very long waiting lists and they adopted an aggressive approach
to reduce their waiting lists. There was a national study that
was done I guess about three or four years ago now which shows
waiting times in England that were comparable to what we had in
Ontario. I haven't seen an updated report from that study. What
we've found is that our radiation therapists here in Ontario who
trained in England are now receiving direct solicitations from
England, encouraging them to move back to England to treat
patients there. So every person who has ever trained in
England-we have people who have been here for 15 years and
they're now getting letters asking them to move back. So it's a
tight international job market.
Mr Maves:
Mr Newman talked about Ms Caplan talking about speeding up the
immigration process. Was that at the CCO's or the Ministry of
Health's request for some kind of assistance in recognizing the
need to speed up getting these folks into the country?
Dr Shumak:
I'm not sure what prompted the minister to call, what specific
event, but the specific call that I received was a call initiated
by the minister. It was not a request from-there may have been
some intervention by other groups, though I'm not aware of what
it was.
Mr Maves:
On page 4 you talked about some satisfaction surveys that you did
in your re-referral of some of the patients you sent out to the
States for more timely care-excellent levels of satisfaction, I'd
say. I just wondered if you'd undertaken a similar process here
in Ontario.
Dr
McGowan: As a matter of fact, we have. We've mounted a
very detailed study which has been coordinated by researchers at
Sunnybrook and the department of health administration. They are
interviewing in a structured way patients who have travelled away
from their home cancer centre for treatment, patients who have
stayed at their home cancer centre for treatment and patients who
travelled for radiation as a normal, expected part of their care,
to compare them in a whole series of parameters: satisfaction
with their medical care, satisfaction with social support,
satisfaction with after-care. The interviews are taking place
prior to going and after return. There are formalized processes for
evaluating these that psychologists and health services
researchers use, and we're just getting preliminary results from
that, so I can't quote anything from there. We'll be able to
compare the satisfaction of people who have gone versus the
people who have stayed to see where the systematic differences
are.
As an oncologist, I can
tell you that people are always unhappy when they're diagnosed
with cancer. We want to find out what the different problems are
that we're facing with this particular group.
Mr Maves:
The next one is-I'm assuming, because I don't know this-if cancer
is detected in someone and it's in an advanced stage, does that
patient get moved up the priority list as compared to somebody
who has cancer, and obviously any cancer is a serious one, but
someone who is not at an advanced stage?
Dr
McGowan: The criteria we use are, number one, anybody
who needs emergency treatment with radiation gets it. There are
really only a few categories. One is when the tumour is pressing
on the spinal cord and there's a risk of paralysis. Those
patients are always treated the same day. There's a risk where
patients have tumours pressing on one of their major blood
vessels, called an SVC obstruction, superior vena cava
obstruction. That's an emergency treatment. They're treated
within 48 hours.
1350
There are very few other
diseases that require emergency treatment with radiation. There
are a few other specific categories I don't need to go into. So
those are all treated on an emergency basis.
There have been some
specific studies that have shown that patients with certain
subtypes of some tumours have a well-documented reduction in
their control rates. Those patients are moved up the list. All
other patients, who constitute the majority of patients who
receive radiation, are treated on an equal basis.
Mr Maves:
So within that 40% who are getting treatment in the four weeks,
the ones who are in the most critical need of care are getting
it.
Dr
McGowan: All emergency patients are treated within the
right time frame, which is anywhere from same day to 48
hours.
Mr Maves:
Do any of the ministry representatives have anything they want to
add, any other answers to the questions we had? No? OK.
One other thing: You talked
about the Ontario breast screening program and you said that you
had plans for an independent evaluation of the program by a panel
of outside experts in recognition of the 10-year anniversary of
the program. When is that?
Dr Shumak:
The specific arrangements are being made. They haven't yet been
made. This is a decision that we've made. We've had some
discussions with the ministry and we'll be commissioning that
review, but it has not yet been arranged.
Mr Maves:
You talked about some other provinces that are doing the
re-referral and sending some patients elsewhere-Quebec,
Manitoba?
Dr
McGowan: Quebec and Manitoba.
Mr Maves:
And British Columbia, I thought I had read, was doing something,
but not any more.
Dr
McGowan: Had referred patients down to the United States
in the past, but they had discontinued that a few years ago.
Mr Maves:
Of course, historically we had similar problems in 1989 and 1991.
I also noted that in your presentations you talked about its
being an international shortage. It seems like we're caught again
in that same shortage and that same dilemma. It seems that
everyone around the world is caught again in that dilemma. What
didn't we learn from 1989 and 1991, and what didn't we learn from
other places around the world that let us be in this situation
again?
Dr Shumak:
Maybe I can speak to that. I think the reasons for shortages are
really very complex. The reason they're recurring, at least in
part, is because they're extremely difficult issues to handle.
Having said that, I think the one thing that we didn't learn but
we have learned now is that it makes some sense to have a
coordinated planning effort, particularly focused on adequate
human resources planning. In my mind, one of the major charges of
Cancer Care Ontario is to do just that. I think that we'll see
whether, by virtue of having the ability to bring all the players
together and talk to the right stakeholders, we can avoid having
the same problems occurring in the future.
Mr Maves:
So one of the key things we did learn was to set up something
like Cancer Care Ontario to avoid this in the future?
Dr Shumak:
I believe so.
Mr Lozon:
I wonder if I could add to what Dr Shumak has said, because
although it is right and appropriate that we talk about the human
resources that provide services for cancer patients-medical
oncologists, radiation oncologists and radiation therapists, who
are obviously unique-the question of health human resources is a
very complex one. There are substantial shortages throughout the
western world in a variety of specialists. It is a national and
provincial ongoing planning exercise which tends to-having spent
20 years in the health care system, I've lived through physician
shortages and physician surpluses, and nursing shortages and
nursing surpluses. It seems to be a bit of a boom-and-bust
approach.
If there's any cold
comfort, labour economists will tell you that it's hard to get
any profession right on this one, whether it's engineers or
teachers. In this case, I think particularly as it relates to the
medical subspecialties, it will ultimately need to be planned in
conjunction with overall supply and distribution of medical
subspecialties which involve all kinds of different types of
health practitioners.
Mr Richard Patten
(Ottawa Centre): I have two areas that I'd like to ask
you about. They will relate to both the ministry and to Cancer
Care as well. They are related to prevention and children and the
relationship between the two. My first question is, where do
children fit in, if they
do at all, in your program? It's obviously heavily geared to
adults.
Dr Shumak:
The answer to that is that in some of our cancer centres we look
after children with cancer and we clearly have the interests of
children with cancer as part of our concern, but the primary
responsibility at the organizational level in Ontario is with
POGO, the Pediatric Oncology Group of Ontario. We interact with
them, but as I say, they have the direct and primary
responsibility. Ours is a more secondary one, save for the fact
that some of our cancer centres are actually sites at which
children are treated.
Mr Patten:
What's the relationship with POGO, anyway?
Dr Shumak:
It's a relationship of keeping each other informed. They have no
formal accountability to us. It's an issue that does require
ongoing assessment. We certainly don't want to have two systems
in the province, one for children and one for adults, but to some
extent there are some realities that that is the way health care
is delivered in the province.
Mr Patten:
Well, you can't treat children as you can adults, as you
know.
The relationship between
children and prevention: First of all, I don't have enough time
to get into the details, but that is a pittance of money, one
third of 1% of the budget for prevention, when we know in the
long haul-I support your statement in saying that you have to
always keep your eye on the long term-this doesn't really support
that. If you're linked up with other systems that have
collaborative, integrative efforts into research-but the children
are at the front end of the environmental impacts on our
society.
The conference that was
just held at McMaster showed that dramatically: children's
incidences of asthma, for example, 400% in the last 20 years-it's
incredible-1% a year for children with cancers, and leukemia and
lymphoma in particular, because they have a more sensitive
threshold. It seems to me that if we're talking about prevention
that relationship has got to be promoted. Frankly, I don't hear
the medical community speaking out enough around the external
impacts in a preventative manner. If you want to talk about root
causes and call the shots on the environmental degradation that
we live with and we know, it reminds me of tobacco companies. Now
we know that for years and years they knew damn well that there
was a direct link with lung cancer, but they never admitted
it.
There's that element and
I'm very concerned about that, and a lot of people are, that we
have all these silo effects, but there is an integrative element
here and the medical profession can be extremely helpful in
pushing governments to assume their responsibilities related to
the environment, to assume their responsibilities related to the
workplace, in terms of exposure to carcinogens. I believe you've
commented on that yourself.
Dr Shumak:
Yes. In fact, I agree. That's one of the reasons that we've
incorporated explicitly these issues into our strategic planning.
I do want to make the point that, as important as it is to do
that, when you talk about children-and you mentioned tobacco-the
major area of emphasis still ought to be in prevention by virtue
of stopping children from taking on the habit of smoking. If we
did that, that would be the greatest contribution we could make.
That is not to diminish the importance of some of these other
areas, and we do intend to do that.
Dr Schabas may wish to add
to my comments, but there's no doubt, as I said before-and I
agree with you-that we need to give more emphasis to
prevention.
Dr
Schabas: Just to expand a little bit on Dr Shumak's
remarks, if we look at the difference, and the question was asked
before about what's changed from OCTRF to Cancer Care Ontario, to
my mind the most important change is that Cancer Care Ontario is
a true cancer control agency. It has a responsibility to cover
all aspects of strategies to reduce the burden of cancer, which
of course go far beyond treatment and in my particular area
incorporate prevention and screening but at the other end also
incorporate things like supportive care. I think that's a very
important difference.
1400
Clearly, our ability to
prevent cancer is going to be constrained by our understanding of
the root causes of cancer. We don't have a perfect understanding
of the causes of cancer. I think if we look at things like the
increase in cancer rates in children, there is a great deal of
scientific debate and controversy about those causes.
However, we do know a great
deal about the causes of some kinds of cancer. We know a lot
about the causes of lung cancer: 90% of lung cancer in Ontario is
caused by tobacco. We know that tobacco, mainly through lung
cancer, causes 25% of all fatal cancers in Ontario. We could make
an enormous impact on cancer simply by dealing more effectively
with the tobacco issue. I think it has been mentioned before that
the Minister of Health, in response to a report from an expert
panel which I had the honour of participating on about a year
ago, announced some substantial new funding, an additional $10
million this year to promote tobacco control. I think that's a
wonderful step in the right direction.
We should all understand,
though, from that expert panel report that that's an important
first step but there's a great deal more that needs to be done.
We also know-there's a very high level of scientific
consensus-that diet and physical activity are important causes of
cancer. The World Cancer Research Fund, for example, estimates
that we could reduce the cancer incidence by between 30% and 40%
if we could shift to a predominantly plant-based diet and
increase our levels of physical activity.
In our prevention focus
that's where we've started. We started where the scientific
evidence shows that the big impacts are: tobacco, diet and
physical activity. But as I said in my remarks before, we're also
keeping an open mind and exploring things we can do in other
areas, like occupational exposures and environmental
exposures.
Mr Patten:
My last question will be perhaps more to the ministry. Once you
get locked into proportions in a budget-I say this generically as a non-partisan
comment-you tend to be locked into that percentage forever and
ever. From the ministry point of view, in terms of research into
root causes related to cancer, what is your view about what will
be happening? Will there be more resources paying attention to
this down the road, along the lines that have just been explained
in terms of root causes?
Mr Lozon:
Perhaps I can make a couple of general comments and then turn it
over to Dr Levin, who has more specific knowledge in this
area.
The health system is
trying, and has tried ever since Marc Lalonde released his
report, A New Perspective on the Health of Canadians, to
incorporate and capture greater preventative activities. It
sometimes gets overwhelmed by the fact that we have an aging
population, we have a growing population, therefore treatment
activities tend to take a little bit higher sense of urgency
within that evaluation. But I think the ministry and the Minister
of Health have taken a number of steps around the prevention
area, usually in a disease-oriented fashion.
For example, I think that
Dr Schabas and Dr Shumak have talked about the Ontario tobacco
strategy expanded by the Ministry of Health. We well recognize
that it is a first step. Also, the heart health program
established by the Ministry of Health is an initiative on that.
We participate with the federal government and our provincial
colleagues in a national diabetes strategy aimed at reducing
diabetes and the like. Within the ministry, we have a series of
informal processes to make sure that anything that comes forward
has a prevention screen applied to it.
So we are doing a number
things in the area of prevention. I would be quick to point out
that I wouldn't suggest for a moment that the current allocation
of budget to Cancer Care Ontario is a fixed set of percentages.
The last 24 months would have indicated quite clearly that that
was not the case. The next 24 or 36 months will be a product of
our multi-year planning strategies with Cancer Care Ontario.
I'll turn it over to Dr
Levin.
Dr Les
Levin: I think this is a very important area in terms of
trying to reduce the cancer incidence in the future. The Ministry
of Health during the past nine months has engaged in dialogue
with the ministries of the environment, labour, and agriculture
and food in an attempt to develop a coordinated response to
environmental issues and focus on environmental health. One of
those issues clearly is our joint coordinated response to the
area of environmental carcinogens. As Dr Schabas has pointed out,
not enough is known about environmental carcinogens. It's clear
that one of the future directions needs to be a focus on
environmental science and issues around which I think there will
be increasing government and public interest.
There is a very healthy
dialogue currently between ministries to develop a coordinated
response. Some of the discussions have centred on scientific
validation of existing standards around environmental
carcinogens. Clearly other areas that need full discussion both
in government and public are the areas of risk communication and
economic evaluation of any policies around environmental
carcinogens. This is very important as it relates to children,
because some of these chemicals are bioconcentrating, which means
that people exposed to these noxious substances at a very early
age might be more prone to concentrate these chemicals and keep
them in their bodies for long periods of time. We're very much
aware of what the problem is and we are trying to deal with this
as quickly as we can within government.
Mrs
McLeod: I appreciate my colleague raising the whole area
of prevention, which is obviously a critical one. I do want to
return to cost of treatment of today's cancer patients, though.
My question would be to the ministry. I understand that the
cost-per-case funding of radiation treatment was just developed
this fall, so presumably the 1999-2000 budget was not based on
that funding formula for radiation treatment?
Mr Lozon:
In fact it was.
Mrs
McLeod: Are you able to tell me what that actually
yielded in terms of the cost of treating radiation patients in
Ontario, the cost per patient?
Mr Lozon:
Perhaps I would turn that to Dr Shumak.
Dr Shumak:
We previously had a budget of $49 million for treatment of
patients requiring radiation, and with the per-case funding that
now is a budget of $60 million.
Mrs
McLeod: You indicated to the Chair just before the break
that that was the cost of treating patients currently. It's a
post-treatment kind of cost so that it's based on the number of
patients you've actually treated.
Dr Shumak:
Yes, this is not the cost of patients who are waiting for
re-referral. There's a separate allocation for that. This is
simply the cost within the radiation treatment program. That's
correct.
Mrs
McLeod: If I can go back to the ministry then-and I know
you're not going to tell me what you're budgeting for next year,
but can you tell me what you use as the estimate? You indicated
that you were looking at what the actual cost per case should be.
I appreciate that's not finalized, but I'm more interested in
knowing what group of patients you consider when you're putting
forward your estimate for the cost of cancer treatment next year.
We know there's a long waiting list. We know that re-referral is
a part of the cost. But in terms of the cost per case, are you
taking into account treating all the patients currently on the
waiting list within the four-year time frame? One of the reasons
I'm asking the question is that I'm not used to ministries
putting in place open-ended budgets, and I'm looking for the ways
in which this is in some way potentially capped, if it is in any
way.
Dr Levin:
Perhaps I can comment and then hand it on to Dr McGowan, if he
has any further comments, or Dr Shumak.
The cost-per-case formula
is applied to actuals in the previous year and it is added to the
base budget by way of year-end reconciliation. In essence, that
means both CCO and Princess Margaret Hospital will treat as many
patients as they can during the year in the knowledge that they
will be reimbursed at year-end. It's only open-ended as it
applies to actuals, not to projected cases.
Mrs McLeod: It's open-ended in
terms of actuals, but in terms of your projection and your budget
estimates, do you have an open budget?
Dr Levin:
In terms of the projections, in terms of a three-year business
plan, that will be open-ended, but the actual monies expended
would be based on actuals.
1410
Mrs
McLeod: I understand that. I'm looking for-you are in a
budget process; I'm looking to get a sense of your estimate. I
know you won't tell me the dollars.
Mr Lozon:
Perhaps I could add to that, maybe not definitive but certainly
helpful, hopefully. We understand that the incidence is growing
3% or 4% per year, so in our budgeting process we at least have
to accommodate that growth. We understand that. It's also
factored, to some extent, on how successful the re-referral
program is, or is not. Those are some of the elements that go
into our calculations, which are a matter of considerable
dialogue between the Ministry of Health, Cancer Care Ontario and
Princess Margaret Hospital.
Mrs
McLeod: So the ministry has made a commitment that to
the extent that CCO is able to treat every cancer patient who
requires radiation, you will reimburse those costs?
Mr Lozon:
That is correct, on a cost-per-case basis.
Mrs
McLeod: And to do that within the four-week waiting
time?
Mr Lozon:
I think the four-week waiting time is a target we are chasing,
that we're moving towards. We are budgeting for a projected
number of cases by Cancer Care Ontario and Princess Margaret
Hospital next year. They are going to try to move that number
closer to the four-week waiting list. I wouldn't say we would be
waiting on the four-week waiting list explicitly. We would be
budgeting on what they tell us they think they can get towards
this year.
Mrs
McLeod: The target for this year was to have 50% within
the four-week waiting time by March 31. In terms of estimates for
next year-I assume that target date can't be met-are you
extending the target with a fairly tight time frame for next year
so that the ministry will budget adequate dollars to fund that
commitment?
Dr
McGowan: We established the target so we could get an
understanding from the cancer centres of how many patients they
would need to treat in the fiscal year to allow us to reach that
target. They weren't able to reach that target. Our target for
treating patients for the upcoming year, essentially, is to treat
as many as they possibly can. That's going to be completely
dependent on the availability of staff.
Mrs
McLeod: I understand that.
Dr
McGowan: So we have a target of eliminating referral to
the US within 18 months, and that would mean we would have
reached that target by that time.
As far as the
open-endedness of the budget is concerned, costs go up in direct
proportion to the number of cases. There is an upward limit to
the number of patients who will need radiation. About 50,000
patients a year develop cancer; only about half of them will ever
need radiation. So there's a limit to the number of patients who
need radiation in a given year.
Mrs
McLeod: I appreciate that, and I also appreciate that
it's not solely dollars but availability of personnel. Obviously
that's a whole other issue.
If I understood you
correctly, the March 31 target date to have 50% of patients
awaiting radiation treatment receive it within four weeks can't
be met now. We all recognize that.
Dr
McGowan: Right, we cannot meet that.
Mrs
McLeod: I'm not sure if you are telling me you have
abandoned the 50% target and that we now have a target that
within 18 months all patients will be treated within four weeks
in Ontario. Is that a new target?
Dr
McGowan: No. One of the problems with this type of
targeting, getting it to within a month or so, given the changes
in referral rates, recruitment and staff turnover, is that this
is trying to get a level of precision over something you cannot
get that level of precision over. In all honestly, you can't do
that. We have to operate within a context of, as you're saying,
how do we plan, how do we get an idea of what sort of budgeting
we need for the upcoming year? So I would say that we would like
to reach this median target of four weeks by the end of the
coming year. We'd like to reach it sooner.
Mrs
McLeod: A hundred per cent within four weeks?
Dr
McGowan: No, median.
Mrs
McLeod: Fifty percent?
Dr
McGowan: Yes, within four weeks.
Mrs
McLeod: Within a year?
Dr
McGowan: Within a year. We would like to be able to
reach that. It is very hard to recruit these people into Ontario.
As we said at the outset, until we start the recruitment campaign
we can't tell you how many people are out there. The reality is
that over the space of a year we've been able to recruit 40
people from out of the country. If we had been able to recruit
90, it would be a different story.
Mrs
McLeod: If we had more people coming out of our own
schools.
Time exhausted?
The Chair:
Yes. Ms Martel.
Ms Martel:
I'd like to follow up on your manpower issues, specifically with
respect to radiation therapists. This is for the deputy. As I
understand it, we now provide radiation therapy training in
Ontario at the Michener Institute, correct?
Mr Lozon:
Yes, that is correct.
Ms Martel:
And the degree program began in the 1999 academic year, in the
fall of 1999?
Mr Lozon:
It's a joint BScN program with the University of Toronto.
Ms Martel:
But the degree part of the program at Michener started in the
academic year 1999, in the fall?
Mr Lozon:
Yes.
Ms Martel:
It's true, then, that no radiation therapists at all will be
graduating from Michener this year. Is this correct?
Mr Lozon:
Yes.
Ms Martel: I'd like to go back
to the reasons for that, and I'd like to start this way: I
understand that in 1997 a decision was made not to offer any
radiation therapy training anywhere in the province. Is that
correct?
Dr Levin:
That is correct.
Ms Martel:
And in 1996-97 there had been regional cancer centres that were
offering their own radiation therapy training. Is that
correct?
Dr Levin:
That is correct.
Ms Martel:
How many centres were offering training?
Dr Levin:
I think five; there were four or five.
Ms Martel:
Can you tell me how many positions would have been in place, in
total, between those four or five regional cancer centres? How
many people would we have been training in 1996-97?
Dr Levin:
I couldn't say directly-
Interjection.
The Chair:
Could you speak into the mike, please. Hansard can't pick it
up.
Dr Levin:
Sixty-six.
Ms Martel:
So 66 people were being trained at the regional cancer centres in
1996-97.
Dr Levin:
That is correct.
Ms Martel:
As I understand it, the government made a decision in 1997 not to
offer radiation therapy training anywhere.
Dr Levin:
Can I answer that in a historical context? In 1996, there was a
joint decision by the cancer centres, the then OCTRF and
government to defer entry to the Michener program for one year,
based on the fact that the ministry was informed at that point
that there was a surplus of radiation therapists in the province.
That occurred at a time when the program was being transferred
from the cancer centres to the Michener Institute.
So the response to your
question is, yes, a decision was made, and it was made on the
basis of a joint decision between the OCTRF, the profession-the
radiation therapists-the regional cancer centres and the Ministry
of Health.
Ms Martel:
May I ask who provided the information that we would not have a
shortage, or that we didn't need to have people in training that
year?
Dr Levin:
I think all the above, as far as I can make out. The information
we have is that this was a joint decision made on the basis of
information brought to a joint committee that met in June 1996. I
can't give you specifics of who exactly brought that to the
table.
Ms Martel:
But as you told the committee, the information was that there
wasn't going to be a shortage, or that we had a surplus of
therapists at the time?
Dr Levin:
The information was that there was an existing surplus of
radiation therapists who could not find employment in Ontario at
that time, and the decision was therefore made to defer that
program by a year.
Ms Martel:
At the Michener itself?
Dr Levin:
At the Michener itself.
Ms Martel:
And at the regional cancer centres?
Dr Levin:
At the regional cancer centres, but the ministry agreed a year
later to continue a parallel program within the regional cancer
centres.
Ms Martel:
What I'm getting at is that if you had 66 people being trained, I
assume you would have the capacity to train at the regional
cancer centres in 1997 as well, or in 1998. My assumption is that
had that decision not been made, we would in all likelihood be
graduating about 66 radiation therapists this year.
1420
Dr Levin:
The answer is obviously yes. But based on the information that
was available in 1996, we would have been graduating a surplus
number of radiation therapists who could not find employment in
the province.
Ms Martel:
But Ontario would have known that these people are needed
everywhere. You've made that clear to this committee, that they
are in high demand in the UK, they're in high demand in British
Columbia, in Alberta etc, so even though they might not have been
needed in Ontario, the potential certainly existed for them to
get employment somewhere.
Mr Lozon:
I can't speak to the specifics of the question, but I think it
goes back to the difficulty that the system has had traditionally
in planning health human resources. It is not a perfect
environment in any way, shape or form around radiation
therapists, cardiac surgeons, nurses, physicians and the like.
What we have tried to do, with Cancer Care Ontario and Princess
Margaret Hospital, is to put in place a process of health human
resources planning where that will not occur in the future. What
we are really trying to do is beef up and improve the health
human resources planning, looking forward and not so much through
the rear-view mirror.
Ms Martel:
I appreciate that that's what you are trying to do, and clearly,
in retrospect, there is a good reason for your wanting to do
that. If we have a shortage of about 77-that's what's been in the
media right now-and if we had had 66 graduate this year, we
wouldn't have anywhere near the serious problem we do right
now.
Mr Lozon:
I think, as Dr McGowan has also pointed out, this is in fact a
moving target. Not only is it moving relative to the incidence
and the requirements for radiation therapy, but it's also a
moving target because, as others become more aggressive in their
recruiting processes, we are potentially at risk of losing the
people who are in our system because they'll go someplace else
where it's a better set of circumstances.
We are trying as best we
can to integrate this health human resources issue into our
future planning with Cancer Care Ontario to prevent this from
happening, along the lines of prevention.
Ms Martel:
I understand that. I guess you've probably made my point. We
could have graduated people and they may have gone somewhere
else; they may not have. But the regrettable situation we're
living with now-people want to point at the feds and point all
over the place-is that, frankly, a bad decision was made to not
have people being trained in 1997. We will have no graduates this year. From
whatever information-we don't know who came forward with it, but
in retrospect, it was not a great decision to have made.
Mr Lozon:
Hindsight in health human resources planning has traditionally
been more accurate than foresight.
Ms Martel:
As a result, we have 77 radiation therapists that we don't have
in Ontario right now.
Let me go back to where my
colleague Mr Patten was going with respect to primary prevention.
I'd move back to CCO at this point. In the auditor's report, we
had your budget for 1998-99. Can you give us your budget for
1999-2000, first from the Ministry of Health and then from your
other sources?
Dr Shumak:
I'm going to ask Dr Shabas to speak about the specific
budget.
Dr Shabas:
You're asking for the budget specifically for primary
prevention?
Ms Martel:
No. First I want your overall budget, if I might.
Dr Shumak:
Our overall budget for 1999-2000 is approaching $200 million.
Ms Martel:
Can you give me the breakdown between the portion that comes from
the Ministry of Health and the portion that is supplied by
donors, bequests etc?
Dr Shumak:
About $180 million comes from the Ministry of Health.
Ms Martel:
What is the budget for primary prevention in 1999-2000?
Dr Shumak:
Richard, do you remember the numbers?
Dr Shabas:
Yes. In the 1998-99 budget, in the operating plan for that year,
we requested for the first time funding to create a prevention
unit within the division of preventive oncology. I should point
out that preventive oncology, at least as we define it in Cancer
Care Ontario, involves more than just primary prevention. That
includes our screening programs for breast and cervix, and we
hope in the near future a screening program for colorectal cancer
as well. It involves the Ontario Cancer Registry and our
surveillance efforts and it includes a research unit which deals
largely with issues related to cancer genetics and the causes of
cancer.
In that year, the fiscal
year 1998-99, we requested $700,000 in funding for primary
prevention. That was approved by the ministry in about February
1999, almost exactly a year ago. Of that funding, $420,000 was
earmarked for a prevention unit which was located at a provincial
office and is undertaking many of the activities that Dr Shumak
described in his opening remarks. Some $280,000 of that-I believe
that's the correct number-was directed to each of the eight CCORs
to fund the activities of the local prevention and screening
networks, which are now operational across the province and are
making contributions in a variety of areas that are more specific
to the local priorities and the local needs.
So the total amount of
funding within the budget was earmarked at that time as $700,000.
We did not receive any increase to that in the current fiscal
year. There were some requests and they were not approved by the
ministry. I hope we'll be making further requests in this coming
year.
Ms Martel:
Can I ask what amount you requested from the ministry for primary
prevention?
Dr
Schabas: I believe the two items that we requested in
this year's operating budget were-I'm going from memory here, so
I apologize if I'm not precise. I believe it was $400,000 to
promote our activities in the areas of particularly diet and
physical activity, and we requested approximately $100,000 to do
improved surveillance of occupational cancer with a view towards
developing a role in primary prevention in that area.
Ms Martel:
Just so I'm clear, you said you will have about $700,000 to work
with this year. I am assuming then the $400,000 and the $100,000
are additional initiatives, over the $700,000.
Dr
Schabas: They were requests-they were not approved-in
addition to that. That's correct.
Ms Martel:
What initiatives will you undertake with the $700,000 that you
have for this year?
Dr
Schabas: As Dr Shumak explained, the priorities we have
embraced in our strategic plan for primary prevention of cancer
are in the area of tobacco, where we have been very active on a
number of fronts-he described the activities of John Garcia, who
is now acting as senior adviser on tobacco issues to the
ministry; our involvement in the media network; our involvement
supporting a variety of anti-tobacco agencies, the Ontario
Campaign for Action on Tobacco, a variety of things.
We have been active in
beginning to establish a strategy to address issues of diet and
cancer. We've established a collaborative group which is
preparing guidelines for Ontario about cancer-prevention eating,
and we're in the process of developing strategies to further
support the implementation of that information.
In addition, each of the
CCORs has established or is in the process of establishing-seven
of the eight actually have functioning prevention and screening
networks, and each of them has been designated $35,000. I'm doing
the math in the back of my mind; I think eight times 35 is 280,
which is the number I gave you. They each have an allocation of
$35,000, which they're all spending in different ways which are
reflective of what their local priorities are. For example, in
Ottawa they are choosing to focus on supporting a network around
cervical cancer screening. In Windsor they are more focussed on
occupational and environmental concerns. There's a whole variety
of uses which is really being left up to the local CCORs to
identify.
Ms Martel:
Your strategic plan notes two other issues in this area. One is
occupational cancer, and that CCO will create a collaborative
group of stakeholders and experts to make recommendations
regarding surveillance of occupational cancer. Is that still
included in the $700,000, or is that the $100,000 that was turned
down?
Dr
Schabas: No. We're proceeding with that. Creating a
collaborative group is not in and of itself a highly expensive
thing, so we're proceeding. Invitation letters are going out. The
collaborative group on occupational cancer surveillance is scheduled to have its
first meeting I believe in May. The additional $100,000 or
thereabouts that we requested was to hire an epidemiologist who
specialized in the area of occupational cancer so that we could
provide some core expertise to support that activity. Obviously,
without that expertise in house, our ability to improve our
surveillance is going to be very constrained.
Ms Martel:
Can I ask which stakeholders, experts, unions are being invited
to participate, to be part of your collaborative group?
Dr
Schabas: The group is being pulled together by our
director of surveillance, Dr Eric Holowaty. I know that
invitations are going out to all those kinds of stakeholders,
including labour groups. I can't tell you specifically which ones
have been invited.
1430
Ms Martel:
Is there a reason this couldn't be a public document? Could you
table that list with the committee?
Dr
Schabas: I don't see any reason why we couldn't.
Ms Martel:
That would be great, if you would do that.
The second one was
environmental carcinogens and that you will identify
opportunities for evidence-based interventions. Can you describe
to the committee what that means and whether or not that will go
forward this year too with the new budget?
Dr
Schabas: Yes. We've already begun a modest project where
we are doing a consultation with key experts in the area of
environmental health and environmental cancers in Canada, and
some internationally, which will lead to a workshop of those
experts. I believe that is scheduled for sometime later this
spring. This is really at the kind of think-tank level of
beginning to identify what they regard as the appropriate target
areas in the area of environmental causes of cancer and beginning
to identify what roles an organization like Cancer Care Ontario
could play in that area.
Ms Martel:
Do you have a list of potential invitees that you could share
with this committee in that respect?
Dr
Schabas: I'm sure there is a list of those invitees, and
I'd be happy to share it with you.
Ms Martel:
Let me go back to-this is in the same area, when you talk about
prevention in your strategic plan-the Ontario Network for Cancer
Prevention. You list some of the members. As I read the members,
they are primarily from the medical community. I'm wondering
whether it is your intention, then, to have a larger body that
would be made up of health activists and environmental activists
as well. As I read the list, you've got staff from the division,
Ministry of Health, I believe, CCOR staff, Ontario College of
Family Physicians. Then there's the Canadian Cancer Society,
Ontario division. It says "other key stakeholders." It doesn't
describe who they are.
Dr
Schabas: We have some consumers. But I should point
out-you say "CCOR staff." Those are the chairs of the prevention
screening networks in the eight CCOR regions, so those are the
people who have been selected by the regional networks, by the
people who are involved in those areas, as the leaders in those
local areas in those fields. In fact, six of the seven network
chairs are medical officers of health. That was their choice. The
seventh is an occupational health physician from the Windsor
area. That's why there is the heavy medical. Certainly you are
quite right, most of them are doctors. But we do have stakeholder
input, consumer input. We do have representation from the
Canadian Cancer Society. So I think the perspective of that group
is to identify targets and coordinate the activities across the
province.
Ms Martel:
When you say "identify targets," can you explain what that
means?
Dr
Schabas: It's essentially to assist us in identifying
the priority areas for cancer prevention. The discussions in that
group are the ones that have fed into the priorities that are
identified in the strategic plan. They are priorities, as I said,
for primary prevention of cancer.
I want to be very clear
that if we really want to make an impact on cancer using existing
knowledge in the area of prevention, the primary focus has got to
be on tobacco. I can't emphasize that strongly enough. As we sit
here and speak, we are facing increasing rates of tobacco
addiction in young people in Ontario, and I can guarantee you
that this committee will be meeting in 30 years' time and talking
about the crisis in cancer treatment if we don't take action on
that, and also the scientific evidence about the important impact
of diet and physical activity on cancer. Those are the priorities
that have been identified by that group, and those are the
priorities that have been embraced by Cancer Care Ontario.
Ms Martel:
I would think, though, that cancer in workplaces is going to
become a more important issue, and cancer because of air and
water quality is going to become a bigger issue. While I
appreciate that those are the priorities coming out of that
committee, I would make the argument or the point that perhaps
those are priorities coming out because you may not have the
fullest range of people who can participate in that committee who
would bring a different perspective.
I go to my own community
and look at the number of cancers that have come out of Inco and
Falconbridge over many years and the number of cancers that are
continuing because of what is being used underground in terms of
what's in diesel fuels. So I'm just wondering if the committee is
going to be expanded further so that you cover off more fully
those other areas where you're going to continue also to see
increases in cancer.
Dr
Schabas: I should also point out that the priorities
we've identified are precisely in line with the priorities that
were identified by the Ontario Task Force on the Primary
Prevention of Cancer, which made its report to the minister in
1995, and which clearly identified tobacco, followed by diet,
physical activity and alcohol, followed I believe in order by
occupational cancer, as the most important causes of cancer.
Those are the priorities that we've embraced pretty much in that
rank order for those reasons.
That doesn't mean for a
moment that we're not acknowledging that cancer goes well beyond
that. That's in our
strategic plan. But part of your first question is that we have
very limited resources at the moment to deal with a huge problem.
It's a tiny percentage of cancer spending in the province, and
with scarce resources it's incumbent upon us to put the best
possible use to those resources and to go after the big targets
first.
Dr Shumak:
Just to make one point, in response to exactly the kinds of
concerns that you've raised, it is important for the committee to
understand that in the original strategic plan consultation
document we said very little about occupational and environmental
carcinogens. Because of the kinds of issues that you've spoken
to, the final document is very clear in indicating that we do
intend to do whatever we can within our resources to try to deal
with that. I wouldn't want the committee to feel that although
these other areas may be more important priorities in terms of
the sheer volume-there is still, as you point out, a significant
concern, for example, with occupational carcinogens and
occupational exposure, which we accept and which we see as part
of our mandate to try to do something about. We don't disagree
with that. The issue will be to do the best we can within the
available resources.
The Chair:
Before I turn to the government, Mr Peters, you had a
clarification.
Mr Erik
Peters: Yes, we just wanted to understand the answer to
the budget question for our report. You indicated that the
overall budget was $200 million. In our report, the year before
it was $209 million, made up of two components: $173 million from
the Ministry of Health and about $36 from donations and other
sources available to CCO. When you gave the overall budget
number, did that include both sources or just the Ministry of
Health? I wasn't clear.
Dr Shumak:
The figure that we have for 1999-2000, the total budget, is $204
million.
Mr Peters:
So it's slightly down from the year before.
Dr Shumak:
No, I don't understand the discrepancy on the year before. May I
ask our financial officer to comment?
Mr Naresh
Khosla: My name is Naresh Khosla, chief financial
officer. You're looking at a budget that includes our own
research and other funding, and the funding from the Ministry of
Health, including one-time funding and flow-through to the
Princess Margaret. In 1998-99 it was $188 million. In 1999-2000
it will be $204 million. If you want 1997-98, it was $159
million.
The Chair:
Thank you very much. The government side.
Mrs Munro:
I wanted to come back to an issue that had been raised earlier,
and that was the question regarding the radiation technology and
the numbers. I wondered if we could just walk through this one
more time. When was the principle of the four-week wait adopted
by Cancer Care Ontario as the goal?
Dr
McGowan: There is the Canadian Association of Radiation
Oncologists, a professional body which recommended this a few
years ago. Cancer Care Ontario formally endorsed this goal in, I
believe it was, the fall of 1998.
Mrs Munro:
Clearly, from the conversations that we had earlier this
afternoon, this has certainly put Ontario in the forefront in
terms of recognizing that 40% and the four-week goal.
Dr
McGowan: Absolutely.
Mrs Munro:
I wondered whether it would be fair to say that when the decision
was made around the radiation technologists back in 1996, that
would obviously have been made in a different environment in
terms of the one we would have today.
1440
Dr
McGowan: I think that in the mid-1990s there was still a
recognition that waiting times were an important issue for
radiation oncology. The endorsement of a specifically articulated
target was different, but the environment was that we recognized
that waiting times did need to be acceptable.
Mrs Munro:
I just wanted to ask another couple of questions, again going
back to some earlier discussion. This is directed more
specifically to the ministry. There was some discussion earlier
about systemic treatment pressures within the system. I wondered
whether or not someone, maybe the deputy, could speak to the way
in which the Ministry of Health and Long-Term Care has responded
to systemic treatment pressures to date.
Dr Levin:
I'd be pleased to answer that. First of all, there's some very
good news in the pressures that are mounting, and perhaps Dr
Shumak might want to comment further on this. Between 1947 and
1992, on average, one new cancer drug came on the market or
became available for treatment. Since about 1992-94, the number
of new drugs that has become available has actually increased to
about six a year, and the cost of these drugs is excessive.
There's enormous cost to that.
The Ministry of Health and
Long-Term Care, in 1994, approved a program brought to it by the
then OCTRF, and carried forward to Cancer Care Ontario, for
what's called the managed systemic treatment program, in which
Cancer Care Ontario would validate the necessity, the
requirements, the guidelines around the use of any new drug that
became available for cancer patients in the province and make a
recommendation to the ministry. The ministry would flow the
dollars for those drugs back to Cancer Care Ontario, which in
turn would make those monies available for hospitals wishing to
use those drugs. That program started in 1994, so it's gone from
zero to, currently, $20 million a year to fund new and expensive
drugs.
To the best of my
knowledge, Cancer Care Ontario has never been denied a single
dollar in terms of its request for new and expensive drugs, and
from the ministry's perspective CCO should really be
congratulated for running a very good program in evidence-based
guidelines for new and expensive drugs. I think that has worked
extremely well. That's been an add-on, if you like, to the
systemic treatment program.
Furthermore, in its 1998-99 budget, CCO
requested $1.5 million as an add-on to its systemic treatment
base and it received $1.5 million. As Dr Shumak has alluded to,
it made a request for $3 million as an add-on to its 1999-2000
base, and that request has been agreed to.
One of the comments the
deputy made earlier which I think is highly relevant to the whole
area of systemic treatment pressure is that we seem to lack the
ability in health care in general to anticipate and to plan for
the future, given the complexities of human resource planning. So
the task force that Dr Shumak alluded to earlier-once again it's
a great pity, and this is not meant to reflect badly on CCO, but
I think it's an overall health care problem. We will probably be
confronted by another crisis, whereas ideally we would have
wanted to have a projection over a number of years to anticipate
and deal with the problem. This is why the MOU that was struck
between the Ministry of Health and Cancer Care Ontario is such a
useful tool. Within that memorandum of understanding there is an
expectation that Cancer Care Ontario will provide a strategic
operating and three-year business plan to the ministry so that we
can then anticipate what those funding pressures are going to be
and respond accordingly.
Mr Lozon:
I'm wondering if I could add a little bit to the notion of
systemic treatment. I think, as Dr Shumak has indicated, that
systemic treatment for cancer therapies occurs to no small extent
as well outside of CCO. It occurs in many Ontario hospitals and
that sort of activity. So as the hospital budgets grow, and they
have grown substantially in the last couple of years, you also
see some greater capacity to deal with systemic treatment
questions.
CCO plays an extremely
important role not only in providing systemic treatment, but also
in developing the guidelines. As well, it is playing an
increasingly important role in the coordination of that entire
sort of activity.
Mrs Munro:
Clearly, we've heard from the ministry over the course of the day
the number of significant investments that have been made since
1995, including $153 million for the development of the five new
cancer centres in Kitchener, Mississauga, Sault Ste Marie, Oshawa
and St Catharines. I just wondered, as the co-ordinator of the
services in Ontario, whether or not you feel these are
significant investments that will in fact come to be able to
reduce the waiting lists and improve the access to service for
Ontarians.
Dr Shumak:
I didn't mention it before, but it's perhaps relevant to mention
now that there was a question earlier in the day about what
happened in 1989 and 1991. In 1991, part of the problem was an
actual shortage of machines and facilities. Although we have a
lot of difficulties today with human resources, with a couple of
exceptions which are being addressed in this construction, that
is not the limiting factor. And with the construction to which
you refer, we will be very well positioned in the province with
regard to the physical facilities to deliver cancer treatment.
There will not be problems with the physical facilities, any
constraints, for a good many years to come as a result of this
construction. Even without the construction, except in an area
such as Hamilton, that is not a limiting factor.
Mr Lozon:
I'm wondering if I could add a little bit to this. I think it's
important for the comment to be made that the technology
underpinning the health care system is advancing and changing so
dramatically and so rapidly that there is a constant forecasting
and planning need by Cancer Care Ontario, by the Ministry of
Health and by every other health care provider. With the Human
Genome Project, with a different set of techniques and processes
which are coming out with increasing rapidity, some of the
technologies, some of the human resource planning, really have to
be current. Otherwise you could be planning for a future that may
not occur.
Mrs Munro:
I believe you referred to the rear-view mirror earlier.
Mr Newman:
Just a question for Dr Shumak. Maybe you can help me out here.
Have shortages of radiation technicians happened in the past in
the province? Has there been a shortage prior to this?
Dr Shumak:
I don't know the past history as well as I'm sure Dr McGowan does
in terms of the numbers of technologists, so I'll refer that
question.
Dr
McGowan: The issue of whether or not there may or may
not have been a shortage of radiation technologists in the early
1990s was a moot point then because there wasn't the equipment
for them to work on. So even if they had been available, we
wouldn't have been able to have them work on the equipment. With
the capital expansion that's taken place over the last decade and
the ongoing capital expansion, it then gets to the point where
you have to look to the therapist shortage. So in your specific
question about whether or not we've had a radiation therapist
shortage in the past, I actually don't know whether or not this
was a specific issue prior to the current problem.
Mr Newman:
My reason for asking is that I was doing some research for today,
and the Toronto Star reported that back in 1989 there was a
shortage of technicians, so I just wanted to know if that was
indeed the case or not.
The Chair:
That's the fountain of all truth, the Toronto Star.
Mr Newman:
In the House, the Chair's statement is, so I just thought I'd ask
if that was the case.
Dr
McGowan: I'm sorry that I don't know.
Mr Newman:
OK.
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Mr Lozon:
I wonder if I could just make a comment here, because I think
this is where both Cancer Care Ontario and the Ministry of Health
and Long-Term Care really value the recommendation of the
Provincial Auditor. He has indicated through his audit
recommendations that it's so important to coordinate the planning
for physical facilities and the human resource facilities against
this incredibly complex health burden. I think we have put in
place, through the memorandum of understanding and through our
ongoing relationship with Cancer Care Ontario, a really good start on
that particular integrating process. The work was underway. The
Provincial Auditor has helped us move it along through his
recommendations. So I think it's extremely helpful to have
that.
Dr Shumak:
I was just talking to my predecessor and asking him if I could
get some further information about this. Intermittently, there
were issues with regard to radiation therapists. At those times
the primary issue was that we didn't have the money to hire
radiation therapists. So that's quite a different situation than
what we have today. Today we have the money but we don't have the
radiation therapists.
Mrs
McLeod: Before I leave the budget question entirely, to
come back to the question that Mr Newman was just beginning to
raise, I wanted to follow up on Mr Levin's responses to Ms Munro.
You were giving her some specifics about the approval of CCO's
budget for the current year. Do I understand, then, that the CCO
budget submissions have been fully approved?
Mr Lozon:
I think I'll answer that question. I would say that it's never
the case where everyone gets everything they asked for in a very
tight fiscal resource. Cancer Care Ontario, in the context of
this particular issue in terms of increasing radiation therapy
activities and helping with the re-referral program, has
generally received quite favourable support from the Ministry of
Health for its budget needs.
Mrs
McLeod: When would the approval response to CCO's budget
submissions have been made in 1999-2000?
Mr Lozon:
I'm sorry, I can't answer that. I'll have to ask Dr Levin when
the approvals came.
Dr Levin:
The approvals came in three different stages. The first was that
CCO was approved for its existing base, just to make sure that it
could continue operating. I think that was in August. They
submitted an operating plan to the Ministry of Health at the end
of July, I believe. The ministry received that and had some
recommendations to make and questions to ask in that respect. CCO
responded on September 8. On September 10 we received a formal
presentation by CCO for its operating requests for 1999-2000.
CCO's requests totalled approximately $60 million, which were
then reviewed extensively by ministry staff, and out of the
$60 million a total of approximately $40 million was
identified as a significant pressure that needed to be dealt
with. The ministry has managed to flow approximately $30 million
of those $40 million either directly or indirectly to CCO through
various programs, and the outstanding amount has been identified
in the business planning process or applications within the
Ministry of Health. The results of that will probably be known
when that process is completed.
Mr Lozon:
Because of the importance of this particular issue, we are in
quite regular contact with Cancer Care Ontario around their
budgets and their issues. We tend to respond as quickly as the
ministry is capable of responding to these particular issues.
Mrs
McLeod: I'll just take the answer in the spirit in which
it was given. I'll bite my tongue on that one. I will note for
the record that I think this committee, the auditor, the
Legislature and the ministry should be concerned about the fact
that CCO budgets are not being dealt with until the end of the
fiscal year in which they supposedly have been providing the
services. I hope that's an issue that the auditor may examine in
the future.
I want to move to the whole
issue of the staffing standards, and I'm back to the radiation
waiting times. The auditor had noted that at the time of the
audit there were no staffing standards in place. I assume that
means both for radiation oncologists as well as for radiation
therapists. The MOU does not speak to the specificity of staffing
standards being in place, so I don't know from the MOU whether or
not staffing standards are in place now.
Secondly, I'd be interested
in knowing whether or not there are staffing standards in both
oncology and in radiation therapy in other provinces that you
take as benchmarks and how we would compare to those staffing
standards.
Dr
McGowan: There are staffing standards that were
presented in the task force on human resources and radiation
services and they were accepted and endorsed by the Minister of
Health. For radiation oncologists, the staffing standard was 215
new cases per radiation oncologist phased in, and we recommended
those be phased in over three years, from 260.
Mrs
McLeod: What would the current be, then?
Dr
McGowan: The current standard for the past fiscal year
was 245, and most radiation oncologists are seeing closer to 260
still. For medical physicists, it was 300 treated cases per
medical physicist. For radiation therapists, it was a standard
based on the number of machines. We had a recommendation that it
be seven per machine, and we're phasing that in over five years
from the current of 6.5.
Those standards are what
form the basis of the funding formula. The current funding was
based upon the staffing standards and the salary levels that were
set in the 1999-2000 fiscal year.
The JPPC process
incorporates those staffing standards, so it's a standards-based
funding formula, based upon the staffing levels and the salary
levels, so that the staffing standards are built into the
funding.
As far as how we compare to
other jurisdictions, BC has staffing standards. There is a
slightly different metric for their staffing standard, and we are
relatively on par with other jurisdictions. Again, professional
organizations nationally are looking at staffing standards. While
they use slightly different metrics, if you convert them, we are
again on par.
Implementation requires two
things: (1) It requires funding, which is implicit in the funding
formula when you can be vigilant that the funding formula
continues to have those contained in it; and (2) the availability
of staff.
Mrs
McLeod: On the latter, and before I ask you specifically
about programs to deal with personnel training and recruitment, the seven per
machine that is the standard-what would the current be now?
Dr
McGowan: It's 6.5.
Mrs
McLeod: I don't have enough time to explore this in the
depth I would like to. If you just looked at the oncology target
to be phased in over three years, how many oncologists would we
need to graduate in Ontario? I understand that people move out,
but do you have an estimate of what we would need to do in
comparison to the number who are now going into it, or even the
number of specialities that are available, let alone the number
going into it?
Dr
McGowan: We need 14 right now and we would need
approximately the same number per year over the next two years.
We have few graduates coming out of the radiation oncology
program.
Mrs
McLeod: I'm sorry, how many?
Dr
McGowan: I think it's two, and then in the following
year, zero.
Mrs
McLeod: I ask the ministry, is this one of the areas
that we are ready to make some immediate moves on in terms of,
first of all, medical school enrolments as recommended by Dr
McKendry for September 1999, in order to start to increase the
number of specialty training positions in hopefully oncology
residency as well as others? I say that recognizing that in terms
of the McKendry report, oncology isn't even recognized as one of
the most urgent shortages in specialties.
Mr Lozon:
A couple of comments with respect to physician human resource
planning. The McKendry report was commissioned by the Minister of
Health in the fall of 1999 to look at the situation around
medical human resources, both supply and distribution factors,
because the information is quite dichotomous and contradictory,
depending on the source of the particular information. Dr
McKendry delivered his report early in the new year and the
ministry acted quickly on a series of short-term recommendations
that the McKendry report had provided around foreign medical
graduates and licensures etc.
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The longer-term approach
will be determined through the work of the expert panel, which
had its first meeting this past week, chaired by Dr Peter George
from McMaster University. I expect that report to be in the hands
of the ministry in a final form by the beginning of the
summer.
One thing that I think is
important to keep in mind is that the ministry has traditionally
not determined the type of residency slots that will be allocated
across the province or the country and has rather more of a
higher-level view on it.
Mrs
McLeod: I understand that. I do want to note for the
record that means medical school enrolment cannot be increased by
55 as of the fall of 2000.
I don't want to cut off Dr
McGowan, but I do want to ask about radiation therapy estimate
numbers too, so maybe I can let you respond to that and then you
can also tell me how many radiation therapists we will need to
meet the target and whether or not your estimates would include
what would be needed for the three new cancer centres, respecting
that we need to integrate that and would include new numbers that
would be needed, for example, at the Princess Margaret Hospital
or at Sick Kids.
Dr
McGowan: Your first comment is regarding radiation. The
medical oncologists were not specifically part of the McKendry
report. Within radiation oncology there's been a change which is
beyond the authority of Ontario, which is that the training
program structure has changed significantly. Medical students now
have to make the decision to go into radiation oncology, whereas
previously that was made after one or two years of training in
another program. So there's been a very significant structural
change in radiation oncology training which has affected the
attractiveness of the specialty. It's something that requires
people to have done something else, typically, before they become
attracted to this actually fairly small specialty.
Mrs
McLeod: And CCO will have some input to the expert
panel, I assume, so that the issues related to radiation oncology
or medical oncology are being addressed?
Dr Shumak:
I can speak to that. I've already spoken with Dr George and he's
assured me that we will have an opportunity to be part of
that.
Mrs
McLeod: I appreciate that. Let's move on to radiation
therapy and the estimates of need and how that fits with our
training numbers in Ontario.
Dr
McGowan: Our training program at the Michener Institute
was authorized and funded for 75 students to come into the 1999
entry class. We were not able to attract the full 75. We were
funded to have 75; there just weren't 75 people who were
qualified and interested in the program. We look like we'll be
able to bring 75 into the 2000 entry year.
We currently have within
Ontario 44 vacancies. There's a turnover of about 40 to 50 staff
per year, so we need to have approximately 40 per year just to
take into account turnover and then we need an increment of 3% to
4% a year, so that brings it up to the 50 to 50-some-odd we need
each year. The three new cancer centres will need 78 radiation
therapists. Our training and our numbers for the entry into the
Michener program take into account two things. One is our need
for the new cancer centres, our need for turnover replacement and
increment, as well as our capability of training people in the
cancer centres. There is a limit to how many people can be
trained in the cancer centres. If you can imagine, there are 450
therapists in the province; 78 is a large percentage of that.
There's only so much time they can devote to training. I think
we're starting to get to the maximum of our training
capabilities, so those two things are taken into account.
However, yes, the answer is
with 75 students per year coming out of the Michener program and
the opening of the new cancer centres, we should be able to staff
appropriately as long as there isn't another jurisdiction that
has a more successful recruitment program.
Mrs McLeod: Appreciating all of
that, based on the planning model, how soon does the recruitment
abroad end?
Dr
McGowan: It will certainly continue this year, in the
year 2000, because, as has been pointed out, there are no
graduates this year. In the following year, the year 2001, we
would have liked to see 70 to 75 graduates. We're going to see
about 50. So we'll likely need to continue recruitment until we
get to the year where we have 75 students coming out, which will
be two or three years from now.
Mrs
McLeod: Again, for the record, I don't know if you need
to or would want to respond, but one of the concerns that has
followed the closure of the training programs in the cancer
centres-and I'm not asking you to revisit that whole debate about
whether it was a good thing or not a good thing and why it was
done-is there is a very real concern for people, at least in
northwestern Ontario-it may be true in northeastern Ontario as
well-that they are not going to be able to access the training
program in Toronto without experiencing significant costs. I'm
not perhaps surprised that you're unable to recruit enough
people. I would like to suggest for the record that if some way
of handling costs for people who have to travel for the program
or of having-I know you started the regional program in an
attempt to deal with the sudden knowledge that we needed people
and we were going without graduates for a while. I think those
regional programs need to be continued as adjuncts of Michener,
if necessary, to give people in northern Ontario an opportunity
to train. We're concerned that we're not going to have people
coming back from the program and we're going to have serious
shortages in northern centres.
Dr
McGowan: Clearly it's easier to recruit people back to
the northern centres if that's where they grew up and they go
back home to work. Because of that, the Michener Institute is
working very closely with regional cancer centres in northeastern
and northwestern Ontario to ensure that we recruit people from
those areas. There are ongoing issues and discussions regarding
the training sites. That does get down to issues of the
educational needs and we have to make sure that people receive
the appropriate training. So we are looking at that issue. We
think it's very important as well. The most important part, we
think, is recruitment from the region. There are issues in Ottawa
as well of needing bilingual staff. So there are regional issues
as well outside of the north.
Mrs
McLeod: Have I exhausted my time yet?
The Chair:
No, you've got five minutes left.
Mrs
McLeod: Good. I can do at least two things.
Before I leave the north,
then-and I do want to come back to the issue of access to
pharmaceutical treatment as well, which you addressed in your
strategic plan and the auditor made reference to-I do want to
just ask the ministry-it comes back to a question Ms Martel was
raising earlier this morning on the inequitable treatment of
people from northern Ontario, whose costs for having to travel
for cancer treatment are not being covered. I know that CCO, in
answering the question, was defining "travel" as those who are
re-referred from the cancer centre they would normally be treated
at. But it is par for the course for northerners to have to
travel. In fact, in 1997-98 there were 12,479 cancer patients who
received northern health travel grants.
Is it unfair to say-I ask
the deputy this-that the reason that the inequitable situation
exists for cancer patients is that in one situation it's
temporary and numerically limited, hopefully, and in the other
situation it's simply too huge and too costly for the ministry to
provide that fair treatment?
Mr Lozon:
I will respond to that in the following fashion: The ministry has
for a number of years had a northern health travel grant. The
purpose of the northern health travel grant is to help people
throughout the north move to centres that are close to them, but
underlying this entire premise is to try to build capacity in the
north to help people in the north access services at home. So
there has been increased funding for nurse practitioners; the
implementation of the rural and northern health framework, the
annual health professional recruitment tour and the like have
always been part of our efforts to build a greater capacity for
medical service in the north. The northern health travel grant
helps to defray the costs, but it's really not an intentional
activity. We would prefer, actually, to have the services in the
north and to build that particular capacity.
Mrs
McLeod: So would we all.
Mr Lozon:
That's how we're approaching the northern health travel grant.
It's going to stay in place. There's no intention of amending
that at this particular time. With respect to Cancer Care Ontario
and the exceptional set of circumstances we have dealt with
there, we have dealt with it as an exceptional set of
circumstances on a temporary basis to allow for the system to get
rebalanced.
Mrs
McLeod: You do realize that the north is exceptional
because we have no alternatives and therefore it is ongoing,
costly and significant and not something the ministry is prepared
to deal with.
I will turn to
pharmaceutical care. In the strategic plan, you indicate-the
question would be for Dr Shumak-that there's a need to expand the
new drug funding program to a comprehensive, managed anti-cancer
drug program. I have so few minutes left, I am going to ask you
to expand a little bit on what you mean by saying there needs to
be a more comprehensive program that includes oral drugs. What
kinds of challenges are we facing on the drug program?
If by chance you have any
time left, I wanted to ask about the breast cancer screening
program. I understand they're not accessing the whole target
group in terms of people getting screened, but why would people
still opt to refer to or to use centres that are not under the
Ontario breast screening program?
1510
Dr Shumak:
I'll try to leave time to answer the last question.
With regard to drugs, the
existing program that we have, which has already been referred
to, is the program for
new drugs which tend to be very expensive. That is an ongoing
issue for us, as Dr Levin pointed out. This is becoming a very
substantial cost. To this point we have been able to ensure that
patients who require these drugs have access to them. That is
entirely handled through Cancer Care Ontario. All patients in the
province who have access to these drugs do it through Cancer Care
Ontario. I share Dr Levin's comment that this has worked very
well.
What we are talking about
with regard to expansion of this is that there are also old and
expensive drugs, as well as new and expensive drugs, and there
are issues in ensuring that patients who need chemotherapy can
get it within our existing health care structure, because
sometimes financial concerns are at issue, and there are
differences in terms of access, depending on whether these drugs
are oral or intravenous.
One goal of Cancer Care
Ontario is to consider and work with the ministry and with the
hospital sector on the possibility of taking charge, taking
responsibility for chemotherapy in general throughout the
province. The concept would be that all chemotherapy drugs could
be funded through Cancer Care Ontario. At the present time, they
are funded in a variety of different ways. This is certainly a
concept that we think deserves further study and exploration.
I would ask Dr Schabas to
comment with regard to the breast screening program and why women
might choose to go to a non-accredited facility.
Mrs
McLeod: Or to be referred, because I understand it
probably comes to a physician referral, and I wonder if it's a
matter of educating physicians in terms of the available
resources.
Dr
Schabas: I wish there was a simple answer to that
question. I think one lesson the Ontario breast screening program
has learned over the last decade-and those who were involved in
medical education probably knew this all along-is that changing
physician behaviour patterns of referral and care is extremely
difficult. You're right, it's not a question of women selecting
to go to non-OBSP centres; it's a question of going to their
physicians and being referred to non-OBSP centres because that is
where the physicians are used to referring not only women for
mammography but all their patients for a variety of radiological
procedures.
The OBSP basically spent
its first five years trying to persuade physicians to change
their referral patterns, with very limited success. The major
change in approach of the OBSP over the last five years has been
to try to incorporate, to affiliate with more and more and,
ultimately, we hope with all mammography facilities in the
province and bring them into the program. That is an uphill
battle. There are a lot of them. We have a lot of prejudices and
inertia to overcome and we have the problem we face with many of
the current facilities that for various reasons the quality is
not sufficient to involve them in our program.
So one thing we have been
focusing on doing particularly last year was assisting
mammography facilities to upgrade their equipment and procedures
so they would be able to affiliate, and with some considerable
success. We have had a rapid growth in affiliated agencies and
mammography sites. I believe we have five more sites that are
going to affiliate before the end of March. That strategy is
working, but it is a long-term, labour-intensive strategy.
Ms Martel:
I'd like to follow up on the breast screening program. It comes
about as a result of a call that Frances Lankin received from a
constituent.
But before I get to that,
so I am clear: Do you have to have a referral to go to one of the
programs?
Dr
Schabas: Not to the OBSP, but if you have a screening
mammogram outside the program, you need a physician referral.
Ms Martel:
The question had to do with this: Is it a fact that there is no
accredited Ontario breast screening program clinic in downtown
Toronto right now?
Dr
Schabas: We have facilities within Toronto, but not in
the downtown core. That is correct.
Ms Martel:
I mean specifically in the downtown core. Was there a program at
Princess Margaret?
Dr
Schabas: There was an affiliated screening site at the
Princess Margaret Hospital. That affiliation agreement
essentially lapsed six months or so ago I believe, related to the
reorganization of the University Health Network. We are currently
engaged in negotiations with the University Health Network to
reaffiliate with the OBSP, but it's certainly a problem.
Ms Martel:
Just so I'm clear, was that clinic paid for by the Ministry of
Health through OBSP, or was it paid for by Princess Margaret?
Dr
Schabas: Just to be very clear, within the OBSP we have
a series of hub sites-there are nine hub sites and one mobile
van-which are paid for by the OBSP. They are fully funded by the
OBSP. The remaining sites-roughly 45, soon to be 50-are affiliate
sites. These sites are either in hospitals or independent health
facilities and are funded by whatever mechanism they are funded
by, and we pay them on a per-screen basis for their screens as
part of the OBSP. Those are what we call affiliate sites.
Ms Martel:
So because she lived downtown, in order for her to get into
Princess Margaret-she was told she couldn't access their
screening program because she wasn't one of their patients. Would
that be true?
Dr
Schabas: I have no idea. My assumption would be that
since that site is no longer an affiliate of the OBSP, she would
require a physician referral, a requisition signed by a
physician. That's true of every mammography facility in Ontario
that is not part of the OBSP. Whether they have additional
policies with Princess Margaret, I can't tell you.
Ms Martel:
Is CCO working to establish something else, then, in the downtown
core?
Dr
Schabas: As I said, this is a source of frustration to
us too. We want to provide coverage everywhere in the province;
we want to have every mammography site affiliated with the OBSP.
But it's a long, slow battle, and I'm afraid it's not all progress. Yes, we are
negotiating with the University Health Network. Yes, we're
negotiating with Sunnybrook and Women's College to establish
exactly those sorts of downtown sites. We'd like all the downtown
hospitals to be affiliated with our program, but at the moment
that's not the case.
Ms Martel:
It's not an issue of funding, then.
Dr
Schabas: It's not an issue of our being able to offer
them funding to perform OBSP screens. Because we've been on a
per-screen funding basis with the Ministry of Health going back
four or five years, we've been in the position that we
essentially have had a blank cheque to increase the number of
screens. It's a question of our persuading these other
sites-public hospitals and independent health facilities-of the
merits of affiliating with the OBSP. I think we've been quite
successful in that regard in the last couple of years, but there
are 200 sites in the province and we are going to be at 60 by the
end of next month.
Ms Martel:
OK. I'd like to return to the issue I was discussing this morning
before we broke, and that had to do with northern cancer patients
trying to access northern cancer services.
Dr Shumak, you mentioned
that CCO has established a task force to look at this issue and
would make some report available to the ministry. Can you
elaborate on this?
Dr Shumak:
Yes, I'm pleased to do that. This is a task force that is being
conducted at the level of the CCO board. One of our board members
is chairing this task force, and the report of that group will
come back to the board of Cancer Care Ontario. Based on the
information that is received, the final board recommendations,
whatever they may be, will be forwarded.
Ms Martel:
Can I ask what you are looking at, who you're talking to, what
issues you're sorting out?
Dr Shumak:
I can't comment in detail on the agenda of this task force, but
it's being chaired by one of our board members from the
north.
Ms Martel:
Is it Gerry Lougheed?
Dr Shumak:
Yes, it is. As you know, Mr Lougheed is very familiar with these
issues, and I believe the task force is not just in the northeast
but also involves input from the northwest. I know that Mr
Lougheed has consulted widely in his deliberations, including
with some of the officials in the ministry involved in the north.
That's all I can tell you. He hasn't shared his agenda with the
board yet, so I can't give you the details.
1520
Ms Martel:
Maybe I can provide two bits of information and then give you my
perspective as a northerner who deals with some of these
patients. I understand from Mr Lougheed that he did approach the
Ministry of Health regional office in Sudbury about the northeast
CCOR assuming funding for the accommodation, travel and meals of
northeastern cancer patients, with the same to happen in the
northwest, and that several months ago the ministry said they
themselves would put forward a proposal internally to have this
happen. This has not been done, and this was several months ago.
I found that to be frustrating.
The second thing is that
you may or may not know that he also received some funding from
Fednor to do a study in northeastern Ontario among communities to
find out their biggest barrier to accessing cancer treatment, the
biggest single barrier people in northeastern communities face.
The report will be released in two weeks. The biggest single
barrier in 37 of the 38 communities is travel to the Sudbury
centre for cancer service.
I say to you as honestly as
I can that this is a very serious issue and the northern health
travel grant is not responding to this situation, and frankly I
don't think it should. I think it's time that we deal with cancer
services under the Cancer Act and under the mandate of CCO, so
that we provide the funding that's necessary to ensure that
northern cancer patients have access to the services they need. I
leave you with two cases to show you why this is serious. You
said before that CCO made a decision to fund southern patients
because these were exceptional circumstances. Let me share with
you what I think are exceptional circumstances for northerners
trying to access cancer treatment in Sudbury or Thunder Bay.
These two instances occur in Thunder Bay.
The first is a woman named
Donna Graham-we raised this in the Legislature with the minister
in November. Donna Graham lives in Pickle Lake. It is 1,100
kilometres to go from Pickle Lake to Thunder Bay and back for
cancer treatment services. We're not going to get a linear
accelerator in Pickle Lake, so of course she has to go to Thunder
Bay. The cheapest flight for her is $570 return. If she goes for
treatment and has to stay over the weekend, she has to pay for
hotel accommodation in Thunder Bay because, for some reason or
other, the lodge does not continue to have people over the
weekend. She also has to pay for her meals, which she pays for at
the hospital at probably a cheaper rate than other places, but it
still is a cost that has to be assumed. Under the northern health
travel grant, Donna Graham receives the sum total of $156 for her
trip. She can't afford to buy a plane ticket, so twice a month
she and her husband drive 1,100 kilometres roundtrip to go to
Thunder Bay for cancer treatment. I think that's an exceptional
circumstance, and she's not the only one. We see people from Red
Lake driving four and a half hours to Thunder Bay. We see people
from Fort Frances doing the same thing.
The second case also
involves a woman whose case we raised in the Legislature too, to
try to get the ministry's head around why this discrimination
exists. This case involves a woman by the name of Gladys Whelan,
who is a senior on a fixed income. She also wrote to the minister
about her case. She had to travel from Fort Frances to Thunder
Bay three times, and the cost of those trips was over $1,000 out
of her pocket. She had to get someone to drive her, she had to
pay the costs of staying on the weekend and she had to pay for
food etc. The fourth time her specialist asked her to come to
Thunder Bay she told him no, because she couldn't afford to come
any more. I think that's an exceptional circumstance.
I raise those two because they reflect hundreds
of other people in northern Ontario who are trying to access
cancer services close to home. But the closest to home for some
of these folks is four and five hours away. It's not going to
change; we're not going to attract the specialists or the
machinery we need into those small communities. So I implore you
today, if I can, to take a serious look at this issue. For many
people, this is what they have to put up with when they look for
cancer treatment. Their situation is not going to change. I think
Cancer Care Ontario could make a legitimate case to the ministry,
as you did for the people in southern Ontario who have to travel,
that northerners in these circumstances should have their costs
covered too. They are trying to access cancer services like
everyone else. I think it would not be untoward to ask the
ministry to flow money to cover 100% of these costs for northern
cancer patients in the same way that you do for southern
patients. It's all about access to cancer care. These are the
only ways these people can get access to cancer care, and these
are the kinds of costs they have to assume.
I know that Gerry is trying
to do some work. I know he's very frustrated because the Ministry
of Health regional office in Sudbury said they would come forward
with a proposal at least three months ago and have not. He will
come out with a report that clearly shows that, at least in the
northeast, this problem is the single most important barrier to
cancer treatment for 37 of 38 communities. That will be released
in two weeks. I just think it is incumbent upon CCO to make a
proposal to the ministry, to say: "We cannot have this
discrimination any more. We need to treat people in northern
Ontario properly when it comes to covering their costs so they
can be sure to access services."
I'll leave it at that. I
don't expect you to respond, but I hope that when you go away
from here today you will really take the initiative to do that as
soon as possible and to make that request for money to flow into
the northeast and the northwest to deal with these very serious
situations.
Let me ask, are we to
assume that this strategic plan is your 1999 report card, or is a
different document coming out? I understand that this hasn't
been-
Dr Shumak:
This is not a report; this is our strategic plan. This is
intended to be the guideline for us over the next several
years.
Ms Martel:
Do you have a 1999 report card that has been prepared and was not
released?
Dr Shumak:
It depends on what you're talking about. Are you talking about an
annual report, or are you talking about a report card on the
cancer system?
Ms Martel:
I'm not sure. I understood that at one point in the last couple
of years you issued a report card. I don't know if that was in
1997-98-
Dr Shumak:
That helps; that clarifies it. A report card was released in
1998-99, and we have a tentative report card that we are working
on, which we have delayed for a variety of reasons, largely
because we want to be very sure, before we release anything-we
know the significance that is attached to this, and we want to be
sure we're giving the right messages. So it's in the works.
Ms Martel:
I apologize that I didn't read your other report card. Can you
tell me some of the details that would be included in that report
card?
Dr Shumak:
I'll ask Dr Shabas, who was the primary author of that report
card, to speak.
Dr Shabas:
I'm trying to remember very quickly exactly what we said. That
was couched as an interim report card, so it was a very
preliminary snapshot, really, of the key issues in the cancer
system to try to identify the priorities for improvement. So it
really touched on the whole range of things: prevention
screening, treatment, supportive care, research and education. It
was called an interim report card because it was a very
subjective document. It was not the kind of document that I think
we like to call a report card by being based on objective
standards or comparative data with other jurisdictions, the sorts
of things that I think would make it a meaningful report
card.
I'd be very happy to share
that document with you and the committee. I'm not really doing it
justice with my description.
Ms Martel:
Thank you. Let me go back to what the auditor had in his report
with respect to several studies or reviews or work that was to be
done by CCO and then handed in to the ministry.
The first had to do with a
comprehensive review of radiation treatment equipment
requirements, both for replacement and new radiation treatment
equipment. The agency response was that this had been submitted
to the ministry. Can you describe to the committee what has
happened to this? I'd be interested in knowing the projected
costs and whether the ministry has approved that funding, and
then when that funding will flow, the time frame.
Dr
McGowan: There are two parts to the capital story for
radiation equipment. One is the expansions and new centres, and
that is all funded as part of the capital budgets for the
expansions and new cancer centres.
The second part is
replacement of the existing stock of equipment. There's a life,
based upon use and technical obsolescence, of about 10 years for
radiation equipment. We have within CCO around 46 machines, so we
replace somewhere between four and five a year. Our current
projections are that we can continue to replace at our rate for
the next five years. Given that, we have funding in our base that
partially funds replacement of all that equipment.
We put in a submission to
the Ministry of Health to allow us to fully fund all of the
replacement. It was a joint submission between Cancer Care
Ontario and the University Health Network. That was submitted; it
was sent back with questions. We answered their questions and
re-submitted that.
1530
Ms Martel:
Are you ready to tell the committee what that price tag was?
Dr
McGowan: For Cancer Care Ontario it was about $13
million a year.
Ms Martel: So you would need
$13 million a year added into your base budget to meet your-
Dr
McGowan: No, we have-six?
Interjection.
The Chair:
Sorry, sir. Could you come forward. We want to get this in the
record. Could you maybe identify yourself again.
Mr Khosla:
My name is Naresh Khosla. I'm with Cancer Care Ontario. We have
in the budget over $6 million of depreciation which comes to us
which we set aside. We fund the replacement of equipment from our
own funds and replenish those funds with the depreciation that we
receive from the Ministry of Health. Currently, we receive about
$6 million, as I said. We need in the years to come to increase
that to about $13 million.
Ms Martel:
So it's the difference you're looking for, of $7 million.
Mr Khosla:
Yes.
Ms Martel:
And you've not heard back from the ministry about that at this
point.
Mr Khosla:
No, not at this point.
Ms Martel:
When was that submitted to the Ministry of Health?
Mr Khosla:
We submitted our first report last year and we heard back that
they wanted some further information. The further information was
supplied to them a few months ago and we're looking forward to
hearing from them.
Ms Martel:
Are you in a position where if you don't get some of that funding
soon, some of the replacement that you would do at centres would
be put at risk, or do you have enough with the $6 million to
start to carry on?
Mr Khosla:
We have enough in our reserves to pay for that. The $6 million
would be sufficient for this year and next year.
Ms Martel:
The auditor also raised the issue that in some centres you would
see a better mix of equipment that would reply to patient needs
than in others, so that in some centres you may have a waiting
list for cobalt but not a waiting list for someone needing-
Dr
McGowan: That's been a change in the pattern of practice
of radiation oncology over the years. Cobalt is actually a
Canadian invention and it's a very useful machine. It has been
something that Canadian centres have used more than American
centres. That really has been based on patterns of practice more
than anything else, and the fact that there's a Canadian company,
Theratronics, based out of Ottawa, that manufactures them, the
world-wide leader in that technology.
As these machines last 10
years-cobalt lasts even longer, 15 years-it takes time for the
pattern of practice to reflect itself in the machine mix. So as
cobalt machines come up for replacement, we replace them with
linear accelerators. There is one centre, Hamilton, which I think
you referred to specifically in your report, that has a greater
mix of cobalt machines to linear accelerators than we see in
other centres. Their replacement is contingent somewhat on the
expansion in Hamilton.
So, yes, there is some
issue of machine mix, but there's been a commensurate change in
the pattern of practice which has occurred faster than the
machine mix could change.
Ms Martel:
So you wouldn't really be using your funding that you've
identified from the Ministry of Health to reflect that mix. What
will happen is there will be a change in practice patterns that
will sort that issue out on its own?
Dr
McGowan: Well, no. As we replace cobalt machines, we'll
replace them with linear accelerators.
Ms Martel:
What is the estimated cost, then, for the new machinery for the
new cancer treatment centres, three of which I understand will
come on stream in 2002?
Dr
McGowan: We're just in the midst of negotiations with
the manufacturers regarding that, but a list price for the
equipment is of the order of $3 million or so. Nine machines-the
list price is somewhere in the order of $20 million to $22
million, so that divided by nine.
The Chair:
Mr Newman.
Mr Newman:
I think I'm going to waive my time.
The Chair:
Mr Peters wanted to make a comment.
Mr Peters:
I just wanted to make a quick comment on an issue that you
raised, Ms Martel. That is the issue of in-year funding of the
agencies and the ministries.
That is a continuous
concern of the ministries, of the agencies, and as well it has
been of our office. In 1995, we raised it. We got an official
government response to that issue at that stage, because the key
factor that is involved here is actually the tabling date of the
budget. Everything flows from there. The recommendation had been
made by the Ontario Financial Review Commission that government
return to the practice of tabling its budget, which would now
include a business plan, before the start of the fiscal year. The
government responded at that time and continues the practice that
is indicated, that the government will continue with its current
practice of tabling the budget and business plans early in the
fiscal year, after receiving input from the standing committee on
finance and economic affairs and from the public consultations
and input from the federal budget, normally tabled in February.
So in-year funding of agencies and ministries is practised, and
it was somewhat exacerbated in 1999 by the fact that there was an
election.
Mrs
McLeod: I appreciate that. Thank you very much. I also
appreciate the fact that it's Friday afternoon and the weather is
lousy, so I have four what I think will be very quick questions.
But if I could first just ask the deputy, you had indicated that
the Peter George panel on physician supply has started meeting.
It may be available on the Internet; I haven't checked lately. Is
it possible to table the list of committee members for us?
Mr Lozon:
Yes, we can do that. The first meeting of the committee was this
week.
Mrs
McLeod: Thank you very much.
I have four quick
questions. Prostate cancer screening: Is any consideration being
given to expanding screening programs to include prostate
cancer?
Dr Shumak:
Richard, do you want to answer that?
Dr Schabas: I'm happy to answer
that. It's a very difficult question. Cancer screening in general
is one of the strategies that can reduce cancer mortality. That's
the basis for our breast screening program, that's the basis for
our cervical screening program and that forms the basis of our
recommendations about a colorectal cancer screening program.
The issue about prostate
cancer screening is, as I'm sure you're aware, very
controversial. The reason it's controversial is that unlike, for
example, breast cancer screening or colorectal cancer screening,
there is not really solid evidence of the benefit of prostate
cancer screening. That's because the randomized clinical
trials-and you have to understand these are very large-scale,
long-term trials, but unfortunately they're the only really
effective way we have of knowing whether cancer screening does
more good than harm-are still underway and are not going to
report for roughly another five years.
So we have, at least in an
informal way, considered the evidence around prostate cancer
screening. Unlike, for example, colorectal cancer screening,
where we felt there was sufficient new evidence to justify a
really detailed and rigorous review of the evidence, we haven't
done that with prostate cancer screening, and I think it's
unlikely that we'll be able to justify doing that until that
randomized clinical trial evidence is in. I don't anticipate,
until that point in time, that not only Cancer Care Ontario but
the other major advisory groups in Canada, like the National
Cancer Institute and the Canadian Task Force on Preventive Health
Care, are very likely to issue guidelines recommending prostate
cancer screening.
Mrs
McLeod: I apologize; I'm going to jump from area to
area, each of which is important, but in respect of the time that
we have. I did want to come back to a bit of a northern issue. I
just want to add to my colleague's caseload-and I'm sure the task
force will recognize the 216 people who actually travelled from
Thunder Bay to communities as distant as Toronto and Ottawa, or
in some cases Winnipeg, and the burden that brings. I appreciate
the fact that brachytherapy is now covered, as the re-referrals
are, but that is only one of the incidences of cancer which
causes people to have to travel significant distances out of
northwestern Ontario.
A very different angle of
the question comes back to the issue my colleague was raising
about children and cancer. I know it's not directly under your
mandate in terms of service delivery, but is it under your
mandate to look at protocols for children who have been treated
at Sick Kids who are coming back into their home communities, and
are those protocols in place?
1540
Dr Shumak:
It's an important area because obviously there's a population,
I'm pleased to say, of children who are long-term survivors of
their cancer. These arrangements have not been closely
scrutinized as part of our mandate. I think one of the areas we
need to pay more attention to is better links between the works
of POGO and the works of Cancer Care Ontario. That's not to say
that there's no liaison. I'm just saying that it hasn't fallen
under the same kind of scrutiny at the level of Cancer Care
Ontario as it should.
Dr Levin:
Just to supplement that, the ministry has funded POGO to
establish at least five satellite POGO centres across the
province where its protocols are in force and where children can
be treated closer to home according to those protocols, as
appropriate.
I think POGO is doing a
very good job in terms of networking across the province and
making treatments available for children close to home wherever
it's appropriate. Certainly for the very high acuity treatments
that these children have to go through it's appropriate that they
be treated in a tertiary or quaternary centre. Of course, the
good news is that the survival and the cure of children with
cancer has shot up from 15% to about, overall, 75% over about a
15- or 20-year period. The actual treatments are paying off, but
they're very high acuity treatments and they have to be
centralized for that reason. But POGO has done a good job in
decentralizing the follow-up and some of the less aggressive
treatments these children have to go through.
Mrs
McLeod: And in standardizing communications back to
whomever the physician back in the home community would be.
Dr Levin:
Yes, absolutely. I can't speak for POGO but my understanding is
that there is close contact in terms of establishing continuity
of care for these children through the POGO network.
Mrs
McLeod: I appreciate that.
Here's a real leap, but I
can't let Cancer Care International go without at least some
comment at the end of the day, a business proposition that runs a
deficit. Is there a future for Cancer Care International or are
you considering a revision of that program?
Dr Shumak:
With respect to Cancer Care International, the business idea
behind it was that we thought we could accomplish a number of
objectives within Cancer Care Ontario by having an organization
that assisted developing countries in developing their cancer
programs. We thought we could do this in a way that would be
profitable and generate funds that could be used for our other
programs in Ontario. It would have that spinoff as well as
providing an opportunity for those members of our staff who were
interested in getting an enriching experience, which many of them
chose to use their vacations to take.
As the auditor reported,
from a business perspective in the early days this was not a
profitable venture, and since that time we have cut off our
financial liability. CCI is no longer a direct subsidiary of
Cancer Care Ontario. It's now an arm's-length organization. We
still are providing support, but we have no financial exposure.
In fact, they're beginning to bring in some income. For example,
they have a project that was accepted in Costa Rica which we
estimate will generate for Cancer Care Ontario between $100,000
and $150,000, so we will begin to recoup some of that loss that
was incurred. But at least, as I say, we are not at any further
financial liability.
Mrs McLeod: Does that make that
a private agency, then?
Dr Shumak:
I'm not sure how to define it, frankly. All I can tell you is
that it's arm's length from Cancer Care Ontario. I guess in that
respect it is operating as an independent agency trying to
generate some sort of profit. I am sure the people who are
running it would see that as part of their agenda, but I can't
really speak for them.
Interjection.
Dr Shumak:
I've just been advised it's actually private and incorporated as
a private company, so your question and my supposition are
correct.
The Chair:
Would that mean that they absorb all their own losses?
Dr Shumak:
That's what it means.
Mrs
McLeod: This was going to be my last question, but now
that it's hopefully no longer running at a deficit, does Cancer
Care Ontario benefit from its revenues?
Dr Shumak:
By virtue of the expertise that we have, we are providing them
with support. As I say, there are many people in our system who
are very interested in doing this on their own time, and by
virtue of the advice that we give, we are generating some profit
as a result of that.
Mrs
McLeod: The dollars come back in.
My last question then is,
is the relationship, in whatever method that relationship should
happen, between the Princess Margaret and CCO such that we're not
having patients lost between the two or bounced from one to the
other?
Dr Shumak:
I can speak certainly from the Cancer Care Ontario perspective.
Whatever issues there may be between Cancer Care Ontario and
Princess Margaret, we have taken the position that any patient
who needs to be cared for will be cared for by CCO, period, and
that's the end of it. We will not let any patient not be cared
for in this province.
Mrs
McLeod: Thank you very much, and thank you all for your
very thorough and frank answers to our questions.
The Chair:
I'd like to thank all of you for attending today. We've
appreciated the information you've provided this committee.
