Legislative Assembly of Ontario

The House resumed at 8 o’clock, p.m.

Mr. Chairman: Before we start the business of the evening, the Chair will recognize then hon. member for Algoma.

Mr. B. Gilbertson (Algoma): Mr. Chairman, I take great pleasure in introducing a class of grade 8 students from C.O. Somes Public School in Batchawana Bay and also some students from Searchmont, Ont. Those in charge are Mr. Hutton and Mr. Grlbich and we have Mrs. Sunstrom as well. I would hope the members would greet them at this time.

ESTIMATES, MINISTRY OF HEALTH

Mr. Chairman: The hon. minister.

Mr. M. Shulman (High Park): You are not going to start without a quorum, are you?

Hon. F. S. Miller (Minister of Health): Mr. Chairman, I’d like to open my estimates with a statement that will outline very briefly --

Mr. Chairman: Order please. Is the hon. member for High Park calling for a quorum?

Mr. Shulman: I was asking if there is a quorum.

Clerk of the House: Mr. Chairman, I see a quorum.

Mr. Chairman: The hon. minister will continue.

Hon. Mr. Miller: I’ll start over again, Mr. Chairman. I’d like to open my estimates with a statement that will outline very briefly some major changes that have taken place in our programme during the past year.

I expect the members are familiar with the World Health Organization definition, which says: “Health is not merely the absence of disease or infirmity but a state of complete physical, mental and social well-being.” That’s a definition we accept. Here in Ontario we are fortunate in being able to work from the premise that the well-being and prosperity of the province require every member of the community to be able from birth to old age to live under healthy conditions with the right to prompt and proper treatment for any sickness or injury. To make this possible the provincial government in Ontario takes responsibility for all essential health services, not only for the general community but for the individual resident.

In recent years, as the members will be aware, the rate of increase in health costs has become a matter of considerable and justifiable concern over consequences of disproportionate increase in health costs compared to our rate of economic growth and development. Cost effectiveness has joined humaneness as one of the essentials of our health care system.

Health care in the past decade has undergone considerable change. There was a time not long ago when health care could be defined in terms of the sick -- those with pains, ailments and clear manifestations of disease. What we called health care was really sickness care. To a marked degree the health care system in any community revolved about the acute treatment hospital and it was that hospital which somehow had to respond to the immense range of illnesses and discomfort to which the human is liable. But definitions are changing. People’s expectations are changing.

This is not to criticize the health care system of the past because, despite its faults, it has given us one of the highest standards of health care in the world. But we will have to look to other ways and other personnel to share the load.

For generations hospitals have been filling in where others should have been active. In our dependence upon the acute care hospital we have only recently begun to develop the alternative care facilities we now see as necessary: Chronic care in nursing homes; ambulatory and outpatient care programmes; home care services; extended care facilities; more effective use of allied health personnel; promotion of more healthful living; and the many new initiatives to which our ministry has been addressing itself.

We’re all aware that a prime reason for a large amount of the skewing in our health care system has been the limitations placed on cost sharing under the terms of the federal Hospital Insurance and Diagnostic Services Act and the Medical Care Act. Discussions are taking place with Ottawa, hopefully to arrive at a more equitable sharing.

Let’s not make the mistake of thinking that by stimulating development of these alternatives the acute care hospital will ever cease to be a major focus of our health care system. In trying to hold down the cost of acute treatment services, we must continue to take the initiative and introduce measures for greater efficiency and cost reduction.

We are proud of our health system in Ontario. But I think it is important for us to recognize that it’s as comprehensive as it is because Ontario, economically, is one of the best favoured provinces of a well favoured nation. In other words, I am well aware that -- compared with many other nations of the world -- we start with many advantages on our side.

We in the ministry are trying to promote health as something more than the absence of illness of disease. We are making every effort to stimulate people to assume more responsibility for the state of their well-being.

Mr. A. J. Roy (Ottawa East): You know that is not true,

Hon. Mr. Miller: We have the resources and the brains to become the healthiest --

Mr. Roy: That is not so.

Hon. Mr. Miller: You be quiet. I’ll listen to you.

Mr. Roy: Oh yes, but don’t give us --

Mr. Chairman: Order, please!

Hon. Mr. Miller: -- the healthiest people in the world, yet, judging by most conventional parameters, we are far from being the healthiest, and thousands of our people continue to die prematurely from diseases and circumstances that are largely avoidable,

The members have knowledge, Mr. Chairman, of the growing extent and insidious effects of poor nutrition, poor dental habits, obesity, indolence and alcohol and other drug use among our young people -- people who should, physically and emotionally, be operating in high gear. And you know very well they are not.

I must admit that I can’t look casually at this waste of human resources and at the ruinous economic spinoffs that impact on our health care system. Consider all the positive things we could do in terms of dental care, acute care, chronic care, disease screening, outpatient treatment, ambulatory care, geriatric services, and so on, if we could be diverting, for these purposes, the funds now being absorbed in the care and treatment of patients with avoidable illnesses.

We squander our health as if it is an unlimited resource.

We can’t compel people to change. It is a free society and if the host thinks the highest compliment he can pay his guest is to drink him under the table, then there isn’t too much we can do about it except to try to change his behaviour.

Health promotion is an elusive task. We can have all the information it’s possible to summon, but unless we get people that respond to that information, to accept its meaning, and to use it to improve the way they live, we are not much further ahead.

The key to successful education for health promotion is attitude. What attitudes do we hold, or do young people hold in respect to health? How valuable is good health?

In Ontario, preventive health programmes have received emphatic support from the ministry. Health protection and health promotion programmes delivered on an organized community basis are efficient ways of delivering preventive public health services -- preferably one that involves the health professionals.

To do this, Mr. Chairman, we need a more equitable distribution of medical manpower. We also need a better balance between families, physicians, and specialists than we now have. But I believe both objectives can be obtained without any sudden major upset. Continuity of health care is absolutely essential and, even though we have to bring about some changes in direction, we’ll be taking care not to rock the boat unnecessarily in the process.

Mr. Roy: At least not before the election.

Hon. Mr. Miller: Go talk to them in Windsor and see whether I am taking steps before an election that you think I wouldn’t. Just ask your comrade on your right-hand side there.

Mr. B. Newman (Windsor-Walkerville): We will discuss that later.

Mr. Shulman: What steps are you taking?

Hon. Mr. Miller: There doesn’t seem to be much doubt that the two areas of health care posing the greatest threat of runaway costs are first, those created by unrestrained cost increases in the hospital system, and, second, those represented by the uncontrolled size, variety and distribution of health professionals, both in the primary care and secondary care sectors.

As I am sure most members are aware, at the joint meeting of the federal and provincial Health ministers in January in Ottawa I was able to raise and successfully carry the point that some sensible system must be introduced to handle the uncontrolled immigration of doctors.

In terms of overall medical manpower, Canada already has a higher number of doctors for every thousand of population than most other countries and that’s particularly true for Ontario.

Some people interpreted this very necessary action as a move to reduce the number of doctors in practice in the province. Far from it. We expect the total number to show a gradual increase, to maintain the present ratio. That’s roughly one to every 575 people.

As a result of the adoption of Ontario’s proposal concerning the flow of immigrant physicians, the occupational demand rating used to assess applications for immigration has been reduced to zero for physicians.

This adjustment is an interim measure, of course, pending detailed discussions with each province. Its effect is to require immigrant physicians to show evidence of arranged employment acceptable to the ministry, or to proceed to a destination designated by the ministry as in need of their services, in order to have their application for immigration approved.

Discussions are being held with the federal authorities to make the necessary arrangements so that all job offers to immigrant physicians be referred to the ministry for approval before they are confirmed for immigration. This will enable the ministry to be informed of foreign graduates who wish to enter the province and to determine whether or not Canadian physicians are available to fill vacant positions.

This, of course, is a highly sensitive area, Mr. Chairman. It is our intent to discuss it fully with all professional bodies concerned as it develops.

Finally, Mr. Chairman, I’d like to say a word about this government’s new approach to the protection of Ontario workers and residents from occupational and environmental health hazards resulting from industrial activities.

Members will recall the recent announcement of the Provincial Secretary for Resources Development (Mr. Grossman) of the formation of an advisory council on occupational and environmental health matters. This body will provide the formal mechanism for industry, labour and other interested parties to advise government on health hazards and to recommend new policies and programmes. It will assist government in defining how health safeguards can be engineered into plans at the design stage and it will be a central reference source for public information about all aspects of occupational and environmental health.

Occupational and environmental health, Mr. Chairman, is a field in which the government can never be entirely proactive but in which it should, nevertheless, exercise control. Such an advisory council is a means of recognizing shared involvement, of ensuring that the interests of all concerned are considered when standards and guidelines are questioned and of visibly displaying a mechanism that is kept current on won developments and able to advise the government on these.

The mechanism should be viewed as an active means of reviewing particular concerns raised by any group, including referring studies the government would like to see conducted.

Terms of reference, Mr. Chairman, are being developed by my ministry, at present, and the project is proceeding on schedule. In this, my ministry is working closely with the Ministries of Labour, Natural Resources and the Environment. We expect this to eliminate a good deal of the fragmentation previously evident in this field.

The last thing I want to do, Mr. Chairman, is to leave the impression that the ultimate purpose of changes in direction taking place in the field of health is cost constraint. It goes beyond that.

The need to restrain costs has forced us all to be a lot more imaginative, innovative and productive. As we face constraints, we must be ever more judicious in the use of public funds. There is no way we can avoid seeing the handwriting on the wall. The public is demanding more access to better health care, and it is holding the trustees of the health care system to better account for the use of those funds. And, Mr. Chairman, that is how it should be.

Mr. Chairman: The hon. member for Ottawa East.

Mr. Roy: Thank you, Mr. Chairman. You know, at one time, when we were hem critical of the Ministry of Health, we had a better target for a minister. I can recall that in the days of even Bert Lawrence and the member for Quinte (Mr. Potter), we could get at them. In fact, a response was more instantaneous or reactionary because of their very nature. But this minister is a congenial fellow, trying to get by on his charm; and he has succeeded. He has succeeded in keeping the lid on in the area of health. He has a nice smile except occasionally when he has his picture in the Globe and Mail, following Webster’s column -- he looks tired; in fact he looks a bit sick.

Mrs. M. Campbell (St. George): Lovely bow ties.

Mr. Roy: Yes, lovely bow ties, the whole bit. And I suppose the Premier (Mr. Davis) should be grateful to him for that, that he has managed to stay out of trouble personally. Because of his charm he has managed to keep his ministry out of any contentious matters.

Mr. J. A. Renwick (Riverdale): Where have you been?

Mr. Roy: His remarks here this evening are typical of those that emanate from him. They suit him very well when he reads carefully and has something prepared. He mentions, for instance, the definition of health:

“Here in Ontario we are fortunate in being able to work from the premise that the well-being and prosperity of the province require every member of the community to be able from birth to old age to live under healthy conditions, with the right to prompt and proper treatment for any sickness or injury.”

But, you know, he really hasn’t said very much. He talks about total well-being. He uses the World Health Organization definition, which says that “health is not merely the absence of disease or infirmity, but a state of complete physical, mental and social well-being.”

Frankly, he has not approached the problem that way -- at least, we have not seen concrete programmes to do so -- even though he says that he has. I intend, Mr. Chairman, to deal with some of these matters.

The first thing I would like to ask the minister is: Where is his annual report from the Ministry of Health for this year? We mentioned it last year; we mentioned it the year before. I think when we are dealing with something like $2.9 billion from taxpayers we should be able to see the report prior to the estimates. You and your predecessors have consistently failed to do that.

In fact, I think last year we got the report sometime after the estimates were over.

I suppose I should congratulate the minister that at least this year we are having the estimates of the Ministry of Health when we still have some -- what? -- 50 hours left in the estimates. I think last year we bad something like six hours, four of which we had to devote to Health and two to Education, or something.

In any event, I think, Mr. Chairman, that it is an insult to those of us in the opposition and it is an insult to the members of this Legislature to be faced with a situation of discussing $2.9 billion in expenditures and not have the annual report of the Health ministry. It is just as though you consistently work your way into a situation where you can do that.

Mr. Chairman, we should point this matter out repeatedly, because this is not the only ministry doing it. My colleague, the member for Downsview (Mr. Singer), pointed out in the Ministry of the Attorney General we did not have that ministry’s annual report either.

Mr. Chairman, I think it is the responsibility of the various departments and ministries to provide reports when they are proceeding with the expenditure of this kind of money, and especially when the Health estimates are not all that detailed to start with. There are only six pages of all these estimates. I quite appreciate that the big bundle is in the area of the hospitals and in the area of OHIP premiums for health insurance. Nevertheless, Mr. Chairman, I think that it is to be pointed out that the critics of the various ministries are not being well served when they are consistently being denied the right to see the annual report of various ministries prior to the estimates.

In fact, I would think that if this government practised some of the dictums of the Premier about full disclosure and the right of everybody to know what is going on, we would all have a book like the minister has sitting in front of him, and which all his officials have in front of them. He has a barrage of civil servants sitting back under the gallery and in front of him and they all have large texts and a breakdown of figures. Why can’t the opposition have something like that to follow the estimates?

Mr. Shulman: Some ministries do it.

Mr. Roy: It may be, but I’ve never seen it. And I would have thought, Mr. Chairman, when we’re discussing spending this kind of money that we would have something like this.

The other matter, I think, that has to be mentioned is the notice we get for these estimates. I suppose the fault of that lies with the House leader, and that’s par for the course for him. We found out some time late this afternoon that we were going to be discussing the Ministry of Health estimates.

Mr. Renwick: It was last Friday morning.

Mr. Roy: Surely, Mr. Chairman, we should have more notice than this. I’m sorry?

Mr. Renwick: It was last Friday morning.

Mr. Roy: Last Friday morning. The critics certainly were not advised by the ministry that the estimates -- even last Friday is not very much notice to prepare for estimates of this size. I think this is a consistent policy on the part of the government to try to get through the estimates as easily and as simply as possible, and to avoid some measure of criticism.

The minister, in his opening statement, talked about costs. We have been talking about costs, I suppose, for three or four years now -- about constraint packages and programmes and so on. There’s a lot of talk about it -- I’ve repeated this in the last two or three estimates -- but there’s very little done for cause. I look in the estimates for 1973-1974, where the actual expenditures for this ministry were $2.2 billion, and in 1974-1975 they jumped something like $500 million. Now in 1975-1976 we’re up another $400 million.

Mr. Shulman: Just wait till next year. I’m going into full-time practice next year, and it’s going to be worse.

Mr. Roy: Who’s in full-time practice?

Mr. Shulman: I’ll be in full-time practice next year and they’re going to be in real trouble.

Mr. Roy: Even you could not affect the estimates of Health that much. Even full time you wouldn’t be making much more, would you?

Hon. Mr. Miller: I wouldn’t count on it.

Mr. Shulman: I’m going to try.

Mr. Roy: In any event, Mr. Chairman, the expenditures again this year are increasing 17 per cent or 18 per cent. And whatever programmes the minister talked about in his statement -- and I intend to mention some of them -- we certainly don’t see their reflection in the estimates.

I quite appreciate that on the hospital side, where you have such large expenditures in the area of manpower and you’ve been faced with increases in salaries for the nurses and hospital workers and so on, that it becomes difficult. But the innovative programmes that the minister talked about concerning the complete health and well-being of the individual, we have not seen. I intend to talk about some of these programmes that the ministry could have gone into, and has backed off from strictly for political reasons.

It is small wonder that the Premier is forced into the situation of having to comment, for instance, on the dental care programme and say, “We just can’t afford such a programme.” The way he’s running the province, and the way this minister is operating the Health ministry, I agree there’s just no way we can afford a dental care programme.

We discussed this matter at 5 o’clock, and we as a party pointed out we could have had such a programme if certain measures had been undertaken. That’s the sad part of it. Because there have been no constraints, and because you’ve not accepted your responsibility, and your predecessors have not accepted their responsibility in curtailing health costs, the public of this province are being denied programmes which other provinces take for granted.

Ontario is considered the richest province, and we’re supposed to be innovative about certain of these programmes. I always look on Quebec as a pretty destitute area, especially these days when we’re talking about meat, but the fact remains that in Quebec they have a denticare programme. They have one in Manitoba. They have one in Saskatchewan. I think even Nova Scotia is talking about a programme. And where are we?

I agree when the Premier says it would be fiscally irresponsible to do so. And as I pointed out at 5 o’clock, I think it’s a matter of priorities. Had you not wasted in other areas, you might have some today. It is unfortunate that in this province -- I don’t want to say that the whole health care system of this province leaves something to be desired. I think it is a good system but if we continue at this rate we will be denying the citizens of this province new and innovative programmes.

You have alternatives and I intend to discuss them, Mr. Chairman. For instance, I would like to ask the minister after he has received all these briefs on the Mustard report, can he tell us what he is going to do about the Mustard report? What recommendations is he going to accept and which ones are being considered?

Hon. Mr. Miller: I already did.

Mr. Roy: Have you made a statement on that recently?

Hon. Mr. Miller: I did.

Mr. Roy: When was the statement made?

Hon. Mr. Miller: That shows you how you are following me.

Mr. Roy: Yes. When was it made?

Hon. Mr. Miller: It was done over four weeks ago.

Mr. Roy: Don’t make that comment. I am in this House more often than you are.

Mrs. Campbell: That’s for sure.

Mr. Roy: You should try asking questions sometimes.

Hon. Mr. Miller: Check the days.

Mr. Roy: You come in, wink at the press, walk back out and avoid all the questions. You’ve done that before.

Hon. Mr. Miller: Albert, Albert --

Mr. Chairman: Order, please. Could we get at the estimates?

Mr. Roy: The person who has probably given you that bad habit actually is the Premier. He does that consistently.

When did you make your statement on the Mustard report? Could you tell me when that was made?

Hon. Mr. Miller: May 9.

Mr. J. Dukszta (Parkdale): May 8.

Mr. Roy: May 9?

Hon. Mr. Miller: May 8 in London; May 9 in the House.

Mr. Dukszta: You made it here on May 8.

Mr. Roy: Okay. Having made the statement, could the minister in his reply tell us when he intends to embark on some of the recommendations of the Mustard report?

The other aspect of the statement you talked about is preventive health programmes. Of course, we are all in agreement that that is really the area of savings. Using your own figures, for instance, in the area of motor vehicle safety, seatbelts and so on, you say, “Motor vehicle accidents cost the health system of this province $1 million a day.” We know that drug abuse, alcohol abuse, eating abuse and so on is costing the health care programme. We know that people, because of their work -- and you mentioned some of this in your statement about getting involved in occupational and environmental health matters -- we know this costs the system money. We know that people who are not keeping fit -- and you talked about young people and so on -- cost money.

What have you done? You mention in your statement about embarking on some of these programmes and I intend to discuss some of these with you.

Basically, what you’ve done was well summarized in a comment you made some time around April 25, when you attended some sort of meeting -- I don’t know what it was -- in Geneva Park. “A conference of about 200 health educators and counsellors heard the provincial Minister of Health warn of the dangers of drinking and then adjourned for a cocktail party last night.” That’s the comment in the Globe.

Hon. Mr. Miller: Doesn’t say I did. It says they did.

Mr. Roy: You were there and you had a drink -- you were quoted in the article. I think typical of your attitude is your comment at the end of the article where you say: “The Premier asked me recently about raising the age [that’s raising the age of young people drinking; I think there are discussions about raising it back to 21 years and I said as Minister of Health I am all for it, but as member for Muskoka why not wait a while?”

I think that is typical of your reaction as a minister. Your congenial attitude and so on mask the old politician in there, knowing what is right and what the public will accept and adjourning certain major programmes for political expediency.

The Minister of Health has gone on the record for safety and seat belt legislation. When his own ministry prints out figures that automobile accidents, injuries and so on cost the system something like $1 million a day, he must really squirm when he sees a production such as “The Human Collision,” put out by the Ministry of Transportation and Communications. It is part of its $650,000 publicity programme to tell people to buckle up.

It borders on negligence on the part of the government to think that they have the gall to print figures like they do in this booklet and when the minister knows how much mandatory seatbelt legislation would save the system. He has statistics from Australia, from Sweden, and from other countries which clearly indicate that -- particularly if that legislation was coupled with a redaction of the speed limit. Not only would that save money for the system, but save lives, and save injury.

How you, as minister, having gone on record for this type of legislation, can continue in cabinet when you see the only effort of your colleague, the Minister of Transportation and Communications (Mr. Rhodes) is a glossy booklet -- well-made as government publications usually are, glossy, very sexy, the whole bit.

Mr. W. Ferrier (Cochrane South): If he spent as much money as he did on that book for denticare he would soon be able to fully implement the programme.

Mr. T. P. Reid (Rainy River): That’s criminal.

Mr. Roy: He is spending $650,000. How can you remain in the cabinet? It borders on being criminal. Just read the introduction of this booklet which says:

“Motor vehicle accidents are a serious social and economic problem. In Ontario, one out of every three reported accidents results in injury, and one in every hundred results in death. During 1973, there were nearly 100,000 people injured; 2,000 killed in traffic accidents. Serious accidents are especially frequent among younger people. For people under the age of 35, traffic accidents are responsible for more deaths than any disease, and for more deaths than all other accidents combined. The use of seatbelts dramatically reduces the risk of injury and death. Scientific evidence strongly supports the value of seatbelts, yet only a small proportion of the people actually use them. People do not wear seatbelts for a variety of reasons: Fear that the seatbelt will trap them in their cars; they believe that good drivers don’t need them; some people feel that they are too much trouble -- ”

Mr. Ferrier: Do you wear seatbelts when you drive your car?

Mr. Roy: You bet I do.

“This booklet provides information to help you decide on the basis of the available scientific evidence whether or not seatbelts are worth the trouble it takes to use them.”

That’s a telling indictment on the part of the government -- having these figures, having statistics and then having coloured photographs of the effects of wearing and not wearing seatbelts. You, well knowing the importance of that on the cost of your own ministry, how you can sit there as minister, or say in a statement, that you have embarked on some innovative programmes?

I really don’t know how you can live with yourself in circumstances such as these. When you know that the government -- that government that in 1974 promised to bring in that sort of legislation -- has backed off for one reason, and one reason alone -- because the polls stowed that it was equally split between those for and those against. And you backed off; you know that you backed off. There is no other reason than for political gain.

You’ve backed off because you are afraid of losing votes. And by so doing, you’re jeopardizing people’s lives, and you’re costing the health system probably between $50 and $75 million a year because you’re not prepared to embark on such a programme. And you have the gall to come before us and say, in a nicely written statement, that we have embarked on some innovative programmes.

Just before I leave this programme, have you talked to your colleague, the Minister of Transportation and Communications about sending “The Human Collision” to all the schools? I don’t think that is on the way, is it, and it should be. At least if you’re going to spend $650,000 don’t limit it to members of the Legislature or have it in selected government offices here and there. This should be in all our schools in this province, and should be printed in a variety of languages to assure that the message gets across.

Maybe once this election is over, we’ll be thinking of implementing that type of programme. You won’t. But the fact remains you should have such a book get around if you’re serious about educating the public about the use of seatbelts.

Now, Mr. Chairman, the other area where the Ministry of Health could have serious impact on the well-being of individuals and on the budget cost of health in this province is in the area of fitness, and I mentioned this to you last year. Now you have created a Ministry of Culture and Recreation and, to my knowledge, there are no serious fitness programmes being started in this province and there should be.

Are you talking to your colleague, the minister? Apart from having Wintario draws here and there, what are you going to do? Are you going to embark on this type of programme? What example is the cabinet, for instance, going to set in the area of fitness? You should, in fact, embark on a programme right here in the Legislature. Get rid of one of the bars and set up a health gym or whatever. If you are serious, surely you have got to think about those areas. You have got to talk to your colleagues. Because your colleagues are not doing their job or because they are not showing enough enthusiasm, it is costing your ministry money.

I see you have embarked on a programme about drinking. It is somewhat ironic to consider the amount of money that the province takes in through taxes on alcohol and to consider the small percentage of it that is used for education. I think not enough is being done in this area, Mr. Chairman.

I think your record in relation to safety at work in relation to environmental and occupational health matters has not really been great. I think what you have done basically is -- and I suppose it is in some degree to your credit; you have reacted at least to some degree -- you have set up this council which you mention in your statement. But to think that the type of situation which we have heard about over the last three or four months existed in these mines and that your people, along with the people in the Workmen’s Compensation Board, were not doing more about it, I don’t think that’s anything to be proud of.

Nor is your record in relation to the Indians up north and the approach that you have taken with them in relation to mercury in the fish. Your colleague, the Minister of Natural Resources (Mr. Bernier) or the Provincial Secretary for Resources Development decided to buy them a few refrigerators up there. I don’t think that is anything to be proud of and I don’t think that should get much mention in your statement.

I think these are all areas where your ministry has not done enough and where you could have shown more leadership. Basically, your approach has always been -- like it has been in many areas -- to react rather than lead.

When are we going to see the second phase, for instance, of the Health Disciplines Act? When is that coming off, or is that too contentious and something that is going to wait until after 1975? Is this something else that is going to be shelved? Have the polls gone out to see if you are going to lose votes if you give the physiotherapists the right to practise and their services to be covered by OHIP, or is their lobby not strong enough?

Mr. J. R. Smith (Hamilton Mountain): They are covered.

Mr. Roy: They are covered, yes, but just in hospitals. What about hospitals?

Mr. Ferrier: You have got to look after the physiotherapists.

Mr. Roy: You really don’t know very much, do you? You should read up on some of these matters. In fact, I think the member for High Park had a story on the prejudice against the physiotherapists. He mentioned that since 1965 the Ontario government has refused to allow any new physiotherapists to provide services outside of hospital departments. Is that right or is that not right?

Mr. J. R. Smith: In Hamilton we have them on home care.

Mr. Roy: In any event, it seems somewhat illogical to cover the chiropractors and not cover these people, and so I ask the minister, what are you going to do? When are we going to see the second phase, or so-called second phase, of the Health Disciplines Act?

In the area of hospitals -- and this is something I mentioned to you last year -- I don’t think you have done enough there. What about the suggestions we made to you last year about having a better system of monitoring expenses and duplication in hospitals? I pointed out to you last year the fact that in industry approximately two per cent of the individual company’s budget is spent on computer systems to provide information. In hospital, I am told, it’s about one-fourth of one per cent that is spent for that. So you are faced with a situation where, when the costs go up too high, you indiscriminately cut off two per cent or five per cent or 10 per cent without being selective and without really knowing whether a service that you are cutting off might be necessary in one hospital and unnecessary in another hospital. I really think that the government or the Ministry of Health hasn’t done sufficient there.

I think again of the minister’s approach to opening up hospitals to all doctors. I think there has been a weakness in that the ministry again sided with the OMA. An editorial in the Globe and Mail I think says it well when it states that the Ontario Medical Association is retreating cravenly from its stand on open hospitals.

“In November, 1971, it submitted a brief to the minister’s committee of inquiry into hospital privileges in Ontario, saying all physicians should have an appointment on the medical staff of the hospitals serving the community in which they practice. This week the OMA passed [and the week we are talking about was in February] a new resolution at the midwinter meeting of its governing council. The resolution says:

“‘The OMA recognizes the responsibility of medical advisory committees of hospitals to advise the board of governors of its hospital to exercise its responsibility on granting, limiting or refusing privileges to a physician applying for hospital privileges, providing that an appeal mechanism continues to exist on the local and provincial level.’”

When are you going to take a stand there? This is ridiculous: “ ... providing that an appeal mechanism continues to exist on the local and provincial level.”

What the OMA should have said is that this mechanism works fine as long as they win, because they going to appeal until they do win, and we’ve seen, for instance, what has happened to Dr. Schiller.

When are you, as minister responsible in this field, going to take a stand on opening up hospitals?

As stated in the article here:

“It is not bad enough that the OMA has bowed to the people who run the hospitals, the people who have vested interests in keeping the system and privileges going. It is worse that the association is prepared to take lying down a decision on the Ontario divisional court in the case of Martin Schiller.”

Well, I think again the minister could have taken a stand in this field and has not done so.

I can think of some more specific questions to be asked of the minister, some of the matters, for instance, raised by my leader sense time back -- was it in March? -- where he suggested that in London, Ont., despite the shortage of beds, there was something like 60 unfilled beds. That is what we mean about inconsistency in your ministry.

Just down the street here is the Mount Sinai. I mentioned that last year. What are we doing with that building? What is going on at that hospital? What has it been now, two or three years it has been unfilled? And we talk about the shortage of beds.

Hon. Mr. Miller: Who is talking about a shortage of beds?

Mr. Roy: Well, we are in some areas of the province. We certainly are in Ottawa.

Hon. Mr. Miller: No, it isn’t --

Mr. Roy: There is no shortage of beds here in Toronto? And that is the reason why it is closed?

Hon. Mr. Miller: There is no shortage of beds in Toronto.

Mr. Roy: There is no shortage of beds? There is no shortage of chronic care beds in Toronto?

Hon. Mr. Miller: No shortage of beds.

Mr. Ferrier: What about chronic care all across the province?

Mr. Roy: It’s like in Ottawa yesterday. It came out on the news that because of the occupation of chronic care beds mostly by people over 65 they were short of something like 200 beds, and I am sure the same situation applies here in Toronto. What are we doing with a building down the street that has been empty for two or three years? Where is the logic of the approach within the ministry?

Mr. Chairman, in closing I would like to mention two matters in Ottawa, one of which I have already mentioned -- a question of the chronic care problem and that is nothing new. I have mentioned it I think for the last three or four years. Last year my colleague from Ottawa West (Mr. Morrow) joined me in the criticism of the ministry, and to my knowledge, there has been no improvement in Ottawa.

But I think I should point out one situation in Ottawa which clearly demonstrates --

Mr. Ferrier: They needed to have the support of the member for Ottawa Centre (Mr. Cassidy).

Mr. Roy: I should clearly demonstrate, Mr. Chairman, the illogical approach on the part of the ministry which sometimes frustrates those of us on the opposition, and certainly those who are working within the system.

Some time ago the Ottawa General Hospital received permission from the Ministry of Health -- that is after it had received permission from the Ministry of Health to continue its cancer clinic and once the cancer clinic was approved, of course, it was necessary to have up-to-date equipment -- to purchase a brain scanner, as it is called, something costing in the area of about $400,000. To do so, of course, it had to scrape and it had to tighten its budget in other areas, but it got to purchase a scanner.

Once this was purchased and the room was set up for it, then the directive comes from the ministry to cut back on its budget two per cent. And so they are in a situation now where they have to go back to the ministry and say, “We don’t have any further funds but we need something like $140,000 to operate this scanner.”

If they can operate this scanner, of course, it is going to be helpful not only to the Ottawa General Hospital, but to all other hospitals in eastern Ontario -- and certainly in the Ottawa area. I understand the closest scanner to Ottawa is in Montreal, and there is a waiting list. There is another one here in Toronto, and there is a waiting list for the one here.

Of course, the response from the ministry was predictable -- no funds. Out of $2.9 billion there was just no funds. If that is one of the hard decisions that the minister is talking about within his ministry, I ask him where is the logic of it if he is not prepared to make some decisions, for instance, in the area of seatbelts and in other areas of preventive health care?

I suppose, to his credit, he finally led the way in Ottawa about the question of foreign doctors coming into this jurisdiction. I think in his statement he accepts a lot of the credit for it, but I think he should also give the opposition some of the credit for it. If you recall last year we discussed that with the minister -- and we discussed it at length. In fact, probably we were the first ones to raise it with him. We have been raising the issue for two years now. But in any event, to his credit, at least he has convinced his federal colleagues about it.

But getting back to the scanner, what in God’s name was the minister thinking about when he allowed them to purchase it in the first place and then, cut back their budget? Now you are not prepared to give them $140,000 to operate it. Before the end of these estimates I would like to hear the minister say that he will give them the money.

As you know, the cancer clinic in Ottawa has had a lot of problems in the past. There was a clinic at the Civic Hospital, and first of all they wanted to close the clinic at Ottawa General. We convinced them at that point that it was important. It was the only one of its kind which could serve people bilingually, which the Civic Hospital could not do and were not prepared to do. So it was allowed to remain open.

Of course, if you are going to have a cancer clinic and you can allow them to purchase the best of equipment, it sounds natural and logical that you will allow it to have the funds to operate it -- especially when you consider the savings this type of machine produces. It reduces the length of time people are going to be in hospital to have the examination. I trust that before the end of the session, that the minister will make some clarification here and tell us that in Ottawa they will get the required funds to operate the machine.

In closing, Mr. Chairman, I just want to say to the minister that in his opening statement there are some matters in which I suppose he can take a certain amount of pride -- and I am looking at this carefully. I suppose the only positive matter, where we actually saw results, was the immigrant physicians. Apart from that, when he talks about programmes he mentioned the balance between physicians and specialists. Of course, Mr. Chairman, we would be repeating ourselves; we mentioned that last year and the year before. That’s when the recommendations of the Mustard report become important.

The minister states on page 7, Mr. Chairman: “Consider all the positive things we could do in terms of dental care.” You must frown or squirm when the Premier makes the kind of statement he did a couple of weeks ago saying that we can’t afford it.

I repeat my point. The way the Premier is operating the province and the way you are operating the Ministry of Health you are right, we can’t afford it. But if there was a changed system of priorities then we could afford it. That’s the sad, sad part of it. Over the years you and your predecessors have consistently avoided taking hard decisions.

Mr. J. R. Smith: Nonsense.

Mr. Roy: The people of this province are now paying for it. Are you paying him to say something, or has he just got his finger in his mouth?

Mr. Chairman, in closing --

Interjection by an hon. member.

Mr. Roy: I want to say to the minister I think it is time for action. But, unfortunately, we will not see any action in 1975, if this is an election year.

I repeat the minister’s comments which he made about the Premier, something about his saying: “I’m all for it, but as member and as a politician, we could lose votes with that,” It’s a sad thing to say to this minister, that in fact what still rules supreme over here are the polls and political expediency.

Mr. Chairman: The hon. member for Parkdale.

Mr. Dukszta: Thank you, Mr. Chairman. I shall try in my remarks tonight to be pertinent, pungent, analytical, problem-oriented, salient, but mercifully brief.

Hon. Mr. Miller: Oh don’t, I need your time.

Mr. Dukszta: But in order for us to come to terms with the gaps and failures of the health care system in Ontario, we must first recognize certain factors characteristic of the present delivery system before we can even consider suggestions for improvement. These general characteristics which we must treat as assumptions include the following points:

Medical care insurance has not solved all the problems relating to availability of health care services. OHIP has provided economic security during time of illness for those people with the expertise and the background to acquire access to services. There are many aspects of health care accessibility to which OHIP has not -- and likely cannot -- addressed itself.

Medical care and health care are not the same thing. Medical care involves the diagnosis and treatment of physical and mental disorders. Health care is a broader concept which involves, in addition to the concerns of medical care, matters such as social conditions affecting overall health, preventive efforts, etc.

A few remarks about the general failures of the delivery system. It is well known that the use of hospital emergency facilities has increased dramatically in the last several years. Many people do not have regular family physicians and, therefore, rely on emergency wards. This is extremely cosily, constitutes a misuse of the purpose of emergency facilities, provides poor health care for the individuals involved, and is a clear indication of failure in one aspect of delivery. No solution can be provided by merely cutting the availability of beds, removing a number of beds from the various hospitals, unless we provide alternative community orientated health services.

While there is information available on utilization of hospital beds, there has been little research on non-utilization -- i.e., who is not served by the hospital system for whatever reasons.

The problems of availability and accessibility for rural and remote parts of the province; recognized as being self-evident by most people including the minister.

Cultural hesitation about using clean, white antiseptic institutions can be enormous. Most physicians are aware, or ought to be, of anecdotal evidence which confirms this, e.g., immigrant women who arrive at hospitals in labour, having received no prenatal care whatsoever.

Part of the difficulty, of course, is that they come often from immigrant stock or they come from the working class, they have no family physicians as virtually 40 per cent of the population of Toronto doesn’t, and they, in fact, don’t get the care until they arrive at the hospital. This problem is particularly severe in places like downtown Toronto. Translation services are available at most hospitals, and to the best of my knowledge, the ministry does not fund interpreting projects at all. That’s something that you can answer later on.

The most significant point is that most hospital administrators and MOH bureaucrats do not even understand the nature of the problem. They do not recognize the fact that immigrants may be alienated, confused and uncomfortable about hospitals and, therefore, will not use them unless absolutely necessary. If they had resources available in the community where they live, within a walking distance, in their own language, they would probably use them much faster.

Cultural barriers manifest themselves in other ways, too. Many women will not see male gynaecologists whether they are of the same ethnic background or not.

Another problem with the delivery system is the simple information gap which exists regarding OHIP. Most people do not know what is covered, but should. For example, at the very least, each physician should be obliged to have a list of insured procedures posted in a clearly visible place in his or her office, preferably in layman’s tongue.

The difference between medical care and health care: The government has concentrated on economic access to medical services. That’s fine but it must now move on to provide social access to health care services. Above all else, this means emphasis on prevention and a revamped delivery system which brings the services to the people rather than waiting for people to seek out services when they are needed.

Prevention: The NDP has made the point many times that the government must stress preventive measures if the level of health of the general population is to improve and if costs are to be held at a reasonable level. It shouldn’t be necessary to belabour this point yet again, but it is necessary, it seems. For 1975-1976 the allocation for promotion and protection is being increased by 12.1 per cent but for treatment and rehabilitation by 13.6 per cent. This is in line with the relative emphasis given prevention for the previous three years, which is minimal.

Social access to health care services: A much more complex problem than financial emphasis on prevention.

Clinics to fulfil specific mandates, while not the whole answer to the delivery problems, would solve many of the difficulties of people who are not served -- special clinics, I mean. Centres now should include clinics for ethnic communities where the staff speaks the appropriate language and understands the background and expectations of the people it serves.

Special clinics for the aged or at least transportation mechanisms for the elderly to reach the facilities and services they need. This could be in the form of OHIP coverage for taxis or even a dial-a-driver system. In general, gerontology is ignored. This type of immediate service could be provided at a relatively low cost without necessarily committing the whole department toward the community health services approach, as you have so obviously now rejected that approach.

Neighbourhood clinics: Especially needed for the working class areas where harsh social conditions cause severe health problems. Also, there is a communication problem which is cultural in nature. For example, many working class people have no effective access to psychiatric counsel and mental health services because they simply distrust the psychiatric profession or because the psychiatrists are largely unavailable to working class people, concentrating in their private practices on middle class and upper class individuals. The solution to the dilemma is not to deny its existence but to design new types of services and make them genuinely available.

There are a number of topics which I will deal with in my opening remarks, some in great detail and some only to remind the hon. members in the government that the problems in health care are manifold and neglected by the government at the moment. The government listens attentively with both ears -- and maybe even what is called by psychiatrists, the third ear -- to the needs of the medical professions, but turn a very deaf ear to the needs and problems of the rest of us.

I don’t want to repeat again the analysis of what is wrong with the present health care delivery system and what is needed to provide good quality, accessible and available health care for Ontario residents since I dealt in length with this topic during the debates on the Health estimates last year. I spoke, I think, for three hours and the effect I had on the then minister (Mr. Potter) was twofold. Either I made him very angry with me or very sleepy.

Still, some aspects of the failures of the government-inspired and -run Ontario health care system need to be mentioned anew. I don’t want to repeat, as I said, my strictures about your management of occupational and industrial health or deal in detail over and over with the problem of inaccessibility and unavailability. You know all that and that is not the problem. It’s a question of action.

I have organized my critical material into eight topics which only partially deal with the failures. 1, provision of doctors’ -- physicians’ -- services; 2, state of dental care; 3, drug care; 4, Ontario Hospital Appeal Board: 5. children’s mental health services: 6, adult psychiatric services; 7, methods of payment for health services; 8, community health centres.

The Conservative provincial government and its Minister of Health have now made up their minds that one way of dealing with the problems in the health care field is to mount another attack on foreign-born doctors. In recent statements, the minister stated that cutting in half the influx of non-Canadian doctors to this province would create savings in provincial health costs of half a billion dollars a year within five years.

I think the minister very wisely observed that to introduce this type of chauvinistic medical protectionism will need the cooperation of the federal government, which unfortunately the minister has obtained. This type of approach is self-defeating and, although it will achieve some saving, it will be achieved at the cost of availability of good health care. I had hoped that the federal government would have had the sense to reject the minister’s approach but when it comes to major issues, the Liberals in Ottawa think like the Conservatives in Ontario.

Hon. Mr. Miller: Three NDP governments accepted it, too.

Mr. Dukszta: I can’t be responsible for foolish things, even if the other people do them. I am telling the minister what should be done. I know that they have accepted it under pressure from --

Hon. Mr. Miller: Under pressure!

Mr. Dukszta: Well, as I said, I am not going to defend them. They are wrong about that, too, as much as the minister is wrong.

It is obvious that the Ontario government and the Minister of Health are not prepared to do the major and much-needed restructuring of the health care system in Ontario a restructuring we need for three major reasons: To improve the availability and accessibility of health care; to shift the focus of health care from bed-oriented to community-based ambulatory care; and to cut costs.

The government has settled for cutting costs by cutting the influx of foreign doctors. I wonder if the decision to cut down on the immigration of foreign doctors had something to do with the fact that a pattern of immigration of doctors to Canada has changed recently. Previously they were almost all from England; now they are mostly from the underdeveloped countries.

At the same time that the Minister of Health announced his proposal, I find it ironical that Dr. Bette Stephenson, speaking at the Empire Club, was demanding a 14 per cent increase in doctors’ fees, which is perfectly ridiculous as physicians on average already make at least $41,000 net yearly.

If one takes those two statements in conjunction, it does sound as if there was collusion between the government and organized medicine. One sees that the physicians have accepted that some cut in costs must be effected, but it is not going to be done at the physicians’ expense. By concentrating on the exclusion of foreign doctors, their present incomes probably can be kept intact and possibly even increased. Who will suffer? The public.

The Minister of Health is preoccupied with the physician-patient ratio, which he sees as adequate for this province but which is immensely misleading in actuality. The overall Ontario ratio, which is now in the vicinity of one doctor for over 600 patients, belies the actuality of the availability of physicians in various parts of Ontario. It may be the ratio in Toronto, and it is probably higher in the suburbs, but it is not the ratio in northern or rural Ontario where it is more likely to be one physician to 1,200 patients.

The centralization of doctors in a large city provides the residents of that city with reasonable accessibility, but even that is in doubt, of course, when we realize how much the emergency wards of our hospitals serve non-emergency and general health needs at night and over weekends -- 50 per cent is the latest estimate.

By cutting down the immigration of foreign-trained doctors, we will make our medical resources scarcer, and at the same time the government will be more liable to blackmail from organized medicine which, insulated behind its protectionist barriers, will be more in demand than ever and aware of its control over the health services.

I remember what the minister said about bringing foreign-born doctors to this province depleting the ranks of doctor in countries outside Canada. I have said before, and I say again, that he is really shedding crocodile tears over the problem, because he is using them more as an example to explain himself than the actuality. I think it is a blatant self-serving of the medical profession, masquerading as a humanitarian gesture towards the underdeveloped countries.

I spoke on the NDP dental policy this afternoon during the debate on Mr. Roy’s motion to implement a denticare scheme. I thought I would just add a few salient details on the NDP Saskatchewan dental plan, which could be used as a blueprint for the introduction of a dental plan when the NDP government is in power in Ontario.

One of the major points of that proposal is to make sure that the introduction of the prepaid system for children from the age of six up to 12 will not strain the services totally as occurred when prepaid medical care was introduced for the medical services generally. One has to accept that to spread the availability of dental services some kind of a change in our professional law is essential, which would allow a dental nurse -- the usual thing; on the model of a New Zealand nurse -- to do both preventive and some restorative work on the majority of the children.

Since dentists again tend to be concentrated in the large centres, with some centres really quite bereft of basic services, to overload those services with demand probably would fulfil the prophecy of the dental profession that it never would be able to manage more than 75 per cent of the demand. One way of doing it is to change this approach. I am not sure how the Ontario Dental Association feels about it but I know that this is a more correct way of dealing with it. It has been quite successful so far in Saskatchewan.

The Ontario Drug Benefit Plan has now been in operation for eight months, I think. The least one can say for this particular plan is to echo one of your officials, Dr. Allan Dyer, chief of drugs and therapeutics for the Ontario Ministry of Health, who, when he was interviewed on radio, said, engagingly enough, “It is a complex plan and difficult for people to understand everything about it.”

It is, of course, very complex and needlessly so. Some of the problems, for example, for the pharmacist are: There is more paper work for the pharmacist. The pharmacist is put in the position of being a major explainer of the system, which has nothing particularly wrong with it, but they complain about it. It takes twice as long to process a drug benefit prescription than a regular prescription to a paying customer.

The difficulty for the physician is the constant need to treat and prescribe differently for the patients who are on the plan from the other patients. Also, the patient has often to return for several visits, and the prescription has to be repeated more often than if he is a so-called private patient. Maybe, of course, it is of some advantage to the physician since for each visit the patient makes back to the physician -- occasionally he’s sent back by the pharmacist -- the physician can legitimately claim twice or however many times the patient comes from OHIP which surely would be to his advantage financially as a physician, if of no real advantage to anyone else.

For the patient the advantages are obvious. Some of the costs get covered but the costs get covered by an involved often needlessly humiliating process. Often the medication finally obtained is not the one that an elderly patient is used to and, consequently, however well tested and equivalent in value and actual efficacy, the medication is still not as effective because of this psychological variable.

In some cases, the necessity of taking many separate pills, instead of a compound, is in itself a barrier to taking medication. I know you may not be aware, but the previous treatment for TB used to be to take quite an incredible number of pills. I remember once having a patient on 60 a day, which led to constant battle between the patient and the treatment staff, because he refused to take so many pills.

In a funny way this operates now with many elderly people who are used to taking one or two compound medications, which are no longer possible to get, however, effective, unless you go through incredible administrative processes. They, in fact, take less.

I was listening to an interview early in March between Tom Clark and Russell Jeans. Russell Jeans and his wife are epileptics. The couple live on a family benefit allowance of $276 per month, so obviously both qualify for free drugs under the Ontario Drug Benefit Plan. That’s partially here the problem begins.

When the Health ministry last year revised the list of drugs that can be provided, it excluded the ones needed by the Jeans and substituted other types. One should never use an example of one individual to prove one’s point, and I’m only using this particular couple to point out the human element. When they had to switch to another anti-epileptic medication, Mrs. Jeans developed more problems with petit mal and other seizures. Even when it was explained over and over again that the medication was basically similar in nature and efficacy, clue to seizures that other element which comes into management of epilepsy -- which I call a psychological variable -- probably had a large effect on the fact that she became decompensated.

I could give you many cases like that, I hesitate only because they don’t really prove the point. But I do want to stress the fact that this whole system is strongly bureaucratic, unpleasant and really needlessly humiliating for many people.

There is really no solution except the total, universal approach. You should not use this present system in an attempt to drive some drugs off the market, or force the price down, because that’s not the way to do it. You do not force the price of the medications clown by removing what you consider the inefficient, and trying it out in that way.

The next point I wanted to deal with is the Ontario Hospital Appeal Board. Prior to the election of June, 1971, the Tory government responded to public concern for its failure to connect monopolistic abuse of admitting privileges in publicly financed hospitals by appointing a committee of inquiry. One hundred and forty-five briefs, 81 personal appearances, six months and many thousands of dollars later, the committee reported. The key observation of the committee was:

“That the hospital should not have the right to exclusive determination of the number of doctors in any category, because where a doctor seeking appointment to a hospital is informed by that hospital that there is no room for him, there may reasonably remain with the applicant the suspicion that his application was refused for selfish reasons.”

The Tory government pledged itself to implement the recommendation of the committee and brought in legislation in June, 1972, purportedly fulfilling that pledge.

But characteristics of the Davis government it perpetuated a fraud on the people of Ontario by giving all the appearance of corrective action with none of it substance. Three years later not one doctor improperly denied admission of his patients to the community hospital has yet secured a remedy. An appeal board to hear complaints, and intended to be unbiased and impartial was packed with what I can only describe as Tory cronies or representatives of the hospital establishment, intimately associated with the very practices they were expected to correct. And predictably they changed nothing.

The appeal board proclaimed that it was not established to effect changes, and announced that every hospital was unique and that the only standards applicable to the decision of hospital staff appointment was experience and judgement of those associated with that particular hospital. Rather a clear case of territoriality -- again by those who have already gained the territory. The divisional court has since ruled that the present law permits non-accountable, non-representative hospital boards to say their staff quota is full, when they have never established what that quota should be.

The latest victim of this charade is Dr. Claude Macdonald, who was refused privileges at North York General Hospital on the grounds that the hospital was full, despite the fact that Dr. Macdonald applied in 1966, two years before the hospital was even built.

I call upon you and the Conservative government to end this deception by incorporating into the Public Hospitals Act an amendment which would provide access to hospital facilities for the patients of all doctors, limited only by consideration of the patient need and the doctor’s definable competence. I demand this not only to provide justice for doctors but even more to protect the Ontario public from being the victims of the self-seeking practice of a small group of doctors who have monopolized some of the hospital facilities.

The next topic is children’s mental health services. It is a very large subject and I will not deal with it at the moment but under the appropriate rubric. I have recently been talking about and reading a lot of material on the subject, including the extensive speeches of the leader of the NDP, and I have developed certain questions, which I think I would probably prefer to have answered in a more immediate one-to-one discussion, which will occur during the particular items as they come instead of dealing with it globally. But I do want to deal with this in some detail when it comes to dealing with the children’s mental health services, if I ever discover exactly where they fit them in.

The next item will be the adult psychiatric services. The three per cent cut in provincial psychiatric hospital budgets will play havoc with many vital, preventive-in-nature, community-oriented programmes. The first thing that will probably go is many of the community-oriented programmes which, in effect, assure us and assure the community that the beds do remain empty if you cancel those types of services which are right in the community -- the people from the hospital, like Lakeshore or others, moving into the community to help keep the ex-patients in the community. If we cut those services I would predict that sure enough some of the beds will start filling up again the way they used to be filled up in the 1950s.

I don’t want it to sound too drastic, but this is a hint that if you cancel this type of service, which managed to empty the hospital in the beginning, you will facilitate the return of many patients to the hospital, because there will be no other way for them to survive.

I would like to deal in a little more detail with the method of payment for health services. Since the government is still committed to a fee for service, except for a few pilot projects of paying for medical services, it behoves me well to go over the advantages and disadvantages of three major methods of payment for health services.

Once more I urge the government to abandon its blind allegiance to the fee-for-service system and consequently to the medical profession, since, for the medical profession the fee-for-service system of payment is most welcome, favoured, lucrative and the closest that one can come in this vale of tears -- which is our lives -- to a blank cheque that one can write oneself on someone else’s account.

Some of the information which I will give you comes from an article called “Paying for Medical Care, the Methods in Other Countries.” It is by Cohn Grant and G. R. Palmer, published Jan. 1, 1975, in Current Affairs Bulletin, which is a bulletin by Investors Syndicate. The three major methods are salary, capitation fee and fee-for-service. I won’t read you all of it, just some salient points. By the way, the authors deal fairly, I think, with both pros and cons of each of the systems.

For the sake of argument, I will read you the ones in favour and I’ll try to summarize the ones against, largely because the authors themselves come to certain conclusions, and at the end of the article I will tell you about them.

“Salaried medical services are said to offer a number of advantages. For the employing body a salaried system guarantees, once the staff has been engaged, that medical services will be available to fulfil its purposes. Additionally, the nature of the contract between doctor and employer usually offers some organizational controls over the doctor’s behaviour with regard to quantity and quality of service which might not exist when he is an independent contractor. A further major advantage for the employer is that salaried service enables accurate budgeting since the only labour cost variables are the number of salaries to be paid which, of course, is directly under the employer’s control, and the level of the salaries, which is fairly predictable in the short term.

“For the doctor, a salaried system guarantees for the period of employment a stable and secure income with none of the problems -- human, ethical and accounting -- of charging and collecting fees. For the most part he is spared the problem of assessing whether the patient can afford further consultation or treatment, safe in the knowledge that his decision can never be construed as advancing his own financial interests. Similarly, in a multi-doctor organization, the same sort of problems with regard to the referral of the patient to further doctors are avoided and do not arise. Less importantly, salaried service usually carries with it side benefits such as paid recreation leave, study leave and superannuation and some control over the night duty.

“For the patient, a salaried system means that he is able to seek medical care secure in the knowledge that there is no financial incentive or encouragement for the doctor to perform unnecessary service such as surgery upon him. Though there is no necessary connection between the method of paying the doctor and the way the patient pays for the service, it is usual for medical care provided by salaried doctors to be either free or subject to only a nominal charge.”

The obvious reason which most doctors present as an objection to it is that there would be no financial incentive to be efficient, productive nor to maintain his professional standards. There is usually no better reason than that given and it says something about a physician’s approach that it’s his belief it is actually valid.

Payment by capitation, I think it is obvious, is similar in many respects, particularly in its advantages and disadvantages, to payment by salary. However, the tendency, according to the two authors who have examined systems in five countries, is to use it mainly for primary or family care.

“Fee-for-service payment: The advantages to the doctor of fee-for-service are clearly seen. Unlike his salaried or capitation-paid colleagues, he retains the full entrepreneurial rights of the individual professional contractor to charge what the market will bear, what the law will allow, or what he thinks the individual patient should pay. He may practise where he likes and may treat as many or as few patients as he likes, free of any sort of organizational controls unless he chooses to enter into partnership or group practice. If he so wishes, he may also increase his income by performing services of doubtful or even negative utility to the patient.

“No matter how few the doctors who abuse their professional ethics, the fact remains that with a fee-for-service payment there exists an incentive to over-treat patients, particularly with regard to surgery and pathology tests. Lastly, for those who regard the financial nexus as crucial to a good doctor-patient relationship, this system readily permits or, indeed, encourages its bipartisan consummation via cash on the nail or, more delicately, a cheque to the receptionist.”

I think the advantages to the doctor are commensurate or co-terminus with the disadvantages to the community at large and they speak for themselves. Almost everything I mentioned which is an advantage to the physician is, in fact, a counter-advantage to anyone who either organizes the system or uses it.

I would like to quote once more from the article by listing -- it is a fairly long article, so I will just list the trends of health care systems which the two authors find are now in operation in five countries -- the United States, Canada, Sweden, New Zealand and Britain.

“From the countries examined and from a wider international perspective a number of trends in financing care seem to be apparent. They may be summarized as:

“1. Toward universal acceptance of access to health and medical care as a fundamental human right. This naturally means the removal of financial barriers to care. Voluntary health insurance leaves barriers and for this reason, apart from any others, is increasingly falling from favour, save with such heavy modifications, support and subsidization as totally to change its character. It may remain to provide fringe benefits but government is increasingly shouldering the burden of financing care.

“2. Toward formal control of quality of care measures, originally from concerned professionals but subsequently and increasingly from government as a guardian of the public good and from the financers of care concerned to obtain value for money.

“3. Toward greater investigation of the effects of payment and financing methods on the outcomes of care.

“4. Away from the traditional doctor and hospital locii of treatment toward a wider range of health care professionals in a wider range of settings. This may hasten the movement from categorical voluntary health insurance financing towards a more open public financing.

“5. Toward higher costs, not as a goal but in response to the greater per capita quantities of higher quality care being delivered.

“6. Away from the fee-for-service system because of its higher costs than the alternative methods and because of its incentives to overtreatment.

“7. Away from simplistic doctor payment mechanisms to more sophisticated ones which will reward doctors according to the quality and quantity of service they provide.

“8. Toward acceptance of the idea that professionals must be reasonably happy for the system to work (or they will down tools and leave it) but away from the notion that a doctor is worth a king’s ransom.

“9. Toward a greater understanding by health service planners of how and why other countries’ systems work.

“10. Toward a greater understanding of the importance of historical and cultural factors which determine approaches to providing care.”

They do not actually comment in any detail on the countries, although there is a very extensive sort of flow chart comparing their health care systems, but I suppose our system is not exactly voluntaristic but fails very short of what would be closer to the acceptable ideal in terms of the system.

Virtually the last aspect topic I would like to deal with in any detail is the community health centres approach. I was very excited by an article I think I noticed before I read the minister’s actual statement. One should probably never read press releases or the articles in the press, because I was actually excited. “My God,” I said to myself. “Frank must have had a change of heart.” I read an article that said, “New Health Centres Planned.” Then, of course, I read the minister’s release on the Mustard report.

I also remember, prior to that -- sometime in April, I believe -- that there was a real concern among the existing community health centres -- the ones that have been promised funding, the ones that hope to get funding -- that this particular source of funds would be cut off completely. Whether the minister had changed his mind in response to pressure, because there were a number of meetings with those people -- in fact, he had denied on a number of occasions that this was so -- nevertheless, there was enough information coming from the ministry and from concerned individuals in the ministry to the various groups in the centres that this was going to happen.

I am not sure what stage we are in right now; again, I will leave that particular part until we come to deal with that appropriate rubric. I want to have much more specific questions answered here in terms of how many are funded, the kind of funding, the kinds of groups that have applied and how many groups have applied. I would also like the names of all the centres and what the ministry proposes to do with them. I am certain that the minister can provide some of this information or can work on it and give it to me when the appropriate rubric is discussed.

But to return to your statement, almost as the last thing, delivered on May 8 -- maybe the hon. member for Ottawa East will listen, because that was the statement of the minister delivered on May 8 in response to what I think the member was demanding --

Mr. Roy: It must be one of the few days I wasn’t here, Mr. Chairman.

Mr. Dukszta: I shouldn’t have stirred you up.

An hon. member: It is one of the days you were here.

Mr. Dukszta: Now I know I shouldn’t have said it.

Mr. Chairman: Order. Shall we return to the estimates?

Mr. Dukszta: Yes, I understand from your --

Mr. Roy: If you only had something to show.

Mr. Dukszta: I have only myself to blame for starting this up. I understand from your statement that you had something like 611 responses. I assume those 611 responses were dealing with the Mustard report and were analysed by your organization.

When the Mustard report came out, unlike other people I have not found it particularly exciting. Its framework of reference suggested from the beginning that nothing could be touched, so you had to work as much as possible juggling with whatever was available. If you read the whole report very carefully and detached the rhetoric from the actuality, there was no question that there was no commitment to the community health centre, nor was there ever likely to be, nor would there be any change in professional law which would allow some of the more innovative trend to emerge or to be implemented.

On page 5, you say:

“First, we agree in principle with and are prepared to act upon the key recommendation of the task force that received wide support, such as development of a strong primary care system; rationalization of secondary care; and local involvement in health planning.”

Well, I am for mothers, too, I will tell the minister.

Mr. Roy: You are for mothers, too?

Mr. Dukszta: Oh, yes. I am for motherhood, too, unless the minister is prepared to tell me exactly --

Mr. Roy: The minister likes mothers.

Mr. Dukszta: -- what he means by it, I say that this is rhetoric; attractive, but nothing but rhetoric. Finally -- this is important -- you say:

“We will not be implementing at present those recommendations with which the public and the health community found many problems; [You mean the doctors] for example, creation by statute of area health services management boards, establishment of district quotas for physicians, reduction of the responsibilities of public health units, or creation of a decentralized ministry structure under regional directors. [Then for all intents and purposes, the Mustard report, like at least 17 other reports, has now been put on the library shelf.]

“In addition, the wide response to the Mustard report has helped the ministry to gain a clearer knowledge of the Ontario health community’s thinking. [I sincerely hope so, after so many reports.] This, perhaps, is the most valuable element of all. Through mutual understanding and discussion, we can move closer to realization of the World Health Organization’s definition of health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

I see that that happens to be your favourite quotation. To use this phrase to describe your system is mendacity. You obviously believe in what you are saying, but it is simply and actually not applicable, as a description, to Ontario’s health system or its products. It is not enough to issue clarion calls to action; you also have to act.

Mr. Roy: You are right on there.

Mr. Dukszta: Let me tell you an anecdote. During the recent cultural revolution in China, the bureaucratic faction -- which was the one associated with the anti-party group -- consistently used leftist slogans to attack the left. In a typical Chinese phrase, this was defined as “talking red to defeat red.” Whether in China or here in Ontario, the same intellectual bureaucratic habits characterize the establishment.

I believe you use the rhetoric of the community health approach to defeat the community health approach, even if you don’t realize it. I will deal with other aspects in more detail when the appropriate rubrics come in.

Thank you, Mr. Chairman.

Mr. Chairman: Does the hon. minister wish to respond to the comments of the critics?

Hon. Mr. Miller: I would like to try to take the points in the order that each speaker presented them.

First of all, the Liberal critic commented upon the lack of a ministry report. I have to tell you it will not be out until the fall. It takes a certain amount of time for the Provincial Auditor to approve certain of our expenditures. Once these are approved we will have our report printed, as it normally is, and you will get this. I think you have to admit that I have leaned toward full disclosure as a minister. I think you would have to say that I have tried not to hide facts from anyone who asked me for them. You were saying, in your opening remarks, that it was an attempt to hide facts or to --

Mr. Roy: I can only come to that conclusion.

Hon. Mr. Miller: I am only telling you that in trying to release reports I have done more, I would say, than other ministers traditionally in this portfolio, because of my belief in the need to do so and the value that comes from letting this information be known. I think the original Elliot Lake study figures are an indication of where I made the information available. Hopefully, from there, we got to our final position. I believe in that approach because I find that very few things (a) are worth hiding and (b) can be hidden. It’s a simple pragmatic approach. I would far rather tell you, than have you tell me.

You make a great to-do each time you stand up and talk about cost controls, and yet I think on contradicted yourself a couple of times in your talk.

Mr. Roy: Me? Oh no.

Hon. Mr. Miller: C’est possible, monsieur.

I think if one looked at the increase in health care costs --

Mr. Roy: I mentioned it.

Hon. Mr. Miller: -- they resulted from the very things your party and the NDP made a great deal of presentation about a year ago -- last spring -- the need for a better and fairer salary for the lower-paid people in the hospital system. If one starts with that assumption, something which I admit you didn’t even contest when I brought my supplementary estimates in, it had been generally accepted that those people deserved a pay raise.

At the same time, we can trace almost all the increases to that one change. At that time we brought certain basic rules out to guide the hospitals. One of them was, after a great deal of discussion with the Ontario Hospital Association, that, in fact, it was possible to live with a two per cent reduction. This was, in a sense, the overhead.

We didn’t tell the hospitals of Ontario where that two per cent was to be found, in any given hospital, but we went forward on the assumption that it was possible within each one. I think the results of the budgets submitted since then, by the hospitals of Ontario, have shown that, in the main, they have been able to do so. They haven’t necessarily been happy. They have, however, co-operated, knowing that it was one of the prices that was necessary if the employees were to get a larger take-home-pay envelope.

I get on to the dental care comments and you try to imply a rift between the Premier and me about his announcement the other day. Far from it. It has my absolute, total, complete support.

Mr. Roy: I wouldn’t brag about that.

Hon. Mr. Miller: No. It is fine to say you’ll implement plans and it’s great to say that there is an unlimited amount of money. Well, I go on the simple fact that I would like to expand facilities that we are already operating. I would like to get in place those people who will deliver the plan -- I will be talking a little more about that later -- the paradental personnel who will make it possible, for this province, eventually, to have some kind of a dental programme, not necessarily entirely state supported, that we can deliver.

At the present time, dentists in this province are exceptionally busy. They are people who have not yet utilized lesser-trained personnel to the fullest. We have launched a crash programme to upgrade dental assistants in three categories -- dental personnel, I would say, rather than assistants because the words “dental assistant” are used. We are going to have those people called dental assistants, who will do extra oral procedures and other functions and duties in the office. They may prepare the amalgams, or something of that nature; they may stand by the doctor and give him the instruments he needs, and so on.

We will then have dental -- for the use of a better word -- “nurses”, and I put that in quotes right now because that is a word that is subject to some discussion before it is accepted as being the use. I say dental nurses because the term has been used historically for many years, and I don’t think I am suddenly coining a new phrase, even though both the medical profession and the nursing profession object to it being used by people working for dentists. But these people would help to do certain intra-oral procedures now done by hygienists.

The third category of person would be the dental hygienist who would do some of the functions now permitted in Saskatchewan of the paradental personnel -- not necessarily drilling, but possibly filling, if I am not wrong; doing some of the jobs that don’t require the top skills of the dentist so that we will have a better delivery system at lower cost.

Our ministry spent some 15 months discussing this programme with the Ontario Dental Association because I believe in looking ahead. It was always possible that in 1975 the government of this province might have determined that it had the moneys available for a dental programme. I can’t make that decision. I have to live with the moneys given to me in my budget. But I wanted at least to be able to start the programme and agree upon its content if we did.

So, 15 months of discussion have gone on and I find they have been very fruitful months. In fact, in spite of the relatively stormy times I had with the denture therapist; legislation last year, I can say I have received the thanks of the Ontario Dental Association for the co-operation of our ministry in defining these three paradental classifications, and in doing the ground work with them for any future preventive or children’s dental programme.

I would point out that one of the reasons Ontario may have trouble sometimes spending the money on programmes that other provinces deem it possible to spend, is that about $900 a year per capita in this province, if my arithmetic is any good, leaves the province and goes to other less fortunate provinces. I have never begrudged that and I am sure most Ontario residents haven’t, but when one takes that pretty large figure, that is more than I spend per capita on health in the Province of Ontario. Let me go back and do my arithmetic.

Mr. R. S. Smith (Nipissing): What are you talking about?

Hon. Mr. Miller: It is about $500. I was doing some arithmetic in my head and one should never try it. Fifteen per cent of the total tax collected in the province goes out as transfer payments. That is municipal, provincial and other taxes, and they amount to about $3,500 per capita if my arithmetic is not wrong. So that would be somewhere around the $500 mark per person per year that is transferred out. I spend $360 to $370 a year per capita on health, as you may know.

Mr. E. R. Good (Waterloo North): That is over $4 billion a year goes out of the province.

Hon. Mr. Miller: Fifteen per cent, if I am not wrong, of the total taxes collected. That is the figure in my head. I haven’t any documentation. I think I can find it for you in the Treasurer’s (Mr. McKeough) statement, if you want to look in there. If you look at the page that shows the amount of tax collected in Ontario, I think, in very round figures, 10 per cent is collected by the municipalities, 30 per cent is collected by the province, 60 per cent is collected by the federal government. Does that sound right? Okay. The province collects, I believe, somewhere around the $10 billion mark as its 30 per cent. Right?

Mr. D. M. Deacon (York Centre): No, no.

Mr. R. S. Smith: Forty per cent comes in in transfer payments.

Hon. Mr. Miller: Well, in any case, we could argue whether it is $300, $500 or $1,000.

Mrs. Campbell: Start again.

Hon. Mr. Miller: Yes, I’ll start again. I will ask my accountants to do my arithmetic before tomorrow morning. A great deal is transferred out of this province each year to help other less fortunate provinces, and it’s taken or sent for more useful purposes.

I suppose I was rather hurt to realize that you didn’t know I’d made a statement on the Mustard report on May 8. I know you’re an all-perceiving, all-knowing critic. It just hit me just a little hard to realize that Hansard, on page --

Mr. Roy: Would you send me a copy?

Hon. Mr. Miller: I thought you got Hansard as a member of this House.

Mr. Roy: I do.

Hon. Mr. Miller: The question is, do you read it?

Mr. Roy: Not your comments very often.

Mr. R. D. Kennedy (Peel South): We’ll put you on the mailing list.

Mr. R. S. Smith: It depends if it’s worthwhile.

Mr. Chairman: Order, please.

Hon. Mr. Miller: I could have the words sounded for you, if you’d like. But in any case, it’s there.

Mr. Roy: May 8?

Hon. Mr. Miller: May 8, page 1519, or thereabouts.

Mr. J. E. Bullbrook (Sarnia): I like the pictures.

Hon. Mr. Miller: I think it starts on page 1518. They are immortally printed and protected for future generations.

In any case, you’ll find we made an interim response to the Mustard report -- and I want to point out that we did so for a number of reasons. We have a number of groups who were afraid that their future planning couldn’t proceed until they knew whether or not they continued to exist. I think, perhaps, the Catholic hospitals, above all groups, were concerned about their future. They were concerned that they would be amalgamated into area service management boards and that they would lose what they consider, and I agree, as a unique identity -- the ability to manage their own hospitals. One of the things we stated clearly in there is that area service management boards weren’t going to be created, and that these hospital boards could continue to plan their own future as they had in the past.

Interjection by an hon. member.

Hon. Mr. Miller: You got on to seatbelt legislation, and I’m glad to hear a plank in the Liberal platform come out -- finally.

Mr. Roy: It is a plank in my platform.

Hon. Mr. Miller: That is, that you’re going to force everybody in the province to wear seatbelts and you’re going to legislate it. Let me tell you, I would be delighted if those two things were synonymous. I am no hypocrite when it comes to seatbelt legislation.

Mr. Roy: You’re for it?

Hon. Mr. Miller: I am for it, four-square, and always have been. I believed in it long before I was even a politician. I have to tell you, though, that even a Liberal province like Nova Scotia, which got so far as third reading -- if I’m not wrong -- in its bill, has discovered that it’s very simple to pass bills but very difficult to enforce legislation.

Mr. Roy: They haven’t tried.

Hon. Mr. Miller: They haven’t tried, absolutely, because of the complete absolute storm of protest that arose in the area. I was talking to the Minister of Health of that province in Halifax not long ago about the issue. Like myself, he’d be delighted to see it in force because of the tremendous impact on human suffering that it would have and the tremendous impact that it would have on the cost of the system.

I find the most discouraging part is the fact the public reaction to it is so bitter and is so violent, when the statistics tell us of the tremendous saving that will be realized by the use of seatbelts. I think we’ve taken a fairly responsible step. The people of the province are not willing to believe us yet that seatbelts are essential or good for you. It’s fine to legislate something but we have a job that we underestimated, and that job is to convince the people of need.

Mr. Roy: What do you think of bicycle helmets and all that?

Hon. Mr. Miller: That glossy brochure is good. I’ve heard it recommended on radio by a number of announcers in the last few days. I think it’s a top-grade brochure. I’ve seen it myself. It by no means costs $650,000, although I can’t tell you how much it did cost. It is only one plank in the platform of public awareness that is so essential for the acceptance of legislation aimed at protecting people’s lives.

I don’t have to restrict my concern about public attitude to seatbelts. I’m just as concerned about their attitude toward smoking. We can stand up, as we have for years, and spend money to discourage smoking and drinking and find that all we’re doing is apparently increasing the consumption of those products.

We can insist upon a man wearing a hardhat if there is any likelihood of a brick falling off a roof, but at the same time we’ll let him work in a factory where the hazards to his lungs are very high, and if we asked him to stop smoking we’d be accused of being a dictatorial state. They are very, very frustrating problems in human relations.

Mr. Roy: That is why you are going to have to take some hard decisions.

Hon. Mr. Miller: I am willing to take hard decisions by themselves. I have never shied away from them. At the same time, I tell you that public education and awareness appear to be the first steps in those directions.

I am hoping the Ministry of Culture and Recreation will have an impact upon the fitness of the people in Ontario. I hope it equals the negative effect that television has had. I believe the Ministry of Health itself will be not too long in preparing a programme of fitness for its own employees in at least one area of our ministry. I believe at the Overlea Blvd. location we have, at my request, been preparing a programme for on-the-job physical fitness opportunities.

Mr. Roy: Now you are talking. You should have it right here.

Hon. Mr. Miller: Let me try it in one location, let me see how it works, and let me see what equipment we need and how active the participation of the people is. We are consciously going to try to encourage people to take part in fitness programmes and we are going to start with our own ministry for the tests. I can say again I am not a hypocrite. The YMCA is around the corner. I don’t meet too many of you fellows when I am in there.

Mrs. Campbell: Do you meet me?

Hon. Mr. Miller: No, I don’t meet you.

Mr. Roy: Do you want a challenge on fitness?

Hon. Mr. Miller: I went there with high blood pressure, as I said, and now all I have is an inferiority complex. They don’t let me wear my bathing suit.

Mr. Bullbrook: You deserve both.

Hon. Mr. Miller: Thank you, honourable sir!

Mr. Chairman: Order.

Hon. Mr. Miller: The drinking education programme is another one of those things that is very hard to assess in terms of success. In fact, I question whether we will ever be able to tell you whether it converted one person besides me. The programme was not aimed at making people stop drinking. Everything we have tried to do in the past with people’s personal habits of that nature has boomeranged. It’s aimed simply at making you and me think a bit about how much we drink.

It’s an interesting thing. Now that I am aware of the effect of alcohol in the body a little better than I was in the past, I have learned not to accept a drink at noon hour. It’s a simple rule to make. I used to be like the rest of us. If somebody offered us a drink at a bar where a meeting was going on, I was quite pleased to accept it. This programme has made me aware that that is not necessarily the best thing for me to do. I certainly now have made that a rule, none till 6 o’clock.

Mr. R. S. Smith: In the morning?

Hon. Mr. Miller: It depends on how long the party lasts. I think perhaps if I can even find one member of Her Majesty’s loyal opposition over there following my example, I’ll be delighted. We’ll start with the member for Ottawa East, if he’ll be glad to do it.

Mr. Roy: I will let you know. It is only water in this glass.

Hon. Mr. Miller: You could fool me from this distance and from your behaviour. You touched upon occupational health. We feel, first of all, that our government has taken some of its most progressive steps in this area in the last while -- I think even the opposition has agreed upon that -- in terms of occupational health and the alternatives we are trying to offer the miners. The right to transfer from a hazardous job to a non-hazardous job before a person is physically handicapped has finally been granted.

Mr. Roy: The opposition forced you into that.

Hon. Mr. Miller: I don’t accept that. It takes a lot longer to negotiate these things than one would think. That was one of those issues that I was delighted to see happen. It is going to take us some time before the plan works as well as I’d like to see it work. I am convinced of one thing; we will not make any real inroads into the problems of occupational health on the job without the assistance of the unions and management. It’s not a one-sided issue.

Mr. B. Newman: It still took 32 years, though.

Hon. Mr. Miller: I have only been a member for three years.

Mr. B. Newman: The government has had 32 years.

Hon. Mr. Miller: I think it is also true to realize that problems of occupational health have only recently seemed to be important to any of us, if one is honest. I can look back at the conditions I worked under at Arvida, Que., that were just unbelievable by today’s standards. No one seemed to care in those days and no one seemed to be worrying. Jobs came first. We are wealthy enough in Ontario, thank goodness, to be able to say jobs don’t always come first anymore, that the health of the worker needs to be protected and that he needs to have alternatives if he works in a hazardous occupation.

The health disciplines bill was the next item you referred to. I should point out to the member for Ottawa East that the chiropractic part is virtually written now. It is past the initial stages. In fact, I talked to the Chiropractic College and association not long ago, hoping that we might even have got that part in during this session. I think it is highly unlikely because of the discussions going on among the ministry, the Chiropractic College, the College of Medicine and those other groups.

One of the things I think I tried to point out during the discussions of the health disciplines bill is that I believe in a lot of discussion on these issues between the various groups before the legislation is finally written. That kind of discussion is going on right now. The speed with which that part comes in, depends as much on that as anything.

As for physiotherapy, I should read the Health Insurance Act as amended by Ontario Regulation 28975. “Physiotherapy services are insurance services where ordered by a physician and provided in those physiotherapy facilities listed in part I,” etc. The amount payable by the plan for each such service is now $5.05. I should point out that a year ago it was only $3.50 and that two increases have been granted to the physiotherapists on fee-for-service in the past 12 months.

Mr. Roy: That is only practising in a hospital setting.

Hon. Mr. Miller: That is not practice in a hospital setting. That is fee-for-service physiotherapy.

Mr. R. S. Smith: But you don’t have any outside of hospitals. Most areas in the province don’t.

Hon. Mr. Miller: I can get you the numbers. Let’s go back to the arguments. You’re all telling me that I should get away from fee-for-service and when we decide that a particular service is best delivered within a hospital setting by salaried employees, you come and tell me I’m not running things right. I don’t know that you can have your cake and eat it too.

Mr. R. S. Smith: You do it. Why don’t you be consistent?

Hon. Mr. Miller: Physiotherapy is one of those services that we feel should be delivered through the hospital or the home care system where possible.

Mr. R. S. Smith: That hasn’t been your practice in the last few years.

Hon. Mr. Miller: It has been our practice for the last few years in terms of the expansion of the programme. You can look at the regulations attached to the Health Insurance Act.

Mr. R. S. Smith: Can you tell me one place in northern Ontario?

Mr. Chairman: Order, please. Can the hon. minister finish his remarks?

Hon. Mr. Miller: You will find a complete listing there of those people who are in fee-for-service clinics.

Mr. R. S. Smith: There is not one in northern Ontario.

Hon. Mr. Miller: All right, but is the service available?

Mr. R. S. Smith: Not one in northern Ontario.

Hon. Mr. Miller: The service is available in my town today, if you want it. I met a person today who just came out of physiotherapy.

Mr. R. S. Smith: At certain hours of the day for certain people.

Hon. Mr. Miller: I must say that, contrary to some of the criticisms, we appear to be meeting the demand.

Mr. R. S. Smith: That is not true.

Hon. Mr. Miller: Both you and the NDP critic refer to hospital privileges. I can simply say that, while I try to keep an open mind in this, I have not yet been convinced that the arguments offered by those people who say all doctors should have access to all hospitals are valid. I would say that the speeding up of the hospital appeal process really depends as much upon the setting of precedents as anything else. I think of those first few cases going through -- Dr. Schiller in particular. He had, what, three hearings? Two courts and one before the Hospital Appeal Board?

Mr. Roy: Is he going up to the Supreme Court?

Hon. Mr. Miller: No, I am saying he went through two courts.

Mr. Roy: He went to the Hospital Appeal Board and the divisional court.

Hon. Mr. Miller: He has gone through three basic hearings on his case. This was doing us a service by testing the decisions. Those of you who should know much more about the legal processes than I do know it takes certain cases to set precedents. I think you would agree with that, in this instance, we cannot tell how the law will be interpreted by the courts until some person takes it to the courts. I suggest to you that very few people will be taking their case to the courts if they think their case and Dr. Schiller’s are the same. If that is denying justice, then I don’t know how one gets justice in our system.

You mentioned the other day during question period that the process was too long. As a layman, the legal process has always seemed too long to me. There always seem to be too many appeals. But I assume those of you who are lawyers have looked at the processes and, allowing for human foibles, have decided that that number of appeals is necessary to ensure that a person receives justice if he or she seeks it and is willing to go through the various levels of the courts.

Mr. Roy: You still haven’t understood our point on that. We are saying the hospitals’ case is overweighted because they have unlimited funds, whereas the other fellow hasn’t.

Hon. Mr. Miller: I don’t know that that’s not true in any court case when it is an individual against a large company, too.

Mr. Good: You should be paying the legal fees.

Hon. Mr. Miller: No, I can’t buy that argument.

Mr. Roy: Your legal advisers are misleading you.

Hon. Mr. Miller: Mount Sinai was mentioned, I should point out to you that within the last three months we have reached an agreement with three Toronto hospitals to see that facility converted into a chronic care facility and it will be used for teaching of geriatrics, gerontology, etc., as well as the delivering of the services and as a regional rehab centre.

Mr. Roy: It has been empty for over two years; it is still empty now.

Hon. Mr. Miller: The fact is that we did have, rightly or wrongly, a surplus of active beds in Toronto and that hospital was an active hospital. It is simple to say it should be converted to chronic overnight. I discovered that the design of a chronic room and the design of an active room are not the same.

Mr. B. Newman: That is what you found out in Windsor.

Hon. Mr. Miller: All right, I recognize that. I recognize, too, that certain rooms in every chronic hospital have to be rebuilt for the patients who must have wheelchair access. I sin not necessarily convinced that every room has to be rebuilt, because not every chronic patient requires that kind of access. The real issue is how much money has to be spent and how high should your design standards be in those kinds of things. I can only say that we reject or throw away hospital buildings that in Great Britain would be looked upon as the most modern in the world, when I see their plant over there.

Mr. Roy: Oh, come on!

Hon. Mr. Miller: You got on to the EMI scanner. I thought there were a couple of points there that were intriguing to me. The first is that I don’t believe the EMI scanner is related to the cancer facility in Ottawa at all. It is part of the radiology department, if I am not wrong. There will be the odd cancer case that will be scanned. I am personally all too familiar with that particular problem within our family at the moment, but there will be the odd case that requires this.

One thing that you touched upon intrigued me, though. Surely with your arithmetical ability you should have realized that when you said I should have given them the $140,000 that it cost to operate the machine for a year because of the great saving available if the machine is operated, you should go back to the fundamentals of global budgeting. We did say that one hospital in each teaching centre could have an EMI scanner -- not more than one at this point, but one. We do hope hospitals will share it. They might be able to work out ways of charging each other for the services if somebody else’s patients are brought in. That’s purely a bookkeeping mechanism to support the hospital rendering the service.

But if, as it was reported in the Toronto press, $2 million a year can be saved in bed care in that hospital or that area by using the EMI scanner, I don’t think any administrator worth his salt would be too slow in approving the $140,000, knowing he was going to save $1,860,000 to boot. Just stop to think of that for a second.

Mr. Roy: How do you get the process started?

Hon. Mr. Miller: He’s got a global budget. He’s got money he can flow. He’s got all kinds of ways. That is something, incidentally, which Ontario has that lots of places don’t have. The administrators have a lot of flexibility within their budgets to divert these funds and use them as they see fit. We believe in giving the maximum amount of management and discretionary decision-making to the administrators and the boards of the hospitals, via the global budget. Having given them this and if the savings are as real as they tell me, they should have no fear about going ahead with that programme because all they could be doing is saving money. I might be tempted to say I would like back $1.86 million if all that money was to be saved and I think you would be right there with me.

Mr. Roy: So you are saying, no money from the province?

Hon. Mr. Miller: No money.

Mr. Roy: No money and that is definite?

Hon. Mr. Miller: No. It is our opinion that you can’t go on giving people money for things which save money. If money is to be saved by using a piece of equipment, for goodness sake find the savings in the system because it has become an add-on if you do it the other way.

Mr. Roy: Don’t you think maybe you should get them started in the process? Then you can prove to the other hospitals that they saved all that money and you will get cooperation?

Hon. Mr. Miller: They have the equipment there. They have the right to take that money from within their budget and, in our opinion, that can be done.

I think that just about covers the points from the member for Ottawa East, does it not? Except you gave me some credit concerning the MDs programme and I’m glad to accept it.

Mr. Roy: The immigrant doctors?

Hon. Mr. Miller: Yes.

Mr. Roy: Yes, you accepted our suggestion of two years ago. Give me some credit.

Hon. Mr. Miller: Oh, toujours. Now, for the member for Parkdale, if I’ve got the right riding.

Mr. Dukszta: Oh, my God.

Hon. Mr. Miller: Is that correct, sir? Let me say, in sincere congratulation, that while I don’t always agree with the content of your address to me each year I do read it carefully. It reads very well. It is well organized and it is thoughtful. That’s where my compliments have to stop.

Mr. Roy: Do you ever use his services?

Hon. Mr. Miller: Do I ever use his services? Apparently we did; the last time he sent me a written report it was on Ministry of Health stationery. Was it not?

Mr. Dukszta: It was. I hope you read that one.

Hon. Mr. Miller: It was fairly long and my poor engineering training made me stop when I passed four letters in any one word.

Mr. Dukszta: And you promised to read it, too.

Hon. Mr. Miller: Yes, I did. I read a lot of it, as a matter of fact. You started by saying that medical care and health care are not identical and I couldn’t agree more. It’s sad that, as I think I tried to point out in my very brief opening remarks, we confuse the two. We use up a great percentage of our money on medical care and not enough of it on health care, the system. I suppose if my speeches have had any theme in the past year it has been trying to emphasize the very fact you stated. They are not synonymous; we need to emphasize health care in the broader sense and de-emphasize reaction to illness. I don’t know whether you had the opportunity to read a little pamphlet called “Medical Nemesis” by Ivan Illich, did you?

Mr. Dukszta: Yes.

Hon. Mr. Miller: Did you find it interesting? Really, he was trying to get into this whole question of over-treating the individual and the reaction to it, wasn’t he? I guess we go back to the old state of affairs where we say the human being is responsible in a large measure for his own health and should take a much greater responsibility --

Mr. Dukszta: Mr. Chairman, the minister is seducing me. He is so charming again. That’s terrible.

Hon. Mr. Miller: I’m sorry for that. Do you want me to go back to being my ugly old self? You touched upon emergency care and you talked about the overuse of it and again I can’t help but agree; we overuse our emergency awards. We use them for all kinds of penny-ante things.

I have gone so far as to think out loud in public -- and I emphasized it on the record, “think out loud in public.” I find too often, when I say something in response to a question that is posed to me, that somebody assumes because I show a glimmer of willingness to consider it that this means it is absolute, engraved ministry policy. It has been suggested at times that maybe the overuse of the emergency wards could be curtailed by some kind of a deterrent fee, provided the person wasn’t a true emergency and was presenting himself or herself at a time that was at their convenience, rather than one of need. I am just throwing that out as a thought, because the hospitals are getting a tremendous pressure put upon them because of the public’s use of the emergency care.

Mr. Dukszta: But they have to go somewhere.

Mr. Miller: Okay, but we feel that the studies we did in the city did show that people were far more aware and far more related to physicians than any of us assumed they were. That was one of the interesting by-products of the Mustard report. We did two studies in the city; one was downtown, although I couldn’t tell you geographically where, while the other one was up in the Sunnybrook region of the city, as I recall. We tried to take two different sections of the city to find out if people knew where to go for medical activity.

The studies were done by Harding Lariche; you would know of him. His studies found that a much higher percentage of people were aware of the availability of services -- where to go, how to get them -- than any of us dreamed.

I question whether a list of services in layman’s terms that should be posted in a physician’s office could ever be made meaningful. Maybe it can. But look at the size of the current OMA fee schedule. It has got to be a half-inch thick; it lists procedures and, as you know, sets the price for each one. I question whether the average patient would know what service he or she came in for until it was rendered or diagnosed by the doctor, and I think it is kind of unfair to assume that they can. But, in fact, the OHIP plan pays for all medically necessary treatment by a physician.

Mrs. Campbell: No, it doesn’t.

Hon. Mr. Miller: Well, okay, I’ll be glad to listen to the counterparts later. I have just put forward an Act in this House last week, amending the Health Insurance Act so that policy decisions, like the one that referred to otoplasty a while ago, can in fact be enshrined in legislation.

I don’t know where either of the critics has taken the time yet to read that amendment to the Health Insurance Act, but it would allow us to write regulations covering certain medical procedures for certain age groups; and we would be able to describe them in regulations so that we could in fact cover the young and not cover the adult population for any procedures that were deemed to be cosmetic for one group but medically necessary for the other. I hope that amendment will be acceptable to both of your parties. It is an attempt to come part of this way.

We touched on prevention next. We are trying to improve preventive medicine, although it still forms a relatively small part of our overall budget, by strengthening the primary care sector. In spite of your statements that I am trying to kill the HSO by supporting the HSO, I am not. That, to me, is one of those areas where we are trying to improve primary preventive care. We are going to experiment with it, and I will discuss it in more detail later on.

You know, I get a little tired -- I guess I must admit, my bias shows -- of hearing about the working class not being able to get access and always being denied things. I have been part of the working class most of my life -- up until the 30-year age group or more before I could perhaps call myself management. I came from a working-class family. I just don’t feel that things are as bad in the working-class element as I hear from day to day. I never really felt as neglected by the state, as some of you have made me feel. I am convinced though that you can make the working-class people think they’re neglected and ignored and hurt, if you keep telling it to them often enough.

I really hope you never want to go back to practise medicine, because if I ever circulated your comments about listening too much to the OMA and being, in effect, in the pocket of the OMA -- I don’t know. I heard you’ve circulated your speech to a bunch of doctors each time. Surely, this one is not going to get that same circulation.

Interjection by an hon. member.

Hon. Mr. Miller: I can only tell you that I haven’t met any members of the OMA who think I’m in their pocket. Far from it. A couple of months ago when we held relatively firmly to our wish to maintain the four per cent increment for physicians in 1975, that was a long way from being considered to be in the pockets of the OMA.

Mr. Roy: I heard a lot of nasty things about you after that. They’re waiting for you next time.

Hon. Mr. Miller: Yes they are. I almost hope someday it’s you. I’d like you to be faced with that problem.

Mr. Roy: Do you think they’ll like me?

Hon. Mr. Miller: Oh, I cannot tell a lie.

Mrs. Campbell: They’ll love you.

Mr. Roy: It’ll probably be us; but I’m not sure it’s going to be me in that job.

Hon. Mr. Miller: You talked about my attempt of saving half a billion dollars a year by the curbing of the immigration of foreign MDs. This wasn’t any racist thing, I’m sure you know that. It was an analysis of our need in the province and our ability to fill that need for physicians -- a recognition that market forces do not work in the medical field. I think you’d agree with that much -- that, in fact, under a fee-for-service mechanism, or any other mechanism that allows physicians to set up a practice where they wish to set it up, in effect, business can be generated.

Mr. Dukszta: I think I mentioned that point later. It is a blank cheque you give physicians.

Hon. Mr. Miller: Whether it’s under the HSO system, or whether it’s under the fee-for-service system, there seems to be an unlimited willingness on the public’s part to believe they need to see a physician if they’re either told they do, or if physicians are available. The one constant, or the one sure thing I’ve been able to predicate from my studies of Mustard and other things, is that the total demand for services, hospital beds, you name it, is proportional to the number of physicians practising in the province. It’s almost a straight line equation.

If one extrapolated that, surely, sometime ad absurdum, it’s going to stop going up -- but not within the resources the province has to pay for the cost of delivering unnecessary health care past a particular point. The World Health Organization says we only need one physician for every 650 people. We have one physician for almost 550. It’s going down so fast I’m afraid to look. It was 585 when we made this decision to request a curbing of immigration.

We wanted to meet two or three objectives. First, to keep the physician-population ratio constant. Secondly, to get physicians to serve in underserviced areas. So we said that physicians coming in and willing to serve in any part of Ontario that was recognized to be underserviced -- even if it’s in the core of the city of Toronto -- would be permitted to come. Or, if they had a specialty that we were short of, they would be allowed to come. There would be contracts --

Mr. B. Newman: Isn’t there a shortage of GPs?

Hon. Mr. Miller: I don’t really think so.

Mr. B. Newman: The doctors tell me that.

Hon. Mr. Miller: I’m sure they do, because they’re all busy. I mean, if one equates business with shortage, there is a shortage. I don’t think the two things can be correlated, just as I don’t think the lineup of people to get in hospitals can be equated to the availability of beds being inadequate. It’s a fact that if you build them you fill them.

Thirdly, we had an obligation to produce more physicians in Ontario. You know that two years ago, under the member for Quinte, it was decided that the teaching hospitals facilities in the province would be upgraded, both the clinical facilities related to them and the direct teaching facilities added to and improved to allow us to produce about 670 Ontario-trained physicians per year. I still think we have a responsibility, as one of the wealthier provinces and wealthier nations, to be producing more physicians than we need, not just 75 per cent of our need. I feel a great obligation toward students in Ontario who have the intelligence and the desire to become physicians, to give them the right to become our physicians and I don’t make any apologies for that point of view. That is not anti-anyone; it is pro the people in this province. On that basis and that basis alone, I feel my policy was necessary.

How can we plan the number of specialists in any field, particularly those that are narrowly staffed, like neurosurgery? How can we plan the post-graduate programmes at the U of T, or at Kingston, or at London, and find that we are allowing immigration to produce 300 per cent of our needs for those particular specialities? It just doesn’t work. All the planning you can do in the world is for naught if, in fact, there isn’t some control.

We’ve been controlling poor guys like plumbers, electricians and you name it, for years, but we haven’t been controlling physician’s because, naively, the federal government assumed there was a bottomless, unquenchable thirst anti need for them. So Ontario proposed a programme which got unanimous acceptance, and I suppose that has not happened in provincial-federal conferences before.

Mr. Roy: Of course, Mr. Lalonde had talked about that for a couple of years, too.

Hon. Mr. Miller: It happens that the hon. Marc Lalonde -- whom I admire, even though he supports your party --

Mr. Roy: That’s an asset, you know, not a liability.

Hon. Mr. Miller: It depends on where you live.

Mr. Roy: Just hang around; hang on here for a while longer.

Hon. Mr. Miller: He was quick to say it was the Ontario suggestion that he supported, and I think that once in a while we have to pat ourselves on the back.

Mr. Roy: I called him up the night before the conference.

Hon. Mr. Miller: On the drug plan, we’ve allowed some 1,500 drugs -- I think 1,535, if my memory serves me correctly -- to be printed in the next formulary, subject to some final adjustments based on the drug quality and therapeutics committee’s recommendations to us. I believe, if I’m not wrong, over 100 of those will in fact will be compound drugs.

Mr. B. Newman: Can we get a copy of the formulary?

Hon. Mr. Miller: I’m sure you can and I’d be delighted to make sure you get one. All I can say is, sadly enough, a great number of the physicians who got one don’t know where it is.

Mr. Dukszta: The compounds are new? That is a new addition?

Hon. Mr. Miller: Yes, the version I’m talking about right now won’t hit the streets until July 15.

Mr. B. Newman: Provide us with one.

Hon. Mr. Miller: I will make a note that the members of the House shall receive it. I’m glad to accede to the reasonable request of the member. His requests always are reasonable.

Mr. B. Newman: Thank you, Mr. Minister.

Hon. Mr. Miller: I may not say that later on in this discussion.

Mr. B. Newman: No, you will agree with what I have to tell you concerning the situation. You will agree.

Hon. Mr. Miller: When we get down to the nitty-gritty of what should and shouldn’t be in the drug formulary -- and I hope the member for Parkdale will listen attentively -- the problem is complex, because the drug manufacturers produced, at our last count, over 18,000 compound drugs. The average physician prescribes, they tell me, a variety of some 22 drugs. We have 1,500-plus in our formulary, so one would think we’d met the need. Obviously, the 22 drugs are chosen from some 20,000 possible materials. So you can realize the difficulty of getting any one formulary that matches any one physician’s prescribing habits.

The issue is, are we wrong by not including all 19,000 and having no control whatsoever over the cost of the drugs dispensed? Are we wrong in sticking by the principles that the OMA and OPA have told us are correct, of asking physicians to review their prescribing habits and make sure that they are tailoring the drugs to the patient’s needs? These things are supported by the executives of those associations.

We have asked them sincerely to tell us how to change the plan or where our principles are wrong. They’ve admitted to us that the problem is more one of education than it is of changing our plan. I do admit that certain senior citizens have difficulty in coping with separate drugs. That is why at this point any physician who calls in and explains his problem has about a 98 per cent chance of receiving an approval for a specific compound drug for a specific patient, good for six months and reviewed at that time.

We only ask that physician to do one thing with us -- look at our side of the argument during those six months because, if the OMA and the OPA are right, he should be reconsidering some of his basic prescribing habits. I am licked if the doctor tells the patient it is the dirty old government which has told him the drugs he prescribes are no good when he knows they are. I am licked right then and you would agree with me. If I have a doctor willing to think about it and willing to prepare a patient psychologically for some change which may be for the patient’s betterment -- certainly it is for our purse’s betterment -- I think we have a fighting chance.

That’s the kind of approach I hope to get from the OMA. I must give them credit; they have been very co-operative with us at the excessive level. The plan will cost us $46 million this year, in its first full year.

I touched upon the appeal board in my response to the member for Ottawa East. Psychiatric hospitals -- I am going to skip children’s mental health because you are really saving your questions until later. On psychiatric hospitals I can only say we are listening to the psychiatrists in going to more community-based services. I think you would agree with me. It is not the minister’s opinion; it is the opinion of competent staff who say this is a better way to treat the mental patient. You can answer that much better than I can; you are a psychiatrist.

Mr. Dukszta: By cutting by three per cent you are actually cutting off the community centres.

Hon. Mr. Miller: I recognize the difficulties of finding adequate community support centres for those people returned to the community. I recognize again the tremendous problems of attitude that you and I and all of us face who are trying to help the mentally ill return to society when you want to create any semblance of a home for them in any reasonable area of the city. It is sad to think the poorest areas of the city end up by getting stuck with the job but that is a fact and that’s the way it has been.

Payment mechanisms: I like fee-for-service; I have never made any bones about it. It works.

Mr. Dukszta: That is frank at least.

Hon. Mr. Miller: At the same time my ministry has been willing to finance alternative payment mechanisms. Human beings aren’t the way the model describes them. Human beings -- and doctors strangely enough are among them -- react to incentives and the fee-for-service happens to be an incentive. It has disadvantages and advantages.

The new health service organization with a global budget and salary has advantages and disadvantages. I didn’t stop signing HSO contracts on a permanent basis; I paused. I paused long enough to give myself a chance to study countervailing arguments coming to me about the pros and cons of this method of delivering health care. I learned in the four to five weeks I paused that the problem was much tougher than I even dreamed it was. We can’t even measure the cost of health care effectively let alone the quality of health care delivered effectively. It is easy to say you can, but the moment you try the experts disagree.

I think with the time running out I should stop at this point and say I am ready to let the House leader adjourn.

Hon. Mr. Winkler moves the committee rise and report.

Motion agreed to.

The House resumed, Mr. Speaker in the chair.

Mr. Chairman: Mr. Speaker, the committee of supply begs to report progress and asks for leave to sit again.

Report agreed to.

Hon. E. A. Winkler (Chairman, Management Board of Cabinet): Mr. Speaker, tomorrow, as I had announced, we will be dealing with some second readings. I have had to withdraw one bill from that list but the orders on the order paper will be as follows: 5, 6, 9, 10, 11 and 12 -- not particularly in that order, but those are the matters we will deal with tomorrow. On Thursday we will probably return -- although I will announce it tomorrow night -- to the consideration of the Ministry of Health, and I shall then indicate to the House what we will do on Friday.

Mr. A. J. Roy (Ottawa East): The Minister of Health is not going to be here at all tomorrow?

Hon. F. S. Miller (Minister of Health): Not at all. My son graduates.

Hon. Mr. Winkler moves the adjournment of the House.

Motion agreed to.

The House adjourned at 10:30 o’clock, p.m.