Committee Transcript 1994-Sep-14 | Legislative Assembly of Ontario

Victorian Order of Nurses: Hastings, Northumberland, Prince Edward branch; Eastern Lake Ontario branch; Lanark branch; Brockville, Leeds and Grenville branch

Penny Smiley, president, Eastern Lake Ontario branch

Mary Lou Workman, president, Hastings, Northumberland, Prince Edward branch

Kathy Robertson, president, Brockville, Leeds and Grenville branch

Kingston, Frontenac and Lennox and Addington District Health Council

Shirley Sedore, chair, long-term care committee

Judith Mackenzie, senior planner

Cheryl O'Connor, long-term care planner

Ontario Community Support Association, areas 8 and 9

Elizabeth Fulford, board member, area 8

Pat Dandelé, chair, area 9

Rideau Valley District Health Council

Peter McKenna, past president

Peter Tudor-Roberts, executive director

Norma O'Shea

Hastings and Prince Edward Home Support Network

Jeanne Goodhand, chair

Haliburton, Kawartha and Pine Ridge District Health Council

Barbara Moffat, chair

Lesley Peterson, chair, long-term care committee, Northumberland county

Royal Canadian Legion, Ontario Command

Jim Margerum, chair, veteran services

Leeds, Grenville and Lanark Home Care Program

Connie Lendrum, home care case manager

Lois Patchell, home care case manager

All-Care Health Services

Georgina Thompson, president

Canadian Red Cross Society, Ontario division: Quinte branch; Kingston and district branch

Kay Summers, president, Quinte branch

Barbara Floyd, chair, homemaker services committee, Quinte branch

Marilyn Connors, member, homemaker advisory committee, Kingston and district branch

Marie Flood

STANDING COMMITTEE ON SOCIAL DEVELOPMENT

*Chair / Président: Beer, Charles (York-Mackenzie L)

Vice-Chair / Vice-Président: Eddy, Ron (Brant-Haldimand L)

*Acting Chair / Président suppléant: McGuinty, Dalton (Ottawa South/-Sud L)

*Carter, Jenny (Peterborough ND)

Cunningham, Dianne (London North/-Nord PC)

Hope, Randy R. (Chatham-Kent ND)

*Martin, Tony (Sault Ste Marie ND)

O'Connor, Larry (Durham-York ND)

O'Neill, Yvonne (Ottawa-Rideau L)

Owens, Stephen (Scarborough Centre ND)

Rizzo, Tony (Oakwood ND)

*Wilson, Jim (Simcoe West/-Ouest PC)

*In attendance / présents

Substitutions present / Membres remplaçants présents:

Conway, Sean G. (Renfrew North/Nord L) for Mrs O'Neill

Johnson, Paul R. (Prince Edward-Lennox-South Hastings/ Prince Edward-Lennox-Hastings-Sud ND)

for Mr O'Connor

Malkowski, Gary (York East/-Est ND) for Mr Hope

Sullivan, Barbara (Halton Centre L) for Mr Eddy

Villeneuve, Noble (S-D-G & East Grenville/S-D-G & Grenville-Est PC) for Mrs Cunningham

Wessenger, Paul (Simcoe Centre ND) for Mr Owens

Wilson, Gary, (Kingston and The Islands/Kingston et Les Îles ND) for Mr Rizzo

Also taking part / Autres participants et participantes:

Ministry of Health:

Quirt, Geoff, acting executive director, long-term care division

Wessenger, Paul, parliamentary assistant to the minister

Clerk / Greffier: Arnott, Doug

Staff / Personnel: Boucher, Joanne, research officer, Legislative Research Service

The committee met at 0906 in the Ambassador Hotel, Kingston.

LONG-TERM CARE ACT, 1994 / LOI DE 1994 SUR LES SOINS DE LONGUE DURÉE

Consideration of Bill 173, An Act respecting Long-Term Care / Projet de loi 173, Loi concernant les soins de longue durée.

The Chair (Mr Charles Beer): Good morning ladies and gentlemen. The standing committee on social development is now in session. We're very pleased to be here in Kingston today to review Bill 173.

JOINT LIAISON COMMITTEE OF THE ACADEMIC HEALTH SCIENCES CENTRE OF SOUTHEASTERN ONTARIO

The Chair: We have a very full day with many presenters, so we'll move right to our first presentation by the joint liaison committee, if the representative of the joint liaison committee would come forward.

Mr Rosenbaum, welcome to the committee. We have 20 minutes. If I could just say to you and to others in the room, because of the number of presenters, we wanted to make sure we heard from everyone, which means that on our side we limit our questioning in most cases to just one member per presentation. We'd like to be able to spend more time, but we felt it more important to hear what you have to say. We can debate these issues in the Legislature.

Mr Paul Rosenbaum: I'll take about 10 minutes, and then if there are any questions, I'd be pleased to answer them.

The Joint Liaison Committee of the Academic Health Sciences Centre of Southeastern Ontario comprises Queen's University, the Kingston General Hospital, Hotel Dieu Hospital, Providence Continuing Care Centre, which operates St Mary's of the Lake Hospital and Providence Manor, the Kingston Psychiatric Hospital and the Kingston, Frontenac and Lennox and Addington Health Unit. The joint liaison committee, or JLC, is a voluntary association of the university faculty of medicine and its principal teaching institutions. As such, the JLC is concerned with the provision of health services, the education of future health professionals and research related to health and health care. We're very pleased to have this opportunity to participate in these hearings on Bill 173, the Long-Term Care Act.

I think it might be asked why an association of large institutions -- a medical school and its teaching hospitals -- is interested in a bill which addresses community health programs. The JLC has for a significant period of time recognized the importance of a health system which balances the need for institutional care and the need for community services.

In our brief we will address three aspects of the bill: The first is multiservice agency sponsorship; the second is what we view as possible threats to the specialized community health programs which have developed; and the third is the purposes of the act. We believe these three issues can be easily addressed with very modest modifications to the act.

First, with regard to sponsorship, for reasons which are not made clear in the compendium, the act places significant restrictions on the ability of a board of health to be designated as a multiservice agency. The act reads:

"Before designating a...board of health as a multiservice agency for a geographic area, the minister shall consider the suitability of all other approved agencies in the geographic area for designation as multiservice agencies."

This restriction is inexplicable, and we believe, in the case of this health sciences centre, contrary to good sense.

First, even without this additional impediment, the board of health would still have to meet all the requirements of a multiservice agency. Failure to meet all the requirements, including that of a governing board which is representative of the community, would disallow any agency, including a board of health, from becoming an approved agency under the act.

Second, even as an approved agency, that is, an agency which meets all the requirements, a board of health would still have to compete with other approved agencies for designation as a multiservice agency.

Why is this sponsorship issue of concern to our members? According to the Ministry of Health's own equity data, our two acute care hospitals are the most efficient teaching hospitals in their peer groups; that is, they have the lowest costs per weighted case. We believe one of the reasons is a very close relationship which has developed between the board of health and the hospitals, and this relationship has fostered the growth of a remarkably strong and aggressive home care program. Our hospitals are concerned that a change in sponsorship of the home care program may jeopardize this relationship. Will a new agency understand the needs of the hospitals and their patients? Will a new agency sustain the growth accomplished by our existing program? We have all heard the adage, "If it ain't broke, don't fix it." We believe that this health sciences centre should serve as a model for hospital-community care relationships. Instead, the act may threaten the continuation of this exemplary relationship.

How to address this problem: We think the solution is simple. The bill should have subsection 11(3) deleted, thereby imposing no restrictions on the designation of boards of health as multiservice agencies. This doesn't mean automatic designation, but it means boards of health could compete equally in designation as a multiservice agency.

The second issue I'd like to discuss is potential threats to specialized community health programs. Under subsection 11(4), the act allows for the designation of more than one multiservice agency within the same geographic area. We believe this can threaten the continued existence of specialized community-based programs which have developed in this health sciences centre.

In order to affect earlier discharge, we have worked jointly to develop specialized services in the home care program. Often these specialized services are provided by a very small number of professionals. With multiple multiservice agencies, how would we divide existing home care staff? If there's one physiotherapist specialist in a particular specialty service, to which multiservice agency would he or she go?

Specialty services require a critical mass. As we move in this centre towards increased specialization, critical mass has become an issue. Dismembering the existing home care program and dividing it among more than one multiservice agency would not only discourage further specialization but will jeopardize that which now exists.

How can this be addressed? Subsection 11(4) of the bill, which allows for designation of multiple multiservice agencies, could be amended. The act should only allow for designation of more than one multiservice agency within a single geographic area under extraordinary circumstances. Where it can be demonstrated that more than one agency will be more effective or more efficient, the act should be permissive, but it should not allow dismemberment without some compelling reason to do so.

The last issue I'd like to discuss is that of the purposes of the act.

We support strongly the purposes of the act specified in the bill. Indeed, the very behaviour of our members over several years attests to our support for these principles.

Our concern is that the purposes are somewhat narrow. They fail to recognize the absolutely essential academic role of community-based health care.

If our health care system is to improve, to become more efficient and more effective, it's necessary to address the education of future health professionals. Locally, our members are doing just that. Our home care program, under the sponsorship of one of Ontario's teaching health centres, has become a training site for physicians, occupational therapists, physiotherapists, dietetic interns and nurses. Will a new multiservice agency recognize this critical need?

We do not believe that this should be left to chance. Just as teaching hospitals have all developed affiliation agreements with medical schools, multiservice agencies within Ontario's five health sciences centres should be designated as teaching agencies whose legislated mandate includes education of future health professionals and programs of health-related research. We have in Ontario a nascent academic program in community-based health care. This program should be supported, and Bill 173 is silent on this.

How to address this problem: The purposes of the act, part I, should be amended to include the development and support of programs which educate future health professionals within community-based health programs and the development and support of research programs in community-based health care. The act should explicitly allow multiservice agencies to become teaching agencies and should require this within the geographic areas in which the five Ontario health sciences centres are located. Teaching multiservice agencies should develop, in collaboration with educational institutions, programs of exemplary service so as to educate future health professionals and programs of community-based health care research.

The Chair: Thank you very much for the presentation. I would note as well that you have left with us a newsletter entitled Board Talk.

Mr Rosenbaum: That actually is a testimonial from an independent organization which studied the joint liaison committee. That's the advertisement.

The Chair: The verification.

Mr Rosenbaum: That's right.

Mr Gary Wilson (Kingston and The Islands): Let me, on behalf of the riding of Kingston and The Islands, welcome the committee to our area. It's certainly a pleasure to be hosting these hearings into this very important subject, and, Paul, welcome to the committee. I think you've already given a good indication of the importance the JLC has in our area and I think will be representative of the others that we hear. But I'm especially pleased to see you because you can offer a good overview of the various health care services we have and where the multiservice agency will fit into that.

Listening to your remarks, I would turn back to the first part, I suppose, to where you discuss the role that the home care program has played here. I'm wondering if you could just elaborate on why you think it has been so successful here. What parts of it have been, I guess, developed here, in your experience, and how could it be a model for multiservice agencies across the province?

Mr Rosenbaum: I think the home care program has been particularly successful in this community. The evidence shows remarkable growth in the home care program, I think growth which probably matches or exceeds any other home care program in the province. Our hospitals believe part of the reason for their efficiency is this growth.

In fact, two years ago, when we had a fairly significant bed reduction in our acute hospitals, the number of patients served over the first 12-month period increased, didn't decrease, and in fact the number of inpatients marginally decreased, with much shorter lengths of stay.

The relationship between the home care program through the health unit and the hospitals is a very close one through membership on the joint liaison committee. In fact, our hospitals have voluntarily transferred funds to the home care program on a number of occasions to sponsor pilot projects. Two specialized programs that come to mind include the placement of case workers in the regional cancer centre and the placement of a case worker in obstetrics. These were originally funded by the hospitals, although they were home care projects.

We have a home care program which has conducted a study of palliative care and a study of the interface between the community and hospitals. Although these studies were conducted by the home care program, they're again funded by the hospitals.

Mr Gary Wilson: Paul, if I may just interrupt there to ask you where the ideas for these new programs come from, is that done in relation with the home care program? Does it come from the need that's been identified by the hospitals, for instance? In other words, what I'm getting at here, I guess, is, how we can develop the programs we'll need for community-based care and just where do these ideas come from for the kinds of programs we'll need?

Mr Rosenbaum: They come from a wide variety of sources, Gary. They come from the institutions recognizing certain needs that can be best met in the community, from the home care program, from the literature, in fact from government policy directions as well. I don't think we can identify one source.

I think the point I'm trying to make, though, is that part of the strength of the system here is the high degree of collaboration. We have tried to operate as though we were a single system. In fact, part of our concern is that we believe for a variety of reasons we can easily get ahead of government in this.

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If you look at the way government does budgeting, for example, we have separate budgets not only for different ministries but within ministries, different votes. In some ways, that acts as an impediment to us. The equity funding data show that our hospitals are underfunded compared with any other hospital in the peer group. It hasn't been as much of a problem as it could have been if we didn't have a strong home care program, but now suddenly home care is capped, and we're concerned about how the home care budget will affect the hospitals. That is, we don't have a single envelope.

So we do our best to operate as a system, but there are impediments, and I don't think these are unusual to this province.

Mr Gary Wilson: As you know, the multiservice agencies are partly designed to use money more efficiently. Do you think this is one of the solutions, or at least will help relieve the pressure?

Mr Rosenbaum: Well, we all have to use money more efficiently, I think, now and in coming years. Certainly giving the stronger tools to agencies concerned with placement and treatment will have the capacity of increasing efficiency. Whether that happens or not I think in part depends on the will of those people who run the agency and their relationship with others.

The Chair: Last one.

Mr Gary Wilson: Just one last one? Paul, what is your sense of the provincial scene here, as far as eastern Ontario and in particular our area? Have you got a sense of what other areas are like and how we compare with them?

Mr Rosenbaum: I think the testimonial from that centre on governance -- I'd rather have them speak for us. They say that we are a model for all of Canada. I agree, but it's nicer to have an independent body say that.

The Chair: Thank you very much. I know one of the things that's very interesting as we go around the province, for those of us who aren't from those areas, is getting a better sense of exactly what is going on and your presentation this morning has been most useful.

HASTINGS AND PRINCE EDWARD COUNTIES DISTRICT HEALTH COUNCIL

The Chair: I call the representatives from the Hastings and Prince Edward Counties District Health Council.

Mr Alan Mathany: I'm Alan Mathany. I'm the chair of the district health council for Hastings and Prince Edward Counties. We also have with us today Barb Jones, who's the vice-chair of the long-term care committee; Steve Elson, our executive director of the district health council; and Jeanne Thomas, our health care planner in long-term care.

As I indicated to you, my name is Alan Mathany. I'm chair of the district health council and have been since its inception in 1991.

Our presentation will be in two parts. One will deal with the part of the Long-Term Care Act which deals with the generic role of DHCs. The other will comment on the implications of the act on our long-term care planning work and on our long-term care planning committee in particular. I will speak and will direct my comments to section 62. Barb Jones, vice-chair of our long-term planning committee, will speak next and will talk about the impact of the act on long-term care planning from our point of view.

First of all, I'd like to say that we are encouraged by and welcome the inclusion of this amendment to the Ministry of Health Act. It gives a clear message of support on the part of the Ministry of Health for the work of district health councils in a way which has not been present before.

We'll deal with the subsections in order.

Subsection (1) codifies the existing situation in that the minister already specifies the geographic areas for which each district health council is responsible for planning health and health care services.

I would simply like to note that in practice, planning by DHCs cannot be defined by political or geographic boundaries but has to be sensitive to the actual patterns of service use which take people outside our boundaries as well as bring people into our district. The need to improve inter-DHC planning mechanisms which recognize these realities is something we see as being important.

Subsection (2) reaffirms the existing situation in that members can be appointed by the Lieutenant Governor in Council or minister, and we really have no comments to make in regard to this.

Subsection (3) states that the government shall consider the importance of ensuring that the membership reflects the diversity of the population in the council's geographic area. This is something we support. However, given the limited number of district health council members and the assumption that the balance among consumer, providers and municipal members will continue to be present, this could impose serious limitations on the ability of DHCs to comply, depending on how prescriptive this expectation is.

In our particular situation, we are striving to maintain a balance of male and female members, and we select most members from six defined geographic areas within our district to reflect the geographic diversity of our district. We obviously have to select candidates who volunteer and are willing and able to fulfil the duties and responsibilities associated with DHC membership, regardless of what other characteristics and experiences they bring forward. As long as these expectations concerning diversity are presented as guidelines, we will do what we can to ensure that the most able people are recommended to the government. We would be uncomfortable if we had to target specific groups or persons and thereby exclude others from the opportunity to participate as council members.

Subsection (4) spells out the functions of district health councils and defines the generic role of each DHC. The functions outlined are familiar ones and reflect our current work. However, while the functions define the accountability of DHCs to the Minister of Health, they do not reflect the responsibility DHCs have to their community and the reality that this responsibility reflects an important aspect of DHC life, especially in the current climate where there are at times important differences between what the Ministry of Health would like to see happen and what communities are prepared to accept.

This squeeze play, so to speak, puts DHCs clearly in the middle, and it would be helpful if the functions of DHCs affirmed this aspect of our work. The functions of a district health council, as stated, could be expanded to include a clause which reads "to respond to health planning issues identified by citizens in the council's geographic area."

I would also like to point out that the functions of district health councils relate to the collective abilities of all DHCs as well as to individual ones.

The work of DHCs is evolving. Part of this evolution involves the shift from a focus on formal, structured planning processes and report production, following a prescribed methodology, to more innovative, flexible planning approaches, a strong focus on implementation planning and giving local leadership to the process of change, which is consistent with the government's vision of health. In this regard we see the functions outlined in the legislation as generic ones, with the understanding that new functions and new applications of these functions will continue to emerge.

Subsection (5) deals with aboriginal communities. The Tyendinaga Mohawk territory is part of our district, and preliminary conversations and exchange of correspondence has taken place regarding the role of district health councils. We assume that the anticipated aboriginal health policy statement will spell out the implications of this clause more clearly. Meanwhile, we support the statement as it has been prepared.

Subsection (6) concerns service providers making plans and information available. Can we interpret this clause to also mean that if there are situations in which the DHC asks for planning-related information which a provider is unwilling to provide, the DHC, through the ministry, can ask to have this information made available? I say this simply because legislation tends to reflect exceptional rather than ordinary circumstances, and I wanted some clarification in regard to this clause.

I would like to add that we have enjoyed a collaborative working relationship with the Ministry of Health and expect that DHCs will be active partners in the development of all regulations and policy guidelines which will affect the way we operate.

Those are all the comments I have to make at this time. As I said at the outset, we are supportive of the general direction outlined in the legislation and have brought forward our comments and questions as a reflection of the realities in which we are operating at the present time.

I thank you for your attention. Now I'd like to ask Barb Jones to speak to the long-term planning committee issues.

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Mrs Barbara Jones: Thank you, Alan. As Alan mentioned, my name is Barbara Jones and I've been the vice-chair of the long-term care planning committee of the district health council since October 1993. This is the first planning committee for long-term care issues at our DHC, and I'm a consumer representative.

The long-term care planning committee also supports the principles of the Long-Term Care Act, 1994, Bill 173. However, the committee would like to draw the ministry's attention to a variety of items, provide general comments and request clarification on specific sections of the act. As such, we request that the following comments be given due consideration by the standing committee on social development and the Ministry of Health. Please note that the use of the term "legislation" in our response is intended to apply to the text of Bill 173 and the regulations which are to be added.

My presentation today will only touch on some of the comments that have been made by the long-term care planning committee. The remainder have been submitted to you.

The long-term care planning committee generally supports the purposes of the act outlined in part I. With regard to clause 1(g), the committee would recommend that this clause be reworded to strengthen the province's commitment to community-based decision making, and to support the involvement of local volunteers in the provision of long-term care services. It's recommended that the enabling word "encourage" be replaced by "ensure" or "require," thus entrenching the essential role of local community involvement. Clause 1(g) would therefore read: "to ensure" or "require local committee involvement in planning, coordinating, integrating, managing and delivering community services."

With respect to the definitions contained in subsection 2(1), the committee would recommend that the definition of "person" include the individual consuming community services, their lawful designate and their care givers. The current definition does not reference the individual receiving services. The committee would suggest that the individual receiving services be called a consumer.

The committee would recommend that the legislation indicate the primary consumer groups who are to be served by the MSA system. The act is clear on the definition of community services to be provided by the MSA system; however, direction with regard to the principle consumer groups to receive these services is absent. The absence of a definition of the principle consumer groups implies that all individuals who meet the eligibility criteria to be defined in regulations will be the consumers of MSA services. If this is the intention of the legislation, it should be clearly stated.

Subsection 2(3) provides a definition of community services. Given that the current long-term care system employs homemakers, health care aides, attendant care workers and is currently preparing a curriculum for a personal support worker, the committee would caution that the services which can be provided by the worker not be limited to the services included under similarly titled community services described in the act. To avoid instances where multiple workers must enter the home to provide specific services, workers should be able to provide a wide range of services. For example, homemakers or personal support workers should not be limited to providing services classified as homemaking services or personal support services.

Part III, bill of rights: The committee supports the inclusion of the bill of rights for consumers in the legislation. The committee would recommend the inclusion of an appeals mechanism, as per part IX of the act, to include violations of the elements of the bill of rights. Such an appeal mechanism is available with respect to service delivery decisions under section 32.

Part V, funding and approvals: Clause 6(g) indicates that the minister may make grants and contributions for consultations, research and evaluation with respect to community services. The planning committee believes that the ongoing examination of community services in the district is necessary.

As the timing for the implementation of the MSA system may not permit the completion of our comprehensive examination of the community services in our district prior to the identification of a preferred MSA structure, the ongoing examination of these issues will be required by joint initiative between the MSA system and the DHC.

Part VI, multiservice agencies: It's suggested that section 11 be modified to outline the role of the DHC and the identification and recommendation of the preferred MSA system to the minister and the minister's commitment to designate MSAs in accordance with the recommendations of the DHC.

Subsection 14(1) deals with the provision of information by the MSA system. Our long-term care planning committee has identified the need for accurate, up-to-date, comparable information on long-term care services as essential to planning. The establishment of a province-wide information system for programs and services offered through MSAs will enhance long-range planning and will improve the accuracy and efficiency of the information and referral services of individual MSAs.

Subsection 20(3) refers to those persons able to participate in the development and revision of a plan of service. The care-giving role of family and friends is supported by the inclusion of care giver support services as a community service in the legislation. This clause recognizes the importance of involving the consumer and those lawfully authorized or designated to participate in the development and revision to plans of service.

The committee supports this participation but would suggest that the requirement to designate persons who are able to contribute to the plan of service not be too restrictive or rigorous so as to exclude input from the variety of individuals, family, friends and others who may be involved in supporting the individual.

Section 21 refers to the provision of services. The committee agrees that services must be provided in a timely fashion. The committee would suggest that the legislation establish a 24-hour period as a target for the time between the MSA's receipt of the phone call and the consumer receiving an assessment of service needs.

The redevelopment of the long-term care service system to achieve one-stop access may lead some members of the community to assume that services will be available as soon as they pick up the phone and contact the MSA system. However, the MSA system will need time to assess and prioritize needs and to arrange the delivery of services.

In urgent or crisis situations, the ability to respond immediately must be available. The definition of "timely fashion" should be dependent on the urgency of the individual situation. Legislation and/or regulations must be flexible enough to support the MSA system in its attempts to deal with crises or urgent situations.

Section 23 refers to the provision of written notices. To support consumer participation and understanding of the process, a written notice should be available in different languages and in formats suitable for those with visual impairments and low literacy levels, and should offer explanations and interpretations as are provided for in subsection 29(12) with respect to a person's plan of service.

Part IX, appeals: The committee would recommend a phased approach to the resolution of concerns involving the consumer, the service provider and a local appeal body. In all cases, every attempt should be made to resolve the concern directly between the consumer and the provider before going to an appeal body.

To reduce the potential number of incidents where a formal appeal would be necessary, and the associated costs and delays in client services, the committee would recommend that the legislation provide for the opportunity and authority for a local, perhaps independent, appeal body to form and operate.

Part XI, general: Section 56 of the act deals with the regulations. The regulations will contain important direction for the new long-term care system. As such, any and all opportunities for consultation with DHCs, service providers, consumers, their care givers and other individuals should be undertaken prior to the finalization of the regulations to the act.

With regard to subsection 56(30), the committee would request that when requiring certain qualifications on the part of service providers, the ability of the consumer to identify the preferred care giver not be sacrificed. This ability is particularly important when the consumer requires assistance with personal needs. The MSA should have the ability, like the current attendant care program, to identify and train an individual suggested by the consumer to provide personal care services. The best care giver for the consumer may or may not be the one who has received training through a formal program. Educational supports to provide training to individuals identified by the consumer should be available if needed.

The regulations should permit the maintenance of existing relationships and the continuance of partnerships between consumers and their care givers. Comfort levels between care givers and consumers take time to develop and must be supported in the new system. In-home workers provide companionship and friendship, as well as direct service.

In closing, I'd like to thank the standing committee on behalf of Alan and the members of the long-term care planning committee for the opportunity to provide our comments and suggestions. As was stated, the planning committee supports the general direction outlined in the legislation. The committee asks that its concerns and suggestions be given due consideration by the standing committee and the Ministry of Health.

The DHC and the committee welcome any questions with regard to the material submitted today.

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The Chair: Thank you for a very full brief. I note for the record the additional document you have left with us with further explanation.

Mrs Barbara Sullivan (Halton Centre): Welcome to the committee. We have had some concerns in our party with respect to the inclusion of the DHCs within this particular bill in that most of the attention throughout the province -- and we've had extraordinary attention directed to Bill 173 -- has been with respect to the multiservice agencies, how they will disrupt or affect existing agencies in communities, and very little response, frankly, to the district health council, what that role should be.

We really feel there should have been a separate piece of legislation concerning district health councils, their mandates, the kinds of resources that would be available to them, the expectations of them and the accountability, not only to the minister in terms of their mandates but to the community in terms of their mandates.

I was quite pleased to see that you've raised some of those issues, although I note that you didn't raise the issue of resources. I think that's one of the issues that certainly has been a matter of some concern for DHCs right around the province.

You also mention the necessity to cross boundaries frequently from one DHC to another with respect to planning and service access, and I think that's something that's important.

One of the things I'm unclear about from your presentation is whether your district health council and your long-term care planning committee of the DHC accepts the model for the multiservice agency that the government has put forward, which is a provincially mandated model that will be a monopoly provider of services as well as the place for one-stop access; how far you are in your planning; and where you see your own agencies such as the VON and home care which now exist fitting in. Are you looking and is the community looking for ultimately some flexibility in the design of the model, or are you willing to accept this new bureaucracy?

Ms Jeanne Thomas: I'd just like to respond to that question, Barbara. Currently, the long-term care planning committee has representatives from the VON, the home care, all of our key stakeholders at our planning table. Over the course of the past nine months, we've been developing as a community-conscious, decision-making planning body to work within the provincial policy direction to design a multiservice agency model or system for our district.

As far as the planning committee's support of the provincial direction, yes, they do support the principles of a multiservice agency: improving access to service, availability of information on services, improving efficiencies, making the system very accountable. Yes, they do support that.

When you mention a provincially identified model for an MSA, I should say that the planning committee doesn't interpret the policy documents to be promoting one model for service delivery. Certainly we would request flexibility, and we have assumed that we do have the flexibility to design an MSA system that meets the needs of the district as a whole.

Mrs Sullivan: I suppose my concern is that the planning documents in fact would have indicated that there was that flexibility, but this Bill 173 takes that flexibility away and allows only one model, which is the central multiservice agency which must not only provide the access but also deliver all of the services. In other words, your VONs and your Saint Elizabeths and so on will not exist under this model.

Ms Thomas: I guess we haven't come to that conclusion, that existing agencies will no longer exist in their current form. Certainly we've accepted that we are going to amalgamate and have an amalgamated system for long-term care service delivery. Certainly not one MSA has been decided yet for our district, but we do support the bringing together of existing agencies.

Currently there are a number of initiatives going on in the district exploring possible interpretations of how we might bring existing agencies together yet still maintain their identities and also the services that they provide in the community and the strengths of their services in the community, whether that's a local presence or a volunteer involvement.

Certainly we keep interpreting the policy to be flexible. From the start we've understood, though, that it is a one-stop access system and that the province's direction and its answer to how to achieve one-stop access was by creating multiservice agencies.

Mrs Sullivan: I just want to tell you that we will be putting forward amendments to reflect the kind of activity that you're taking. This bill does not allow that activity.

The Chair: I'm afraid I'm going to have to intervene there; we're over our time. I know we could spend most of the morning reviewing a number of questions, but may I again thank you very much for the work that you put into the presentation this morning; we really appreciate it.

NIGHTINGALE NURSING REGISTRY LTD

The Chair: I then call on the representatives from the Nightingale Nursing Registry, if they would come forward, please. Welcome to the committee. Please go ahead with your presentation.

Ms Sally Mark: Thank you. I'm a little nervous, so try and bear with me. I'm here today to --

The Chair: Don't be nervous. We get up in the morning the same way as everybody else does.

Mr Jim Wilson (Simcoe West): Don't worry. With this legislation the whole province is shaking.

Ms Mark: I'm here today to put a personal slant on how this legislation affects us as individuals.

First, I'd like to thank the committee for giving us the opportunity to make a presentation on Bill 173 affecting long-term care in this province. I'd like to introduce myself. My name is Sally Mark. I'm the director of finance for Nightingale Nursing Registry. I'm here today with my mother, Maureen Mark, president and director of operations. Together we wholly own and operate Nightingale Nursing Registry Ltd.

I'd like to tell you a little bit about how Nightingale evolved and then I'd like to outline how Nightingale is affected by Bill 173. Finally, I'd like to make some recommendations for the committee's consideration.

First, the evolution of Nightingale. In 1981, my father retired from the transportation industry with 30 years' service and we relocated to the Peterborough area. My mother, Maureen, a qualified registered nursing assistant, looked for work. After some time, Maureen began working for a health care registry on a sporadic basis. Her employer then defaulted on payment of over $1,000 in wages and court action was necessary.

My father, concerned about the financial security of his family in the future, encouraged Maureen to open her own health care registry, to be a small business owner. "After all," he said, "many women had become successful entrepreneurs." Thus, in February 1985, Nightingale Nursing Registry was established.

The first two years of operation were a struggle, as experienced by many new businesses. Certain that the future would hold an increased volume of business, they decided to take out a second mortgage on their home in the amount of $30,000 to finance future operations.

Late in 1986, the company saw its big opportunity. Local administrators were actually inviting private agencies to make proposals to become the service providers of a new provincially funded program, home care. Peterborough county was also chosen as a test site to run a parallel pilot program, integrated home care.

Nightingale's proposals to provide health services under these new programs were accepted immediately. The contract was signed with local administrators and Nightingale's revenues increased dramatically. Everyone felt that the hard work and difficult financial struggles had finally paid off. In 1988 the company incorporated. In early 1991 my father passed away and I joined the company hoping to carry forward and build on the financial security he had built for his family.

In the fall of 1991, long-term care reform began. Soon the government's not-for-profit preference policy was clearly stated. Even though 50% of the services in Peterborough county were provided by private agencies, the government maintained that only 10% of these services should be provided by the private sector. This news was devastating, but the biggest shock of all was that the government was going to expropriate our business without compensation for the time, energy and money that our family contributed and the sacrifices that we made. The same government that invited us to participate in the industry was now forcing us to close our doors for ever.

Nightingale provides quality care where and when it is needed. Nightingale employs 120 home support workers and nurses and thus we are the second-largest employer in the village of Lakefield. We service approximately 300 clients, totalling more than 5,000 hours per month in both rural and urban settings. Some of our service is provided on weekends, holidays and evenings when no other agency is able to or desires to provide this service. We deliver quality care seven days a week, 24 hours a day.

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We realize we are part of a highly regulated industry. Local home care program administrators set a fixed priced for the services that we provide. A minimum wage for home support workers is also regulated. This means that both our revenue and wages, our principal expense, are controlled. Still, we managed to operate economically, without year-end deficits. After all, no one was going to help us sustain a loss, unlike our not-for-profit counterparts.

How does Bill 173 affect Nightingale? Some 90% of our revenue is generated from publicly funded homemaking and nursing. I want to emphasize that -- 90% of our revenue is from the government home care program. Of the remaining 10% of private business, only 5% of those clients absolutely have no connection with home care. In other words, 95% of our private business results from the extension of home care services that we currently provide. What do these numbers mean?

If the private sector is limited to a maximum of 20%, which means 10% for Nightingale, because it's split between two private agencies in the Peterborough area, Nightingale will not be able to retain the critical mass necessary to survive.

If the government goes ahead with Bill 173 as drafted, Nightingale will become non-existent. Some 120 field workers and 7 administrative staff will lose their jobs. What is the justification for such a policy decision? These workers will draw UIC and other social assistance, costing the province a great deal of money in benefit claims. Has the government done a cost study to determine the underlying ticket price of creating an MSA and revamping the system?

The government, with this policy, seems to be promoting unemployment at a time when job creation seems to be a strong party agenda. Will the government guarantee that all of Nightingale's laid-off employees will be hired elsewhere when Nightingale's doors are forced to be closed?

I leave you with one final thought. As you know, small business drives the economy, creating employment and national wealth. Is bankruptcy the message that the government wants to give to the entrepreneurs of Ontario? Does the government believe that this degree of control exercised over small business will attract domestic and foreign investment for our province in the future?

We'd like to make a couple of recommendations. Nightingale recommends that section 13 of Bill 173 be amended to give administrators of the MSA the power to purchase unlimited quantities of service on a contractual basis from any service provider. It is, of course, reasonable to expect that these service providers will meet an explicit set of standards at a reasonable price. Nightingale believe that local autonomy is crucial in the delivery of services in highly diversified communities.

Nightingale recommends that the committee consider keeping the positive aspects of the current in-home health care system such as competition, consumer choice and local autonomy when creating new legislation to reform long-term care in this province.

I thank you for listening and we will now attempt to answer any of your questions.

Mr Jim Wilson: Thank you, Ms Mark and Mrs Mark, for what indeed is a thoughtful presentation and one that I know comes from the heart. I can't explain to you as Ontario PC Health critic why in the world this government wants to put you out of business. We've been fighting this since the 10% rule came in.

For what it's worth, the sympathy of my colleagues and I go out to you, your family and your over 120 employees.

Ms Mark: Thank you.

Mr Jim Wilson: It makes no sense. It defies common sense. The government itself, during the hearings on Bill 101, the first piece of long-term care legislation last year and again this year during these hearings, can provide no justification whatsoever, no cost-benefit analysis, nothing tangible to explain their simply ideological preference.

There's some hope. Yesterday we actually had a union, the third-largest union in the home care industry, come forward and tell the government they were crazy, that there was no justification, that this hurts both the private sector and the not-for-profit sector and, unlike last year's hearings where the not-for-profit sector was essentially silent about the 10% rule, this year both sectors are continually hitting the government over the head in presentation after presentation after presentation, because the bottom line is that it's going to hurt consumers. I just want to ask you that.

First of all, I assure you that we'll be moving amendments to delete any reference to this. The policy of my party has always been to have a balance in the health care system between the private providers and the not-for-profit or public sector providers, and we will maintain that policy as we always did. We didn't start this. The previous government started into this sort of social engineering.

With that, I want to ask you, the people you actually serve, your over 120 employees, how are they going to feel when -- I assume they've built up a number of trusting relations over the years with your people. Do they know what's coming down the pipeline and that the people currently providing services to them in all likelihood will not be employed in the new system or by the MSA? You also have to remember the government's made a promise publicly to displaced hospital workers, unionized, that they will get the first jobs in the MSAs. How do real people feel about this?

Ms Mark: First of all, a lot of our clients are unaware of the legislation that's going on. We've attempted on several occasions to communicate with them the significance of the policies that are taking place. Of course, there's continuity of service. We have several of our homemakers who have been with us for five or six years, going to the same client every Monday, Wednesday, Friday, and of course they feel that if they lose their trusted worker, their companion they've built this relationship with over a number of years, obviously they feel they won't be getting the quality of care that they got in the past.

ASSOCIATION OF ONTARIO PHYSICIANS AND DENTISTS IN PUBLIC SERVICE, KINGSTON BRANCH

The Chair: I invite the representative from the Association of Ontario Physicians and Dentists in Public Service, Kingston Branch. Good morning and welcome to the committee.

Dr Jane Baldock: My name is Jane Baldock and I'm a psychiatrist working at the Kingston Psychiatric Hospital. I have with me Dr Yousery Nashed, the director of the psychogeriatric inpatient unit at the hospital, who will join me in answering any questions you might have after this presentation.

I'm here today on behalf of the Kingston Branch of the Association of Ontario Physicians and Dentists in Public Service. As you've heard in previous presentations, the association was formed in 1974 and we have a membership of 400 full- and part-time salaried psychiatrists, general practitioners and dentists. Our members work in Ontario's 10 provincial psychiatric hospitals and nine regional centres for the developmentally challenged.

We work with a group of the most vulnerable people in society today, people with chronic mental illness, schizophrenia, manic depression, dementia, illnesses that so far are only controllable, rarely curable and not preventable. Many of these people live to be 65, 70, even 80 years or more. Every day the staff at our hospitals grapple with the long-term care issues for these patients, yet the severely mentally ill are not recognized in Bill 173.

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This is our greatest concern about this Bill 173. Where are the provisions for the young adults and adults in midlife who also require lifelong care due to their mental illness? This bill as it now reads ignores the existence of a core group of severely psychiatrically disabled patients who can never adequately remain in the community without periodic support from the psychiatric hospital system. Both the community-based programs and the psychiatric hospitals have an important role to play in the long-term care of the severely mentally ill. This bill seems not to recognize the complementary needs of three very necessary systems, home, community, hospital, when it comes to those with chronic mental illness.

Here in Kingston we've been very lucky because we've been working towards that balance. The Metcalf clinic where I work is an outpatient program based at Kingston Psychiatric Hospital. Metcalf is a front-line clinic that's been operating for 16 years, and I've been there for just over five. Clinic staff were multidisciplined. We have psychiatrists, community nurses, a psychologist, a social worker and an occupational therapist, and we offered a broad range of adult psychiatric services on a walk-in and referral basis. We had more than 800 patients. Some we saw several times a week; others only every few months.

This sounds like just the kind of community psychiatric outpatient program we've all been working towards. But because of funding cutbacks, since the beginning of July, the Metcalf clinic is closed to new referrals and the number of patients we see now number just over 300.

Where do the new patients with severe mental illness end up now? Probably in Kingston Psychiatric Hospital where further funding cutbacks will see $6 million cut from the budget over the next 18 months. That's probably about 50 beds which would've been available to up to 250 patients over the year. With cutbacks, we won't be able to accommodate these patients now or in the future.

Who are these people we currently deal with every day in the psychiatric hospital system? Let me give you a couple of examples.

One of our patients is a 56-year-old man who has had a relapsing and remitting schizophrenic illness for more than 30 years. He lives in a town outside Kingston. Since being diagnosed, he's required four long-term admissions -- that's more than six months -- for stabilization and treatment of his illness. Recently, he was readmitted at the request of the police on a form 1. As you know, that's a three-day assessment period allowed under law for someone who risks his or her own safety or that of the community.

He was brought to us because of his disruptive behaviour. He had set a fire to a boarding house. He was assessed and treated by a multidisciplinary team that included a psychiatrist, nurses, social worker, psychologist and occupational therapist on the ward. Within three months, he was ready to be discharged. However, discharge planning organized by his social worker revealed that officials in the town refused to accept this man's placement back into their community, his own community.

How does this bill, or how will mental health reform deal with the plight of such a person who is unable to return to his community because it is not able to cope with the effects of his severe mental illness. In a few years, he'll be elderly. How will Bill 173 look after him then?

Another example is a patient at the clinic. This example shows the complexity of the issues of both mental health and long-term care. This patient is in her 50s and has schizophrenia. She's lived with her elderly mother for the last 10 years. She's well maintained on medication and monthly outpatient visits. Her mother has taken in lodgers over the years to help with the upkeep of the house she and her mother live in. Increasingly, over the last few months, this patient has become agitated because her mother is beginning to become very paranoid about the lodgers, paranoid to the point that the mother thinks the home is being vandalized and she wants to take legal action. This patient know this is not true, but her mother is growing increasingly irritable and critical of her because she won't deal with the perceived problem by starting legal action.

In her sessions with us, we've been able to determine that what may be happening is that the mother is showing the first signs of dementia or Alzheimer's. The mother needs assessment at least by trained professionals in geriatric mental illness. For this one example we may be facing two different but very needy people who require long-term care in the near future. Where are these complex mental health and long-term care issues integrated in this Bill 173? We can't see it. The attitude seems to be: "Somebody somewhere will deal with you. We don't know who or where, but don't worry." Unfortunately, these people do worry.

Two of the three psychiatrists recently retired. We didn't know who was going to pick up the patient load, so the hospital told the patients in a letter: "Don't worry. We'll assign someone soon, once we know the schedule." Then these same patients heard that because of cutbacks, the clinic was going to be closed. They became very upset. They'd lost their primary counsellors to retirement; now they were losing their clinic. It's become so bad that some non-clinical staff have asked for training in counselling skills because many of their patients are so agitated about their caring environment being changed.

There's one other point I'd really like to make. With all the uncertainty surrounding the future of the psychiatric hospitals and the whole health care system, the very people who are the care givers are themselves affected.

Let me give you an example of this. As you know, the government recently has introduced a system by which people who spend more than 90 days in a psychiatric hospital will have to start paying up to $40 a day for room and board. In order to determine who can pay and who can't, someone in the psychiatric hospital system will have to carry out a means test. It will most likely fall to the social worker. Why should a highly trained social worker have to turn into a bureaucrat? So now we're going to turn the social worker into judge and helper in the same breath. That's wrong. Social workers are important for supportive inpatient and outpatient care. This new policy is turning them from a supportive role in the care of the severely mentally ill into a judgemental role. We're already understaffed with social workers. Why would any government want to turn this vitally necessary group of mental health care providers, who are one of the main links between the mentally ill and the community, into paper pushers?

Kingston is privileged to have both a geriatric psychiatry inpatient unit and a community outreach service. That means we can offer both kinds of care and treatment right in the community. But we're finding it's becoming increasingly difficult to return elderly with psychiatric problems to their nursing homes after treatment at the hospital. This is not surprising since nursing home staff do not have the expertise, and staff-to-resident ratios in nursing homes are less than those in geriatric wards of psychiatric hospitals. So we at the hospital can deal more appropriately with behaviour problems as a result of mental illness. However, as further beds are cut from the psychiatric hospitals, we wonder by whom and how these difficult-to-manage patients will be cared for. Where in Bill 173 are their needs recognized and dealt with?

Elderly mental health issues are a growing, not a diminishing, concern. Stats Canada 1991 figures state that 12% of the population are over 65. What seems to be overlooked in the long-term care bill is that not only will the aging population increase, but those suffering from dementia will increase exponentially. You've heard the figures before about the rates of dementia in the elderly: 8% for those 65 or over, 16% for those 75-plus, and as much as 35% for those 85 and over.

This long-term care bill doesn't even recognize that there exists an elderly population who have severe psychiatric illnesses, particularly Alzheimer's, which is a deteriorating, lifelong illness with no chance of recovery or improvement. Kingston is particularly concerned about these statistics because we have the second-largest percentage of people over 65, after Victoria. So long-term care provisions are of prime importance to this local community.

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You've heard the presentations from our association in Hamilton, Thunder Bay, London, St Thomas, Toronto and now Kingston. We hope that we've presented you with an understanding of some of the local mental health concerns of Bill 173. We also hope we've been able to show you that there are many common concerns with Bill 173 that affect all of us on the front line of treating and working with the severely mentally ill.

In closing, I'd like to remind you why I came here today. I came here to talk to you about people who often can't speak for themselves, people who are going to be affected, very much so, by the bill that you are deliberating. All I can do is ask you to consider their needs and their plight when you deal with the task ahead.

Thank you for your attention. I would welcome any questions you might have for myself or Dr Nashed beside me.

Mr Tony Martin (Sault Ste Marie): Thank you for coming before us again and painting a picture that I think is what challenges this government to take on some of the tasks that we have put in front of ourselves and you for some answer, some response, some plan to try to deal with certainly the area of long-term care and the demand that will be put on that system as we look into the future. I think you painted that very nicely, the number of people particularly in this area, and the fact that we have to work collaboratively in this is going to be really important.

You mentioned the need for the home community and the hospital to be working in tandem or together cooperatively in front of this, and I certainly can't disagree with you. I think that's why this government has finally put some wheels on some notions that have been floating around for about 10 years now about how long-term care should be delivered in this province, and trying to put a framework around that so that it can happen.

You're aware as well that we're in the process of carrying out a mental health review that will be really important and hopefully, if we all work together, fit into the context of long-term care so that the pieces fit and one will follow the other. It's been certainly my experience in life before politics that we're not going to get a handle on this very difficult problem of how we deal with folks with mental health difficulties unless everybody is working together.

Our expectation is that we will put in place the framework, which is Bill 173, and that the community, through the long-term care committees, district health councils, will work with us in a reasonable, committed, intelligent fashion to use the scarce resources we have available to us at this particular time in our history as a government to put in place the best that's possible.

I guess my question to you in front of all of that, recognizing, as you've painted for us, the challenge that's there, is, are you participating at the local level in the long-term care planning process, and are you participating in the mental health review? How are you finding that participation? Is there opportunity for you to bring the very specific questions and issues that you've raised here today to those tables?

Dr Baldock: For myself particularly, I have not been asked, and no one in our association has been asked, to take part in the Long-Term Care Act development. I'm aware of committees in the DHC, which is very much struggling with this task, and I'm aware of a social worker in our psychogeriatric unit who asked to be allowed to sit on the committee. She had to present herself; she had to push herself in to be heard in the committee on the Long-Term Care Act.

On the mental health reform, of course our association -- because I'm secretary of our association -- has been instrumental in beginning to have our voices heard around the issues of the severely mentally ill and the need to have at least a base number of beds still within the confines of an institution because of the needs in the extremes of this illness. But I think our major concern, even though integration may be verbalized, is that the pace that the Long-Term Care Act is going through is contrary to the pace at which mental health reform is taking place. I believe that once the act is in place in Parliament, if it is proclaimed, it will be very difficult to alter it or integrate it. There are some very specific issues in the Long-Term Care Act which will not allow a flexible approach with mental health reform to take place, and that's one of our concerns.

Mr Martin: I'm not sure how much time we have here this morning, but certainly the question of pace I think is important. I don't understand, to be honest with you, and maybe it's because I'm not involved personally in the mental health review process. I know that this piece has been on the table for about 10 years now and people are telling us it's time to get it on, to get it done, so that we can build on it and, as with everything else, improve it as we go. I guess my hope is that the mental health piece will fit into that. I haven't been shown yet specifically where that will or cannot happen. Perhaps you could comment on that for me.

Dr Baldock: I don't see that mental health, as I said before, is even considered in the Long-Term Care Act, and it is not. So it seems to me there are two isolates developing, perhaps in tandem, but there's no bridges between the two of them at the moment.

As you're aware, our association gave you a copy of the Mental Health/Long-Term Care Interface Working Group yesterday. I think the areas which are still deficient in the Long-Term Care Act are fully written up in that working document, and these people are linked with the DHCs.

The Chair: As you noted, we have had other representatives, so I think as we have gone along, we have come to a better understanding of these particular issues. Again, I apologize that we can't continue the questioning. We could go on for most of the morning, but we do appreciate your coming before the committee today.

PETERBOROUGH COUNTY-CITY DISTRICT HEALTH UNIT;
HALIBURTON, KAWARTHA, PINE RIDGE DISTRICT HEALTH UNIT

The Chair: I next call upon the representatives from the Peterborough County-City District Health Unit together with the Haliburton, Kawartha, Pine Ridge District Health Unit. I want to thank both of you for coming today and also for making a joint presentation.

Ms Debra Cooper Burger: Good morning, ladies and gentlemen of the committee. My name is Debra Cooper Burger and I'm a supervisor of coordination with the Peterborough County-City Health Unit, definitely the home care program in particular. I'm representing Dr Garry Humphreys, our medical officer of health, who is quite disappointed that he wasn't able to be here today to present directly to you. I've provided you with copies of the brief representing the position of the Peterborough County-City Health Unit regarding Bill 173. It's not my intent to read the brief; however, I would like to comment and elaborate on certain points.

Before I begin, I'd like to tell you a little bit about myself. I'm a registered nurse and I've spent the first 14 years of my career in hospital settings. The last six years have been spent with the home care program, four years as a home care coordinator -- also known as a case manager -- and the last two years as a supervisor of coordination. I'm also the past provincial president of the Ontario Nurses' Association, which, many of you can appreciate, is the largest union representing registered nurses in Ontario. It's on the basis of my professional and labour relations background that I can speak to you today from both of these perspectives. I have been on the front lines of health delivery in this province, and now as a supervisor I am coaching and supporting other front-line workers in their efforts to provide quality care.

I can tell you that our health unit, our program and our staff welcome and support legislative changes that enable us to be more creative, more flexible in meeting our client needs. In fact, we have advocated and agitated for many of these changes for many years. At the same time, we're puzzled and somewhat defensive with aspects of Bill 173.

I represent a health unit that has done an excellent job of serving over 2,000 home care clients on a daily basis. As I'm sure you are aware, the home care client can be a newborn infant or the most senior of senior citizens, and we serve both the continuum of age groups and also acuity of care. We have done this in the most integrated, accessible and responsive ways that we could, despite prescriptive and rigid ministerial criteria. We have been cost-effective and efficient. We have demonstrated our abilities and held true to our responsibility for meeting client and community needs. I know this to be true because the health unit administration has facilitated many smooth transitions. We have been able to respond quickly to changing needs by implementing chronic care, school health support and integrated homemaking services, all during a decade of rapid increase in demand for our services.

As I mentioned, we were able to smoothly integrate the homemaking services program into our operation. We were one of the first programs to offer the integrated homemaking services. Our experience has provided us with a recent example that I'd like to share with you.

In collaboration with our homemaking agencies -- and I might point out that Nightingale Nursing Registry that just presented to you is one of those agencies -- we have been very successful in matching our clients on the integrated homemaker program with the right amount of service. As a result, we have achieved a savings in homemaking hours and we are now able to increase the number of clients that we serve. This has not happened overnight and it has come from the experience that we have as a program.

Matching the right service, in the right amount, with the right client are objectives of service planning and coordination. We provide service planning and coordination within a case management model. Our coordination staff are skilled in holistic assessment, resource management and multidisciplinary service care planning. Our health unit believes that case management is a professional service that objectively identifies necessary services and remains unbiased when evaluating service and changing needs.

Bill 173 ensures that people who apply to an MSA for service will be assessed and their eligibility determined, but it fails to ensure that this will be carried out by trained, skilled and experienced professionals.

Bill 173 further ensures the right of appeal. We believe this underscores the need for the sound assessments and sound decision-making skills demonstrated in professional case management practice. We encourage you to include case management in the list of professional services identified in this bill.

In our brief, we state that we have a proven record and that we provide a wide range of community-based services in a caring, accountable and fiscally responsible manner. We work hard to listen to and respond to what our clients need. Our home care program has provided an on-call service long before quick response was ever fashionable in this province.

We have implemented initiatives in palliative care, intravenous therapy and complex care, and our clients recognize these efforts. We receive numerous handwritten thank-you notes and cards from our clients. Our clients or their families often express their gratitude for our services in newspaper acknowledgements, and some even make financial donations, even though we're not a charitable organization and we can't provide them with a tax benefit.

We recently did a home care client satisfaction survey. We had a 40% rate of return on that survey, which I'm sure you can appreciate is a very good response for surveys. Our clients told us, and I can quote: "Great services," "Keep up the good work," "Could not wish for better," "Don't think it can be improved," and "The service I received was absolutely first-class." Our case management service was rated as excellent. Ladies and gentlemen, these are real consumers and these are real comments based on their personal experiences and their perceptions of the service we delivered to them.

The success of our program is directly attributed to an administration that has fostered a client- and community-centred approach not only in the home care program but in all of the programs under the umbrella of the board of health.

In summary, our health unit not only supports the purposes of the act as outlined in Bill 173, but we have made and we will continue to make them a practical reality. We encourage the committee to build on our strengths and to allow us the equal partnership in our communities that we have worked hard for and that in fact we deserve.

Dr Alex Hukowich: I'm Alex Hukowich. I'm the medical officer of health for the Haliburton, Kawartha, Pine Ridge District Health Unit and I too have to express my regrets on behalf of my vice-chair, Bill Wensley, who has spoken to this committee in the past on the issue of long-term care. He was not able to be here today. I've left a copy of the health unit's brief, a large part of which has some very specific comments and questions relating to various parts of the act, and I don't intend to read that. I've got a couple of more serious concerns that I'd like to express.

Clearly, the board of health, as in the past, has indicated its support of the intent behind all of the steps that have come so far in terms of trying to improve long-term care services, make them more accessible to the public, make them better coordinated and make them more efficient, and in trying to improve the quality of service to people who require long-term care. However, my board and I do not believe that the plans, as outlined in Bill 173, particularly in relation to the creation of new agencies or a forced amalgamation of service-providing agencies, will accomplish those ends.

We believe that the ideals of coordination, improved access, are going to be highly dependent upon cooperation and coordination and that legislation does not create that. I think there's been reference to this legislation providing a framework. I would suggest that it will provide a straitjacket. It does not have the flexibility to lead towards improved services. In fact, as I've indicated in the brief, it really has created a potential fault line for a lot of disputes and difficulty in getting groups together to provide improved services.

We believe that this legislation is overcontrolling, and I have tried to get some explanation from the long-term care office as to the rationale and the reasoning behind the wording in various parts of this legislation and have not been able to get an answer. I had some preliminary discussions. I was told that the person had to speak to the lawyer who was involved in the drafting, that they would get back to me and they have not. So I'm at a loss to understand what parts of this have some kind of legitimate rationale in terms of the actual wording and what parts are purely ideologically driven by the desire to create new agencies.

The one thing that really concerns me, however: I wonder whether my board, myself and all of us have been wasting our time. I'm not sure whether you're aware of this document that was issued the date of August 22 on behalf of a Doug Jackson, office of the special adviser on MSA implementation. I have copies of this document. I only received a copy of this yesterday, but when I read this document, all of this, all of what's in Bill 173, seems to me to be a foregone conclusion. This document deals specifically -- and I do have copies of this document -- with governance of multiservice agencies.

It seems to me, as I say, that I'm just wasting my time talking to you individuals here. I hope that's not the case, but this seems to lay it all out. It's going to be the way it's in Bill 173. It has to be this way.

The thing that I find particularly ironic in this document, because it is something that I do firmly believe, is stated here under the accountability of the MSA board, "The board is accountable to the MSA's voting membership and ultimately to the community it serves." I would say that it's more important that the board be accountable to the community not ultimately but directly.

The other part of this document that I find particularly amusing is that it says: "Elected individuals bring to the board their special knowledge and experience. Their role is to serve the best interests of consumers in the community." I believe that. I believe that election provides a direct way of individuals being accountable to the public they serve.

This document basically says that if you're elected from a small, select group of members out of your community, you are somehow more accountable than if you are elected by the entire community at large. I fail to understand how that can possibly be. As I say, I've got copies of this document if you have not been made aware of this, but it really seems to preclude any of this kind of discussion as to how this bill can be changed, amended to provide some flexibility in terms of how services are provided.

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As I say, I believe this will provide a straitjacket. This will not lead to the kinds of things that need to be done to improve at a practical level services in the community. I would say that just because you pass a law doesn't mean that certain things happen, and the absence of a law doesn't keep those things from happening.

I guess the prime example that I've just been able to find is, of course, there is very little in the way of legislation relating to district health councils, yet they were created, they have expanded across the province, they exist and they function even without legislation. On the other hand, I believe that under the Ministry of Health Act there is the requirement that, "There shall be a senior advisory body to the minister...known...as the Ontario Council of Health," and I'm not sure that even exists any more. So, clearly, the fact that you can put it down on a piece of paper, pass a law, will not make it so.

I believe that you can implement pilot projects across this province that should have been done some five and 10 years ago. You can see how they function; you can see how they operate. You don't need the act, as it's currently drafted, in order to do that, and then you can take from that the things that work and improve on those rather than putting us all into the kind of straitjacket that this legislation will produce.

The Chair: I've asked the clerk and we have circulated that document, but there are some members here today who may not have it, so that would be useful.

Mrs Sullivan: I can't tell you how much I agree with your presentation. I'm pleased you have pointed out the implementation document, which came to our attention just earlier this week and which we received. We too share your concern that the implementation materials which are being prescribed are in fact being distributed and insisted upon before the legislation is passed, before there has been the public discussion of the issues, when in fact -- the clerk could give me the precise numbers, but I think we've had well over 200, possibly even closer to 300 presentations and I can only count two presentations before our committee that support this legislation.

Interjection: Three.

Mrs Sullivan: I'm told three. In most cases, where there is support for the principles of the legislation, what we see are recommendations for substantial amendment to the bill that would provide the flexibility for structural change and would certainly allow, by example, boards of health of municipalities to not be considered the last place for the MSA but there with other approved agencies.

I'm also interested in the point you have made in your brief which speaks about, on the one hand, the ministry requiring accountability within the community. But as you point out, the minister can approve agencies, premises, multiservice agencies and can intervene by way of controlling membership in organizations, removing directors, replacing directors, appointing program supervisors -- I should say that is within the ministry -- and taking over agency operations. No other legislation, such as the Public Hospitals Act, the Health Protection and Promotion Act and so on, have those kinds of powers that are allocated to the minister.

Do you want to talk about that for a minute, what that means for accountability at the community level?

Dr Hukowich: As I said, I believe this legislation is overcontrolling. I'm not a lawyer. I can't speak to the need for it to be drafted in this particular way. I do know that in looking at other pieces of legislation, it's nowhere near that kind of empowering to the minister.

If the intent is really to make the communities somehow accountable and have their structures within the community for the accountability, then I don't see the need for having the minister have so much power, given that there are already other means -- clearly, there are means of financial control. Clearly, the government always, in the end, has that level of authority. They don't provide the funds; you can't provide the service. They provide you direction by way of policy and you have to abide by that.

I can't see the need for the minister to be able to control at so many different levels, all the way from deciding who the members may be within an agency -- those are the ones who then elect the board of directors under this scheme -- to replacing those individuals. I've asked people at the long-term care office: "What's the need for having both a piece that says you approve the premises as well as a piece that says you approve the agency? Are you really going to be in a position where you're going to approve an agency and no premises, or premises and no agency?"

It seems very strange to me, but I have not been able to speak to anyone, although I've tried, to find out whether there is some legal rationale for this. Clearly, I'm not a lawyer. Maybe there is some legitimate need for that, but I haven't heard any argument. I haven't heard anybody present any kind of information that says this is required.

The Chair: The parliamentary assistant would like to comment on a couple of the issues that you've raised.

Mr Paul Wessenger (Simcoe Centre): Yes, just some of the issues raised. First of all, with respect to the issue concerning this degree of control doesn't exist elsewhere, I think I should point out that the legislation sets out a framework for community accountability, and without the legislation there is no framework for community accountability. There is absolutely the total control at the provincial level. Secondly, with respect to the public hospitals, there are similar provisions with respect to control and with respect to investigators and with respect to taking over with respect to the public hospitals area as well. So there is a parallel situation with the hospital situation.

Dr Hukowich: Again, I don't want to start interpreting law and I don't know whether the committee has had the opportunity or will have the opportunity of meeting with the legal drafters and reviewing other kinds of legislation, whether it is similar or different. There are powers of control over public hospitals and there are powers of takeover relating to boards of health as well, but they are quite different, in my view, from the level and the degree of control indicated in this document, in this bill.

The Chair: I want to thank you both for coming before the committee this morning and for the various points you've raised. We appreciate it.

KINGSTON, FRONTENAC AND LENNOX AND ADDINGTON HEALTH UNIT

The Chair: I call on the representatives from the Kingston, Frontenac and Lennox and Addington Health Unit. Welcome to the committee this morning.

Mr Alex Lampropoulos: Thank you for coming to our city. My name is Alex Lampropoulos, the chairman of the board of health for Kingston, Frontenac and Lennox and Addington. I have Dot Broeders, a member of the board who is appointed by Queen's Park, and Dr David Mowat, the medical officer of health and chief executive officer of our corporation.

First of all, we're not against the bill, period. I want to make that clear right from the beginning. Bill 173 is a matter of tremendous importance to the residents of this district as well as to the board of health and its more than 200 employees. I know you will consider carefully the written brief which we have provided. We could say much more about the bill but we have concentrated on one issue only, subsection 11(3), which requires that "the minister...consider the suitability of all other approved agencies in the...area" prior to designating a board of health as an MSA. You know how I feel? That we're at the bottom of the barrel, and that's what makes me very uncomfortable.

I want to very briefly summarize some of the points in our submission and I might help you to save time in going through the submission yourselves later on.

Why was this subsection 11(3) included in the bill? The three local members of the provincial Parliament, all from the governing party, had assured us that there was no reason why boards of health should not be considered. The only written explanation we have from the ministry is that it is a -- listen to this -- position of the government "designed to ensure that the composition of the board meets the" abovenoted "criteria to be considered by the minister." It is the composition of the board, and we'll deal with that in a minute.

This does not make any sense to me and the reasons why will follow. The bill says that all potential MSAs are to be reviewed to see if they meet the criteria. So why are the boards of health singled out or excluded, if I may say? If we don't meet the criteria, then it's obvious we're not going to be chosen.

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Hospital boards can be considered. Listen, are they much more representative of the community than the boards of health? I don't think this is a valid reason. I think it is pure discrimination. Subsection 11(3) is very discriminatory towards the health units of Ontario.

We are also denied the opportunity to change our composition in order to have the diversity of membership which the bill is looking for. I agree, we agree with the diversity. It has to come from all walks of life, and membership should be truly representing all segments of our society.

At present, this board has 10 members who are members of the councils of this area. They are reeves, they are mayors, they are councillors and they are elected by their own citizens, whom they represent, every three years. There are three more members appointed by Queen's Park, and listen to this: Since they're appointed, then we find it ironic that the minister comes back with subsection 11(3) and now tries to disqualify them. They're not suitable. The composition of boards of health can be changed and solve the problem. I'll outline briefly three ways to do so:

(a) Municipal councils do not have to appoint councillors. They can appoint citizens' representatives and that could be done if it is asked for by you.

(b) Without changing the Health Protection and Promotion Act, the minister can increase the number of provincially appointed representatives up to almost half of the members of the board, and this can be done tomorrow.

(c) The simple deletion of section 8 of the Health Protection and Promotion Act would give the minister complete freedom to change the composition of the board of health by regulation, the so-called "ministerial discretion."

I have a parallel here. Children's aid societies which, like public health, receive municipal and provincial funding are governed by a board combining municipality appointments and directly elected members. Boards of health can do the same to be like the children's aid societies. We also wonder why, if boards of health are so obviously unsuitable for long-term care -- that's what subsection 11(3) says -- they are good enough for public health. Is public health less important, to be entrusted to the boards of health and not the elderly at home?

There is a perception out there that boards of health are not corporations. We can change that perception by promoting it, by explaining it. That is not true. The act states that every board of health is a corporation without share capital.

So what is the reason, then? To be frank with you, I see no reason for boards of health to be excluded from the process of developing MSAs.

I want to make it abundantly clear that we're not asking this committee today to say that the board of health should be the MSA. No, we're not here for that, but only that the district health council, on behalf of all the residents of this area, is entitled to consider all of the options. We want to be considered along with the other boards. We are very proud of our record and we'd like to be considered according to our record.

I have two areas to deal with. On cost-efficiency -- this is our record; these are the facts -- we have a network of branch offices, an extensive administrative structure already in place, and we're very proud of that. We are the only administration in long-term care locally which is familiar with a unionized environment.

Effectiveness, the facts again, I will list them to you:

(a) Twenty-five years' experience in building the program right from small beginnings to its present state, and we serve daily 2,100 patients.

(b) Cooperation with hospitals: We have pilot projects in the cancer centre and obstetrics; a study on reducing length of stay in the hospitals -- very important to save money; patient satisfaction surveys etc.

(d) Ability to cooperate with public health services in providing wellness programs. We already have in place the care giver support programs suggested by the ministry. It is here.

(e) Full capability and experience in marketing campaign.

(f) Volunteers and a volunteer coordinator. The volunteers, ladies and gentlemen, in our community are the backbone of the community, offering their services. We attract the best and the hardworking people are with us.

(g) Teaching health unit, the first to involve home care. A critical, research-based approach to practice, emphasizing innovation, efficiency and quality.

(h) Research and education: A field training for all kinds of health professionals.

We are one of the few agencies in the province of Ontario to operate both a home care program and a placement coordination service.

In summary, by not allowing the board of health to sponsor the MSA, you create the maximum amount of dislocation and expense in bringing a new MSA into existence. What we want, ladies and gentlemen, and what we know the public wants is as much funding as possible to go into services. The way to do that is to -- and I'm not trying to teach you here, I'm not trying to make you listen and go and do it, but these are the facts.

Mr Noble Villeneuve (S-D-G & East Grenville): Don't be shy.

Mr Lampropoulos: No, I'm not. The way to do that is to maximize the administrative efficiency. People call it downsizing, people call it restructuring. We call it administrative efficiency and we believe that this is what we can do, the health unit of this area.

My last thing: We do not speak for all boards of health in Ontario, only for this one. I was a listener on August 23 when the president of the ALOHA and the past president made a presentation to you, Mr Chairman, and to your committee. They asked me to do my bit here, and that's why I'm here. But if only one health unit in this province of Ontario were to be the ideal candidate to become the local MSA, then your committee has an obligation to strike out subsection 11(3) of Bill 173.

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Mr Jim Wilson: Thank you for your presentation. I think you made an excellent presentation and I agree with all the points, except for your first point, and that is that you're in favour of the bill. Other than that, we're on the same wavelength and we will be moving an amendment to delete subsection 11(3).

Mr Lampropoulos: I'm pleased to hear that.

Mr Jim Wilson: You make a very persuasive argument. I certainly can assure you that during third reading debate we will use some of what you've said today in debate among I and my colleagues in the House. I guess, though, what you have to remember is that after three and a half years of being Health critic and four years of sitting in opposition to the NDP, one has to always look at what is the hidden agenda on any piece of legislation they concoct.

It has been suggested, since they can't seem to come up with a rational argument for why they're discriminating against municipalities and boards of health with respect to who can be an MSA, that perhaps because of the overprescriptiveness of the bill -- just using the example of Simcoe county where I'm from, certainly I can tell you that because municipalities are made up of legitimately elected local officials, and boards of health for the most part also have those representatives on them, they probably wouldn't put up with much of the directive that's coming. Therefore, one of the suggestions is that the NDP needs to start all over again with some new people in an MSA, in a new agency, so they can ram through their social engineering.

I can tell you, my municipal councils don't even adhere to their welfare rules that they changed a few years ago. We still have welfare inspectors in the county of Simcoe and we keep hiring them all the time. They just keep saying to the government: "Sue us. We don't care. You're wrong." So we don't follow a lot of their directives now locally because we still have common sense in our locally elected officials. That's one theory.

The second one that's been approached is, we know unionization will increase under this. The Christian labour council yesterday said yes, indeed, the speed of unionization in our sector, and we also know that over half of the community-social service sector right now, those delivering services, are not unionized in the province.

If you combine this bill with last year's labour bill, Bill 40, this is one-stop unionization. You get a new MSA, and you know once there's one union in under the same roof, it's very easy to put a petition before the labour relations board and you have one-stop unionization. So that's the other thing that you can come up with as an explanation of why the bill's written this way.

Do you want to comment on those theories?

Mr Lampropoulos: In all fairness to the governing party, we have the support of the three local MPPs, as I said, and we have the support of others who are sitting around the table who are members of the governing party, and the bottom line is that they're good listeners and they prove it by coming to this area. You are coming here to listen to the grass roots, and we appreciate it very much. I hope what you said about 11(3), that it will be deleted -- I hope you will agree and I hope we have a unanimous decision for that to be recommended to the government for the third reading.

Mr Jim Wilson: Well, let's just find out. Because we're in week three, we're down to the wire. I'll ask the parliamentary assistant: Is that an amendment the government is willing to accept, and then we don't have to go through this, hearing presentation after presentation?

The Chair: I'll turn that question to the parliamentary assistant. He also wanted to comment on that aspect.

Mr Wessenger: I think you'll have to wait for clause-by-clause, Mr Wilson. But if we deal, first of all, with 11(3), it should be made clear that 11(3) does not prevent a board of health or a municipality from becoming an MSA. I mean, there's a local planning process. It certainly states a preference, but it doesn't state a prohibition, and there's quite a difference between a preference and a prohibition.

I might just add that Mr Wilson had indicated there has been no reason expressed, but I think we have to realize, and I'd appreciate your comments on this, that a board of health does have many responsibilities besides, for instance, the whole area of long-term care.

Certainly one of the bases, I would suggest, for preferring a single-purpose, non-profit corporation is the fact that the board would be solely responsible for the delivery and supervising of the whole long-term care aspect. It wouldn't have other responsibilities, as a municipality does, which has very many others. Even a public health unit has certain other responsibilities. I suggest that is one of the underlying principles with respect to the preference for the single-purpose, non-profit corporation. I certainly appreciate your comments on that aspect.

Mr Lampropoulos: That begs an answer from me and the gentleman to my left. First, that's wrong, what you are telling me. If it's true what you are telling me, then why is it there? Delete it; take it out. If it spells it out that will be considered at the end, that is almost as well excluded. If what you are telling me is true, just delete it; take it out. We don't need it.

Mr Wessenger: Could I just ask what you're asking, then? Instead of having that particular clause, you're requesting that criteria be established, rather than sort of dealing with the question of --

Mr Lampropoulos: No. The DHCs will decide, not a centralized government trying to govern everything from Queen's Park. I have the medical officer of health who wants to elaborate on this.

Mr David Mowat: If I could just comment, Mr Wessenger, I'm having some difficulty following the government's position on this.

It was in this very hotel a few months ago that the minister herself told me she accepted the argument we had made about an earlier version of the policy that MSAs should be set up under completely separate new bodies. Our argument was that if we did that, we would have all the dislocation and expense of setting up a separate governance and a separate administration. We were told by our government party MPPs and by the minister that they accepted that argument and that in the legislation the MSAs could be run by existing bodies. I heard you two minutes ago say that we can't do that because whatever body you choose, whether it's a board of health or any other existing body, the fact that it's already in existence means that it has other duties.

What is the government's position? You're going to have a body that looks only after long-term care, in which case by definition it's a new body that didn't exist before, or you're going to have an existing body, which by definition must be looking after something other than long-term care. What's the position?

Mr Wessenger: Well, the position is that existing agencies can become MSAs. That's clear; that's very clear. But there are other existing agencies that --

Mr Mowat: But you just told me you can't look after long-term care and something else. What it seems is that that only applies to boards of health. I get the reason.

Mr Wessenger: Respectfully, I would suggest that I said it is a preference aspect.

The Chair: I'm sorry; I think the points have been made very clearly and I'm afraid we are going to have to move on. I want to thank you for coming before the committee and for the material which you have left with us today.

Mr Lampropoulos: I just provided you with this. It was in our local paper. It doesn't look good to me. It doesn't look good to the government of Ontario. Please delete the clause.

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PROVIDENCE CONTINUING CARE CENTRE

The Chair: I call upon the representatives from the Providence Continuing Care Centre. Thank you very much for coming to our sessions today.

Mr David Bonham: We're delighted to be here to participate in these discussions, which are important to all of us. I'd like to first of all introduce myself. My name is David Bonham. I'm the chairperson of the board of Providence Continuing Care Centre. With me I have -- and you'll have no trouble distinguishing them -- Sister Sheila Langton, the administrator of Providence Manor and also vice-president, east, of the larger body, the Providence Health System, which operates right across Canada or at least in many of the provinces; then the other individual here, Guy Legros, who is the president and CEO of the centre. We're the people who are here on behalf of the centre.

My task is going to be quite brief. I'm going to make a few comments -- in a descriptive sense, without too much history, so don't worry about that -- about the centre, and then I'll ask Sister Sheila and Guy to carry the discussion further.

You can see from our material that we have really just three points to make, and these will come later. Obviously, in a bill of this magnitude there are many, many things that could be said and should be said, but we've confined ourselves to those three points. But maybe just to put this in a setting, I should comment about the centre itself. It has a long history in Kingston and we, I don't mind saying, I'm happy to say, are very proud of the centre. I think it's made a great contribution over the years to this community in many, many ways. It has two branches. One of them, of course, is St Mary's of the Lake Hospital, and the other is Providence Manor. They are operated as one entity now in terms of the governance.

With regard to the bill itself, it touches more on the Providence Manor side, so I'm going to comment primarily from that aspect. That of course does not mean to say that we aren't equally concerned about St Mary's of the Lake Hospital.

We've endeavoured over the years, and I think the track record is very clear, to provide high-quality care and service to this community in a responsible way, in an open way, in keeping with the standards of society and the religious order, the Sisters of Providence of St Vincent de Paul, that has sponsored these institutions from the beginning. We offer a very broad project, and I'm happy also to say that we've done this, I think throughout, staying within our budget. That is true today, although, as you know, that's becoming more and more difficult as time goes on.

With regard to the hospital -- I'll just touch on this; you'll see it in the notes -- we have a major continuing care aspect to it which covers 169 beds. Then we have the geriatric program with 18 beds and the rehab program with 36 beds. That's the situation as it now exists and will continue in the future.

With regard to Providence Manor, we provide long-term care to residents who have chronic diseases and disabilities and we serve a very wide community. We do this, and I want to emphasize this, both within the institution and by a whole variety of outreach programs. It's primarily the outreach programs that relate to this bill: not exclusively, but that is where the emphasis lies. I'd like to draw your attention particularly to two such programs, and I might just say in introducing them that we are of course somewhat concerned whenever changes occur that could affect these programs. There's a lot of work and history and devotion and commitment and now heritage that relates to these programs.

The first one I'll mention is the Hildegarde Day Centre, a very significant program which began about 20 years ago, at that time in collaboration with the government, and ever since. It offers a seniors' day program for people who are not residents within the institution. They come and participate and it's a very positive thing for many of these people who don't have any other outlets in their lives. On a regular basis, we serve about 118 persons. So it's quite a significant program. These people come, physically not all every day. On a daily basis about 26 people come, and they stay there and participate in a very wide variety of activities, and we have a lengthy waiting list. So that is a very important, I think, initiative within this community.

I'd like to also mention the attendant care outreach program. This isn't quite so old. I think it goes back about 10 years. But again it's something that is growing, and it's becoming much more relevant, I think, to our society as changes occur. It enables people with disabilities to remain in their communities, and we provide services to them. The idea here, of course, is to take the services to the people so that they don't have to become institutionalized, but this requires a tremendous support group and skilled attendants and others. At the present time we have about 63 clients in this program. And this will interest you: The average commitment in hours per week is about 21. So it's a very significant responsibility that we have to serve these people in their own environments through the attendant care outreach program.

These are the two particular programs that would be impacted, if that's a verb, by this bill primarily, and therefore I think that's where our attention should lie. I will just say, as chair of the board, that we are concerned with any change that could affect -- and it's not just a selfish concern. We feel these programs have developed very vigorously, in a very positive and effective way, and we feel they are not only important to us but they are important to this community and to this province. Therefore, I don't mind saying -- I feel I should say -- that we do have concerns whenever changes are on the horizon that could affect them and therefore we come from that point of view, not in an attitude of obstructionism but of legitimate concern, because we feel we've developed these and we want to continue to carry them forward with the particular stamp and flavour of our institution and the religious order behind it that has I think contributed so immensely over the years.

Those are my comments, and I'm now going to ask Guy Legros, the CEO of the centre, to continue.

Mr Guy Legros: Good morning. First of all, I'd like to say that we do support the basic principles of the bill, and that is the equity of services, increased, simplified access to the services and also the reform of long-term health care. We agree that changes are required.

However, we suggest that the potential impact of changes should be investigated before they are implemented. This will require very serious and extensive analysis before implementation, and we see no evidence that impact cost studies, for instance, will be initiated prior to passing this bill. What is the cost, for instance, of setting up MSAs across the province, and with that, there would be an ongoing cost as well.

Here I'd like to quote a couple of paragraphs from the compendium. The first one is:

"The Long-Term Care Act, 1994, creates a legislative framework for community-based long-term care and support services for elderly persons, adults with physical disabilities and persons who require health services at home."

Secondly, "The act provides for a new way to plan, manage and deliver community services consistent with government's strategic directions for reforming community-based long-term care and support services."

It's very clear from these statements that the emphasis is only on community-based services.

We would like to suggest that chronic and rehab hospitals play a significant part in the continuum of long-term care services. The chronic care implementation task force has reviewed the role statement provided in the Chronic Care Role Study and the following role statement has been finalized, and I think it's very important that you really listen to this, these words that are included in that role statement:

"Chronic care hospitals and units will serve clients with complex needs. They will function in the continuum of health care, along with other client-focused partners: acute care, long-term care, mental health and community services....

"These hospital services may be provided in ambulatory, inpatient and community settings. Within the chronic care system, people of all ages will be served."

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It should be noted that hospital services are not the last resort. They do provide assessment and treatment allowing people to return to the community, both inpatients and outpatients. It is often very necessary for hospitals and homes for the aged to admit patients or residents due to the complexity of medical and personal needs and the limitations of home support.

Our centre does provide in the Kingston region institutional coverage for those requiring assessment, treatment and rehabilitation. For example, a young disabled person serviced by the attendant care outreach program at Providence Manor may require the professional therapeutic care of St Mary's of the Lake Hospital for a period of time and then return to the community. Another example would be the Alzheimer-diagnosed person living at home who may benefit from the respite care provided by the Hildegarde Day Centre at Providence Manor.

Bill 173 deals with the issues of access, coordination and integration of essential community services. MSAs will provide "one-stop shopping," but consumers will not be aware that choices have to be made between the provision of health services and social services, as they will all come from the same spending envelope. Also, an individual's needs may have little to do with the level of care provided.

Under the current system, consumers have a choice in the services they receive and from whom. Under the new system, MSAs would absorb existing community services, such as the Red Cross and VON, and take away that choice. The elimination of freedom of choice will not likely improve services provided.

MSAs will become very powerful and centralized agencies, rigidly controlled by the provincial government. We can expect serious competition for scarce resources. For example, social services providers will be competing for health care dollars at a time when the home care program for acute health care needs is increasing due to shorter hospital stays. Will MSAs grow to become monopolies, that is, bigger and more expensive?

Many charitable organizations presently offer services to the community. One of the major ties to the community is through our volunteer boards. Under Bill 173, these boards will be replaced by a large regional provincial bureaucracy directed by government appointees. It is likely that many volunteers currently available within our community would not identify with government-controlled agencies.

The commitment of our staff and volunteers to the philosophy and value system is not the product of, here quoting the bill, a "service name, logo or a service location," as suggested in the new legislation. It is the product of our heritage. Our board members and volunteers respond to the vision of providing patient/resident-focused holistic care, meeting physical, social, emotional and spiritual needs.

We are convinced that volunteers and their fund-raising activities are essential to cost-effective long-term care and to the development of new services in the present environment of constrained government funding. We suggest that it would be the role of agencies working under MSAs to maintain, support and coordinate their own volunteers consistent with their individual philosophy, values, mission and the founder's heritage.

As stakeholders in the system, we recommend that agencies could operate together more effectively under an MSA umbrella, rather than the single integrated board structure in the proposed legislation. We recommend that the MSA for this region use multiple providers which continue to retain their individual identity and mission. In other words, use the brokerage model whereby the MSA purchases the required services from a variety of existing agencies. This, by the way, is how the health unit in this region is now functioning efficiently and cost-effectively.

I think Sister Sheila will give you the conclusions that we have.

Sister Sheila Langton: Good morning. In bringing these remarks to a conclusion, these remarks that have been made on behalf of Providence Continuing Care Centre with regard to Bill 173, I begin by saying that the Sisters of Providence and their associates have been on the front lines of human services delivery in this province and in the Kingston area for more than a century. Inspired by their historic roots and traditions, and often in collaboration with government, they have been leaders in designing, expanding and improving programs.

We do not believe that this province will be better served by the destruction of community-based volunteer boards in favour of a large bureaucracy directed by a handful of government appointees, as proposed in the legislation. The enlarged health care bureaucracy will not attract the volunteers and the private donations that now augment the services provided by charitable community agencies.

The institutional system of care and the community-based system should not be isolated from one another. Together, they should offer a continuum of care that shares resources, standards and accountability.

As we acknowledged earlier, changes are required. However, we should be sure the changes will bring about improvements to the system before they are implemented.

It is good that we have the opportunity to make our contribution to the process of long-term care reform, and we are appreciative of this.

We are asking our legislators to make significant modifications to Bill 173 to better respect the dignity of those we serve by recognizing their desire for a continuum of services that are based on personal, faith, cultural, social and linguistic preferences and to permit the continuance of voluntarism and community support.

Mr Legros is going to now refer to the summary of our three recommendations, which is on the first page of our submission.

Mr Legros: Thank you, Sister. There are three, and the first is recognition and support for continuum of care. We recommend that institutional services be considered as part of the continuum of MSA services. Institutional and community-based services must not be treated as mutually exclusive but should be recognized as complementary programs in the provision of long-term care.

Providence Manor operates a highly successful adult day program focusing on the needs of clients with dementia. The expertise necessary to maintain this program is located in the homes for the aged program, and we think the community should continue to have access to this expertise.

The second recommendation deals with the provision of consumer choice. We recommend that the new legislation not eliminate the freedom of choice. Under the current system, the public has a choice in the services they receive and from whom. The delivery of care should continue to be the responsibility of the well-established and high-quality service provider agencies which currently exist and operate under the brokerage model. Agencies could function under an MSA umbrella organization.

Our third recommendation deals with the retention of voluntarism and community support. We strongly recommend the continuance of existing community-based volunteer boards. The loss of volunteers will also significantly reduce the financial support which now augments the services provided by the charitable community agencies. Volunteers donate time and money because of the heritage, philosophy, mission and value-based holistic care. Our health care system needs volunteer commitment and dedication, and we recommend that we build on the existing strengths rather than destroy the level of voluntarism, which, by the way, is working very, very, very well.

I'm sure there will be questions.

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Mr Paul R. Johnson (Prince Edward-Lennox-South Hastings): As is probably evident, we members of the committee don't get a lot of time to ask questions or make comments. Maybe twice throughout the course of the day I'll have that opportunity, so I'm going to try and say as much as I can in this short period of time that I have.

With regard to all the presentations that have been made by agencies that are within my catchment area or that I'm within theirs, it's very good to hear them say that generally they're supportive of the bill. However, they have some specific concerns, and indeed we recognize some of those concerns, and indeed, as was stated by previous presenters, the local government MPPs have taken these concerns consistently forward, and I think that was indicated.

Mr Jim Wilson: And, and, and.

Mrs Sullivan: And.

The Chair: Order.

Mr Paul Johnson: And I think it's --

Interjections.

Mr Paul Johnson: And as you can tell, all the members of the committee get along very well and we seldom interject when our colleagues are speaking.

But just with regard to your presentation specifically, I don't know whether MSAs were characterized fairly. That's the one, if it's at all negative, I wanted to make.

But with regard to your summary of recommendations, it's my understanding that what you're asking us to recognize and consider has already been done and been granted. I thought it would be important for me to make that statement now so that you could go away today, at least, satisfied that we have already taken your concerns into consideration and that things are better.

Mr Legros: Well, that's nice to hear that. We're pleased.

Mr Jim Wilson: It's not true.

Mr Legros: If it is, we're okay. So that's the other side of the coin.

Mr Paul Johnson: I don't have a question per se, and as I said, I don't get a lot of opportunity to make any comments, but other than what I've said, I think that concludes my remarks.

Mr Wessenger: Perhaps I should just clarify what has been stated. Certainly with respect to the recommendations, we do recognize and support the continuum of care and appreciate those comments, and also with respect to the matter of volunteerism and community support, and certainly with the matter of consumer choice, that is indicated in respect to the development of plan of service, the fact the consumer is involved.

One thing I would just like to clarify: I think it should be very clear that MSAs are not appointed boards. They are a volunteer board and non-profit corporation, hopefully a charitable corporation. I just thought that should be clearly put on the record.

The Chair: Any comment --

Interjections.

The Chair: Excuse me. Order, please. Would you like to comment on that, Mr Legros?

Mr Legros: I am not exactly sure of what the process will be for the formation or the composition of those boards.

Mr Wessenger: Perhaps I should indicate that obviously there will be differences as each local community establishes its own recommendation, because it's clear that it's laid down that it has to be a non-profit corporation; or it could be, for instance, a cooperative, or it could be a board of health or it could be a municipality. There are various choices set out.

Mrs Sullivan: It can't be Red Cross, though.

Mr Wessenger: It has to have a corporate structure, obviously, of some sort. But there's a great variety within that that can be developed. It's up to the district health council to sort of recommend what type of model, or maybe an existing organization. It's going to be the local planning process that determines what models come forward, and I can anticipate there will be various differences throughout the province which recognize the differences in the province in what is developed, just as there will be a differing timing schedule. Some communities will move ahead faster than others with respect to developing MSAs.

The Chair: I know we could continue with questions, but I'm afraid we have to move forward. Thank you again for coming before the committee this morning.

VICTORIAN ORDER OF NURSES: HASTINGS, NORTHUMBERLAND, PRINCE EDWARD BRANCH; EASTERN LAKE ONTARIO BRANCH; LANARK BRANCH; BROCKVILLE, LEEDS AND GRENVILLE BRANCH

The Chair: I next call upon the representatives from a variety of Victorian Order of Nurses branches: the Hastings, Northumberland, Prince Edward branch; the Eastern Lake Ontario branch; the Lanark branch; and the Brockville, Leeds and Grenville branch.

The four VON groups that are before us, we had agreed with them that they would make a joint presentation. We don't have time for four presentations, but we have provided some extra time because they are coming together as one. If there is sufficient time, I will permit a question from each caucus.

Ms Penny Smiley: I have been elected as the spokesperson for the group, to actually read the presentation to you, but should there be questions, I may well be calling on my colleagues to assist with the answers.

The Chair: Congratulations on your election.

Ms Smiley: Thank you. As we are the last presentation before lunch, we'll try and respect your biological needs and be somewhat brief in our presentation. However, we have, as was already mentioned, submitted a lengthier written brief for your consideration.

My name is Penny Smiley. I am the president this year of the Eastern Lake Ontario branch of the Victorian Order of Nurses. I am, in my real life, I guess, employed in the education field as a labour relations adviser for the local school board. However, today I am here as a volunteer of the VON.

With me I have Ross Craig, from the Lanark board of the VON; Kathy Robertson, president of the branch in Brockville, Leeds and Grenville; Mary Lou Workman, president of Hastings, Northumberland, Prince Edward county branch, as well as a member of the executive of VON Ontario representing southeastern Ontario. Judy Roth is also from the Brockville, Leeds and Grenville branch and is also a member of the VON Ontario executive.

Also present today are many staff members of the various branches. From Hastings, Northumberland, Prince Edward branch we have Mary Clarke, who is the assistant executive director. From Eastern Lake Ontario, which covers the Kingston, Frontenac, Lennox and Addington area, we have Ivan Ip, the executive director, as well as Deborah Pennell and Sheilagh Nowlan, and from VON Ontario we have with us today Don Austin, who is the assistant provincial executive director.

These branches provide a multiplicity of services. They include visiting nursing; shift nursing; community foot care clinics; Alzheimer's programs, which includes respite care; Meals on Wheels; friendly visiting and palliative volunteer visiting; information and referral; telephone reassurance; income tax assistance; medical transportation; home maintenance; home help; occupational health; a grand friends program; assessments for the Department of Veterans Affairs, insurance companies and placement coordination; bereavement services; cycler-assisted dialysis; mildly ill care services and student placements for colleges and universities.

We have 456 staff members and 454 volunteers among the four branches. At one time we had over 5,659 clients on our combined caseloads. We service a total population of about 538,000. Through the four VON branches which I represent, our communities benefit from 14,818 hours of volunteer service a year and about 371,062 community nursing visits. Thus as major providers of health and social services in this area over many years, we have watched with interest the progression of the redirection of long-term care and the development of this legislation.

The mission statement, objective and core values of VON are included in our written brief. The Victorian Order of Nurses is committed to providing leadership across Canada in the development of health and social policy, the delivery of innovative community-based nursing and other health care and support services based on the principles of primary health care.

We are actively involved in many ways in planning for the future of our community services.

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In reviewing Bill 173, our boards found much to endorse. The idea of a single access to services is one which we have long recommended. We support the establishment of core services to meet the community's needs. The elimination of duplication in assessment, client choice and a client bill of rights are in keeping with the philosophy and objectives of VON as well. We know that well-organized and integrated services are essential in this uncertain economy.

The VON branches are dedicated to the provision of community-based, client-centred care. We caution, however, against unnecessary rigidity in designing systems to meet the long-term care needs of residents in our communities. We request that the act and any regulations to the act provide for and promote a partnership model for the MSA involving a federated board -- that would be a board which has representatives from all the service providers which still are independent entities -- and an integrated service delivery model.

We believe that current staff from community agencies should have equal access to jobs in the MSA, irrespective of whether they are unionized or not. Otherwise, the severance cost to agencies would be prohibitive.

There are other areas in Bill 173 that seem unclear to us. The effect of a government funded and controlled MSA on volunteer service and on private donations, in memoriam donations in particular, is impossible to predict, yet these fund-raised dollars and donations of service represent an enormous economic contribution to the current system. We would hope that good planning might ensure that services to our communities are not lost because of the passing of this bill.

The branches on whose behalf I am speaking support the purposes of Bill 173 as cited by the minister. Our own programs have been expanded to provide comprehensive services at the home and in community settings. We support consistent eligibility criteria but question the intent of uniform rules and procedures.

We believe procedures need to be kept simple and practical. The purpose of assessing eligibility for a meal or a drive to a medical appointment may be significantly less involved than the initiation of a complex service plan for a palliative client dying at home.

We believe that communities, working with the DHCs, should be able to develop flexible models and to have local boards govern their multiservice agencies in ways that best meet the local needs.

Encouraging such local involvement and flexibility will promote the most efficient management of resources. VON itself is founded on the practice of local community boards planning, coordinating and overseeing the delivery of services in partnership with the community, clients, staff and other providers. This participation and commitment of voluntary boards has enabled us to provide excellence in health and social services throughout the 97 years of our history.

Looking at part II of the act, "Definitions and interpretive provisions," the branches support the inclusion of the services listed. We suggest that respite, palliative care and bereavement support be cited as additional, distinct components of community care. Our branches support the availability of mandatory province-wide services in keeping with consumer needs.

The bill of rights cited in the proposed act is incorporated in VON's philosophy of service and we are pleased to see this entrenched in Bill 173. We do not, however, see that this bill ensures the right of the consumer to choose a type of service, location or provider within the resources available. We would welcome some assurance that the advice of the community and its district health council will be taken by the minister in making final decisions regarding the best administrative models for the future.

Our branches recognize the need to control the escalating expenditure in health and social services and to allocate scarce resources carefully and wisely. Providing services at home by community-based agencies has been shown to be cost-effective. However, we have concerns that the legislation gives no guarantee of adequate funding for services to meet future consumer needs. The gradual shift from institutional to community care has resulted in more acute and complex service requirements at home. Visits for treatment now take longer and are thus more expensive to deliver.

We believe that funding of community care should be determined by the actual needs of the population and not by historical or census data. The current cost structure is known, but the costs of the future are not. Populations over 65, epidemiological factors, population density and travel required are only a few of the factors to be considered in determining funding needs. We hope that community planning will progress at a rate that permits good research into all the economic factors, and planning based on accurate data and well-informed predictions.

Financial data on integrated models in other provinces, such as Quebec, could be made available to community planners, and a detailed cost analysis of various models could be completed before a request for proposals is made. In the absence of necessary financial planning data, a pilot should be considered to minimize the potential adverse effects.

As I have said, VON supports community partnerships in sponsoring the MSA. Alliances of current health and social service providers would ensure a one-stop access to the range of core services and to information and referral.

The governance boards of consumers and experienced providers created by this legislation would provide good accountability and increase the likelihood of success. Additionally, this structure avoids having another level of government, such as boards of health, as the sole sponsor of the MSA, when they may well have other priorities and thus might not have the time and comprehensive focus that an MSA deserves. Community partnership is preferred.

Because this volunteer involvement in governance of the MSA is so tightly tied with the agency identification, a partnership model of community agencies would be more likely to preserve the current volunteer involvement so necessary to the system's future.

In addition, any human resources planning done as part of the redirection of long-term care should consider, as a labour relations issue, the role of volunteers in service delivery within a fully integrated MSA.

Our boards believe that the preservation of jobs of experienced people working for all agencies within the current system is an important issue. Recognition of seniority rights of non-unionized and unionized workers within the system and of those in non-profit community agencies, as well as government-funded agencies, is paramount in preserving the expertise to operate the new system well.

Unless jobs are protected or unless a partnership model with a federated board is chosen by the community, severance costs for non-profit community agencies could be significant. Since any surplus in non-profit agencies is returned to service in the community, few organizations have any equity to pay severance.

If severing employees becomes unavoidable, the government, having brought on the situation with this legislation, should reimburse the agencies for these costs. Offering current agency staff jobs in the MSA or promoting the federated model could avoid this unfortunate situation.

The four VON boards of directors have some concern that the term "MSA" is already in common usage and that it means little to less-informed consumers. Perhaps a more descriptive title, such as "county community service agency," could be considered.

In summary, the VON branches support the purpose and intent of Bill 173 and we propose, where community consensus exists for a partnership model for the MSA, that incentive transitional funding be allocated to allow for appropriate local implementation.

Mr Dalton McGuinty (Ottawa South): Thank you very much for your presentation. I want to touch on this aspect of volunteerism and the impact that Bill 173 is going to have on it.

The government members have assured us that they expect the volunteers who have developed a loyalty to individual organizations, each with their own characteristics, culture, uniforms, logos, mottos, special missions, will somehow be transferred to an MSA.

I think our life experience dictates that people in Ontario in 1994 perceive the government, or an extension of the government, as being at best neutral, at worst something negative. I think we're going to have a difficult problem attracting volunteers to work for your local MSA. That's my interpretation based on my life experience, and I think many people would agree with that.

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To pursue this a bit further, and I want you to comment on this, I got hold of the people who run the Canadian Centre for Philanthropy. They, as you might infer from the name, promote philanthropy throughout the country generally speaking, and volunteerism in particular. They told me that of all the registered charities, those two which attract the least numbers of volunteers are hospitals and universities. Interestingly enough, those registered charities which receive the greatest proportion of their funding from the government are hospitals and universities. So they are perceived to be extensions of the government, and "I'm not going to help the government because, surely to God, there are other people there with greater need than my government."

Would you care to comment on that?

Ms Smiley: Well, I'll start out commenting and then others may wish to give their own perspective on it.

One of the greatest concerns of VON Ontario and all the branches it represents, I believe, from the first draft paper that we saw on the MSA, was the effect on and potential decimation of the volunteer sector in Ontario as a result of this bill.

Certainly speaking from my own perspective as to why I volunteer, I volunteer for the VON because I believe in what it does and I believe in it as an organization. It certainly makes full use of its volunteers, both in terms of board members and in terms of those volunteers who provide direct service, such as the Meals on Wheels drivers, and I don't think that sense of belonging and that sense of contribution to a community not-for-profit charitable agency will be there for many volunteers for an MSA. That would be perceived to be a branch of the government by many people in the community. That's my perception. I don't know if others would care to comment.

The Chair: Please go ahead.

Ms Mary Lou Workman: I'm speaking from the loyalist section of the province, and I guess I don't have to describe what that geographic area is, but I have had many people personally speak to me about their role as a volunteer and their disinterest in continuing the role and the service they're providing now as we move into the development of an MSA, because they perceive it as an extension of a government. Not only do we lose their time in that aspect, but we will also lose their funding. It's been made very clear to me in our area that that's their attitude.

Ms Kathy Robertson: I share that as well. In my area we have a very strong home support program, and it has been expressed by the volunteers who provide all the service in this home support program that they will not work for a government agency. We are encouraging them that we hope to maintain a lot of local autonomy, that we can keep this strong base in our small communities. I think you find in your rural communities that where you get a lot of support to your local people is through the volunteers. We do not want to lose this, and we're working very hard -- we've had meetings together -- to keep up our feeling of, you know, "Let's continue on; we do not want to lose this."

They do provide an awful lot, but there are areas like Meals on Wheels and providing service to people receiving medical service in other areas where they have to have transportation. That funding is still going to have to be available from the government. Volunteers cannot provide that alone and we hope that funding will remain and perhaps be enhanced.

Mr Sean G. Conway (Renfrew North): Your geographic area is where?

Ms Robertson: It's Brockville, Leeds, Grenville and Lanark as well. We've been meeting together.

Mr McGuinty: Just one final comment: It just seems to me that at any given time the government ought to be doing whatever it can to promote, nurture and encourage volunteerism, but particularly when we've hit the fiscal wall. We have no more money. It's all the more important that we do whatever we can to promote volunteerism, and my concern is that this bill is going to do the exact opposite.

Mr Jim Wilson: Thank you for your presentation. I may just say that in my area of the province Meals on Wheels is 100% volunteer, both in its delivery and administration. There is, of course, some government support in terms of financial dollars, but why this government would want to destroy that -- and the people who are currently volunteering in that program are quite distraught over this legislation. They can't understand why they would want to be brought under an MSA at all.

I do want to talk for a moment, though, about the federated model that you put forward; at least, that's what it's been called by many groups. I think that makes sense, and I think -- and this is the question -- was that not the original intent, an idea that really we were all talking about, I thought, for the last decade with respect to the reform of long-term care, that we would see a governance model that was, as you suggest, made up of representatives of existing agencies? I still for the life of me can't figure out where the government got the idea that the MSA should be a new agency plus it should have a monopoly on the delivery of services.

I attended many of the public consultation meetings that preceded the drafting of both Bill 101 and Bill 173, and I didn't hear an outcry from the public that they wanted a new agency, that they wanted to destroy the VON and the Red Cross and the Saint Elizabeth Visiting Nurses and many, many other agencies and that there should in the new model also be an 80-20 split that says you should also deliver the services. I just didn't hear that. I want to know -- because the government says that we did hear that in its 75,000-person consultation; that this was the overwhelming consensus -- is that true in eastern Ontario, were people crying out for the model, or did they think we were just going to get one phone number, a fairly simplified system with a somewhat federated governance model?

Ms Smiley: I guess I'll start. I can't speak for all of eastern Ontario on what they wanted; I can, however, speak for what VON wants in eastern Ontario. I think that when we, as the four branches represented here today, got together in July to try and look through the bill and plan out our presentation, it was a uniform feeling around the table that the federated model was definitely the preferred model for our general area. Certainly, for Kingston, Frontenac, Lennox and Addington, we've had the pleasure of speaking with all of our local MPPs to express this concern to them from our very local perspective as well.

We feel quite strongly for the preservation, as I've said, of volunteers and for the preservation of the service as it is provided, that you can do that by keeping the agencies, by having a federated model and yet looking to the main common goals of the bill, the reduction of duplication of service and all that kind of good stuff that the bill represents, and do that through a federated model without wiping the whole slate clean and starting over with something completely different.

Mr Jim Wilson: Perhaps what I'm trying to get to, though, is the basis for this model, and let's be clear: We're told time and time again that it came from the people of Ontario during the long-term care consultations. I'm just wondering if in this part of Ontario -- because I'm assuming that you were part of those consultations, that you held forums in community halls two years ago. We're told even that the notes from those meetings indicate that this is the type of model the people of Ontario wanted. Yet in public hearings colleagues who have been around the Legislature longer than I can't remember a time when well over 95% of the presenters to this committee haven't told us this is not the model that they thought we were discussing when we were having consultations on long-term care.

So for the public record, and if we are to ask for changes with this legislation, we need to know, were the people of Ontario here crying out for this model or did they really have something else in mind?

Ms Workman: If I might just respond to that, VON has always promoted the type of model that we again bring forward in this presentation, as we did at the hearings. Many, many times at the hearings, both at our Ontario level and as it moved across the country, we raised the issue of the concerns that we again bring forward here and the concerns that you say. My personal reaction is that the bill has responded to a specific consumer group that was very successful in lobbying the government in the formation of the bill and does not reflect very well at all the provider aspect that we fed in as these other former hearings took place.

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Ms Jenny Carter (Peterborough): I must say it is frustrating just to get so few cracks at this, and I do thank you for allowing time for rather more questions. I certainly welcome your general support for the bill and the concern that we share for helping the consumer and the good work that you do.

We just touched on a whole raft of things. It was mentioned that we did have a very extensive consultation before this bill was drawn up. I believe the first suggestion that was put out by the government was much more bureaucratic than what we are in fact getting here. A major change that was made as a result of the consultations was to have multiservice organizations and very independent local functioning in this field.

We did something that governments haven't really done much before: We went right down to the grass roots; we consulted consumers, very large numbers of them, as well as stakeholders. It is a fact that the representations that we're getting to the committee are largely stakeholders. That is not to say anything against stakeholders, but I think we should remember that what we're all trying to do ultimately is to serve the consumer, and the consumers were consulted and listened to.

Also, I'd just like to point out that large amounts of extra money are flowing into the community level of long-term care. I believe it's going from $550 million in 1991 to over $1 billion in fiscal 1994-95. So we're not cutting back; we are expanding community services here, because we feel that's where people want the services to be and we want to keep them at home as long as possible.

You, like many other groups, have a particular concern with volunteers. I'd just like to put it to you that we are definitely hoping and expecting that volunteerism and fund-raising and so on will continue through into the new system. In fact, there's actually a series of forums cosponsored by the ministry, the Association of District Health Councils of Ontario and the United Way of Ontario that are examining volunteer recruitment, retention and fund-raising in the new system. Also of course the local planning is being done by volunteer boards, and we're not doing this overnight. There is a long transitional period so that the existing agencies and the volunteers can, as it were, come together in the new system.

Of course the VON itself is a very large organization, yet you do attract volunteers, as do hospitals, which are large organizations. I know both St Joseph's and Civic in Peterborough, which I represent, do have large and devoted bodies of volunteers. So I don't see that we are necessarily jeopardizing that, and we are working very positively to make sure that the volunteerism is not lost. I just wondered if you'd like to comment further on that.

Ms Smiley: I guess I'd like to pick up, to start out with, on one of the last things you said, that VON Ontario is a very large organization, and that's true. We are a very large organization in Ontario, composed, however, of very many small organizations. VON Ontario itself has some offices in downtown Toronto and a few staff; not very many staff. The staff and the people who are VON are at the local level, and we operate as four local boards. We have our own boards of directors, and we operate very much at the local level. We have different programs.

Our concern is really at the grass-roots level. So I don't want the committee to have the impression that we have some monolithic person in Toronto who dictates what we do for the rest of it. Our basis and the backbone of VON and the strength of VON is in the community and in people we serve in the community. I just want to make that point very clear.

I think that the volunteers who volunteer for VON volunteer for VON, eastern Lake Ontario, to serve the people of Kingston, Frontenac, Lennox and Addington, or they volunteer in Lanark to serve the people in Lanark, or Leeds and Grenville or Prince Edward, Hastings and Northumberland. I don't know that they necessarily identify with the provincial whole, but they identify with the local and with the VON and what it represents in their community and the services it provides. I think our concern is that that's where the volunteers come to us from and that's why we as volunteers work for the organization.

Ms Carter: I think that's what we're saying, that volunteers are serving their own communities, and they can continue to do that just as much under this new system as they have done before.

Ms Workman: The message we are attempting to get across is that the volunteer identifies with the agency that he or she chooses to respond to. We do not see that this will continue in this act. This act describes an agency that is developed at length, is an arm of the government. I can only say it over and over again that volunteers will not respond to that type of agency.

Ms Carter: But you see, it's not really an arm of the government; it's a local organization.

Ms Workman: We're talking past each other.

Ms Carter: We feel that we did respond to what the public wanted by making it less an arm of the government and much more a locally generated and governed organization. I think that's the point that we're having difficulty maybe in getting across.

Ms Workman: But the point is that the people in the communities are continuing to identify with the agencies that have been in their communities for years and years and are really upset and concerned that these agencies will be redesigned, broken up, and they don't know whom they are to relate to. They want to continue to relate to the agency that they're comfortable with. Is that clearer?

Ms Carter: Well, I hope they would want to continue to relate to the people they're serving, which will be a certain group, whether it's people who need Meals on Wheels or people with arthritis or whatever. Those people will still be there.

Ms Workman: That's true, but it is the mission statement and the goals of that particular agency that also bring the volunteers forward.

The Chair: If I might at this point, I think the position is quite clear. At this stage, perhaps we all need a little long-term care in the form of lunch. May I thank you all for coming before the committee this morning.

The committee recessed from 1157 to 1345.

KINGSTON, FRONTENAC AND LENNOX AND ADDINGTON DISTRICT HEALTH COUNCIL

The Acting Chair (Mr Dalton McGuinty): Our first presenters this afternoon are presenting on behalf of the Kingston, Frontenac and Lennox and Addington District Health Council. I'd ask you to introduce yourselves, please, before beginning.

Mrs Shirley Sedore: I'm Shirley Sedore. I'm a consumer member of our district health council and the chairman of the long-term care committee. With me I have Judith Mackenzie who's the senior planner on staff, and Cheryl O'Connor who is the long-term care planner for our committee.

Our comments will be in three parts. First we will provide some background information about the Kingston, Frontenac and Lennox and Addington District Health Council. Second, we will make some comments about Bill 173 as it relates to planning issues for long-term care reform and, lastly, we will provide comments as the bill relates to changes in the Ministry of Health Act.

The Kingston, Frontenac and Lennox and Addington District Health Council was established in September 1981 with 16 members. We have had and continue to have some unique challenges in meeting our mandate to provide advice to the Minister of Health on health issues for our district. We also see these challenges as opportunities. The geographic area is long and narrow with the majority of the population residing close to the 401 corridor. The district population structure is relatively similar to that of the province, but within the district there are wide variations. The population in the southern part of the district tends to be younger, has a higher income level, has attained a higher level of formal education, has less unemployment, lives in urban communities and has a wide variety of services.

Residents in the north live in widely dispersed hamlets and rural areas where there are fewer services from both the comprehensive and the quantitative aspects and transportation is a major issue. Being from Flinton, I can safely say that there is a cultural difference, with northern people having a strong sense of independence as well as interdependence. Every issue which council works on requires us to consider both the rural and the urban perspectives.

Some district initiatives which council spearheaded and believes have had a significant impact for district residents include the community health centre in north Kingston, the long-term care facility in Northbrook, the community mental health program in Lennox and Addington counties, the redesign of the eating disorder program at Kingston General Hospital and the design of the base hospital program at Hotel Dieu Hospital which included the services in adjacent districts. More recently we have been working on designing a community mental health service for Frontenac county and working with Hotel Dieu Hospital on the consolidation of acute hospital psychiatric services at that institution.

Many years ago council decided that if district resources were to be used by people outside our district, they should be involved in the planning for these resources. This requires council to work closely with adjacent districts and communities both from a provider and consumer perspective. The cost to council for this regional planning is greater intensity in the use of planning resources and greater complexity in decision-making and problem resolution.

Areas in which we have led regional planning include transfer and transportation issues among tertiary hospitals, community hospitals and long-term care institutions; diabetes education for prevention of complications; and activities to enhance the information exchange and problem resolution between the 11 hospitals in southeastern Ontario. Two ventures we are especially pleased with are the design of the regional geriatric assessment program which allocated resources to the two adjacent districts and the development of the renal dialysis strategy which made the development of a unit in Belleville a priority over the expansion of beds at Kingston General Hospital. People in Brockville who remain in their own community for geriatric assessment, and people in Belleville who go down the street for renal dialysis will echo how successful these ventures have been.

In relation to Bill 173 and long-term care reform, we would like to commend the government for this major step towards achieving consistency throughout the long-term care system and for making consumers, their care givers and the informal supports such important and visible entities.

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Part X of the bill refers to "revocation and takeover powers." We support this section but have concerns that district health councils, which are responsible for the initial and ongoing planning for this reform, may be left out of this issue. We are not suggesting this needs to be addressed in the bill but we do ask that in the development of regulations and/or policy that the requirements for involvement of the district health council in the redevelopment and planning for the service be specified. This kind of situation is a local community problem, and ultimately any resolution must come from the community.

Sections 25 and 26 refer to charges for certain services. In Ontario, we have had copayment in chronic care and long-term care facilities, and it has now been extended to psychiatric hospitals. These copayments are for housing and food costs which do not apply when care is provided in the home, but there are many costs associated with providing care in the home which do not occur when care is provided in a facility. These include transportation, higher percentage of indirect care costs and higher costs for delivery of supplies, equipment and tests.

Having no charges for mandatory services is a laudable objective; but we question, given the economic environment and changing demographics, how sustainable this direction is. Now that the home care program has a definitive envelope, being able to meet the increased demand for services will have to come from internal efficiencies and the establishment of priorities or user fees for some services. Consumers in this district support the concept of a user fee for non-health services for those who have an ability to pay. We believe this is an issue which needs to be reconsidered and options explored.

We would like to commend the government for not using the word "consumer" in relation to the board composition on the multiservice agency, section 11. We believe clause 11(2)(a) clearly states that the board must reflect those who will be using the services.

In relation to section 62, changes to the Ministry of Health Act, we have a number of comments. First, we would like to commend the government for taking the significant step of specifying district health councils in legislation. We believe that over the past 20 years councils have demonstrated their ability to accept the responsibility for credible district planning and progressing towards regional planning. We believe being specified in legislation can significantly strengthen how councils discharge their responsibilities for health planning in the communities where members live and work. It would be helpful if the act or regulations specified that councils are responsible for community-based planning.

Subsection 62(1), clause 8.1(4)(c) makes reference to planning "for the development of a balanced and integrated" system. We would like to suggest that councils need to make plans for the development and implementation. This suggestion is based on the increasing body of evidence that effective change is achieved when plans are immediately followed by effective implementation.

We strongly support the enabling section in relation to aboriginal communities. We are pleased to see acknowledgement in subsection 62(1), subsection 8.1(6) that councils work best when they have the required information.

Clause 62(2)(d.1) refers to the establishment of regulations in relation to recruitment and selection of candidates for council and committees. We support the wishes of the government to specify in regulations, requirements governing the recruitment and selection of candidates for appointment to council.

Councils have two mechanisms for fulfilling their mandate: a committee structure and a small secretariat. If councils are to be responsible and flexible to planning needs as they arise, councils need to be able to adjust these mechanisms quickly in order to achieve their mandate. It is impossible for councils to sustain the same level of intensity of planning on all issues, thus councils succeed by modifying their committee structure and reallocating staff resources to address the priority areas. Most issues are planned and then go through a period of implementation before additional planning is required. Councils take this opportunity to work on other issues.

If a committee were to be designated in regulations, council would be required to establish and maintain activity in this area even though it was not a priority for that given year. We believe the government can achieve the same outcome by using policy to influence the recruitment and selection of committee members. This allows greater flexibility, which is greatly needed by councils. Long-term care and mental health may be the major issues today, but next year it could be diabetes, cancer, children's services or violence issues. We urge you to use government policy, not regulations, to influence council's committee structure and delete clause 62(2)(d.1).

In relation to the development of regulations, we look forward to district health councils, individually and collectively, working with the government in the development of any regulations which affect district health councils. We view this legislation as a sound framework upon which to continue to build a solid and successful partnership for health planning.

In closing, we hope our comments have been helpful and we thank you for listening. If you have any questions, we'll be glad to respond.

Mr Jim Wilson: Thank you for your presentation. I think you've raised a couple of points that had not been brought to our attention previously, and one of them is with respect to clause 62(2)(d.1). I think you make a very good point, because one of the concerns I and my colleagues express from time to time about district health councils is one that's echoed in many communities, and that is where government's consistently asking them to do a lot and resources are strained. I know that in the ones I've visited throughout the province.

For example, you mentioned dialysis services in this area and how successful you were. We were aware of that, actually, as a committee because when we studied dialysis services a few months ago certainly Belleville and your area were brought to our attention as examples of how one might proceed to address deficiencies throughout the province. But when we went to the government, it said: "Well, this has to go to the district health councils." A lot money is being spent right now for DHCs.

The membership -- to be quite frank, and not politically correct about it -- of a number of the DHCs simply don't have the expertise to deal with the issues so my executive director in Simcoe county said, "You know, Jim, I'm going to spend eight months bringing them all up to speed to try and deal with the crisis in the province." As a result, we were supposed to have a report back from the central Ontario DHCs on the dialysis crisis in the province several months ago, and it's nowhere in sight. It's not their fault. They haven't got the resources and the expertise.

I want you to comment on that, because you say maybe recruitment should be based more on the task at hand. At least that's my interpretation of what you're saying. To me, that might be a good, commonsense way to structure some of the committees of the district health councils.

Secondly, because I gather you're supporting this legislation -- first of all, how many MSAs will be needed in the area you serve? Have you any idea what the cost is going to be, whether there is additional cost to the system and where that money might come from?

Mrs Sedore: We've more or less looked at the service sites, not the specific number of MSAs in our district. I think I'll defer to Judith, as far as that goes. But our point was not necessarily structuring the committees towards the work, although we do that. If you legislate that we must have a certain committee, then it's there for all time, and we may not need it for all time, which is why we would sooner have the committees established in policy rather than in regulation.

Ms Judith Mackenzie: The other point we're making is to distinguish between the requirement for appointing members of the council, which we see as quite a different process, as opposed to appointing -- I don't know how many committees and task forces we would appoint in the course of the year, but they need to be able to be put together quickly to respond to tasks and then to be disbanded when their particular job is finished.

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Mr Jim Wilson: So you interpret, after the "and" in (d.1), that the government will pass regulations specifying particular committees. Is that the way you interpret that? Because the first part deals with candidates to the council --

Ms Mackenzie: Right.

Mr Jim Wilson: -- and then the second part.

Ms Mackenzie: And also being very specific about the composition of the committees. We've been pretty rigorous in trying to involve consumers in our committees and I think we've done very well in that regard. There may be some other areas that will come up in a generalized piece of legislation that wouldn't be that appropriate to our particular district, because the province is not homogeneous. Every district is different from every other one and I think it would be very difficult to come up with a good piece of legislation that could be applied equally and made sense.

Mr Jim Wilson: Are you close to establishing costs at all for MSAs in this area?

Ms Mackenzie: I'll defer to Cheryl now. I'll give you the tough one, Cheryl.

Mrs Cheryl O'Connor: We're in the process of designing MSA models and consulting with the community. Part of what we will try to share with the community are some estimated costs, although this stage is an estimated cost; and it is not our understanding that there will be more money in our community funding envelope, so we recognize that whatever model we create, if it would cost more it will have to come from priorities or internal realignments in the system. Those are the dilemmas the community faces.

Mr Jim Wilson: I appreciate it.

Mr Wessenger: I was just wondering if I can clarify about the intention with respect to committees. The intention wasn't really to use the regulatory power to specify what committees a DHC would have. The purpose and intent of the regulatory power are to ensure that district health councils, for instance, when they do establish committees, like you do in your area, have consumer representation. So that's the purpose of the regulatory power, not to specify the committees that should be established.

Mrs Sedore: That would still be done in policy, would it not, or could be?

Mr Wessenger: Yes, it could be done in policy, but I think there have been probably some DHCs where there have been some difficulties with respect to their having the consumer representation on some of their subcommittees.

Mr Jim Wilson: Mr Chairman, if I may just put a point in here. One of the problems, and the group makes a very good point in terms of being too rigid here -- take dialysis, Mr Wessenger, in our area. When someone's dying of renal failure, they don't really feel like sitting on a committee of the district health council. In structuring what we've gone through in our area locally, it required consumers. Well, we didn't quite get the consumers. We ended up getting friends of the consumers. So you want to be careful that you're not too prescriptive, I think. The consumers were a little ill.

Mr Wessenger: I think we would agree you need a broad definition, a reasonable definition of "consumer."

Mr Jim Wilson: It's broad when we're dealing with it here, but I'll tell you, when the directive goes down to the front line, it somehow doesn't have your interpretation on it.

ONTARIO COMMUNITY SUPPORT ASSOCIATION, AREAS 8 AND 9

The Acting Chair: Our next presenters are presenting on behalf of the Ontario Community Support Association, areas 8 and 9.

Mrs Elizabeth Fulford: Good afternoon, Mr Chairman, ladies and gentlemen. Thank you for coming to Kingston to hear the community response to Bill 173.

My name is Elizabeth Fulford, board member from area 8, and presenting with me today is Pat Dandelé, the chairperson of area 9. The areas we represent include Durham region, Northumberland, Peterborough, Victoria and Haliburton counties, and Prince Edward-Hastings, Frontenac, Lennox-Addington, Lanark and Leeds-Grenville counties. As you will see on the maps enclosed in the presentation package, we stretch from the border of Metropolitan Toronto to east of Cardinal and north to Algonquin Park.

Throughout the past month of hearings, I understand that you've become very familiar with the Ontario Community Support Association's mission, goals and objectives and the services provided by our member agencies' volunteers and staff. A copy of the services provided in our areas is included in the appendix. You have also been presented with the areas of the legislation that OCSA endorses and our key areas of concern.

Consequently, today we would like to look at Bill 173 from a local perspective, and the effect it will have on the clients we serve. The role of volunteers, fund-raising capacity and changes to the Public Vehicles Act are the areas we will be highlighting. A copy of our presentation has been provided for your review. We intend to make our comments reasonably brief to allow time for discussion or any questions you may have.

The community-based organizations which we represent support the intent of Bill 173 to simply improve client access to a continuum of community services and promote equitable access to those services. We've been waiting for more than 12 years to see a concrete attempt made to address the long-term care needs of our clients who live in the community.

The areas we represent present a rich diversity of urban and rural communities. Some are starting to meet the changing cultural needs of their areas while others are struggling to gain acceptance of the need for local community support services.

Some urban communities are stretching their resources to provide a range of services to meet the needs of frail seniors and adults with disabilities representing only 6% of the population, while others in rural areas are meeting the needs of the same group that represents 26% of the population.

Few urban centres have public transportation to serve all of their designated geographic areas. The majority of our rural areas do not have paratransit services such as Handi-Transit or indeed any public transportation at all. The residents rely greatly on escorted transportation provided by volunteers in private cars.

In area 8, a high percentage of home support and homemaking agencies has been developed on a regional or county-wide basis. The majority of home support services are provided by community-governed multiservice agencies which support clients through local grass-roots community involvement. We are concerned that assumptions are being made that there will be administrative cost savings as a result of the proposed amalgamations. In area 8, this will be impossible if service coordination volunteers must become paid staff.

Mrs Pat Dandelé: We are very pleased today to see a number of our area 8 and area 9 members in the audience, some of whom have already presented to the committee today and others who will be presenting later.

In area 9, there are 32 member agencies with approximately 6,000 volunteers spread throughout a primarily rural area. Many services have developed at the grass-roots level, with agencies such as my own responding to each community's individual and unique needs. Dedicated pools of volunteers from each community reinforce the commitment as a multitude of services are accessed through the local neighbourhood agency.

In both areas, the effectiveness of the work of our member agencies is due to the continuous collaboration and cooperation with other agencies, community groups and facilities.

It has long been accepted by community support agencies and funding bodies that local community volunteers have a key role to play in the provision of direct client service and service coordination. One agency, for example, in area 8 has over 1,200 volunteers who last year provided 77,723 hours of direct client service and 23,407 hours of office assistance and committee work. Their contribution can never be transferred into staff hours.

The social support system which an individual has available to him or her has been well documented as a key determinant of health status. Community support agencies have mobilized volunteers and groups in our communities to show in a tangible way our care and concern for our neighbours in need and are dedicated to providing the necessary staff leadership to provide quality services.

We believe that a recognition of the role of volunteers must be entrenched in the legislation to assure clients and volunteers alike that we will indeed be providing the least intrusive, most cost-effective client-centred support services possible.

Volunteer management requires appropriate funding to provide for agency practices which ensure the successful recruitment, screening, training, scheduling, supervision, retention and recognition of community volunteers. Agencies which follow these practices continue to attract an increasing number of volunteers who participate in a meaningful way in their community.

We are concerned that the act stipulates in paragraph 56(1)30 a regulation "requiring that service providers have certain qualifications or meet certain requirements and prescribing the qualifications or requirements" without stipulating a companion regulation for volunteer management requirements.

Our agencies have skilled staff who must meet the case management, service coordination and service delivery needs of our clients. They also provide effective management of our volunteers. No other sector in the proposed reform requires such a broad range of responsibilities and skills from an individual staff person. Our clients and volunteers must be confident that Bill 173 will strengthen the staff support required to maintain and improve services.

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Mrs Fulford: There is concern that the bill may fail to reflect the unique funding that community support service agencies receive compared, for example, to the funding for home care programs and the agencies with which they contract service.

When home care contracts for professional and homemaking services, the hourly rate includes administration and supervision costs. Therefore, when new dollars were allocated through quick-response proposals and the integrated homemaker program, the contracted agencies were able to provide service in a timely manner.

Over the past two years, those of OCSA's members who are providing other approved community support services but are not contracted by home care have not had an increase in their funding except as the net result of proxy pay equity offset by the social contract. Despite this hardship, many of our member agencies continue to increase service to their clients to avoid the waiting lists that would otherwise develop.

Volunteers and staff in those agencies play a key role in meeting the agency's approved budget. Agencies with a strong history of successful fund-raising have the ability to consider expansion of their programs to meet local pressures for needed services if they have already met their budget requirements. For example, the board of directors may decide to pick up any deficit created by adding another Meals on Wheels route, foot care clinic or strengthening the visiting program. That flexibility seems to have been lost in the act, and it is essential to maintain a true community response to local needs.

We support the changes to the Public Vehicles Act which would allow our agencies to operate for the purposes of transporting persons deemed eligible by an approved agency. Many agencies will be grateful for the opportunity to provide van service to their day programs and other group activities.

However, we would be very concerned if regulations were developed which would in any way indicate a preference for transportation services to be provided by paid staff in agency vans or cars. In any given community, you can be sure that if there are three people requiring a ride to the doctor, the appointments are all at the same time, on the same day, to three different doctors in three different towns.

Given the absence of public transportation in many areas and the eligibility criteria for many of our agencies, clients who require escorted transportation would be at a distinct disadvantage if such a regulation was imposed.

Mrs Dandelé: Our clients in the community deserve to have legislation which will protect their interests as we strive to improve services to meet their needs. We believe our suggestions will strengthen the ability of communities to respond to our clients' needs.

OCSA members have been active participants in promoting long-term care reform. We applaud the leadership demonstrated by the provincial government in the development of Bill 173. We look forward to continued participation with the government and our communities to implement meaningful change for the people we serve. Thank you.

Mr Gary Malkowski (York East): Thank you for your presentation. You were talking about volunteer management. You're right, there's nothing in the bill that recognizes management of the volunteers. I'm just wondering, perhaps you have a recommendation in terms of volunteer management or coordinator that should be put into the legislation that may talk about the role of the coordinator as someone who would recruit and do those others things, or do you have another suggestion or a comment that you'd like to make?

Mrs Fulford: I think I would suggest that the distinct characteristics of volunteer management be highlighted in the legislation rather than a position. In any community, especially in the community support sector, you have different people with different roles within those community organizations, all of whom may carry an element of the volunteer administration role, whether they themselves are volunteers or if they're paid staff. So I think we have to be very careful about saying "a volunteer coordinator," but looking at those areas of responsibility that fall under volunteer management.

Mr Malkowski: Perhaps I could ask the parliamentary assistant to maybe take this back to the minister to consider an amendment to what they were just describing.

Mr Wessenger: Yes, we'll certainly take that under consideration.

RIDEAU VALLEY DISTRICT HEALTH COUNCIL

The Acting Chair: The next presentation is being made on behalf of the Rideau Valley District Health Council. Welcome to the committee.

Mr Peter McKenna: It is my pleasure and privilege to be present today to submit comments in response to Bill 173, An Act respecting Long-Term Care. I'm Peter McKenna, the past president of Rideau Valley District Health Council, and I would like to introduce my colleagues. Lorette Sutton is the chair of our long-term care committee, Peter Tudor-Roberts is the executive director of Rideau Valley District Health Council and Jo Harris is our long-term care planner.

I wanted more specifically to talk about section 62 of the act. Our council has already submitted a written brief regarding Bill 173. I have met with the past chairs of this council and current council members and I've also had the opportunity to discuss this response with the chairs of the six eastern Ontario DHCs. I want to briefly tell you a little bit about our community and the role of our district health council, but I wanted to start by saying that we're delighted to see this legislation, in particular section 62.

The Rideau Valley District Health Council was established in 1979, which means that we've had a presence in our community for the past 15 years. The DHC is very proud of its history of support and collaborative planning with the community. Lanark, Leeds and Grenville are rural communities situated halfway between here and Ottawa, for those of you who aren't familiar with the counties.

We play a key role in bringing our community members together to work on issues that have real meaning to our communities. Because of this role, a mutual respect has been developed with our community over the last 15 years. You will find that we have seen many programs develop and we're now seeing much collaboration as we plan for system reform. We were fortunate to have the first rural community health centre in the province and we were part of the pilots for both placement coordination services and the integrated homemakers programs.

As we engage planning for health systems reform, we as a DHC have never hesitated to tackle difficult issues. We have seven hospitals in our community and we are working with every one of them to rationalize and reorganize the hospital system. We have recently been highly successful in two particular hospital rationalization projects. For example, council has led the planning within the local community, which has led to the recent announcement of the plans to merge the Smiths Falls and Perth hospitals and the review and rationalization of roles of the two Brockville hospitals.

As a rural district health council, we have long since recognized the need to work collaboratively with other district health councils in the area. We participate in the eastern area chairs' and executive directors' meetings. We were instrumental in the development of an area long-term care committee comprised of chairs and staff from long-term care committees of the six eastern DHCs. Rideau Valley District Health Council also works closely with the other eastern DHCs for all the major health reforms, including mental health, cancer, diabetes, substance abuse, health promotion etc.

As I said earlier, we are delighted to see section 62 of Bill 173, which will amend the Ministry of Health Act. It will strengthen our mandate and ability to work with the community. We would, however, wish to make a few suggestions to clarify the role of district health councils in their communities.

We see the community as an integral part of the district health council's role and functions and would like to see that added to section 62, subsection 8.1(4) on page 48. It could read, "The functions of a district health council are...to work with the community."

We also feel the functions should be reorganized to reflect the planning role of DHCs. I think that our legitimacy and our real strength come from our community and not necessarily exclusively from a mandate from the minister. Our strength lies in the people we serve. As part of the current role we are very much involved in assisting with the implementation of plans for reform, certainly in the evaluation of implementation plans, and we would like to see these included in the functions under subsection 8.1(4).

We also wish to raise some concern regarding clause 62(2)(d.1). We would like to see this read, "governing the recruitment and selection of candidates to be nominated for appointment to a district health council." Very similar to our colleagues in Kingston, we are concerned about the prescriptive nature that is implied when you get down to the committee structure the act is proposing, and we suggest that perhaps that section could end right at the end of "nominated for appointment to a district health council." By requesting this, we are asking that you remove the second part of the clause. This is very important to us as a community.

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As we mentioned earlier, we have a strong history of working with community groups. This is done within provincial guidelines and in a manner in which it makes sense to our community. We need to ensure that the process remains responsive to the community and that we are not encumbered by a lengthy process. District health councils work with many community groups. Some of these are committees of councils and some are separate from council altogether but maintain linkages through staff and reporting structures, and some of the issues that we establish committees for are clearly local issues and often reflect collaborative efforts. DHCs need to maintain the flexibility in their committee structures in order to remain and be perceived to be responsive to local issues. The current process of receiving direction regarding committee structures from the ministry is respected by this DHC and has worked well. We request that you act on this recommendation.

We'd like to suggest that the wording of this particular section of the act be reviewed by a joint ministry and association of district health council working group. Further, we would suggest that any of the regulations for the act which affect district health councils be developed by a joint ministry and district health council working group.

In summary, we wish to restate our pleasure in seeing the recommended amendment to the Ministry of Health Act through section 62. We feel strongly the need to adequately reflect the role of district health councils in working with their communities. It is imperative that district health councils are able to maintain a committee structure that is both responsive to the community and respectful of ministry guidelines.

Thank you very much for the opportunity to present to you today.

Mrs Sullivan: I'm interested in the concentration of the last two district health council presentations on a different approach to the mandate of being a representative body bringing opinion from the community and recommendations from the community with an accountability to the community, as distinct from being a body which this legislative approach would require that is an advisory body to the minister carrying out the mandate and directions of the minister.

I for one am disappointed that we don't have a separate bill on district health councils, because I think we have not through these hearings been able to give the attention to their mandates and resources and all the other issues that have to be faced with DHCs. I wonder if you'd expand more on that conflicting role that DHCs are facing every day.

Mr McKenna: It's a double-edged sword. When I've gone to the ministry with plans representing our district, the strength I bring forward is because of the community I represent and because I feel confident in the process that we've established. We've had wide consultation. The power comes from that process, because I feel that I've got the players, that we've discussed it right across our community. The strength lies in the people that we bring the message forward for. When we do that, we build credibility within our community, which allows us, when the ministry is proposing a change in the health system, to come and sit down and we've got the respect of our community when we bring messages or information or changes to the system back to our community. It is in the middle, and I don't know -- that's just the nature of the beast. I can't imagine it being any other way, perhaps.

And I'm not disappointed that we don't have a separate piece of legislation for DHCs. I'm not sure when that would ever take place. That's why we're very supportive that this is here now.

Mrs Sullivan: I think the DHC conference and review process has just finished, within the past two or three months, and what I see as having happened is that that discussion has been limited to the DHCs. There has not been major public participation in that entire discussion. It's people who are involved in district health councils who have participated in that. I don't think the average citizen knows what a DHC is. So when you're talking to me about trying to have the credibility within the community and therefore be an advocate for the community, that is a very different role and a very different function than what this law is going to require of district health councils.

Mr McKenna: I guess that's why we would like to see an added responsibility in there to the community that we serve, which is the ultimate master, I think, here. I don't know if you want to add any more.

Mr Peter Tudor-Roberts: If I could answer very briefly, we would support any legislation, however you want to tack it on to anything, as regards DHCs, because after they've been around 20 years, I think they've proven their point. I in particular, as executive director, am very proud of this DHC, because the people who work in this district seem to get on very well together and they seem to work collaboratively together, and that's a key part of our success.

I would agree that most people in the population, if they were asked what a district health council was, probably wouldn't answer, "Yes, I know what a district health council is." But on the other hand, we are not shy. If you go into hospital rationalization issues, you have to keep your head up and you have to be there to work with the members of the community. We have met in public consultations in our district with roughly about 350 people, and those items do make you well known. I think across this province, wherever hospital rationalizations are going on, it usually is a very well-known issue and the public get involved and the district health council is exposed.

I think the point, though, that we would say as regards any of the major issues, such as hospital rationalizations, is that the DHC has taken the initiative and taken the lead and that it's done with a collaborative cooperation of the hospitals, the hospital boards, the community health agencies. When we come to Brockville and when we come to Perth and Smiths Falls, one a merger, one a total rationalization, it's been done in a collaborative way and it's done in an all-inclusive way with the DHC firmly there in the centre facilitating the process. So we may not be known to everybody, but we are not shy about moving into difficult areas.

NORMA O'SHEA

The Acting Chair: Our next presenter is Ms Norma O'Shea. Welcome to the committee, Ms O'Shea.

Ms Norma O'Shea: I'd like to thank you for allowing me this opportunity to speak as a consumer. I am Norma O'Shea, a consumer and recent retiree from the health care field. As I note, the great joy of retirement is you can neither be fired nor short-listed for future downsizing.

From 1966 to 1992, I was involved in long-term care, and I've included my résumé there so you can get an idea of what areas I worked in.

As an avid supporter of innovative, cost-effective approaches to the delivery of health care services, I am deeply disappointed if this bill is what has evolved from endless hours of discussion, conferences and position papers during the past 10 years. A pack-rat by nature, I still have a folder labelled "Long-Term Care Reform." Reflection on its contents and the resulting Bill 173 leaves me wondering why it was necessary to have so much discussion and deliberation if the object was to dismiss and dismantle rather than enhance.

To construct and operate a totally new system to meet Ontario's diverse needs, rural, urban, ethnic etc, while remaining universally accessible and acceptable and cost-effective is virtually impossible. Supposedly, Bill 173 puts the needs and preferences of the consumer and their families first, allowing them to remain in the comfort of home and community settings. But will it? For how many, for how long, at what cost and to whom?

In many areas of this document, reference is made to "in accordance with the regulations." To which regulations does it refer? Is the document incomplete? Is a parallel document of regulations available? I am certain that the document was prepared to address any eventuality that might arise in the development and introduction of a multiservice agency, community services etc. I was and still am confused. However, I think part V outlines the approval of agencies to provide services that may be purchased by MSAs.

Part VI, page 11, indicates an approved agency may be an MSA, depending on the makeup of its board of directors. On reading the requirement for board composition, I wondered, as I have while working through this document, is the person mix in this proposed legislation of greater significance than the actual expertise in the services to be provided and delivered?

Section 13, page 12, describes the limitations placed on an MSA in the purchase of service from approved agencies to 20% of the budget for that particular component. Does that mean, if there are four agencies providing a similar service, they might each receive only 5%, or would one receive 20%? Is the economy so buoyant that this government can afford to put legitimate businesses out of business, let alone replace them with a totally tax-supported monopoly?

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Does section 15, page 13, of part VI mean an approved MSA could be in place for four years without either providing or purchasing services of any type for anyone? And what purpose would it serve from now until 1999?

Section 20, part VII, page 15: Many referrals for services tend to originate from hospital settings, such as emergency room, day hospital, inpatient. Who will assess for eligibility and when? Does the hospital have a responsibility to ensure that these services will be in place on discharge? If an assessment is made and eligibility denied, will a person remain in hospital or be discharged to home without service? The appeal process, once initiated, can take a minimum of 28 days before a hearing is held and a decision is reached and communicated to the involved parties. In a bureaucratic world this may be considered warp speed, but to the family hanging by their emotional thumbs, this may well be an eternity both figuratively and literally.

Section 21, page 15, person's plan of service to be provided to the person in as timely a fashion as possible: What is meant by a timely fashion? Would the person remain in hospital an additional two to three days? Would they be sent home to manage as best they can until their assessed plan of care is implemented? This might well result in readmission to hospital and a need for reassessment with service delivery, again, in a timely fashion.

Waiting list: "If a community service outlined in a person's plan...is not immediately available" etc, they shall be placed on a waiting list for the services. Would not availability of services be due to (1) a qualified staff shortage, (2) budget shortfall, (3) program capping or (4) at the direction of the minister?

Section VIII, page 17, section 26, purchase of service and collection of fees from the recipient: Subsection (1) refers to community services, which could be any of the four listed in subsection 2(3) of part II, ie, definitions. Does this mean that if a person is assessed for services not available through the program, if the service is purchased by the client from a private agency, the cost would be at a rate fixed by the MSA, and second, assessed for services that are available but there is a dollar limit on the amount that the MSA will provide, per admission to the program or total per individual? If either is a correct interpretation, what happens to the person who has neither the money nor the insurance to purchase the needed community service? These are examples of questions I had as I read through the document.

While it espouses local initiatives which address the characteristic needs of communities and volunteerism, Bill 173 virtually destroys agencies that are an integral part of communities. The history of these dedicated pioneering agencies in the service of the people of Ontario predate the honourable minister and her party by many, many years. Long before elected officials responded to identified community health needs, our voluntary agencies and charitable institutions had recognized and were providing much-needed hands-on health care and health teaching in communities, both rural and urban. Historically, these unofficial agencies blazed the trails that were later followed by tax-supported official agencies in community health.

Bill 173, if enacted, will put at risk those most dependent on service, the frail, the elderly and the disabled, and it will wreak havoc on our current community health programs.

The haste with which this bill is being pushed through the Legislature and on to the people of the province of Ontario has everything in common with the charge of the Light Brigade both in logic and in outcome. In a cash-strapped province, why should any government plan to spend more than $1 billion to fix what ain't broke?

Interruption.

The Acting Chair: Order. Ladies and gentlemen, I'm required to remind you that the parliamentary committees are deemed to be extensions of the House, and as such demonstrations are not permissible. There; I've done what I'm supposed to do.

Mr Conway: But we heard you.

Ms O'Shea: Sizeable as this amount is, it is small change to the evaporation of donated dollars, person-hours and goodwill which will take place with the engineered closure of volunteer agencies and charitable institutions as proposed in this bill.

The honourable minister, in her June 6, 1994, press release, referred to "the confusion, duplication and patchwork approach to the provision of services across the province." I appreciate that for anyone living in the shadow of Queen's Park, it might be difficult to visualize how efficiently and effectively other communities have recognized and addressed, cost-effectively, perceived needs and deficiencies within their boundaries.

Kingston, Frontenac, Lennox and Addington and the adjoining tricounties of Leeds, Grenville and Lanark long ago developed a single-application, prioritized waiting list system. At user agency request, they put in place placement coordination services according to ministry guidelines. In 1967, a transportation system for the disabled was initiated, followed by a residence facility for the physically disabled in the early 1970s. Kingston Homes for the Handicapped Inc board of directors, committed to a belief in independent living where possible, envisioned apartment living with contracted support services based on assessed need. Through the combined efforts of this board, the Kingston housing authority and a for-profit community service agency, the Endymion project was realized in the 1980s. The management system and support services have changed in the past few years, but the concept remains the same.

These few examples suggest the current unique patchwork of community services spread evenly across the province may be more coordinated, integrated, user-friendly and cost-effective than any bureaucratic monopoly likely to be imposed by this particular bill.

As to support for the care givers, the Minister of Health, in applauding this legislation as enabling more people to receive care in the comfort of their home, assumes that the family members are available as care givers, that they are physically and emotionally capable of assuming this role and that the home lends itself to the provision of such care.

Changes in family structure and the economic climate ensure that working family members cannot be home to provide care or relief care in the long term. Care givers currently are on call 24 hours a day, seven days a week. A plan for affordable respite that includes scheduled relief hours, vacation times and emergency relief is essential for the emotional and physical health of both the recipient and the care giver.

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In earlier discussion papers, there was great emphasis placed on the enhancement of respite programs, their availability and their accessibility. I may have missed or not recognized its inclusion, but I found no reference to respite care in this document.

With the committee's indulgence, I shall make no further reference to Bill 173 or the minister's press release, but rather address the human face of long-term care that has been my experience in the past 40 years, and particularly the last 30.

A number of initiatives have changed the provision of health care in time, place and outcome, but none more than the introduction of regional ambulance services with equipped, well-trained staff. The survival rate for both illness and accident dramatically increased, as did the demand for some forms of long-term care, in number and in level of care required.

A critical accident involving a young person usually results in the availability of intense support from family and friends during the first few years. The ensuing years see the once high hopes crystallize into no further improvement. Siblings and friends move on with their lives and what might have been described as the empty nest syndrome is replaced by aging, anxious parents agonizing over what will happen should anything happen to them. There are those who would say this is a role that loving parents readily accept, even though one or both may occupy a long-term care bed long before their time.

What of the young person? Is this the setting where his or her psychosocial needs can best be met? To date, we have provided a reassuring pat on the back but little else.

The disabling accident or progressively disabling illness for the young adult has quite a different face. Where this illness or disability occurs within the second or third decade of life, regardless of who is the disabled partner, this marriage or partnership will last no more than two to three years, while partnerships tend to remain constant where the same disabling event occurs in later life. During my years in long-term care, exceptions to this observation were rare and infrequent. The health crisis that resulted in the disability may be the same, but the demands on the health and social service system will be quite different.

Furthest on the age scale you'll find the elderly couple where the physical dependence of one is exhausting the other, both aware that it requires their combined incomes to keep their home or apartment afloat. Not infrequently, the issue is resolved with the care giver's deterioration and one or both requiring long-term care facilities.

Putting the needs and the preferences of the consumers and their families first may well not mean living in the comfort of their homes, for a variety of reasons. The system must remain insightful, sufficiently flexible to respond in as supportive and as humane a manner as possible.

The advances in both response time and treatment have increased survival rates and public expectation of what should be available to them at little or no cost. With bed closures, an even greater demand has been placed on our community health programs of all types. The proposed massive replacement of the existing system will be more costly and less flexible and will neither increase nor improve the services presently available.

Recommendation: If the government is unwavering in its commitment to Bill 173 as written, it is imperative that numerous well-publicized pilot projects should be carried out to ensure that this new approach to community health care delivery is user-friendly, efficient and cost-effective before it is implemented.

I also assume that the $1 billion set aside for Bill 173 could be better used to enhance existing programs, and the loss of volunteer dollars and time must be considered.

Mr Villeneuve: Ms O'Shea, thank you for having brought your many years of experience as both a worker and a volunteer, and I certainly commend you for your list of accomplishments here. I appreciate the fact that you have explained where you are coming from, the fact that you, in your own words, say, "If it isn't broke, don't fix it," or "If it isn't fixed, don't break it."

The situation you bring to us regarding volunteers, for example: Could you just put that into a little better perspective? If indeed 173 comes to the fore, what do you feel will occur to volunteers such as yourself, with a long list of accomplishments? Do you see them throw their hands up and say, "Really, it's in the hands of someone else"?

Ms O'Shea: Yes, I do. A volunteer is committed to a particular interest and perspective. I don't really feel that a rather nameless organization will attract that same interest. Plus, I think many of our volunteer agencies won't be there, as I read this act. Because they will only receive such a small percentage of the services to be provided, like 5%, there wouldn't be sufficient funding to keep the system going.

Mr Villeneuve: I gather you were not here this morning when we had presentations by a number of concerned groups that exist now. They're worried about their very existence, let alone being able to continue providing the services that they have over the past number of years. Now, you reside on Wolfe Island to this day yet?

Ms O'Shea: Yes.

Mr Villeneuve: And you bring a very real perspective from the rural part of Ontario, wish is vast, and I proudly represent one of those vast areas of rural Ontario. The autonomy to a degree that you speak of that you've had in the past you see pretty well being taken over by big government.

Ms O'Shea: Yes.

Mr Villeneuve: Therefore in losing the autonomy that you have had, or to a good degree, in the past, you see a deterioration in the quality of service that would be provided to those areas.

Ms O'Shea: What I see as much as that, sir, is that the identified needs that are unique to that community will go unnoticed or ignored in the overall big picture because it's the local interest that creates the volunteer and the willingness to put in the extra hours. It is growth from the bottom up. It's not from the top down, as this act is doing.

Mr Villeneuve: I think you've posed some very good questions with question marks. Of course, they're unanswered. Could I ask the parliamentary assistant if he and his staff would have a look at some of these questions that are unanswered in this presentation and possibly provide the committee with your thoughts on the replies?

Mr Wessenger: Certainly the whole planning process is designed to be with the district health councils coming up with the models to ensure a system that is responsive to the community. It has an approach, for instance, of community satellites and that sort of approach. Certainly the community itself is going to be determining what the model of delivery will be.

Mr Villeneuve: This is not what we're getting from --

Mr Wessenger: By having the planning process done by the DHC, we think that's the best way to ensure a delivery system that is responsive to the community.

The Acting Chair: Ms O'Shea, I wonder if I could ask you to make these your final comments, please, because we've run out of time; if you wanted to respond to the parliamentary assistant, that is.

Ms O'Shea: The final comment? The recommendation?

The Acting Chair: No. I mean, did you want to make a response arising from that last exchange?

Ms O'Shea: No. I feel that without regulations there, to review this act -- it's very difficult to know just how it will affect a community. I have great fear that in order to save institutional dollars, cost of care, it just can't be moved to the community.

The Acting Chair: Thank you very much.

Mr Conway: Maybe we'll use the Wolfe Island ferry.

Mr Gary Wilson: What are you worried about, Sean? That's what you wanted.

The Acting Chair: That would require an entire other venture on the part of the government.

Ms O'Shea: I was going to wear my "No fare" button, but I --

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HASTINGS AND PRINCE EDWARD HOME SUPPORT NETWORK

The Acting Chair: Our next presentation will be made on behalf of the Hastings and Prince Edward Home Support Network. Welcome to the committee.

Ms Jeanne Goodhand: Thank you for this opportunity to speak to this legislation. My name is Jeanne Goodhand. I'm the executive director of Tweed and Area Community Care, a home support agency in the centre of Hastings county. I'm also the executive director of the only community health centre in Hastings and Prince Edward counties. I'm the chair of the Hastings and Prince Edward Home Support Network, on whose behalf I make this presentation.

With me today are Wanda Stringer, who is the executive director of North Hastings Seniors Home Support; Debbie Moynes, Prince Edward County Community Care for Seniors; and Barbara Clarke, Community Care for Belleville Inc. We represent the whole of Hastings and Prince Edward, right from the top to the bottom. You talk about remote and rural, we've got it.

The Hastings and Prince Edward Home Support Network was formed in 1987 to provide an informal connection of agencies providing home support services in the two counties. Since 1987, this group has kept well informed about local and provincial issues which affect the delivery of a community-based service as well as parallel health and social service issues.

We're not VON, we're not Red Cross, we're not home care. We represent the agencies that organize those volunteers. We are the agencies that are called when a senior needs a ride to the doctor, help to bury their dog, help to fill out a form, someone with whom to talk, or a bat removed from their porch. We are the agencies that offer the supports that help the seniors stay in their own communities. We promote strongly wellness and the prevention of illness.

One key concern has been the involvement of volunteers in service delivery and fund-raising. Home support programs are provided by local, community-based, non-profit agencies. The supports we provide are flexible, personalized, responsive and least intrusive. They focus on health and wellness and are strongly centred on the client's need. They strengthen the ability of family and neighbours to support the choice to live in the community.

The programs provided include a broad range of practical support services designed to help the elderly and people with disabilities accomplish the tasks of everyday living. Our programs include information and referral, Meals on Wheels, congregate dining, friendly visiting, security checks, transportation, care giver support groups, intergenerational programs, home help, yard work, assistance with forms, advocacy, handy bus transportation, fitness groups, and others, believe it or not.

Home support agencies have strong accountability to local boards of directors and, through them, to their communities. Countless volunteer hours are involved in those service deliveries. We have over 2,000 volunteers working for the agencies that I represent today. These agencies are vibrant and viable and have deep roots in their communities.

We acknowledge that reform is necessary in the present system of long-term care. We ask you, however, to recognize, to celebrate the areas that do not require change, and one of these is volunteer involvement.

In discussing reform of long-term care as we know it now, we have identified the strengths and weaknesses we perceive existing in the current system:

(1) The home support agencies, as we now know them, depend heavily on a strong volunteer component. Many services are delivered not by paid staff but by willing, caring volunteers.

(2) Much of the funding for our services and programs comes from community fund-raising, again with a large volunteer component.

(3) The community, as we have defined it, represents specific serviced areas which are very distinctive in their needs, particularly in our rural communities. Programs are created to respond to a need identified by grass-roots support.

(4) The community, being responsible for the identification of specific needs, also therefore supports the necessity of local autonomy for accountability. Services are varied and dependent upon demographics, accessibility and geographic location.

The weaknesses of the present system:

(1) There is no protection for non-union employees presently involved in community-based services in the event that employees must be hired by a new system such as a multiservice agency.

(2) There is currently a lack of shared supportive and/or administrative services among providers. These services include payroll, human resources, purchasing and pay equity.

(3) Access to some services is confusing and frequently uncoordinated for the client.

(4) Client assessments are frequently duplicated, as they are performed by various agencies. This leads to frustration by the client as well as increased cost to the system.

(5) The present system does little to encourage team cooperation and collaboration in developing a plan of service for the individual client.

(6) Resources are scarce for volunteer management and development.

Non-union employee security must be a priority in less cosmopolitan areas where unemployment is already very high. In the document Partnerships in Long-Term Care, the guidelines for the establishment of MSAs which was released in September 1993, messages regarding the perceived preferential treatment of unionized employees in the new MSA became very apparent. Subsequently, in Bill 173 there are no references regarding the protection of not-for-profit, community-based employees as a result of implementation of long-term care reform.

Long-term care reform acknowledges the need for experienced, trained staff for the provision of services, yet the proposed process for development of multiservice agencies, along with social contract reductions and constrained finances, all currently have, or will potentially have, a negative impact on employment in the broader socio-healthcare sector. The skills necessary for community-based services are quite different from those necessary in the institutional environment. There must be a commitment to fair wages and benefits for employees.

We strongly recommend that client continuity and respect for the relationships between existing employees and consumers of service should be paramount. Consequently, the employee transfers to new agencies should be seamless, with no break in client service or provider employment. We further suggest that all employees of not-for-profit community support service agencies should be guaranteed comparable positions in the new service delivery structures without loss of seniority.

Volunteers have long been the backbone of community services and they must be recognized. Volunteerism is an essential component in the delivery of community-based services. The volunteer base must be recognized as being deeply rooted in the community and potentially fragile.

There is a lack of detailed planning in the legislation regarding volunteers and long-term care, even though there is a concern about an inadequate number of volunteers currently to support the expansion of programs and services. We recommend, then, that there be a recognition of the role of volunteers in the body of the legislation.

We recommend that volunteer management in regulation 11 should be expanded to require MSAs to develop and implement a plan for the recruitment, training, scheduling, supervision, retention, recognition and expense reimbursement of volunteers.

It is imperative that there be sufficient flexibility to allow communities to develop an MSA system to meet local needs. It is unclear what the final MSA model will look like in each community until the community planning process is completed. It is difficult to define the intent of the legislation. We are astonished that the legislation does not allow for local planning flexibility. It was our understanding that community responsiveness was to have been a necessary element of the developing process.

The district health council and long-term care planning committee of our area are actively promoting community involvement in planning for the future. The legislation suggests only one model for the MSA. Why then should our communities participate in this exercise of futility?

Community-based services have been traditionally driven by the needs of consumers. We believe that the legislation does not allow for a consumer-responsive or driven reform. We cannot support a single model for an MSA.

We believe that the MSAs must not be allowed to develop into large bureaucratic organizations. They must be small enough to be able to be responsive to local community needs.

We believe that there must be consistent standards developed or the unacceptable status quo will be maintained. We believe that the legislation must be amended to guarantee reform which is consumer-driven and that a responsive system becomes a reality.

We would recommend that members of our provincial association, the Ontario Community Support Association, be involved in the development of definitions of service to be provided, as these services are provided by our members. We would further recommend that our provincial association, OCSA, be actively involved in producing and approving the regulations to be developed for Bill 173.

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Having told you who we are, I emphasize the roots we have in our communities, which are manifested in our locally elected boards of directors and in our volunteers. Strengthened by this foundation, I must also emphasize that it is essential for the act to allow flexible models for MSAs based upon characteristics of communities. Let the people of our counties tell you what is local and what is a community; it's one thing that cannot be legislated.

Mr Paul Johnson: Thank you very much for your presentation. You gave us a lot of detail, certainly a lot of food for thought. I get the feeling there's a sense that how our communities associate with one another, how our communities interact with one another based on an urban model versus a rural model -- I come from rural Ontario; I speak with my colleagues from urban Ontario, and for a short time I lived in urban Ontario. I just get the sense that communities know themselves better in rural Ontario than they may know themselves in urban Ontario. Now, that may be unfair, but for the length of time that I've lived in rural Ontario, it's not unusual to know your neighbours great distances away and to know many, many neighbours. I don't think that same characteristic is prevalent in urban Ontario.

I raise that because when we talk about how Bill 173 will affect the people of Ontario, there is certainly a different sense from rural Ontario of how this bill may affect agencies that exist, agencies that are already doing a good job, as I know your agencies are, as opposed to agencies in urban Ontario, which may have a little different perspective on how they meet the needs of people requiring care under the long-term care provisions.

I know that Community Care for Seniors in Prince Edward county -- the one I'm most familiar with because that's where I live -- does a very, very good job. Indeed, even my mother is a volunteer.

Volunteerism in rural Ontario is phenomenal, just absolutely phenomenal. It just amazes me to no end. I'm certainly concerned when I hear comments like, "Volunteers will disappear if Bill 173 as it exists is enacted." I question whether that's factual or not. It's something that some people believe may happen, but I'm not so certain that's the case.

Also I hear that -- and I think it was evident in your proposal or your comments today -- there was a perceived lack of flexibility. Yet I, who advocate on behalf of agencies in rural Ontario, have insisted that there be flexibility within the programs under Bill 173. I hear conflicting evidence I guess. I hear the ministry saying, "Yes, there will be lots of flexibility; there will be all the flexibility that any agencies that exist could want," yet it's very fearful that indeed there isn't that flexibility. I wonder, even as I sit on this committee, which side is right. There are perceptions, and there's maybe some confusion.

If Bill 173 is enacted as it is presently -- and we know through our deliberations that there are a number of amendments that are certainly wished for, and there are a number of amendments that I expect will be realized as a result of these proceedings -- as it stands, give me the best example of how this will help you and maybe the worst example of how this will affect you negatively. You've given us a lot of information already.

Ms Goodhand: Probably the best way that it'll affect us is perhaps the washing away of the duplication of services, the joining together of all of the services rather than just individualized.

The worst scenario, I think, is the fact that we will lose volunteers. Volunteers have made it very clear to us that they serve our agencies. I think also what I'm afraid of, and I think we all are afraid of, is the loss of the local input, local autonomy, local boards. They're not going to be responsible to, say, an agency that's located in Belleville. It's long been known that we don't like to go to the city -- I mean, if we could put it in the centre of Hastings. Anyway, that's an aside. I think that's probably one of the biggest things, the loss of autonomy of the boards as well as volunteers.

HALIBURTON, KAWARTHA AND PINE RIDGE DISTRICT HEALTH COUNCIL

The Acting Chair: Our next presenters are presenting on behalf of the Haliburton, Kawartha and Pine Ridge District Health Council. Welcome to the committee.

Ms Barbara Moffat: We thank you for this opportunity of speaking to you today about Bill 173. My name is Barbara Moffat, and I am chair of the Haliburton, Kawartha and Pine Ridge District Health Council. With me today is Lesley Peterson, who is chair of our long-term care committee for Northumberland county. All of the material which we are presenting is in the kit which you have received, and we're providing a somewhat condensed version.

It's my privilege today to represent the many community volunteers who from Haliburton, Kawartha and Pine Ridge District Health Council offer their comments on Bill 173. Our council serves four counties. You have a map just inside your kit on the left-hand side which outlines our four counties. We are unique in this. We go from Northumberland along the lakeshore, Peterborough county, Haliburton county and Victoria county, from lakeshore to Algonquin Park. We have a geographic area of 11,416 square miles. Our counties are predominantly rural. Our total population is approximately 263,200, and we have a large percentage of seniors in all of our counties. We have three first nation reserves, and we have currently a high quality of services characterized by collaboration among our provider agencies.

In its strategic plan, the Haliburton, Kawartha and Pine Ridge District Health Council expresses its commitment to the very sound principles guiding the long-term care reform. Even before the large provincial consultation in 1991-1992, our council had developed a process for long-term care planning that foresaw the creation of committees of consumers, service providers and others to plan and advise on issues affecting seniors and persons with disabilities.

With the advent of the long-term care committees outlined in the ministry's partnerships and planning policy papers, our DHC put its four county-based, long-term care committees into action. Members of these committees generally agreed that the long-term care system needed change and a legislative basis for that change. We now have the legislative basis in Bill 173. However, we do have some concerns with the bill, which will be outlined specifically by Lesley Peterson.

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Ms Lesley Peterson: We have four major concerns today. I'm going to list those concerns, and then I'll backtrack and enlarge on each one. Our first concern is the changing role of the district health council and the enshrinement of its functions in Bill 173. Our second concern is around lack of flexibility and quality of advice. Our third concern is the one you're hearing most about it seems this afternoon, and that is volunteers. Our fourth concern is staff and labour issues.

I'd like to start with the changing role of council. The first of these concerns is the question of why the role and functions of district health councils are being enshrined in legislation that deals only with long-term care. Health councils deal with all determinants of health, not just for seniors and disabled persons. Multiservice agencies are not the only projects and planning in which they are involved. Our district health council's network of community volunteers addresses rural wellbeing, addictions, mental health, youth, hospital restructuring, injury prevention and rehabilitation, and you will see examples of all these activities in the handout that's been provided. We suggest very strongly that Bill 173 is not the appropriate place to legislate district health councils, or if this is not possible, that the bill be amended to reflect the wider scope of the councils' planning function.

On page 49, part XII, section 62 of the bill, dealing with council roles and functions, does not address the reality of the changed roles of councils as a result of the demands of the long-term care reform. Particularly with the lead in developing the multiservice system, they are moving into implementation planning and away from their traditional role of health system and project planning. We recommend that further discussions be held with the ministry to strengthen this section of the act to reflect the new expectations of district health councils and to prevent them from being perceived as yet another arm of government.

Our second concern is the potential in the legislation for restriction on the district health council's ability to represent the voice of the community and its local vision for health and social services. Such restriction could affect the quality of the advice our council is able to offer the minister. The following provisions of Bill 173 pose a potential for such restriction.

On page 6, part II, section 2, the listing of mandatory services leaves little local latitude to develop a multiservice system uniquely appropriate to local needs and culture. Our area is probably the most rural of all the district health councils in the province, with all that means in the way of lack of public transportation, non-urban attitudes and the additional costs of service delivery.

The list of regulations on page 36 in subsection 56(1) has the potential for further limiting the flexibility that district health councils need in planning a multiservice system that truly responds to local needs and realities. We encourage you to respect that flexibility by including councils in discussions formulating the regulations.

On page 49, in subsection 62(2) there is a need for clarification. Does this section mean that the ministry will have a say not only in appointment of council members, which is appropriate, but also in the recruitment and selection of subcommittee members, which through experience we suggest is unworkable and an unnecessary level of control? I think we have currently about 40 subcommittees. Just the logistics of helping to choose subcommittee members for 40-odd committees is horrendous. We propose that reference to subcommittees be deleted from this section of the bill.

Our third concern pertains to volunteers, and I've been hearing in the last 20 minutes or so most of the concerns that we have expressed, but I'd like to present them to you from a slightly different perspective.

Paragraph 56(1)11 is the only reference to volunteers in Bill 173. The life support of many service provision agencies and the group upon which the council relies heavily to carry out its functions is probably not getting a fair deal in this document; they are the council, and council cannot function without its array of over 300 community volunteers. With this legislation, an inappropriate level of responsibility is being placed on volunteers. Yes, they do act in an advisory capacity, strictly speaking, but in the bill there is no acknowledgement of the role of volunteers in the multiservice agency, no reference to their responsibilities in service delivery and no protection for council volunteers, especially when it comes to their responsibilities and potential liabilities when recommending on allocation of funding. We request that this issue be discussed with councils and included in the sections of the legislation touching on multiservice agencies.

With the integration and amalgamation of agencies envisioned in the multiservice agency, the recruitment, retention and attachment of volunteers is threatened, and they cannot and must not be lost in the shuffle. As well, the potential for fund-raising could be weakened if multiservice agencies are perceived as quasi-governmental agencies, and this perception must be avoided. I know the previous speaker alluded to that very strongly.

Regarding staff and labour issues, there will inevitably be some dislocation of the labour force in the transition to the multiservice system. Besides volunteers, employees in affected agencies must be protected, not only the unionized ones but also the non-unionized workers. This has been well identified by previous speakers, and we heartily endorse those concerns.

In conclusion, the Haliburton, Kawartha and Pine Ridge District Health Council believes that the changes and additions to Bill 173 that it has suggested will enhance council's mandate to give good, community-based advice to the minister, advice that will (a) maintain council's honest broker role in the community, (b) define and protect the integrity of its planning functions, (c) recognize and protect the importance of community volunteers and non-unionized staff and (d) will establish a multiservice system that truly responds to the needs and circumstances of our local communities.

We trust that our constructive suggestions and comments will enable both the Ministry of Health and the district health council to better serve our public. The fuller version of this submission is in the handout that has been given to you. Thank you for the opportunity to present this afternoon.

The Chair: Thank you very much for your submission. Mr Conway.

Mr Conway: Thank you very much, Charlie. "Charlie" sounds a lot better than "Mr Chair." I refuse to refer to my friends as pieces of furniture.

Ms Peterson: What would you have said if I'd sat down and said, "Hi, Charlie" as my speech?

Mr Conway: I would've been impressed, actually.

The Chair: I might've been surprised.

Mr Conway: Think about it; think about referring to one of your colleagues as "Mr Chair." Anyway, where I come from, chairs are pieces of furniture.

I look at your district, and I know it reasonably well. I'm from Renfrew, which if anything is even more rural, so as I look at the catchment area of your district health council, I'm trying to understand the status quo pre the implementation of, say, Bill 173. Let me just say that in the county of Haliburton are a lot of these services that are intended to be controlled by the new MSA. How are they now delivered in a place like Northumberland or Haliburton? Would it be the local health unit that would be doing a lot of the program delivery now?

Ms Peterson: No. I would say that these programs are fairly evenly divided pretty much as the bill lays down. I think we are referring back to the comment made by a previous presenter that these services in many areas do exist, are being performed extremely well and may require definition and streamlining but are currently there. In our area, we have a very strong health unit. We have very strong community care. We have Red Cross. We have VON. We have many agencies that do meet on an informal basis and do provide, without a whole lot of duplication, those services.

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Mr Conway: What concerns me about this -- I'm just a visitor to this committee, but I've listened to a couple of days of hearings and I think there clearly is a consensus out there and in here about some of the basic ingredients of long-term care reform. I don't think that's an issue any longer. I think the real concern is about the instruments to get from here to there and some kind of a read of the financial context in which this is all going to develop.

In an area like mine, for example, the health unit is a very key deliverer of many of these programs. All kinds of people around my communities, particularly in the big rural areas, say that if we go ahead with Bill 173 as it's currently written, and this deals with some of the staff labour questions, for the first two or three years of the new order we are going to be faced with a situation of complete paralysis. There is going to be nothing much done other than everyone trying to figure out where they go in the new scheme of things. The delivery of these vital services to needy people in small communities and rural townships will essentially, if not stop, certainly grind to a much, much slower pace while everyone goes to court or the Ontario Labour Relations Board to figure out where they fit in the overall scheme of things.

Ms Peterson: May I respond to that? I don't think you're giving enough credit to the service providers. I think the concern of all the service providers that I've met with over the last year, and I've talked to plenty, is the client.

Mr Conway: But let me ask you -- let's say you had a health unit that was not going to continue for whatever reason to deliver any of these services, that there was going to be a transfer to some other organization. What do you think is going to happen there over the course of the first two or three years? My experience in nearly 20 years in the Legislature, whether it's in school affairs or -- there is a very real concern about what happens to me and my job.

Ms Peterson: I think that concern is there, but I don't think it stops people from delivering service. In the hypothetical situation that you have mentioned, a difficult one to think of in our area because our health unit is not only strong, it's very cooperative and works with all the other agencies -- but if you had that situation arise, I think you would have to remember that most of these services were founded from the ground up, were delivered originally from the ground up. You would simply find people coming out of the woodwork, coming together and saying: "We're going to have a gap here, a loss in service. What are we going to do about it?" And history would repeat itself, because this is how most of us got started in the first place.

Mr Conway: I look at places like Haliburton. I'm trying to imagine that if we disenfranchise certain players, and I'm up in north Hastings, west Renfrew, east Haliburton, who else is there in Carlow township or in some of these places? It's not exactly a great list of possibilities. Some of what we have may be imperfect, but if they're going to be, for whatever -- I'm thinking of health units, because in my area they are a very significant -- if they're disqualified, I'm trying to think, who is it going to be?

Why would we go through this misery of getting everybody upset just to try to recreate more or less what we've already got? My great fear, based on a lot of experience, is that we would spend months and years and hundreds of thousands of dollars to end up not quite where we were when we started. We'll have a lot of taxpaying constituents trying to figure out: "So you're from the government and you're here to help me. Go to hell," they will say, rightly so.

Ms Peterson: Have some faith in your district health councils. The process is a sound one. Most of the district health councils, I understand -- I can only speak for our own, on which I'm a volunteer -- are working very hard to put a planning process in place where the example that you've just given could never happen.

Mr Conway: But I've got to tell you that my experience with a lot of planning -- they're good people, but this is in downtown Haliburton. This is going to be real interesting raw politics. I meet my grandmother and she's furious, because that nice person who has been looking after her for 15 years is just gone and there's nobody yet to take her place. They don't want to talk to the district health -- they're going to want to talk to Villeneuve, Wilson, Conway, Hodgson, you name it: "What the hell is going on here? I've just seen too much of this from quite frankly all levels of government. Those good people at the district health council are just that, bureaucrats and planners. I pay taxes. I had not a bad service and it's gone."

Ms Peterson: Do you want to go outside for two seconds?

Mr Conway: Let me be very frank. I remember my dear old friend Billy Davis announcing a school policy once, and I was the happy soul who went around the province for two years explaining to people what this joyful noise was all about. And you know what? There was a gap between promise and performance, and a lot of people on Main Street, Ontario, had figured it out a lot sooner than a lot of the politicians. On stuff like this, delivering really significant, sensitive programs to the elderly, I don't really want to make a miscall, if I can avoid it --

The Chair: On that positive note, I think --

Mr Conway: Sorry.

The Chair: -- in order to move Mr Conway from the misery in which he was --

Ms Peterson: From which he's just put himself in.

The Chair: Yes. I think I will allow you a last comment and then we'll need to move on. Was there anything -- ?

Ms Peterson: Tell him he's wrong in two seconds?

The Chair: Yes.

Interjection.

The Chair: In here or out there?

Ms Peterson: I hope there's nothing you know that I don't know coming to these hearings, because what I'm reading in Bill 173 and what I'm hearing in our planning process precludes the kind of scenario you're talking about, and if I didn't have faith in that, I wouldn't be sitting here and spending hours working through the process, and I'm glad I'm not a politician.

The Chair: Thank you.

Mr Conway: We've heard a lot of evidence here to suggest that there's a lot of worry out there.

The Chair: We thank you very much, both for the presentation and also the other attachments that you've made to the documents.

Ms Peterson: Thank you very much.

The Chair: Thank you.

Ms Peterson: Thank you, Charlie.

The Chair: Yes.

Mr Malkowski: On a point of order, Mr Chair: I just wanted to take the opportunity to thank the speakers for educating some of our members in the opposition parties. Perhaps maybe they'll use those thoughts wisely.

Interjections.

The Chair: Order.

Mr Paul Johnson: This is a legitimate point of privilege.

The Chair: Okay.

Mr Paul Johnson: I didn't hear that immediate point of order, if it could be repeated, so I could hear it. It was because of the noise.

The Chair: Okay. Could we just repeat the point of order?

Mr Malkowski: Oh, you want me to say this again. I just wanted to thank the last presenter for maybe educating our opposition members and maybe some of this information will come in useful.

ROYAL CANADIAN LEGION, ONTARIO COMMAND

The Chair: I call the Royal Canadian Legion. Gentlemen, welcome to the committee. Mr Margerum, I know you've been before the committee before, I think on Bill 101, and we welcome you and your colleagues today.

Mr Jim Margerum: With me is Comrade Earl Kish, who's our deputy district commander from the Kingston area, and Comrade Jim Mayes, who is veteran services chairman for district G, which is eastern Ontario. I am the veteran services chairman for Ontario Command.

My initial comment is, ideally, I believe there are possibilities in Bill 173 and it's on the right track. However, I believe there are a number of things realistically that will not work and certainly need to be revisited and amendments made. I believe if you're listening to the presenters here, you will find a large amount of material that can assist in resolving it and making it a workable proposition.

For the information of people here, we represent 173,000 members across Ontario. We provide three million volunteer hours a year and we donate approximately $19 million in donations. Our involvement is in housing, Meals on Wheels, hospital, medical centres, youth, club scouts etc, adult sports, canvassers, volunteers for fund-raising, seniors' activities, seniors' care such as foot clinics, transportation, income tax assistance etc and we provide our branch facilities for community activities. We are members of boards of directors, communities, auxiliaries and sick visiting shut-in groups of hospitals, youth and senior organizations.

While we fully support some of the complaints and concerns as presented by numerous groups, we represent a particular group of veterans, but I would ask you to bear in mind, if you're looking at adult males over 70 in the province of Ontario, three out of five are veterans, so it has a significant impact on seniors and their spouses, which is our concern.

Representatives of this legion committee appeared before the standing committee on social development when Bill 101, An Act to amend Long-Term Care, was being discussed in public hearings. We will leave with the members of this committee on Bill 173 the briefs we presented then and copies of a review report prepared on the long-term care facilities program manual, which details many of our concerns, then and now.

Level 1 care, which had a particular application to Canadian veterans, no longer is recognized with respect to admission to long-term care facilities. An exception to this is the agreement to grandfather those veterans housed at the Rideau Veterans Home in Ottawa.

Our concerns with Bill 173 are primarily the same ones expressed in our briefs on Bill 101. The legion said then, without particular mention in the act of recognized rights enjoyed by veterans, those rights would fade away into the sunset in Ontario and eastern Quebec. We see this happening now and again are concerned that the situation will worsen if this bill, as proposed, becomes law. Administrators and others who operate exclusively under the language before us cannot ignore the well-earned rights of veterans seeking care in Ontario.

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We have had meetings with the provincial Minister of Health and her staff, as well as with Veterans Affairs Canada, to attempt to work out a solution to this growing problem. While not trying to be adversarial, we must strongly insist that veterans' rights should be expressly recognized in the acts and regulations so they cannot be overlooked unintentionally or otherwise. The two levels of government have engaged in an exchange of letters which they indicate to us will suffice in allaying our concerns on behalf of veterans. However, if the operating staff or administrators are not directed regarding veterans' special rights, they will become part of the general citizen group and their rights will dissipate and perhaps die.

Veterans Affairs Canada assures us that the veterans' health care regulations will continue to be the sole admission criteria to be met where veterans are to be admitted to veterans' priority beds. With due respect to their declarations, we can find no language in the current act, the long-term care facility manual or the bill now being considered, which anyone may read, to come to that conclusion. As we see it, the community is simply not equipped to handle the load implied by the current bill which, in turn, fails to recognize the special group of veterans. By not recognizing in Ontario legislation the acquired rights of veterans in Canada, the accelerating question arises: Where will our veterans go and who is to ensure the services and benefits contained in the veterans' health care regulations?

Our committee has already corresponded with federal and provincial administrators concerning the newsletter, Reaching Out, published by the Ottawa-Carleton Regional District Health Council in July 1994. It is, in part, on the question of admissions, raising great concerns on our part. We leave you with copies and will elaborate in any questions on this particular comment. I refer to the fact of admissions where the placement coordinating person can in fact overrule a medical diagnosis of a doctor.

Bill 173: We have explained that in respect of the existing act and Bill 173, our main concern is one of omissions. Example -- no formal recognition of veterans and their special rights. Unless that principle was to be incorporated, then specific comment as to existing language and possible amendments would be futile. We are confident, however, that should the principle of formal recognition be considered, language changes could fall in place.

A few sections do raise questions in our mind and we would like to address them, notwithstanding our general comments.

Under definitions, a "service provider" includes minister where funding and approvals are provided, and the act, clauses 6(a) and (b) state the minister may operate and maintain facilities.

The question: Where Veterans Affairs Canada funds and provides, directly or indirectly, care to veterans, where is it recognized under Bill 173? Is there in fact any recognition of veterans' priority beds in any long-term care facility contemplated by the act, and primarily the admission?

Part III, Bill of Rights, lists a number of rights which must be ensured by a service provider. Paragraph 3(1)3 recognizes certain rights arising from the "cultural, ethnic, spiritual, linguistic and regional differences." These probably arise from other legislative rights, federal or provincial.

Question: Could it be that veterans' rights under the veterans' health care regulations may, in like manner, be formally included under this or a separate section?

Those sections dealing with multiservice agencies and placement coordination services make no mention of veterans' rights under federal legislation. These are operating groups responsible to apply conditions of admission and care in long-term care facilities.

Question: Where is the legislative or regulatory language which they will apply in respect of veterans and, in particular, to those occupying -- if they meet whatever admission criteria -- federally supported contract beds?

Summary: We trust our brief representations here, together with the other material we have provided, will serve to demonstrate the growing concerns we have in regard to developments we feel arise from no recognition of veteran rights in provincial legislation and regulations affecting them. We do not believe systems and programs are in place in Ontario to handle extended care requirements in the community. By that, we refer to the institutionalization of people and returning them to the community. There are no sheltered or domiciliary care infrastructure and facilities to handle that particular area.

By not recognizing and dealing with this special group of citizens, the veteran population, the government is burying its head in the sand. We stand ready to cooperate and work in conjunction with the ministries and others to develop such infrastructures and the necessary independent facilities for veterans, seniors and the less fortunate.

In closing, we wish to express our appreciation for having had the opportunity to appear, and we trust our efforts on behalf of veterans will have a positive impact on your deliberations. Thank you.

The Chair: Thank you very much and thank you as well, as you mentioned, for the submissions you made when we were reviewing Bill 101 which are in the back of the document you have passed on to us.

Mr Jim Wilson: Thank you, gentlemen, very much for appearing here on behalf of veterans. I recall very much your presentation during the hearings on Bill 101 and we were able, at that time, to put forward amendments in support of the Royal Canadian Legion's position at that time. However, I'm just trying to recall, we weren't terribly successful. I think they all got voted down. Could you tell me -- there was the side agreement that you've mentioned with respect to the grandfathering of some veterans in the Rideau -- what do we call it?

Mr Margerum: Rideau Veterans Home.

Mr Jim Wilson: Yes. But other than that -- you're right, your concerns here today are very much concerns that were expressed under Bill 101. You mentioned today that you've had meetings, I gather subsequent to Bill 101, with the Minister of Health. I'd really like to know what kind of answer you're getting from the Minister of Health and why the government, to date, has not put special recognition in here for veterans. What kind of answers are they giving you?

Mr Margerum: In fairness to the ministry and Veterans Affairs, we did in fact receive very comprehensive answers. The difficulty we have is, and I guess we agree to disagree, they say our fears are unfounded, but our argument is, if it's not in the written word, it's in the hands and the heads of those who are interpreting it.

I'll show you an example. Both the Minister of Health and the Minister of Veterans Affairs -- or I guess they call him secretary of state from the American changeover in federal politics in Canada; they're fast becoming Americans. Their comments to us were that a person who was going to be admitted to one of these contract beds, if Veterans Affairs Canada health care regulations stated they could get in, that would be it. We disagree because the legislation states that the placement coordinator will determine. As an example, it states in that article in July that there's more emphasis for the placement coordinators and that a placement coordinator can -- even though a medical doctor has assessed the person to be admitted, if in the opinion of the placement coordinator the person can be served at home, that's where he'll stay.

I'll give you an example, and I would ask the question of everybody at the table what you would do. We have a 90-year-old veteran who has just been diagnosed in an acute-care facility on Friday. He's dying from cancer. He has from one week to two months to live. His wife is 79. She's had a number of heart attacks and is in a difficult state. I phoned her at 9 o'clock this morning and she has told me the unfortunate circumstance that he's passing away. It has taken two months to get him into the acute care hospital.

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He is a veteran; he is entitled to admission. He wasn't admitted because there's no room. However, it took that long to look after him, and the most astounding part of it is the fact that one of the doctors there, one of the staff at the hospital, the acute care hospital, asked the lady, if she would take him home, they would look after him. He's on intravenous continually and he takes strong doses of morphine. I ask anybody, is that fair to put that person back in the community on a lady who's not well, 79 years old?

That is the kind of concerns that we have. We just feel that it's beyond comprehension to put people in the community if the services aren't there to look after them. Fortunately, VON and other support agencies are going there, but they're six days a week during the day. They're not there overnight. This lady was in a real state of panic when she called me this morning.

Mr Jim Wilson: The real-life case you bring to our attention is very disturbing and it highlights that you're not just surmising that veterans are losing their special rights, but it's actually happened out there. That's what we need to hear, because I sat through the hearings, as you did, and the assurances given last year by the government with respect to the first phase of long-term care. What you're telling me, though, is that veterans are subject to the same medical test to get into a bed, whether it be an acute care hospital or a nursing home, as everybody else, and that the special rights have been eroded.

I will ask the parliamentary assistant to respond to that, because that's very disturbing and contrary to what we've been told.

Mr Wessenger: First of all, we should be clear that the issues that are being raised have nothing really to do with Bill 173. They relate to facility beds, and there's nothing in the bill --

Mr Jim Wilson: Except that placement coordination service is what he referred to, and that comes under the MSA.

Mr Wessenger: That's under Bill 101 as well, placement coordinating services --

Mr Jim Wilson: But it becomes assimilated under MSA.

Mr Wessenger: -- so this bill is no reference.

However, with respect to the question of the facility beds, as you may recall -- I'm doing this from memory, so if I don't present the total details maybe Mr Quirt could, who is probably more familiar -- the concern that was raised during the previous hearings was about the loss of beds in particular institutions, three hospitals. Perley was the one that was most in note, and I believe there's one in London, and Sunnybrook in Toronto. There was concern that these preferences for the certain number of beds that were in an agreement between the federal government and the provincial government were not adequately protected. I believe, if my recollection serves me correctly, that there was an amendment that went through with all members' support to clarify the protection. I think I'm correct there. I'll ask Mr Quirt if there's anything he can add.

Mr Geoff Quirt: Currently the province ensures with an arrangement with the federal government that there be priority access for veterans to beds in three hospitals: one in London, Sunnybrook in Toronto, and the Perley Hospital in Ottawa. As you know, the Perley Hospital in Ottawa is undergoing a redevelopment, and when a brand-new facility is built, it will be funded as a long-term care facility and governed under the provisions of Bill 101. Even though Bill 101 currently doesn't fund any priority access beds, if it is used to fund, and when it is used to fund the Perley, it will continue to guarantee priority access for veterans. That's why there was an amendment specific to that facility introduced for Bill 101.

Mr Margerum and others raised the issue of language in the transfer agreement between the federal government and the provincial government, pointing out a particular clause that might have been construed otherwise. We took it upon ourselves to confirm in writing from the Minister of Health provincially to the federal minister saying that the Minister of Health or PCS had absolutely nothing to do with who went into those priority access beds, that it was clearly a Veterans Affairs responsibility.

We received correspondence back from the federal government that said: "Yes, it's totally our responsibility. The province has got nothing to do with it." Both those letters are in the possession of the Legion, I understand. I'm not sure what other form of assurance we can provide, other than to say it was our intention to amend the bill, and we did do that, and put specifically in the transfer agreement that Veterans decide who goes in regardless of what a physician says. It's clearly up to the federal government to decide who gets access to those beds.

Mr Margerum: I would just read you a passage of the statement. If that is in fact the case, then the district health council in Ottawa should really be checked up. I'll read you verbatim what it says: "The legislation also provides for a stronger role for PSCs in authorizing all admissions to long-term care facilities. Although physicians" -- which in this case would be Veterans Affairs Canada senior medical officers -- "will continue to complete a medical report as part of the assessment of need, the placement coordinator is required to document whether or not a person's needs can be met by existing community services in determining their eligibility for admission."

It says to me that the admission is determined by the placement coordinator. Even though they're eligible, the admission to the facility is determined by the placement coordinator.

Mr Quirt: The placement coordinator determines admissions to all long-term care beds in Ontario with the exception of the beds that will eventually be funded -- aren't funded now, but will be eventually funded -- by Bill 101 in the new Perley long-term care facility. The PCS will have nothing to do with and nothing to say about who gets into those veterans' priority beds in the Perley.

Mr Margerum: Well, I would appreciate that in writing that the admission -- and we're talking admission, not accessibility.

Mr Quirt: The Minister of Health thinks she's written to you specifically with that message, and she will write again next week.

Mr Margerum: Okay, thank you.

Mr Jim Wilson: Well, now I'm a little confused, because the 90-year-old gentleman that passed away, should he have had admission?

Mr Margerum: Our concern on that was that this gentleman was in dire straits, which has been confirmed by medical authorities. His wife was in a panic state when she called me, and it took considerable time to get her in there. I'll leave it at that.

Mr Jim Wilson: Right.

Mr Margerum: The other concern we have that is rather obvious, I'm sure, is that once and if and when the MSA system is in place, is their decision on placing people going to be determined by budgetary restrictions or by the medical and genuine need of the individual? That's a question I ask.

Mr Jim Wilson: It's a good question, and it's one where I think the answer is probably a combination of the two. We don't know as members of the committee what the eligibility criteria are, and that's a problem. I will give the parliamentary assistant a moment to answer that on behalf of the government, though.

Mr Wessenger: Well, I understand there's a working group being established to develop the criteria. I'll ask Mr Quirt to again indicate, and I think he has indicated on previous occasions with respect to that.

Mr Quirt: Mr Wilson, are you referring to the eligibility criteria for admission to a long-term care facility or the eligibility criteria to receive services from a multiservice agency?

Mr Jim Wilson: Well, to date we've been given a rough outline, I guess, of what the committee is looking at in terms of putting together what the current eligibility criteria are on both fronts and, secondly, what the government is envisioning or what the committee might come up with. We don't really know the answer to that. I don't know, Mr Quirt, whether you can enlighten us any further on those, unless the committee has done something miraculous in the last week or so.

Mr Quirt: Well, certainly the admission criteria for long-term care facilities are in place now and have been for some time --

Mr Jim Wilson: Under Bill 101?

Mr Quirt: -- under Bill 101, and we'd be happy to remind you about those. My staff presented to the committee on the work to date on clarifying the eligibility criteria for MSA services. As you know, one of the themes behind those eligibility criteria is to provide services that allow people to remain independent in their home and avoid institutionalization, and there's some further work that needs to be done on the threshold for when services are publicly funded and so on.

As was presented to the committee, a fair bit of work has been done already and a group with a number of stakeholders represented, including people who bring in both a provider and consumer perspective, is continuing to work on the eligibility criteria. They'll be contained in the multiservice agency manual that's under development by those 11 work groups we mentioned earlier.

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Mr Jim Wilson: I appreciate your response, except just going back to the real-life story that was presented here, I think the concern was that the gentleman was not in very good shape at all and neither was his wife, and that he was being essentially told to stay in the community because supports might be available in that community.

Now, you've got your eligibility criteria, and I do recall them very well, in Bill 101. It's to me a very high test, and we had a lot of discussions about that, so you're kind of blocked from getting into the institutional side of health care with that test if there are community services available. How do you respond, though, and I ask the parliamentary assistant, to that scenario? How much weight is given to the 79-year-old spouse at home who's not able to cope and we're told community based services aren't in place? That should have been an admission according to the eligibility criteria that are in place now. It shouldn't have been a two-month delay.

Mr Wessenger: Again, I will answer initially and maybe Mr Quirt will add some facts. But the relevant situation, I would suggest, is, first of all, are they admissible? Their doctor has to determine whether they should be admitted to hospital or not. In the question of a palliative care situation, certainly the community support services were available, I would suggest, in the community. I think the suggestion was that the community support was maybe not the most appropriate in the circumstances, that maybe a facility option should have been there, and that of course would depend on a placement coordination.

I guess there would have to be an application to a facility. If it's considered to be of an urgent need and appropriate, and a bed is available, then of course the placement would occur. I don't think there would be any question that somebody in those circumstances would be eligible for a facility placement. There's no question of eligibility; it's just a question of what is possible and what's available at that moment.

Mr Quirt: First of all, if the gentleman that Mr Margerum referred to was a veteran, our eligibility criteria would have nothing to do with him getting in the Perley Hospital, where those priority access beds are. That would be clearly up to the federal government's Veterans Affairs people to determine where that gentleman stood in terms of their waiting lists for those priority access beds in there.

If the other options were to be explored, if the gentleman and his family were interested in other long-term care facilities and if he was requiring palliative care in a hospital bed and if care givers at home were having difficulty in coping, then I suspect this client would qualify as a priority admission under our new eligibility criteria, which tend to make sure those people most in need of facility services are first in line.

The Chair: Mr Margerum, and then I regret we're going to have to move on.

Mr Margerum: Very quickly, I should inform you they are the only two survivors of the family, the husband and wife. They have no living relatives.

The second comment I have is, I realize the Minister of Health and the Minister of Veterans Affairs have written and stated something in a letter. But if you look at that article from district health council, the message hasn't got there, primarily because of the absence of the reference to veterans, period.

LEEDS, GRENVILLE AND LANARK HOME CARE PROGRAM

The Chair: I next call on the representatives from the Leeds, Grenville and Lanark Home Care Program. Good afternoon and welcome to the committee.

Mrs Connie Lendrum: I would like to thank the committee for giving us the time to make this presentation today. I am Connie Lendrum and this is Lois Patchell. We work as case managers for the Leeds, Grenville and Lanark Home Care Program. I am here to speak on behalf of our home care program and case managers.

The word "reform" implies improvement. We who work in the system you aim to reform would agree there is much room for improvement. However, we do not think that throwing the baby out with the bathwater is the way to go.

We presently have a health care delivery system that took 20-plus years to develop. In our tricounty area, we have the home care program, placement coordination service, 12 home support programs, two non-profit nursing agencies, one non-profit homemaking agency, three commercial agencies offering homemaking and nursing services, one Alzheimer outreach program, one non-profit attendant care program, three hospice volunteer visiting programs, three elderly persons' centres and a multitude of volunteer-based agencies. These agencies know each other well and work together with great cooperation to meet the needs of 144,900 people in the area.

The proposed MSA structure will take this sophisticated culture and virtually wipe it out as we know it. The British Empire was very fond of doing this to any native culture it happened upon. The consequences weren't usually so wonderful for the heathens, and as a result the world lost much of its colour.

In part I, under "Purposes of Act," clause (d), it states that the act intends "to simplify and improve access to a continuum of community services by providing a framework for the development of multiservice agencies."

The government seems to believe the solution to the problem of a confusing, difficult-to-access system of community health care is an MSA. We agree that there could be some improvement in the present system but suggest that improvements could easily be made with additional technologies to the current structure.

At the present time, home care is woefully behind the rest of the world in its system of operations. We plod along under the weight of paper-oriented information systems, and in our office the fax is still a novelty. I personally remember that it was only three short years ago when I shared a black dial phone with another case manager. There was one phone line and you waited for it.

Improvements such as 1-800 numbers to provide a direct entry into the system, computerization and a common database for related agencies are tools that would greatly assist in achieving a "simplified and improved access" to services. Spending a few dollars in advertising and educating the population about community health services and how to call for help would simplify access. In our office, we get regular calls from people asking how much two-by-fours cost, or do we sell plumbing supplies, because they think the number in the phone book under "home care" means Home Care Hardware. Clients constantly tell me that before they needed home care services, they never knew they even existed. What a shame that the government has been paying for such a wonderful service and they don't even get much credit for it because of the lack of advertising.

Two other stated purposes of the act, clauses (c) and (f), which are "to recognize the importance of a person's needs and preferences in all aspects of the management and delivery of community services," and "to promote the efficient management of human, financial and other resources involved in the delivery of community services," are currently well addressed by the position of the case manager. The role of the case manager is one of direct service, though few recognize it as such because there is no laying on of hands and we are often just a voice at the other end of the phone line. But we individualize every plan of care for every client. We use a holistic approach. We access many other community services for people on the program, and especially for people who do not qualify for the program. We have years and years of experience behind us that has taught us to listen to the client. Any plan of care is doomed to failure if it isn't tailored to their needs and desires.

At the same time that we advocate for our clients, we serve the government in allocating services in the most cost-effective way possible. It is really a remarkable concept when you think about it, but every square inch of Ontario is assigned to a real, live person, a case manager who will be responsible to assist in achieving the best possible outcome for the client. But what is even more remarkable is that Bill 173 doesn't even mention the words "case manager."

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The first three stated purposes of Bill 173 are briefly as follows: "(a) to ensure that a wide range of community services are available...; (b) to improve the quality of community services...; (c) to recognize the importance of a person's needs and preferences...." We have serious doubts that the proposed structure of the MSA will promote these goals.

To explain, in the past we had only one nursing provider and one homemaking provider. When we had a case that required something unusual, the agency might say, "Sorry, we don't do evenings, or we don't do continuous infusion pumps," and the client did not receive the services he or she needed.

Then along came competition. There really is something to be said for it. A runner will never do his best time if he only races with himself. He needs someone to gauge himself against, to urge him to higher levels of achievement. Our business is no different. We need the competition in order to get more and better for our home care clients. Now that we have it, the government wants to remove it. The consumers will lose the quality and range of services, their right to choice will disappear and there will be little reason for the service providers to remain cost-effective.

We who work in the system have seen rapid change in the demands for more complicated procedures to be done in the home setting. This requires great skills and a willingness to be flexible, two attributes that we have seen grow in all of our agencies that we work with in the current environment of competition.

To further the discussion on improving the current system, we would ask the government's help. We need to be able to run our organization in a more businesslike manner. One essential element is that budgets have to be approved by the ministry before nine months have gone by into the fiscal year.

As well, the public has been told repeatedly that money cut from hospitals will flow into community care. The reality in our area is, our home care program has been capped. We continue to grow at a level of 18% but have been told there will be nothing to pay for that growth.

Not only do we need adequate money to pay for adequate services, we need the government to be open and honest with the public. They must know the truth about the real financial picture that we work with. Consumers, hospital staff and even doctors have been led to believe that we are the rich kids on the block, and when they are told the reality, they vent their frustrations on us.

Other suggestions for improving the current system include increasing moneys to support services such as Meals on Wheels and friendly visiting programs.

Also, the duties and role of the homemaker, which translate into dollars to be spent, should be carefully examined. Some suggest removing housecleaning from the role of the homemaker. Homemaking skills have become quite sophisticated over the last years due to a demand from the system. Cleaning could be provided by the private sector while tax dollars are used for higher levels of care giving.

Another practical suggestion is for arbitrary and costly program divisions to be eliminated. Clients should be allowed to flow through the services they need as determined in conjunction with a case manager.

We have been told repeatedly of how this government has talked and listened to the public before drawing up this legislation. The flaw in this approach is that everyone is left wondering who it was exactly that they listened to. No one feels it was themselves who were heard. We certainly hope it's not too late for you to listen to the many presentations made to this committee and reconsider your approach in the reform of long-term care. We also hope that you will recognize the good in the present system and the wonderful skills of the people who currently work in it.

We have a system of community health care that is the envy of the world. To destabilize it, to turn the basket of services upside down, to create what might end up as mass unemployment or mass bumping of displaced hospital personnel into the unfamiliar territory of community health, to limit consumer choice would all be sad outcomes but very real possibilities.

To conclude, I would like you to listen to a statement from a colleague of mine who is not only a case manager but also a consumer of the home care program. Her experience as well as others' who have been on the receiving end tell us the greatest truths because they come from the heart. Thank you for your attention today.

Mrs Lois Patchell: Briefly, I would like to comment both as a case manager and as a consumer who has been there during the illness and death of my husband and again of my father. I might add that these two occurrences happened three hundred miles apart, so we are talking about service in more than one part of Ontario.

During the illness of my husband, the first nursing provider my husband was referred to was unable to provide the service that he required. His needs were more emotional than physical. He talked to his case manager about this as well as his concerns for his family. She in turn was able to provide another nursing service that was able to provide the palliative care he required. This is an option that is not readily apparent in the present legislation. She was also able to be more objective and to provide me with respite at a time when I was unable to recognize my own needs or the concerns my husband had for me, and she did it without making me feel that I was not doing my job, not doing all I could.

As well, she was able to suggest appropriate services that I knew were there as a case manager but I forgot that they applied to me as a consumer. On the rare occasions that there were differences of opinions between service providers and my husband, he was able to talk to her about them without feeling he was reporting the individual to her supervisor, and he relied on the case manager's judgement to decide if the matter needed to be reported further.

Each of us here today is a consumer, either past or future. Many of us who have used the service in the past have found that except for a few minor areas that could be adjusted, we were in receipt of quality product. We hoped that this product could be preserved and enhanced with the least amount of disruption. When you or someone near you is experiencing a critical illness, you want the least amount of confusion and disruption. Families need someone to lean on and, if the length of illness is long, come to look on the primary service provider as a friend who should not be upset. For this reason, both my mother and I were happy to have the case manager as an approachable professional to provide us, with one phone call, someone to cope with our concerns.

Thank you very much for listening.

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Ms Carter: Thank you for your presentation. I'm really upset that you see this legislation as the colonizing power coming and upsetting the grass-roots civilization, as it were, because that's certainly not how we see it and how we want it to be. In fact, I have seen it put differently, that, as has been suggested here this afternoon, a lot of the services and agencies we have, have grown up because people on the spot could see the need and they cared and they made the effort and so the services were provided. This was -- what shall I say? -- something that happened spontaneously, but now we have the results of all that uncoordinated growth which maybe grew like Topsy and is better in some areas than in others. Now we need to take stock to look at the total picture to say: "Well, yes, some of this is great, but there are certain things missing. Some areas are served better than others."

We need to make sure that everybody in the province is getting at least minimum service. That is why we are looking at legislating and changing things and certainly there has been a big demand for change. To say that everybody is happy with things as they are is not true, and certainly this is something that we discovered when we went out and consulted with the public. That was genuine grass-roots consultation and there was feedback and we did change what we're doing as a result of that feedback.

We see this as evolution, as something that tries to bring existing agencies together and just coordinate things a little better. Certainly, case management is going to be a large part of what we envisage. People will be able to make this one call to access services instead of having to think: "Well, who do I need? Where should I call? What's the number?" People's needs will be assessed. Obviously, case managers have a large part in the assessment and in the ongoing process and I see them coming into their own, as it were, having an even greater role to play than now.

I was quite upset where you said the money is not there as regards home services. I just wonder if we could have a little bit of enlightenment on that topic, maybe about the inclusion of case management and the financing of home support services.

Mr Wessenger: I think what you're asking is, what has happened with respect to the financing of community care? There certainly have been, overall, more moneys going into the system. There was a presentation today that was given to all committee members about what moneys have been invested in the system and what will be invested in the system.

I think the concern raised by the presenter is the aspect that some home care programs have been capped in some parts of the province, and Mr Quirt perhaps can give the basis on which that is done, but that sort of indicates what we're trying to do here. We're in a situation where basically we have limited financial resources and we have to deliver our services in a more cost-effective manner which puts more emphasis on the front-line delivery of services. We have to look at ways of rendering more efficient the administrative structure that delivers that service. At the same time, we have to look at a system that serves the consumer best.

I note there was an interesting presentation from, interesting enough, a home care director from Oxford, if I remember correctly, who set out what she thought were the advantages of having a system that was functionally integrated and also having, of course, a system that is responsive to the community. That's certainly the basis on which we're bringing this program, but I'll ask Mr Quirt on the specific matter of the financing.

The Chair: If you could just comment briefly and then I'll go back to our presenters.

Mr Quirt: In terms of the $441-million investment in the long-term redirection budget, by the end of this year about $250 million will be invested and there'll be $190 million extra coming in the next two fiscal years.

The home care program itself grew by about 13% last year. We expect it to grow about 8% this year, and helping us manage that growth is a committee we have established with the Ontario Home Care Programs Association where we're looking at trying to match the growth across the province so that those areas with relatively less community services receive more growth than those programs that are relatively well resourced by comparison.

At one of end of the spectrum, for example, one community can have five times as much spent on community services and long-term care as another community. So it's that inequity that we're trying to address by providing the money in accordance with an envelope funding system that tries to measure the requirement for community-based funding on the basis of population and age and so on.

The Chair: One last comment.

Mrs Patchell: I appreciate what you're saying about the growth and about the inequity across the country. I even recognize inequity among our own program because we do cover both a rural and an urban area. We already have had 11% to 18% growth in our program this year and with the capped budget we are therefore unable to provide the kind of service that we're being asked for.

In addition, that's growth. It's not saying anything about the type of care that we're being asked to present, which is becoming more and more complex each day. I think this is something we do need to recognize when we're looking at this bill.

The Chair: Thank you both very much for coming before the committee today. We appreciate it.

Mrs Sullivan: Point of order, Mr Chair: I think I have heard Mr Quirt speak about the increase in home care financing for the second time. We received today a document indicating where the $647 million was supposedly going. Could we have a further breakdown of the home care spending? Virtually every group we have heard, and certainly in my own community, tells me there's no more home care money and indeed their budgets have been capped and they are not getting the additional flows that we continue to hear about in the committee.

The Chair: We'll work out getting that information.

ALL-CARE HEALTH SERVICES

The Chair: If I could now call upon the representatives from the All-Care Health Services.

Ms Georgina Thompson: My name is Georgina Thompson. I want to thank you for allowing me to come here today.

I'm here today to address the committee with respect to the proposed structure of the MSA under the provisions of Bill 173. In particular, I want to speak of the negative effect of what I believe to be a completely irrational and unnecessary provision in the bill. This is the provision which restricts to a maximum of 20% the amount of home care services that can be provided by so-called commercial, and not approved, not-for-profit agencies. This provision will simply erode everything from community health care services to services provided in group homes.

I would first like to take a brief moment to give you some background on myself as a small business person with a strong interest in the welfare of my community. I have included as an attachment to my material a copy of my CV.

It will probably be said that in making this presentation, I am simply trying to look after my own self-interest, and in a couple of senses that's true. Certainly, as one who started a health care service some 13 years ago, I'm despondent, to say the least, about the proposed exploitation of something I've worked very hard to create. But my interest is also that of the welfare of the community and of the consumers we look after as well as the dedicated staff that I work with.

In 1979, I graduated from a nursing program and worked three years at a local hospital. It was during that time, in 1981, that I left the hospital because of a need that I saw in our community, a gap in services. I started a health care service in the living room of my home. I started this enterprise because there were clear gaps in the health care system in our community.

While working at our local hospital, I came to realize there were no home nursing or homemaking services in our community that were prepared to offer services on a 24-hour-a-day, seven-day-a-week basis. As a result, there were many people who wanted to go home from hospital, and in some instances simply to die in dignity at their own home, but couldn't do so because of the lack of service. So I made services available not only around the clock, seven days a week, but also in remote areas others were reluctant to serve.

Now I have a clear impression from the bill and from pronouncements from the Minister of Health that in earning a salary and in maintaining a responsible and viable service I am doing something that is morally wrong and that I'm stealing health care dollars. I ask the committee, how can this be, when I receive from the home care program the same amount per hour as a not-for-profit agency for homemaking services, and for visiting nursing services in Hastings and Prince Edward county I receive a lesser amount than not-for-profit colleagues, which have resulted in a saving to the province of over $900,000, approximately, in the three and a half years we have been sharing this service.

I find it very difficult to accept, and I think every one of you would too, that I have taken the initiative to provide a much-needed service to the community and at the same time to earn a living and I am now confronted with the expiration of my business. I created jobs for over 450 people, almost all of whom are women, and in the case of many of our homemakers or home support workers these are people who do not have the educational background to be able to get many of the jobs that are out there now. For many of these people, I have not only created jobs but I have provided the means by which they can improve their knowledge and skills and certainly raise the level of their self-esteem, and now I'm being asked to turn that over to the government.

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I would also add that I have every reason to believe that the services I provide are well respected, not just in the communities we serve but also in the Ministry of Health. Two years ago, representatives of the ministry did a study of the three agencies in Prince Edward county and found no shortcomings in the scope and quality of services.

We have worked very hard for the past 13 years -- and when I say "we" I'm including a staff of whom I'm very proud -- to provide a quality service to the home care program which is not only efficient but cost-effective and innovative. In conjunction with people in the home care program, I've assisted in identifying gaps or inconsistencies in our programs. The existing structure for home care services isn't perfect and there are improvements that can be made, but this does not require the destruction of the system and the creation of another bureaucratic empire, with all that entails.

Over the past few years, I participated along with other providers in many meetings with home care personnel to discuss needs in the existing programs. There are gaps to be filled, and I think we all agree that a single access point for consumers makes sense for the services in the community.

But why not provide these services through the existing structure of the home care program in its 38 province-wide sites? If the government wishes to have more community involvement, there seems to me to be no reason why each of these sites couldn't be governed by a local board of directors responsible to the ministry.

But why add to a single-access referral service the near-exclusive, direct provision of services that are already being provided effectively by a mix of not-for-profit and commercial agencies? For many in the not-for-profit sector, and I know this from my personal experience, volunteerism and its tremendous contributions to our society will be at best eroded significantly and at worst destroyed. Those agencies that are folded into the MSA will lose their identity, despite the contrary views that have been expressed, and that loss of identity will be accompanied by the loss of thousands and thousands of volunteer hours, not just in providing services but in the raising of millions of dollars in volunteer contributions. I'm sure you've heard this before, but don't be deluded: The folding into MSAs of not-for-profit organizations will destroy volunteerism in those agencies.

And why eliminate the competition factor that exists in the present brokerage model? As you know, this was done in Manitoba with unfortunate results. Competition is perhaps the most important factor in ensuring that there's quality and effectiveness in the provision of services. The absence of competition, which is what the proposed structure of the MSA will create, has brought many foreign states to their economic knees. Surely we should have learned from their ill-founded ideologies.

And why destroy the so-called commercial sector? On the one hand, government is saying it supports small business. But through the creation of the proposed MSA and the virtual elimination of the brokerage model, a significant element in the small business sector will be destroyed, and destroyed without any form of compensation, and its destruction will mean that consumers will lose the right of choice that is now available in the selection of a provider of home care and other services. Is this in the interests of the consumer?

What about the displacement of thousands of qualified workers and the loss of choice they now have in the selection of the organization with which they will work? Certainly this is not in their interest, nor is it in the interests of the consumer.

Ladies and gentlemen, there's much more I could say, but in the interests of letting you get on with your job, let me simply urge you, and through you the government, to:

-- Create a centralized referral service, but utilize the existing home care program structure for this purpose.

-- Don't abandon the existing brokerage model. It's a good model that embraces competition, and competition is the assurance for quality and cost-effective service provision. Combining a referral service with the direct provision of service in MSAs will serve only to create a costly and inefficient bureaucratic nightmare.

-- Don't destroy volunteerism and its tremendous social and economic contribution to this province.

-- Finally, don't for purely ideological reasons destroy the small businesses that are providing services, like agencies like mine. We have met and will continue to meet unfilled needs 24 hours a day, seven days a week, regardless of inconvenience of place. That has been an effective force in ensuring quality service, not just because of our dedication to quality service but because of the competitive influence we bring to the system, and that has not cost the ministry a single extra cent and that, in my instance, has and would continue to save the province's taxpayers many millions of dollars.

Thank you very much and I will be pleased to try and answer any of your questions.

Mrs Sullivan: I appreciate your presentation and the work that you've done, not only in health care but in other venues in the community that show in fact that even a commercial entrepreneur can be an involved citizen as well, and that's precisely the area I want to discuss with you.

In the hearings previously we have heard that the Ministry of Health has agreed to pay severances to those personnel from agencies who will no longer be able to stay in business, to the VON, to Red Cross and so on. They have not at this point made a public commitment to paying for assets that would be no longer used by those agencies when a new MSA came in, but I'm wondering if you would comment on the kind of policy approach the ministry is taking that says it will be prepared to pay for severances and possibly other costs. You've talked about expropriation. This is not an expropriation, because it appears to me that you wouldn't be compensated for the loss of your business. Would you comment on the kind of approach and the rationale, or the lack of rationality, in paying severances and other dislocation costs -- it may be pension plans, it may be wage parity issues -- that are involved, instead of putting that money into service provision?

Ms Thompson: To me, that's a waste of money, and I hope I answer your question. If not, you could correct me on it. I don't want compensation from the government to provide this service. I came out in this community because I saw a need for the service that I had to provide, and I don't see the forming of an MSA as being able to fill the gaps any better than what we're doing out here right now. If anything, it's going to be worse and confusing.

I don't want their money. I want to continue to provide a good, competent health care service in this community. My staff want to continue to work where we're working and provide that service. To take that money and spend it, to pay me off, to pay my staff off, when you can pay for the care that that consumer needs, the care that all of us are talking about here, 24-hour care, the care that people need to go home with an IV -- the money that home care needs to do that kind of service, take the money and do that with it. Don't pay me off.

Mrs Sullivan: Thank you. I don't need to ask any more questions.

The Chair: Thank you very much for your presentation and for coming before the committee this afternoon.

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CANADIAN RED CROSS SOCIETY, ONTARIO DIVISION: QUINTE BRANCH; KINGSTON AND DISTRICT BRANCH

The Chair: I call on the representatives from the Canadian Red Cross Society, Quinte branch. Good afternoon. I want to thank you for coming to the committee today. We have a copy of your submission, so if you'd just introduce yourselves, then please go ahead.

Ms Kay Summers: Mr Chair and members of the standing committee on social development on Bill 173, I wish I could address each of you by name here today.

Mr Villeneuve: Go ahead.

Ms Summers: I'd love to, but I'm afraid that's just not possible. And may I use this as a first-class example of what I think the results of Bill 173 may be if it's implemented without some major changes.

Supporting me today in my presentation I have Barbara Floyd, from Belleville, and Marilyn Connors, from Kingston. As well, we are supported by some Red Cross volunteers and a number of Red Cross staff people.

I'm Kay Summers. I'm president of the Quinte branch of the Canadian Red Cross Society. I would like to address you today about how I see the role of the Red Cross, the Red Cross homemakers and the Red Cross volunteers in our community.

In our community locally, our profile is very high. For example, March is Red Cross Month, and our Red Cross flag flies high over city hall during all of that month. We have a very high profile with United Way and in other parts of our community. We've had a sold-out fashion show as a money-raiser, and we're already planning for another high-profile community money-raising event in the future. We're hoping to have Big Ben's footprint on that contract.

Mr Villeneuve: He's retired.

Ms Summers: Yes, but we're going to use him as a money-maker for Red Cross and we've already made our initial contact with Big Ben. Glad to know you know who Big Ben is there. It's not London.

Public awareness at the local level is very high. My reason for emphasizing this is in relation to the volunteers. High profile locally; high response from volunteers. Therefore, to take away the Red Cross local connection and replace it with a government-run homemaker program, you immediately lose the profile and you will lose the volunteers.

Clients like to relate to their care givers, and they do relate to the Red Cross homemaker. The clients trust us and they want Red Cross homemakers to still be there for them.

At present, the Red Cross home support service has a core of 10,000 volunteers and a staff of almost 6,000, the majority of whom are women. Do you think this core of 10,000 volunteers will transfer their loyalty and their support to a provincially run organization? I do not. Mr Wilson, I believe in Simcoe county you have 1,000 Red Cross volunteers. I don't think they'd transfer their support.

We, a taxpaying population, need to keep as many organizations volunteer-based as possible. We cannot afford to pay for all the services volunteers are now doing, and this relates not only to home support and homemaking but to all health and community services. You have to keep a strong volunteer base, and to do that you must keep the volunteers connected with an organization that they trust and relate to, the Canadian Red Cross branches.

The Red Cross wants to remain a part of long-term care. Based on our fundamental principles, we must maintain our identity and independence. Bill 173 must be changed to allow this to happen.

Ms Barbara Floyd: I am Barbara Floyd. I'm the volunteer chair of the Quinte homemaker branch. I like to call myself the voice for homemakers throughout Hastings and Prince Edward.

There have been many presentations to this standing committee on social development on behalf of the Canadian Red Cross Society, and I would like to provide for you further insight about Red Cross homemakers from my own experience, an explanation of some of the Canadian Red Cross involvement in the long-term care development process and the assistance which has been provided in the analysis of ministry documents -- and, as we all know, those have been many -- and, thirdly, a reaffirmation of points for your consideration.

I'd like to give you a little bit of my background, as other speakers have said they included their CV. I didn't, but I think wearing this many hats has made me very, very interested in this whole process. My background is as a home economist-nutritionist, and I was involved in gerontology both at the university and college level in Toronto. This led me to volunteer as chairperson, and I've been that chairperson for six years. I'm also the Ontario east-central representative to the Red Cross. Therefore, I attend the Ontario division homemaker services committee, and at those meetings I've heard so much about what's happening in long-term care all across the province. I have been actively involved for the last year and a half as a south Hastings provider representative on the Hastings and Prince Edward long-term care committee. I also chair the seniors' subcommittee, and that subcommittee -- any of the subcommittees -- study the long-term care issues from the different population group perspectives, and then we report to the long-term care committee.

However, today we will focus our remarks on the services that as Red Cross we provide in the areas of Simcoe, Muskoka, Haliburton, Victoria, Peterborough, Northumberland, Hastings, Prince Edward, Lennox-Addington, Frontenac, Kingston, Lanark, Leeds and Grenville. We've heard from many areas like that today.

In this geographical area, the Canadian Red Cross Society employs approximately 1,500 homemakers, providing almost 1.3 million hours of service to 18,000 clients this year. The support staff is made up of 80 full-time equivalent positions.

From my experience when I first joined Quinte and went to the in-service meetings that the homemakers attend, one of my first comments was, "I can't tell you how I felt being with 100 very warm and caring women." It was a marvellous feeling, and that can only be created by the supervisors and the clerks in the office. They help to create that atmosphere, as they often go the extra mile in serving our clients and assisting the homemakers in providing a high quality of service.

I thought of an example to give you of the responsiveness. We had a weekend client. On the Saturday morning, the homemaker called in and said she was ill. We have a supervisor on call, who had to find another homemaker in that same geographic area, and as you know, we go from Lake Ontario to Algonquin Park, so one has to consider mileage etc. After a number of phone calls, yes, we found a homemaker who happened to be on a visit with her parents but, yes, indeed she would go and fulfil that role. They are certainly to be admired.

For 75 years, the homemakers have been ambassadors for the Red Cross for all its programs throughout all the areas served in Ontario.

Now, thinking of the time -- and I know you people have been here all day -- I thought perhaps we would just move on. You can read section 2. The point I was trying to make there was that I wanted to emphasize the geographic challenge as well as the way we have tried to work, the interrelationship between Red Cross, the long-term care committee, the local branches, the province, and the fact that we've been meeting with other providers throughout Hastings and Prince Edward.

My final statement under that section 2 is that the challenge has been to understand the needs of the client, the diversity of existing personnel and services and to combine the expertise and goals of the provider agencies, including the Canadian Red Cross Society, with the long-term care plans of the ministry. I would really like to know if there aren't ways by which Red Cross services could stay in this long-term care system. So I thought of that, and the factors I felt were important for this committee to address and to think about and hopefully relate to some of the information which I've included. The first had been mentioned often before, flexibility.

The legislation and the regulations need to be flexible for the individual communities to design a system that fits and responds to the needs of the community. For example, as the system is presently structured, homemaker service is funded on an hourly basis. If the funding envelope could allow for block funding, the hands-on provider would be better able to decide with the client on how to address their needs.

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I'm referring to this, which was the cover of the presentation that you received, and in the second recommendation there, which is on the second half of fact sheet 1, ask that the legislation be reworded to remove limits on the amount of service that an MSA may purchase. This allows each community to determine the best mix of services available for its citizens.

Our third recommendation there is that it would provide communities with the time they require to create a design that best suits their needs.

After flexibility, I'd like you to consider the human and economic resources. Greater consideration needs to be given to the effect on the workers and the cost of facility and equipment changes in what Douglas Jackson, from the office of the special advisor on MSAs, sent out on August 22, calls "the integration of existing services." For instance, some changes may take longer than the four years allowed in the legislation, but perhaps some of the interim models that are set up could even be made permanent. There must be wise use made of all resources.

The complex task of long-term care reform has been under way for many years. So many principles of the reform are widely supported by the Canadian Red Cross. In committees, we've discussed the strengths and weaknesses of our present system. As an aside, I was intrigued when Community Support mentioned its list; we were in on that discussion. So you've already heard part of that. As we continue to meet throughout Hastings and Prince Edward counties, suggestions will be made as to how to implement one-stop access, information sharing, delivery etc. We look forward to being a participating partner in the delivery of long-term care services as part of the reform process. However, as has been said so often before, as Bill 173 is presently drafted, the Canadian Red Cross Society would be excluded.

Presenters for Red Cross across the province have identified a number of initiatives that would increase the efficiency and effectiveness of service provision. I have added my thoughts on factors that should be considered. The Canadian Red Cross volunteers and staff are willing to assist and to discuss ways of implementing our proposed suggestions for change. The Canadian Red Cross Society wants to continue to participate in the planning and to be part of the long-term care service delivery. Marilyn?

Ms Marilyn Connors: Hi, everybody. My name is Marilyn Connors. I'm a Red Cross volunteer and a member of the Kingston and district branch homemaker advisory committee.

I would like to briefly outline some insights into service provision in the surrounding areas. In the Kingston area, the Canadian Red Cross Society has been a vital element since 1900. At a recent district health council consultation, participants were heard to say that they want community agencies to continue to exist and to be part of the long-term care system. It has also been clearly identified in this community that choice of service provider is important to the consumer. In Kingston, the Canadian Red Cross has provided leadership, initiating community discussion and planning for enhancements in access and coordination of services.

The Kingston district includes a large rural area. This presents an ongoing challenge to service provision. In this district, we experience an ongoing deficit because of the significant cost of travel in our rural areas and to the three islands that we service. The Red Cross made a provincial decision to provide payment to homemakers for transportation costs. As well, in keeping with our fundamental principles and mission, we provide services where help is needed, not just where it is cost-efficient.

Homemaker service has been provided in Lanark, Leeds and Grenville since 1961. Currently, we are working towards collaborating with other service providers, including home care, VON, home support services and attendant care, in an effort to improve access and enhance the services to our communities. One of these initiatives is a shared care project within a non-profit housing complex. Shared care increases flexibility and is more cost-effective. Through the use of a team of homemakers, fewer homemakers are able to provide services to the same number of clients by streamlining the duties. Also, we have embarked on discussions to reduce duplication of case management of integrated homemaker program clients. This will improve coordination of service to the client and reduce costs.

In the Brockville area, key providers have been working together for several years to improve community services. Our accomplishments include a generic home chart, streamlined assessments and community-wide protocols for caring for clients with AIDS and DNR.

In conclusion, the Canadian Red Cross Society is proud of its homemaker and home support services. The Ontario division genuinely hopes that changes brought about by long-term care reform will not preclude us from continuing our over 75 years of providing services to our communities. Through our comprehensive range of programs, we are fulfilling our mandate to support the frail and vulnerable, enabling them to live with dignity and as independently as possible in their homes.

We are also proud of the Canadian Red Cross's contribution to the professionalization of the role of the homemaker. This occupation, primarily filled by women, continues to evolve. We are the largest employer of homemakers in the province. We are committed to continue to provide leadership to the industry, setting standards through our comprehensive provincial programs for quality management and risk prevention and our educational programs and resources.

The Red Cross is ready to play a constructive role in the future of community-based services within Ontario. We have demonstrated our willingness to cooperate with other providers to improve services in our communities. We have identified a number of initiatives that we feel would increase the efficiency and effectiveness of service provision and are willing to provide leadership in implementing these changes. We sincerely hope that the legislation can be amended to allow us to continue to provide home support services and homemaking to the people of Ontario.

Mr Jim Wilson: Thank you very much for your presentation. This being near the end of the second-last day of hearings, this may in fact be the last time in the history of Ontario that the area of the Canadian Red Cross that you represent will be making a presentation outside of Metropolitan Toronto, because you may not exist when this legislation comes into place. I'm very cognizant of that, as are my colleagues.

Kay, I thank you for reminding me and in fact Mr Wessenger, the parliamentary assistant to the Minister of Health, who also represents Simcoe county, that we have 1,000 volunteers. I think, Paul, that most of them are in my area, because, as you know, we both attend their volunteer appreciation luncheons each year and say thank you to them on behalf of local residents and the province. I hand out pins to the ones who actually live in my area, and I think last year I gave out close to 600 pins to people to show our appreciation. I didn't know this was coming down the pipeline. Had I known, I might have taken the opportunity to get a grass-roots demonstration going or something.

With this bill, I'm not sure how much hope there is that the government is going to change its mind. Things that you mention, like the 80-20 rule, as far as I can tell, the government thinks that's key. It's certainly driving the private sector out of business; they did it in day care. That's key to them, and I can't see them changing their minds on that. We are going to try, and we're going to introduce amendments.

How we deal with volunteers and the loss of volunteerism that will result from this bill: I think the evidence is overwhelming in the three weeks of public hearings that MSAs will not be structured, according to this legislation, so that they can retain the individual identities and the heart and soul of all those agencies.

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Red Cross has made it very clear to us, at all levels of the Red Cross, that the corporate structure of the Red Cross does not allow it to become part of the MSA. So on that front, how will the services in the areas you represent possibly be replaced if Red Cross and commercial agencies and other not-for-profit agencies are simply driven out of the delivery of home support and homemaking services? How are the people going to receive those services if Red Cross doesn't blink? I wonder if the government is playing a bit of a game here. Do they want Red Cross to change its corporate structure, to buy into the MSA? Who's going to blink?

It's a very dangerous game, because I just can't picture how in the world government is going to replace all the services and the volunteers and the dollars and the fund-raising dollars that you people represent. So you tell me what they tell you in response to that, and I'll judge whether it's credible or not from the government's point of view.

Ms Floyd: I'm not sure I exactly know how to answer, if you want me to answer. I heard the VON presentation today. I'm now wearing my long-term-care hat. I don't know if any of you realize what a challenge it is to have sat in on all the long-term care deliberations and read all the documents and so on and have still said to myself: "Please, we've got some great Red Cross homemakers. How can we keep them in business?" Can I go to a Red Cross homemaker meeting and try and explain it to them? That's a tremendous challenge that I haven't honestly faced yet.

I wondered -- I don't wonder, I wish that more serious consideration could be given to an integrated model so indeed -- with some legalese that I'm not quite familiar with in the Corporations Act, and the fact that Red Cross is incorporated, there are other people in the room who probably can answer this a little more clearly than I can -- the Red Cross and our other provider agencies would be able to at least receive some block funding and continue to provide the service. Does that answer a little bit of what you're hoping that we might be thinking about? Can I take it another step with the long-term care?

Mr Jim Wilson: Sure.

Ms Floyd: I know from the deliberations that we are holding -- we are going to now have six or seven meetings throughout Hastings and Prince Edward, Belleville, Bancroft, Picton and so on -- we want the grass-roots input. Knowing our homemakers and being a bit of a care giver myself, I know what some of that input is going to be. They want the service locally, as it's now provided.

Are there not some ways that our community support agencies can also still maintain some of their identity and allow those volunteers, as we keep calling them, to be able to identify more closely? If you've got somebody who's a transportation person who lives on rural route 8, and so and so needs a ride, can't that person still be the one who's going to provide that transportation? Those kinds of things.

Mr Jim Wilson: Well, all I can assure you is that we're going to do everything we can, and we've already talked to legislative counsel -- not the one represented here but the ones that work for members at Queen's Park -- to try and see what we can do in a technical way with the bill to ensure that Red Cross can be part of the MSA. I don't know how you preserve individual identity.

You mentioned Simcoe county. We've gone through municipal government amalgamations with regional government, essentially, now. When you amalgamate places or integrate them or whatever bureaucratese you want to use in this day and age, they lose their identity. There are many places in regions in Ontario, again using the municipal model, that simply don't exist any more. I think of Galt; the sign is not up any more.

Mr Conway: There should be a state trial for that man, Darcy McKeough.

Mr Jim Wilson: All three governments have gone through this. We just fail to learn, and I think people are fed up. I think, and perhaps you'll back me on this, when you get out there and you go to those meetings that you're talking about, all hell will break out with people. There is no way I can picture that the 1,000 volunteers in Simcoe county are going to let Mr Wessenger away with bumping the Red Cross or me away with having any part of it -- and I'm trying to do everything to prevent it -- or the government away with bumping the Red Cross and the VON and everybody else out of business. When people get word of this bill, all hell is going to break out in this province. I think Mr Conway was alluding to that earlier. Do you think we're going to see, finally, the people say, "I've had enough of this stuff"?

Ms Floyd: At this point, I don't think they even realize what's happening. I do a lot of talking, and even with my own bridge-playing friends I try to say, "Do you realize how this is going to affect you?" We've got such a big advertising job to do. Who is going to do it? We don't want to promote our own demise.

The Chair: I'm sorry that I have to jump in. We have one more presenter, and then I'm afraid we have to get to the railway station. On behalf of the committee, I thank the three of you for coming before us and making your presentation this afternoon.

Ms Floyd: Thank you very much for your time, and I wish you well in your deliberations.

MARIE FLOOD

The Chair: I call upon our final presenter, Marie Flood. Mrs Flood, thank you very much for coming before the committee this afternoon.

Mrs Marie Flood: First off, ladies and gentlemen, thank you, all of you, because I'm one of the ones you have helped, and I totally agree with everything that you've said here today. They are not going to get away with this.

The Chair: Mrs Flood, could I just ask you -- because of the Hansard reporting, that might not have been recorded.

Mrs Flood: Yes, sir.

Mr Conway: People call him Charlie.

Mrs Flood: Charlie. My name is Marie Flood. I live in a small farming community called Plum Hollow. I'm the mother of six adults, and I've eight grandchildren. I do not belong to any organization that these people here belong to. I have been a homemaker and a care giver for 39 years in my own home.

In 1981, my husband, Bernard Flood, took ill, and over the next 13 years I was the prime care giver. On July 31 of this year, Bernard passed away in our home, with lung and brain cancer. In one year, I watched my husband go from a 201-pound man to less than 80 pounds, with a lace of skin over his bones. I'm here today to speak on behalf of my husband, my friends and my neighbours.

We need changes in our health care in the farming community. The VONs, the Red Cross homemakers and the home care are our lifeline to the outside world when we have someone who is housebound. These girls are handicapped by rules that don't apply out in the country; they might work well when you live in a city or a town.

I did not know about this piece of paper. I was just handed it just a little while ago. I didn't realize that you were trying to get rid of the Red Cross homemakers, you were trying to get rid of our VONs and you were trying to get rid of our homemakers. I'm furious. I'm just furious to think that you would do such a thing.

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We need changes, but we don't need the type of changes that you're going for. We need nursing practitioners out in the country. This would be an asset to our VONs. We need better access to medications such as heroin and morphine for cancer patients. We need our VONs so that they can sign a death certificate instead of waiting six hours for a doctor to come to our homes, and maybe even a little bit longer than that, because, you see, doctors who live in the city don't like to come out on holiday weekends. If your husband or a loved one dies at 12 o'clock at night, they expect you to keep that loved one there in the home until 6 o'clock in the morning.

Red Cross homemakers: I don't know what I would have done without them. They chased me out of the house when I wanted to stay. I don't know if any of you have ever been in the position that I have been in, but they give you a sense of being. They're there to give you that little extra push you need to go to town. That's fine for people in the city; they can just get in their cars or they can get on a bus and go to town, but people in government forget that the ones of us out in the country have to travel a long way to get to town. My nearest town is 11 miles away. My nearest city is something like 35 miles away. So if I go to town and a Red Cross homemaker cannot give my husband his medication, it means that if I leave at 1, I have to be back at 2 to give him his medication, because the law says that the Red Cross homemaker is not allowed to give out meds now. These girls are trained for this, but this has been taken away from them.

We need paramedics in the country. You don't need them in downtown Ottawa or downtown Toronto. My, you've got hospitals all over the place. We need them here. We need our ambulance drivers and our firemen to be trained as paramedics. We need more places for helicopters to land to take farmers or their children who have been hurt by machinery into town, into big hospitals like Ottawa or Kingston for proper care.

I don't know whether you know this or not, but people out in the country are tied down to ambulances going to certain hospitals. At one time my husband was very ill in this past 13 years, and I had him home. I was told by our family doctor that if he took sick during the night, instead of calling the ambulance to my house, to put my husband in the car, drive him as far as Seeleys Bay, and the Seeleys Bay ambulance would then take him to the hospital that he needed to go to, where his records were. You see, where I live, if I call an ambulance, they would come to my house, but first off they would take him to Brockville and then they would transfer him into Kingston, which was a waste of time. When my husband needed care, he needed it that minute. He didn't need it three or four hours from then.

These are things that city people don't think of. Our medical centres out in the country I would like under some kind of a blanket coverage where they all work the same, so that they can interact. We have doctors out in the country who don't have privileges at certain hospitals. This does not do country people any good. It just doesn't work. I mean, if we're in one part of Leeds-Grenville --

The system isn't working for us; it just isn't. Sickness doesn't stop at 4:30 on Friday afternoon. If any of you have children, you know that, or if you have sick loved ones. We need better access to medical care on the weekends. If Bernard had lived the day of the 31st, our VON would have had to travel for 40 minutes to pick up vials of morphine at the psych hospital in Brockville, because there were none available anywhere out our way, not in any drugstore. Things like this have to be looked into.

Doctors do not prescribe heroin for cancer patients because they might become addicted. When you're told this 11 days before your husband dies, there's another thing that's wrong with our health system. There's something wrong. It's just not right.

My own feelings? I'm going to work with Svend Robinson now and I am going to fight for euthanasia. I don't want another human being going through what my husband went through. I think common sense has left and education has taken over. I was raised that if you used common sense and you used your education as a tool, you would end your life in good shape. I think a lot of you, if you stopped and used your common sense, you would do a lot better.

If you want the ones of us who are looking after our sick people, our sick loved ones, to do it at home, then you leave our VONs, our Red Cross homemakers and our home care alone, because I'm telling you, if we have a change and we don't have women or men coming to our homes whom we know and we trust, you are going to have the biggest uprising that you have ever seen, and I will start it. I'm not threatening -- yes, I am threatening. Yes, I am, because I'm that mad. If you want us to keep them at home and you don't want them going to the hospital, leave our services alone.

I'd like to thank you very much.

Mr Martin: I want to thank you very much. You certainly tell a compelling story. I guess I couldn't think of any more effective way of painting the picture that we as a government look at as we try to get our heads around how we better deliver services to all of the people who live in every corner of this province.

You've obviously pointed to some areas of some very real concern, areas where there are shortcomings, where there needs to be enhancement of program delivery. In fact, believe me or not, that's what this piece of legislation is about.

I would ask you, Mrs Flood --

Mrs Flood: I don't think so.

Mr Martin: -- to be wary of those who would tell you differently, be wary of those --

Mrs Flood: No.

Mr Martin: -- who have agendas of self-preservation as opposed to --

Mrs Flood: I'm not listening to anybody with self-preservation.

Mr Martin: -- an agenda of trying to better the services that we now have, that are in themselves very good but are not in many instances adequate.

I'm a politician. I'm a part of this government. I'm a son of two elderly parents who are dependent on home care. I know the commitment of the people out there who work for Red Cross and the VON. They will not be turfed out or left out of the equation. In the end, if local people under the guise of the district health council and the long-term care planning committees that are formed by them, members as well who live in communities, decide that another organization that will be more coordinated and efficient is the one that will do the job best in that area, those people will work for that organization and will continue to be as committed as they are now in the delivery of that program.

I guess the only question I would have of you, Mrs Flood, is, what is it that you see that we're doing re this piece of legislation that will in fact not do that?

Mrs Flood: I think you're wasting money. That's the biggest. I think that you really don't have any idea; you don't have a clue. Have you ever been to Princess Margaret Hospital? Have you ever been to Henderson hospital in Hamilton, Mac hospital? Have you ever been out in the country and walked into a living room that's been made into a hospital room?

Mr Martin: As a matter of fact, I come from Ireland, Mrs Flood, and we used to have wakes in the living rooms of homes, you know? So I understand that.

Mrs Flood: No. No.

Mr Martin: I understand the culture of that particular piece of --

Mrs Flood: You see, you have made up your mind. You have made up your mind what you're going to do. I have made up my mind what I'm going to do.

Mr Martin: I would hope, I guess, that it's based on the truth.

Mrs Flood: Common sense.

Mr Martin: And common sense, yes.

Mrs Flood: Common sense. That is the key word: common sense.

Mr Martin: And you would choose to work with your local district health council and planning agency as they grapple with the questions of how we improve the system so that everybody gets good service.

Mrs Flood: But we don't need -- what do we need? What are you planning to give us that we don't have already except --

Mr Martin: Well, you listed a whole pile of shortcomings in your presentation.

Mrs Flood: Now I want to add a thing here. What are you going to give us except a telephone number, one telephone number that we can call? Here we are again: When you call a health system, you get an answering system that says, "If you will hold" -- they don't tell you for 25 minutes -- "you will be the next on the list to be answered." Then you get on to another telephone line and somebody else says, "We're sorry, but we have nobody available right now, but if you will hold..." You're telling me that you're going to have enough people on the end of those lines to look after our needs?

The Chair: I think you've made your point very clear. At this point, Mrs Flood, on behalf of the committee I thank you for coming and making your presentation at the end of our hearings here in Kingston.

If members would just remember, please: Tomorrow morning, 9 o'clock, we begin our hearings again in Toronto.

The committee adjourned at 1713.