Legislative Assembly of Ontario

The House resumed at 8 o’clock, p.m.

ESTIMATES, MINISTRY OF HEALTH

On vote 2901: (continued)

Mr. E. J. Bounsall (Windsor West): Thank you, Mr. Chairman. The Minister of Health (Mr. Miller) knows that someone from Windsor getting to his feet at this point in the estimates must be talking about the proposed hospital shifts that are occurring in Windsor.

I understand, Mr. Minister, that part of what you’re trying to do there is attempting to consolidate specialized services in one hospital, and thereby doing away with fragmentation and perhaps cutting down on some of the costs. But if you or your ministry were trying to find a way of getting the entire Windsor community irritated at the Minister of Health -- irritated at the whole health plan -- you have certainly found the way.

In questioning in the House, the minister has consistently said that this proposal of Mr. Backley’s is simply a proposal to get the Essex County Hospital Planning Council down to the serious business of considering consolidation and efficiencies and shifts. He has said he is willing to consider any reasonable proposal, but along the same lines that would still save that $4 million, or would still get rid of the so-called surplus of 242 active treatment beds.

I’d like to ask the minister, and I’d really like to have the answers here, how you justify, in the city of Windsor, the need to save $4 million on hospitals or the saving of 242 hospital beds. Is the situation in Windsor such that the active number of hospital beds per capita is so much higher than the other cities in the province? Are they so much higher than the other five cities in the province, in which Windsor is tied for fourth in population? Are they so much higher than that that you’ve decided that Windsor has to cut back to the size of those other cities in hospital beds per capita? Or is the expenditure per capita through hospitals in Windsor higher than those figures for the other five cities, or even 10 cities, in Ontario?

Just what are the figures that cause you to go into the Windsor area and say, “You’ve got to save $4 million here by some sort of consolidation, and you’ve got to get rid of the 242 active treatment beds plus 96 other beds” which you say are not in use at the time?

I’d be happy if it were conclusively pointed out that I was wrong -- you’re an engineer as well as I, so you’ll understand the figures we’re talking about -- but I don’t believe that this is the case. We’re talking about 250,000 people -- the 200,000 in Windsor and another 50,000 in the immediate vicinity -- who use the Windsor hospital facilities. I don’t believe that the figure of beds per capita is sufficiently higher than the other nine cities in the top 10 in Ontario, that this has to be accomplished, nor that the expense per capita is such that it has to be accomplished.

Are you saying that Windsor has an expense of $16 per year per capita more than in those other localities? That is what it works out to; $4 million divided by 250,000 population; $16 per capita per year higher expenditure than elsewhere. Can the minister prove that the surrounding area has a ratio of people per beds that is 1,000 to 1 greater than those other nine communities? The ratio of people per beds exceeds the other nine communities by around 1,000? If you can’t, then what on earth are you doing down there in Windsor? Why have you decided that you’re going to put the entire community to such an upset as you obviously have with this?

Mr. Minister, I can’t keep up with the phone calls and the letters that have come in on this issue alone. I think there is only one other issue in the time of my four years in this House that has produced more letters or phone calls than this has. That was a mailing campaign which you were expected to answer in a standard way. This is a different type of contact; mainly by phone. People are very upset. The medical and nursing communities are quite upset by it, they believe it’s a backward step and are concerned about reducing the availability of services and the effectiveness of services in the city of Windsor.

Taking a look at the proposals, there is one which seems to irritate the people of Windsor more than any of them. It might be that it’s because the hospital is on the west side of Windsor and I get more of the complaints associated with the proposals of that hospital than I do of some of the rest. It is the proposal to transfer obstetrics out of Grace Hospital.

Let me make this a little bit personal. In 1968, we had a child in one of the hospitals in the city of Windsor. At that point, we had not had a child previously in Windsor and we simply went to the hospital which our doctor suggested. I wouldn’t say the experience was negative, but it wasn’t very good. It wasn’t very good to the point where we, in fact, asked around the community where you went in Windsor to have good obstetrical care. The answer came back loud and clear: “You go to Grace Hospital.” Some two years later, when there was another addition to the family, we went to Grace Hospital and the difference in attitude, the difference in patient care and the difference in treatment was the difference between day and night. And in what hospital do you choose to close down the obstetrical care? You choose to close down Grace Hospital; the one which is accepted in the community as the hospital in which the patients and the babies get the best care.

If you took a look at the hospital situation in Windsor and said, “This is what we should be doing; these are the moves we should make so that they are all wrong,” that proposal for Grace Hospital really fits the category perfectly. Last year, the greatest number of births took place in that hospital -- 722. In March, 1970, there were 162 births at that hospital; higher in both categories than any other hospital in Windsor, and they have no problem in averaging 140 births a month in that hospital. It is more than any other hospital in the city of Windsor.

This hospital was founded as a maternity hospital and they have taken special care to develop that hospital along those lines and to instill in the entire staff there that attitude; the attitude that gives the best maternity care in the city. That’s the hospital which first allowed the Lamaze treatment in procedures in the hospital, and the atmosphere, as anyone who goes to have a child there and as many mothers in the community can testify, is very superior at Grace Hospital.

The minister is proposing to save money if obstetrics is taken away from Grace Hospital and a certain number of those births are going to take place at Hotel Dieu. Up until now Hotel Dieu has had a policy of no sterilizations, no tubal ligations, and it certainly won’t, as far as I know, up to now, let the natural childbirth procedure take place within the hospital. Not only do you have a drop in attitude toward the birth of a child by not allowing one’s husband in to help at the time of birth, you have a situation where there are services which are not performed there.

I understood that if someone has a tubal ligation, for example, at the time of the birth of the child, they spend an extra couple of days in hospital. But if that child is born at Hotel Dieu, and they don’t have tubal ligation, it means they are going to have to come back into hospital at some later date and spend five days for a tubal ligation. That’s an extra three days, an extra three-day charge over and above what is necessary for a tubal ligation.

Hon. Mr. F. S. Miller (Minister of Health): It’s done on an out-patient basis.

Mr. Bounsall: Tubal ligation? That’s not really the norm there.

Hon. Mr. Miller: It can be.

Mr. Bounsall: How often is it done?

Hon. Mr. Miller: I will check that.

Mr. Bounsall: All right, you have the staff there. You can give me the provincial averages without any problem. They are oriented to figures and averages that should easily be turned out. I understand one usually goes into hospital for tubal ligation and that’s a longer period than if you had it done right at the time of birth. If that’s incorrect, I’d be interested in hearing what your figures are on that.

That’s the one shift which emotionally upsets the community more than any of the others. There are very good points which can be made on the other hospital shifts but that’s the one which is the real problem and the one that makes the least sense in terms of the history of the community. It’s not taken very kindly when a deputy minister, who doesn’t know the community very well, comes in and says this is what is going to be done with the community in terms of hospital care, paying no attention to or knowing nothing about the history of the community. I would say that any official would not come in and make that recommendation about Grace Hospital if he knew anything about the community, let alone the current feel of the community.

One might say of the obstetrical physical plant at Grace that it’s the most out-of-date of those in the city; that could be said. But here again you are choosing physical plant over people and Grace Hospital would certainly be willing to go through any minor alterations -- or major if you want to pay for them -- to bring their obstetrics and number of delivery rooms up to what the Minister of Health might feel would be necessary for the numbers. I think the minister might even agree there wouldn’t need to be any expansion there. That is one suggestion which cannot be allowed to take place and will not be allowed to be pushed through, by this ministry no matter what we have to do.

If you are going to save money by ending fragmentation by consolidation, what in blazes are you doing closing the chronic care hospital, which has an expertise built up and a physiotherapy team specializing in the problems the elderly have, and dispersing it among all the rest of the hospitals in the city? What sort of cost saving do you get there? You can probably say there isn’t a cost saving to be attained there. You are just spreading it around a bit. What you are doing is you are destroying your specialized teams at Riverview Hospital.

The argument, again, about Riverview Hospital may well be its plant; it’s the oldest in the city. It isn’t very attractive. It just so happens that the people in that hospital who go there for chronic care get very good care. Here again, it looks as if you are choosing plant over care and specialized units, which should be more efficient. If we are looking at it from a dollars-and-cents point of view purely, it should be more efficient in delivering that service to the chronic care patient.

The minister has come very close to saying that the directive, as passed down by Mr. Backley was because the Essex County Hospital Planning Council hadn’t been able to arrive at a proposal, and that you are now quite willing to have them come up with an alternate proposal to the one proposed as long as it still does the same thing -- save the $4 million.

The ministry surely must be in receipt of the letter dated Aug. 19, 1974, by the Essex County Hospital Planning Council in which they specifically talked about the chronic care. Partly because of the age of the building, they said that Riverview should close but they planned in that letter to add 80 more beds to IODE Windsor Western Hospital at the Casgrain Building and make a slight expansion of chronic care beds in new facilities at that hospital so they could again virtually all be accommodated at that site where they would have the specialized team and a specialized physiotherapist.

When you say there was no proposal made, there certainly was a proposal made in the entire area of chronic care which, when the conversation arises about it, seems to have been completely forgotten by your ministry. The suggestion which was rather rudely thrust upon the hospitals down there came as a complete surprise in terms of what the ministry was wanting to do. I cannot find a doctor, a chief of staff or an administrator whom I have talked to that had any inkling that the ministry was trying to get rid of this number of beds down there. They have seen no correspondence to this effect.

As for the number, 246, that would save us $4 million, if you’ve got that in writing, then I would be pleased if the ministry would send me photocopies of those letters that went out to those hospitals prior to the proposal of the ministry official that this is what they are going to do in the shuffling of facilities there.

There is a minor problem with paediatrics being removed from Metropolitan Hospital. This is the hospital in which the cancer centre is located in Windsor. At the moment, there is a certain number of children who have cancer who are treated there. Leukaemia is treated there. If the paediatrics are transferred out you will have the situation where the children are going to be located in other hospitals and transferred on a daily basis in an ambulance at a cost which I suspect you have not counted for treatment.

Mr. Chairman: Vote 2903 deals with what the member for Windsor West is talking about. Cancer treatment and ambulance services and everything else are in vote 2903.

Mr. Bounsall: No, Mr. Chairman, we had a sheet handed to us on what was in this particular vote. Certainly ambulance services are in there.

Mr. Chairman: It is vote 2903.

Mr. Bounsall: All right, I will save my remarks on ambulance services. I have got a lot of remarks on ambulance services.

Mr. Chairman: Save it for vote 2903.

Mr. Bounsall: I am talking about cost of transferring children by ambulance to have cancer treatment at the one hospital that has cancer treatment.

The only alternative to that, because the paediatrics has been moved, would be to admit the children, to take them to the paediatrics ward at Metropolitan Hospital where there is no one trained there to look after children. That is the only alternative; so take your pick on that one. Whichever way on want it isn’t a satisfactory situation. There has been a decrease in treatment care.

Mr. Chairman, I am informed we have been dealing with the entirety of vote 2901. I understand that other speakers have been dealing with the entirety of vote 2901.

Mr. Chairman: You are so right, but I am talking about vote 2903 where we really get into ambulance services.

Mr. Bounsall: Item 3 in vote 2901 is the ambulance service branch according to the notes that the minister has handed out.

Mr. Chairman: I guess the minister would just as soon discuss it here as in vote 2903, but there are a lot of other speakers who want to deal directly with items in vote 2901 and I would like to give them a chance.

Mr. Bounsall: Mr. Chairman, according to the minister’s handout, item 3 of vote 2901 deals with ambulance services.

Hon. Mr. Miller: Mr. Chairman, we have been fairly broad in our interpretation after a ruling by you, I believe, or by one of the other Chairmen the other night, that opened up vote 2901 to general discussion.

I suspect that when I am through with vote 2901, I will be almost through my estimates.

Mrs. M. Campbell (St. George): I think so.

Mr. Chairman: You mean you are hoping.

Hon. Mr. Miller: I’m sure these gentlemen wouldn’t be repetitive.

Mr. Bounsall: Just give us a chance to deal with it in more detail later on, Mr. Chairman. The other main shift in this proposal is to transfer psychiatry care out of two of the active treatment hospitals, Hotel Dieu and Met, and put it into IODE, Windsor Western.

One could look at that say, “Okay, there is a consolidation of services that will save some money.” It concentrates your psychiatric staff in one point. It allows the specialized facilities for the treatment of psychiatric patients, which you now have at Riverview for chronic care in that field, to be wholly developed at one hospital.

But because it is psychiatric care we are talking about, you have an additional two or three problems arising. Windsor Western-IODE is going to become known as the hospital where crazy people go. This is unfortunate. Mental illness is not yet looked upon in this province as something which everyone suffers from time to time, but it is still looked upon by many of our population as an ailment somewhat different from the rest. People who have to avail themselves of that kind of treatment are referred to by many people in our community as crazy.

This hospital is going to be looked upon as the hospital where the crazies go, when it is all concentrated in one. That is the disadvantage of taking that particular ailment and isolating it in one hospital. Again, you’ve ignored the attitude of the people in the community. You’ve divorced yourself from the real-life reflections of the people in the community with that type of a suggestion. Also, there would be no psychiatry available on an emergency basis at any of the other hospitals when the need arises. The staff of the Windsor Western Hospital and the Windsor Academy of Psychiatry are not in favour of this consolidation at what in essence even now is the hospital that has the most psychiatric capability.

In addition to the point I mentioned, that the hospital will become known as the crazy hospital, I stress that no psychiatric services will be available on an emergency basis. When a patient with a drug problem turns up at, say, Hotel Dieu or Met, he or she is going to have to be transported across the city in an ambulance -- and at whose cost? Plus there is the fact that you lose the whole contact at those other two general hospitals with psychiatric staff, a contact which is rather valuable to maintain and leaven and to have around the staff rooms of those other two hospitals. The more mixing you can have, the better it is going to be and the more understanding will continue to be developed among the medical profession as to what ailments need some psychiatric treatment, depending upon the symptoms. All of that gets lost in this whole shuffle, Mr. Chairman.

I sort of feel the minister to be an honest man. So far I have been quite willing to accept the fact that he is and that he is trying hard. He is very smooth here in the House on his estimates. He is either saying, “We are trying our very best” to indicate they are in deep humility, or he is joking and making comments that would show he is forward-looking and trying to get at the best solutions. He even asks us for our help and our understanding in the problems that he has, and that all leads to one of tending to trust the minister.

So one hopes that one can trust the minister when he says these proposals are only proposals -- these proposals that Mr. Backley threw out -- to get the Essex County Hospital Planning Council down to some serious business of planning.

You prove to me (1) that that is the case, by accepting the suggestions that are going to come in, and (2) that you don’t really need that $4-million saving or that 246-bed saving. If you do, prove that we have, by that saving and by that bed removal, just come equal to the ratios that are occurring in the other nine major cities in the Province of Ontario. Show us that need for this type of cutback in this community, because the other nine communities of the top 10 communities in Ontario are at that ratio now and you are just bringing us into line.

The general feeling out there is that this is going to be a distinct downgrading of services and of great detriment to the community. That point has never been made publicly. That’s a point of public relations, if it is the case, which the ministry hasn’t even attempted, as far as I can read in the press or have been told from conversations. That point not being made, I wonder if it’s even possible to be made and I suspect what is going on in terms of the entire consolidation.

All of this consolidation is taking place in a community in which two other interesting evolutions or happenings took place over the last couple of years. Citizens’ groups raised money for a heart/lung machine, which the Ministry of Health instructed them not to unpack, and also more than $200,000 has now been raised for a burn unit.

In May, 1974, the ministry did give approval for a burn unit to be developed in the city of Windsor, and $30,000 worth of equipment had been already purchased. However, it’s going to require some renovations at Metropolitan Hospital to accommodate this burn unit, and other than another crash cart available for use, no more equipment can be effectively purchased until that renovation has come about.

I am in contact from time to time with the people interested in the establishment of that burn unit. They certainly have burn facilities in operation at the moment, and the nurses who are going to be associated with that burn facility have been over to Ann Arbor and taken additional training in the treatment of burns. They need to purchase, in addition, a hydrotherapy tank, an operating table and various other facilities, but you need the renovation first.

I also gather from my contacts that if the consolidation takes place, there will be money for the renovations. All right. In talking about when the renovations would come for the burn unit, if one were to ink if any of that $4 million coming off the budget would be reinvested in the Windsor area, the answer comes back, oh yes, some of it will be put back into the community. If that $4-million saving isn’t achieved, there won’t be moneys available for the community.

That sounds almost like blackmail in talking to the burn unit people, and those backing it. “You achieve some money savings, then you can get the renovations. But, boy, if you don’t achieve those money savings which we are proposing, there will be no moneys available for renovations in the Windsor area.” If that is not the case, if the minister can stand up here and announce from his conversations that are taking place at the moment with Mr. Backley that, in fact, the moneys are going to come for those renovations, then the people in the Windsor community will be very glad to hear of it.

If not, that seems to be the story that has got through to the organizers of the group which managed to get that $200,000. So, here again, you are taking a community-oriented, completely volunteer group which has raised $200,000 to establish what is going to be, I think, one of the best burn units around -- and they are involved in this cutback.

You are not doing very much, Mr. Minister -- as other ministers are very proud of doing -- to involve the community in the whole health care scheme. It’s really a bit surprising that you have got public enthusiasm for the burn unit going in the light of your turndown of the heart/lung machine. I know the entire background on that and know that the arguments were evenly divided as to whether or not that should go into operation there.

The only thing which the minister wouldn’t agree with me on was that you should stand up and say: “This is its use, for coronary bypass, and we are not going to let it be used for anything further than that. We are not going to let an open-heart surgery team be an addition to that.”

They were willing to take that heart/lung machine under those conditions. The minister was leery about the conditions, and feared in the future the demand would come for open-heart surgery.

It is amazing you had any citizen involvement in the burn-unit fund raising, considering the way the heart/lung machine financing was entered.

Well, Mr. Minister, I would like to hear some of the answers to some of the points I have raised with respect to hospital consolidation -- particularly where we stand with respect to other communities in the numbers of persons per active treatment bed; the number of dollars per capita in hospital costs, and some of the replies as to why you find it economically feasible to consolidate psychiatry, but also economically feasible to fragment chronic care. You can’t argue both sides of the question in both cases -- needing teams with some expertise and some specialized equipment in both areas, where you save money by consolidating one and fragmentizing the other.

Mr. Chairman, there is one other hospital matter that comes up at this time. I have written to the minister recently about it; and that is one particular change in the regulations which came in in the spring of 1974. It was regulation 174, an amendment to section 61, the whole being an amendment to regulation 729. If a hospital so chooses, it can require employees that have been absent from work because of illness three or more days to report to a registered nurse in the employ of the employee health service before returning to work.

I have written to the minister asking him to consider a particular change there. I understand why both the Ontario Hospital Association and the Ontario Medical Association suggested that this be added to the regulations. It is simply protection for the hospital from an employee who may have some communicable or contagious disease. If he has been off more than three days, he should simply check into the hospital health service.

Before I make the main point on this, first of all, a rather interesting situation developed. It was not very well known around the Province of Ontario that this regulation existed. I suppose that slowly the OMA and the Ontario Hospital Association are getting the word out to their membership, particularly in the hospitals, and we will get more institution of this particular way of going about preventing contagious or communicable diseases being spread amongst the hospitals by workers who have them.

It was first brought to my attention last Feb. 17 by some of the nursing staff at Windsor Western-IODE Hospital in Windsor. I and my secretary, both of us, off and on over three days, spent three days phoning officials of your ministry inquiring about that regulation. Did a regulation such as that exist? After three days, we had to come to the conclusion, because we were told it so many times, that in fact it did not exist. From the list of people that we went through, the legal department, the regulation people and so on -- we found no regulation like that existed.

I dutifully passed the word on that the hospital must be incorrect in saying that such a regulation existed. When that was passed on to the hospital, they were able to quote it. I then got back to the ministry and in rather speedy time did find a Dr. Evis who knew that it existed and could give me the background on it. And so I was able to get a copy and deal with the situation in Windsor.

The reason that I wrote the minister of late on it is that there are some hospitals instituting this in a way which is not very reasonable. They are saying that even if they have a report from their own doctor stating what their illness was and that they are fit to come back to work, they still have to report to the RN in the hospital’s employee health service before returning. Surely that is unreasonable, if they have a letter from their doctor or from a specialist saying it is okay for them to return to work, whether or not they specify the illness.

I can understand that there may well be some confidentiality needed with respect to some of the ailments which persons may have who are also hospital employees. But if they get from their own doctor, or from a specialist that their own doctor referred them to, a note certifying that they are able to return to work, that should be sufficient to be handed in to the employee health service. That should be enough so that the employee health service doesn’t require them, as it has the power to do or seemingly has the power to do, to be sent to the staff doctor. That’s the unreasonableness of it.

One of the main problems is arising out at Queensway Hospital here in the west side of Toronto. It is interesting to find out who it is who is required to be referred by the employee health service there for a staff doctor to take a further look at. It just happens to be those who are members of the bargaining unit and particularly those who are on the executive of the bargaining unit. So, in essence, what turns out to be a regulation which protects the public and patients in hospital against employees who, perhaps unbeknownst to them even, have a communicable disease, has given to the hospitals a lever by which they can harass particularly the elected officials of the bargaining agent that is in that hospital.

It could be very easily changed, if not by an addition to the regulation, then by a note going to those hospitals that are using this regulation saying that a current statement from their medical doctor or the specialist to whom their ordinary doctor has sent them is sufficient for the purposes of that regulation. That would then take them out of the position of being sent by that RN, under directions, no doubt, to the staff doctor for the purpose simply of harassing people.

I would hope that the minister would take this rather seriously, because here again, it’s a problem that people are having today that needs to be solved before tomorrow. It involves people, it involves your hospital workers in the hospitals of your system, and whoever is doing it in the administration of that particular hospital has chosen to use that regulation not in the way the ministry intended, but in point of fact, to harass the workers of that hospital.

Finally, at this point -- I can come back to all these points in more detail later on, of course -- I have a few queries about the ambulance service branch, and I really would like the minister to comment as to what is happening in the ambulance service branch.

Has the amalgamation of the ambulance services in Toronto taken place yet? In that amalgamation, has the minister taken some care to ensure that the five private services affected in the minister’s own ambulance service branch, which are all being transferred to the Metro Toronto service -- I suppose it is formerly the department of emergency services and perhaps it still is -- are fully informed, each unit, as to the dates of the transfer; that they are having transferred with them, when that amalgamation takes place, their seniority positions, the same wage and salary scales that they had within the ambulance service branch or within each of the five private services their vacation entitlements, pensions and sick leave are all that they have accumulated, and that the details of those plans are all transferred with them that, if possible, when that transfer occurs a transfer takes place simultaneously so that they’re not just transferred one group at a time and that as a result of a total transfer, the question of which bargaining agent they’re going to have, can all be settled at one and the same time?

It isn’t fair to employees of your own branch or to the employees of the five private branches, nor to the employees of Metro Toronto, when they’re all to be put together with Metro Toronto, if they’re brought in piecemeal over a period of months, with new members being added, with perhaps the lowest wage and the lowest benefit paid to all of them that one can get away with. It should take place simultaneously, so the whole issue of what their wages are, what the carry-over is, and their choice of bargaining agent can take place at one and the same time.

I urge the minister to give us an up-to-date report on what is happening with your own ambulance service branch, and what’s happening with respect to the amalgamation of it with the other five branches and with the Metro Toronto ambulance service. I think for the moment Mr. Chairman, I’ll end my remarks there and get back to them at some other point.

Mr. Chairman: Does the minister want to respond?

Hon. Mr. Miller: It depends on whether there is any more on Windsor, Mr. Chairman. Are there any more comments from Windsor?

Mr. Chairman: The next speaker is from Nipissing.

Hon. Mr. Miller: Mr. Chairman, it’s great to hear the unanimity that I get from the opposition. On the one hand, the official critic for the Liberals has berated me for not taking enough steps to rationalize services. The member for High Park (Mr. Shulman), the other night, took me apart bit by bit for not doing this. The moment we do it in any community, the members for that community stand up and defend the status quo. You can’t have it both ways. It’s as simple as that. You can’t be criticizing me for not doing anything then criticizing me for doing something.

Mr. Bounsall: It’s the way it is done.

Hon. Mr. Miller: The way it’s being done, it is being done in a reaction to a lack of community response, and you know that.

Mr. B. Newman (Windsor-Walkerville): You didn’t attempt to get the response.

Hon. Mr. Miller: We attempted and attempted. I personally visited each of the hospitals in that community, and you know it, and I discussed this with those hospitals. Those hospitals are more interested in protecting their own individual status in the community than they are in providing good services for the community.

Mr. Bounsall: Will you say that about the obstetrics in Grace?

Hon. Mr. Miller: I am talking about the hospitals collectively.

Mr. B. Newman: It is unworthy of you to talk like that about Riverview Hospital.

Hon. Mr. Miller: I have many problems.

Mr. Bounsall: Could I ask the minister this one question? Did you at any time say to the hospital planning council collectively -- and you are talking now in terms of the hospitals collectively -- that our aim will be at some time in the near future to save 200-plus beds and an amount of money in the vicinity of $4 million?

Hon. Mr. Miller: I did not personally say those words to them but I assume my staff have because they have had a number of discussions with them.

I personally went to Riverview; I personally looked at it. Certainly I admire the services and the individual parts you have talked about. I have never denied the quality of the service at Grace Hospital in obstetrics. I stated that when I was in Windsor last week. I have not denied the quality of the service at Riverview and I stated that last week. But when we almost have each hospital trying to be each thing to all its patients in a community where basically we can’t afford those things, I have the rather unpleasant duty of trying to rationalize the services. That is what we have been trying to do.

For some year and a half, or whatever time it is, we have been trying to work with the groups of people to get a response agreed upon by all people in that community. I have seen your doctors down there, and when I made even a minor announcement one day which didn’t go through the proper channels I was quickly chastised for not using the official channels. It was an inadvertent and minor gesture but I quickly learned that that group wanted the responsibility of talking for the hospitals of that city and so in my discussions I have refused to see any one hospital lately. I am not going to be a party listening to one versus the other but rather to the group as a whole, whether it is Grace or Windsor Western or whatever one it is which wants to come to me privately and state its case.

We are working with the other cities in this province to get the bed numbers down. Some cities have done a tremendous job -- the city of Hamilton has; the city of North Bay has; the city of Kingston has. These people have tried their level best without any coercion.

Mr. R. S. Smith (Nipissing): They are getting penalized for it.

Hon. Mr. Miller: All right. You will have your turn in a second. The fact remains we feel those hospitals have done their best to help us with the kinds of problems we are faced with.

You are an engineer; you said that a second ago. Would you honestly design plants in a community all of which would provide duplicate services? I don’t think you would if you were planning it.

Mr. Bounsall: That is right, but here again is the point I made about the obstetrics at Grace Hospital. Anyone who knows the patient care, let alone past history, would not have made that proposal about Grace and based it on the plant there.

Hon. Mr. Miller: I consistently made the point that if our options are unacceptable, please agree upon alternatives. I made the comment when I was in Windsor the other day, and it was taken as if another covert plan was in the making, that I would be delighted if one of the hospitals would recognize the need to be a geriatric centre and elect to be so. I would be delighted if one hospital chose what I consider one of the most important roles in medicine today -- chronic and geriatric care -- as its main emphasis.

Instead of recognizing this, these hospitals continue to think of that as a second-class reward if they have lost all other battles. That is wrong.

Mr. B. Newman: If I can ask the minister -- what happened to the proposal of the ministry on the construction of such a facility in the community phasing out the obsolete Riverview Hospital?

Hon. Mr. Miller: I made the straight comment when I was there. First of all, there will eventually be a brand new chronic hospital in your community I am told.

Mr. B. Newman: At that time you can phase out Riverview.

Hon. Mr. Miller: No, we cannot afford to wait until then. I am sorry. I have the problem of having excessive capacity around the city. I have the problem of meeting it in the meantime because I can’t meet all the needs of the people in this province for health care.

When I can’t meet justifiable demands for many services which are necessary I find it virtually scandalous for me to waste anyone’s money on the duplication of services. Of course, each hospital is proud of its facilities; I understand that. I understand it very deeply; I don’t think these people hypocrites when they stand up and speak on behalf of services they are intimately and emotionally involved in.

The fact is they occurred in an era when this type of expansion was permitted. I am now faced with the need, as Dr. Mustard pointed out, of going around this province and rationalizing health care. The member for High Park the other day told me -- I think some of you were here -- how scandalous it was that I wasn’t doing it faster.

I am simply saying that if we have made the wrong choices in our letter -- I am willing to admit we may have, because I honestly don’t know -- then I suggest that the community come back with equally acceptable alternatives.

Yes, Grace Hospital does have the best obstetrical unit in Windsor, but in terms of amalgamating the other obstetrical units into Grace it appears to be technically very difficult and very costly. Therefore it’s a very difficult choice to make. If I had my druthers -- if the physical plant would let it happen -- that’s the place I’d like on the basis of performance.

I find it difficult, though, to switch to psychiatric care and say those people that will go to the hospital’s psychiatric care will be going to the funny hospital, or whatever it is that it is going to be called. For years none of you has criticized us for having hospitals totally and solely for mental care.

Mr. Bounsall: It should be back in the community.

Hon. Mr. Miller: We have been trying very valiantly to return psychiatric care to the place where, in our opinion, acute short-term care should be delivered -- the community hospital, rather than the provincial hospital. At least there are 15 or 20 other services in that hospital. At least one need not know positively that you were there for mental treatment. You’ll admit to that.

Mr. Bounsall: I will admit to that but there is still the connotation --

Hon. Mr. Miller: Sure there is a connotation, because it’s in your own head sometimes.

Mr. Bounsall: It’s out there in their heads, not in mine.

Hon. Mr. Miller: The fact remains if four hospitals give psychiatric care, the odds are just as good your neighbours will know why you went to the hospital.

Mr. Bounsall: You are not going to accept support from them, are you?

Mr. J. Dukszta (Parkdale): That is the kiss of death.

Mr. Bounsall: Now we know you are wrong.

Hon. Mr. Miller: Do you realize that in the final analysis you will have more than 100 more chronic beds in Windsor than you currently have? Do you realize that?

Mr. Bounsall: But what treatment are they going to be getting?

Hon. Mr. Miller: Let’s be honest about chronic care. A small part of chronic care is rehabilitative. The great bulk of it is not -- it’s caretaking, isn’t it?

Mr. Bounsall: That is right -- where the philosophy leads toward that, and the staff have chosen to work in that location because that’s the type of care they want to deliver. I am concerned when they are now to be fragmented around that you’ll get staff who are not there specifically to do that, but who find themselves on that floor in that orientation. The patient is going to be worse off for it.

Hon. Mr. Miller: I quickly pointed out the other day when I was in Windsor that I would prefer not to fragment chronic care. I would prefer not to fragment it. The alternative still lies with the hospitals in Windsor. If they believe in the delivery of good health care, as they say they do, why wouldn’t one of them want to become a chronic hospital? Why would you demand a brand new hospital at this point when we find it very difficult to justify the cost when there are 242 beds, by our calculation, plus 96 closed in the community that are surplus to our current needs?

Look, at four beds per 1,000 we are 0.8 beds ahead of the Province of Quebec, I am told, we are almost 200 per cent of the values in England in a number of cases. The fact is the number of beds per 1,000 people is an empirical decision. It is not theoretical. It gets filled no matter what is the number of beds you have. That’s a fact. Any of us in the hospital business knows it. The argument that one waits three months to get in for elective surgery is no more valid when there are eight beds in the city than when there are three. It is simply a question of the use of those beds. We expand our patients’ length of stay.

You talked about a five-day stay for tubal ligation. That to me would be a classic example of what I am talking about. One of my neighbours went to Toronto in the morning, back to Muskoka at night and had a tubal ligation in the meantime. I find it difficult to believe that a Toronto hospital faced with constraints does it that way and your hospital talks about a five-day stay for the same basic operation. That is because the bed is available -- that’s why it takes five days. It’s because it is better to show 84.6 per cent bed occupancy than 45 per cent, because somebody is going to complain about your budget if it is 45 per cent occupancy.

No, with great respect, I suggest to you that the people in the field need to stop to realize that if it was their money, if it was raised on a local tax base, you would have a tremendous pressure against you to make some of the economies I am making reluctantly as a politician, knowing full well I cannot help my party in any way whatsoever by taking the steps I’m taking. You would be the first to admit that. You guys should be cheering for me quietly. All I am doing is building you a safe seat.

Mr. B. Newman: I am interested in the patient care in the community.

Hon. Mr. Miller: Patient care happens to be a function of the expertise of the unit --

Mr. B. Newman: You said that as well about Riverview, and you are going to spoil that by scattering the patients in Riverview to four other hospitals.

Hon. Mr. Miller: That is the weakest of my arguments; I admitted that earlier. I only suggest to you that that is one of the alternatives the hospitals in Windsor can consider. I don’t have a solution. Perhaps one of them may decide, in the interest of the growing demand -- and it will be a growing demand -- for chronic geriatric care, that perhaps that’s where their future role lies and perhaps that’s where they’ll get as much satisfaction as being a fragmented active treatment hospital.

Mr. B. Newman: We don’t ask for an additional hospital in the community when we ask for an addition to the IODE hospital. We are simply asking for something that has been in the making for years and years in this ministry, and it is badly needed.

Hon. Mr. Miller: Well, we have talked about the heart pump machine a couple of times; we have talked about the burn unit in almost all the speeches I think. You know, as thinking people, all three of you, that the public concept of what that heart/lung pump machine was going to do and what it really would do were so totally different that it would have been almost a fraud if we had put it there.

Listen, I had people telling me that their husbands had died of heart attacks and if I’d had that machine they would have been saved, because there would have been some way of keeping them alive. That, you know, is not true. It wasn’t made for that kind of emergency. It was made for the surgery that gave you time to investigate it by catheterization or by other means, that permitted the surgeons to carefully diagnose the problems of a person who was either static or who had a condition, like a valve problem in the heart, that was not necessarily imminently critical or fatal, and gave that person time to sort out the chances of success before the operation was done. But the people who came to see me -- and I am just trying to think which one of you was with me the day they came in --

Mr. B. Newman: All three of us.

Hon. Mr. Miller: All three of you?

Mr. B. Newman: Yes.

Hon. Mr. Miller: Many of them had the belief that somehow we would be saving people with heart attacks. I think you would admit that.

Mr. Bounsall: That must have been a different meeting, a second meeting, Mr. Chairman. The executive of that group and the major fund-raisers were not under any illusion. Maybe some of the people who donated were; someone who had a heart attack may well have thought this was going to be an aid in the treatment of it. But the major organizers, the ones who were in contact with the staff at the IODE, knew its use and were willing in writing to say to the minister, “This group will not push for it.” Dr. Marshall also was willing to put in writing that he and the group which gathered around him would not push for the expansion of that unit to include an open-heart surgery team.

Hon. Mr. Miller: But it would have happened. Well, I would only point out that when I went to St. Clair College the other day, the first question was whether that decision was based on economics or good health care. The answer was a simple one in that case, “Both.” It was good health care, as determined by an impartial, non-ministerial group of physicians, not to have it there. It was good economics because the total demand could be met by existing resources, and not the way the Toronto Star put it one day, as having taken your money, bought a machine in London and put it there. I think you must have seen that article; it was one of those sad quotes that was innocent, but it occurred. Editorials popped up around the province saying what a nasty guy I was to use Windsor’s money for people in London.

The burn unit is an interesting thing. The member talked about the renovations. Has he any idea how much they are now estimated to cost?

Mr. Bounsall: One quarter of a million dollars.

Hon. Mr. Miller: It’s $500,000.

Mr. Bounsall: That is when you bring in the air-conditioning and the transformer cost. The transformer is brought in to run the air-conditioner but in point of fact that transformer is badly needed right now. The ministry, I believe, is on record as saying that the power situation at Met is critical now so the transformer and its increase of that facility is needed irrespective of whether you put air-conditioning into that burn unit area. You really can’t take that and include it in the total cost of that burn unit renovation.

Hon. Mr. Miller: Let me read a letter dated Feb. 5, from the Essex County Hospital Planning Council to the Windsor firefighters which states:

“Dr. Roenimele has requested that I reply to your letter with regard to the burn unit at Metropolitan Hospital. At the moment, the Essex County Hospital Planning Council is awaiting a report from Metropolitan Hospital and the Ministry of Health with regard to the apparent power shortage at Metropolitan Hospital.

“Please be assured that the planning council continues to support the principle of a burn unit in Windsor, however, council would be derelict in its duty if it did not query the expenditure of half a million dollars to place six beds in full operation. Certainly the situation warrants a full study.”

That’s your local council appraising a local need we have agreed to. They in turn have told us it is a No. 2 priority and it still sits that way with us.

In other words, at their request it’s been moved back a year or so in creation -- not our request, not our refusal but a local assessment of need. That’s the way I was told it was when I went last week and this letter confirms it.

I am very anxious to see that burn unit in operation. I question that many dollars, too. I think sometimes there’s an attempt to build everything into a renovation which one might want for other purposes in order to achieve a rather specific goal.

Mr. Bounsall: I think there’s a somewhat wider air-conditioning cost built into that renovation.

Hon. Mr. Miller: Should they be trying to sneak it in?

Mr. Bounsall: It’s reasonable to air-condition the burn unit, right? People with pretty bad burns in the humidity and the heat you get in the summer in Windsor are going to be pretty darned uncomfortable. One needs to air-condition the burn unit area, the area specifically handling people suffering burns. You can’t really cut it out. But the additional transformer requirements needed to handle that air-conditioning is a need which the hospital already has now. You can’t really count that as a charge to the burn unit or as a renovation which isn’t necessary because the whole hospital is underpowered, I think, at the moment.

Hon. Mr. Miller: I’d like to get on to the two specific questions you brought up which weren’t related to the Windsor issue. I repeat, in closing the Windsor issue in this discussion today I asked the group there to sort out its priorities without trying to hold on to everything it already has. That’s the one message I’ve got to put through. There is no use trying to maintain the status quo, but let them please tell me what the alternatives are as seen from their point of view.

We can document the $4 million. I understand, rightly or wrongly, that three or four of the hospitals have not really quietly argued about potential savings. Publicly, maybe privately, no. They feel we aren’t being totally unrealistic. I can’t swear our estimations are correct but certainly our staff have looked at them and they certainly have been discussed.

Mr. Bounsall: Before we leave the Windsor issue I gather you can supply us with those figures. I’d like to have the figures, at least, of the population per bed to be achieved by this in Windsor what the population per bed is in the other nine largest cities in the Province of Ontario what restrictions are being placed on them to get them to a different number, if it’s higher or lower than Windsor’s and their target date. As well as the funds per head of population in those 10 areas, so we can see what is currently in practice and what is being specifically aimed at.

Hon. Mr. Miller: Before promising those statistics I’ll make sure they are available for you.

Mr. Bounsall: If they’re not available, how arbitrary is this ruling you’ve taken in Windsor?

Hon. Mr. Miller: I might say that the rulings will become arbitrary in other areas, too, where we don’t get local co-operation. Other cities I’m dealing with have similar problems. Just north of you, in Sarnia, we’ve been carrying on very similar discussions there for some time. Again, Sarnia has been charged with the responsibility of finding a solution and there will come a point in time when we will either have a solution in Sarnia, or we’ll have to impose one.

Surely, you on that side will not say I mustn’t impose solutions. If I’m not imposing solutions, then I’m not using my responsibilities properly, am I, after I’ve tried all areas? You should know that I’m not, by nature, an arbitrary person. But it happens that most people, in the absence of any pressure, truly believe that we’re kidding and they simply say: “Let’s put it off until tomorrow. The longer we can put it off, the better chance we have of no action by the ministry.”

Mr. Bounsall: All I’m saying, Mr. Minister, is this: I’ll be willing to agree that you, yourself, are not an arbitrary person. One can prove this by showing that you aren’t letting guidelines for beds per population differ from one area to the other. Show us, in those areas that you are dealing with, what that ratio is and what your objectives in that changed ratio are by the changes you’re requesting in those other areas.

Hon. Mr. Miller: Mr. Chairman, I don’t necessarily pick on ridings that are not well represented by my party. I’m surprised a question to that effect didn’t pop up tonight.

Mr. Bounsall: No?

Mr. B. Newman: We don’t look upon it that way.

Hon. Mr. Miller: I was in a town last Friday night, immediately adjacent to my riding, where the chairman of the hospital board is a resident of my riding. I clearly stated to that community that the same kind of change had to be made there as I was asking Windsor to make. In other words, there were two active hospitals -- when one chronic and one active was needed in the community. I pointed out that their future role in saving one was to go that route. So, in other words, it’s not happening just down there.

Mr. Bounsall: All right, you say the same kind of change is happening in Windsor. Surely, it is more quantifiable than that. Surely, you can say: “This is the objective of beds per population that we’re aiming at. We have looked at and thought about the number of chronic care patients in Windsor vis-à-vis the distribution of chronic care needs elsewhere. On that sort of basis, this is the number of chronic care beds that are indicated.”

Windsor does happen to have a higher population of senior citizens, I’m told -- and I’ve seen some statistics on it -- than other places in Ontario. Surely, you’re doing that sort of qualification. If you haven’t, you should be -- and if you have, you’ve got them. And can we have them?

Hon. Mr. Miller: First of all, I have books that thick in my office right now on the bed ratios around the province. They show not only this year’s needs, but I think for five years hence. We’ve made out projections. We are looking carefully at the whole province on that basis. I am not choosing one area for planning bed needs and not others, if that is what you’re talking about.

I’m not sure that any written form, or even verbal form, will get you the detailed information you need. I may have to invite you to come and inspect the data for your own edification, because I don’t think of it as confidential or hidden material. I simply say we have gone through this exercise.

We admit certain things; that it is very difficult, in any theoretical sense, to justify any given planning standard in a bed ratio. And this is whether it’s chronic beds at one per thousand; whether it’s nursing home beds at 3.5 per 1,000; whether it’s active beds at four per thousand; whether it’s general rehab at -- I don’t know what -- 0.25 per 1,000.

We have overall guidelines which I have learned have to be weighted -- and I’m sure staff have already weighted them for me -- for the given needs of an area. Age isn’t the only weighting factor. I can go to Hanover and find half the people over 65 out planting potatoes or looking after beef. I can go to Toronto and find all the people over 65 in homes for the aged. I’m exaggerating.

Mr. M. Gaunt (Huron-Bruce): Not much.

Hon. Mr. Miller: Milking cows or looking after chickens -- I’m just making a point.

Mr. Gaunt: What’s the situation in Mildmay?

Mr. Bounsall: They are healthy in Mildmay; they are all my relatives.

Mr. Gaunt: Now you’re hitting close to home.

Hon. Mr. Miller: I’m hitting close to home with the old hens. The fact is that simply having figures in a book isn’t always the answer. They have to be tempered by the experience of a given area, to a degree, and I think all of us recognize that.

Mr. Bounsall: I would be willing to be convinced by the tempering process of thought you have gone through but I won’t be satisfied in my mind until I think I actually see the decisions which went into your saying, “246 beds, $400 million,” and how that compares, using your tempering factors relative to the tempering factors you would apply in other parts of the province.

Hon. Mr. Miller: May I make a suggestion to the three members who have spoken on behalf of Windsor today? I recognize your sincerity; I recognize your need to do it. Even if you tend to agree with me, I recognize your need to do it. May I suggest that we bring you in to meet with my assistant deputy minister and take the time to go over some of these figures and reasons with his staff -- collectively, the three of you together?

Mr. Bounsall: I’m surprised you would not have thought of that long before and before that announcement was made in the community in Windsor.

Hon. Mr. Miller: Hindsight is great, as your leader was telling me all afternoon. I am making the offer now -- will you accept it?

Mr. B. Newman: We will accept it.

Mr. Chairman: Before the member for Windsor-Walkerville speaks, when I assumed the chair I had a list of speakers which the previous chairman had left for me. I don’t know whether --

Mr. B. Newman: We would like to clean up Windsor and get it over with.

Hon. Mr. Miller: Are you talking of it in a Yonge St. strip sense or in any other sense?

Mr. B. Newman: No, we’re not sin city at all.

Mr. R. S. Smith: Once you get Windsor cleaned up.

Mr. B. Newman: We’re a law-abiding community. One of the elements you’re neglecting in your statistical analysis of needs is that we’re a border city. A certain number of patients come from Detroit and use our services and when you come along and try to find a bed-population ratio, you’re neglecting that. As a result, you’ll find your statistics may not be as accurate as you would like them to be. It’s much cheaper to hospitalize the patient in our community than it is in the city of Detroit and environs. You can rest assured that our hospitals aren’t going to turn down a patient in need simply because he happens to come from across the border.

Hon. Mr. Miller: I tend to agree with that. On the other hand you may be surprised to discover that when we try to set actual net bed ratios in communities, we usually have the compensating factors allowed for because at the same time, patients from Windsor are receiving specialized care in London or in Toronto.

Mr. B. Newman: Or in Detroit?

Hon. Mr. Miller: Or in Muskoka. I have a lot of them come up there who are wise enough to find a good place to spend the summer and they happen to take ill every so often. They have stayed at my place.

Mr. W. Ferrier (Cochrane South): It isn’t called Paterson Kaye, is it?

Mr. B. Newman: Have you a discount card for us?

Hon. Mr. Miller: Ask the member on the far left. He’s one of the few who has the wisdom to spend time with me each year.

Mr. Gaunt: Every summer. We will have to stop meeting like this.

Mr. B. Newman: You give us problems with the hospital situation in Windsor so we don’t have time to take advantage of your good nature.

Mr. R. S. Smith: Can’t afford his good nature.

Hon. Mr. Miller: I may get caught on a conflict of interest here yet. I’m not quite through, Mr. Chairman.

Mr. Gaunt: I spent a week with him so I am sure we won’t have any problems. I get them sorted out before they start.

Hon. Mr. Miller: You made two specific references which didn’t refer to Windsor, one was the public health regulations. In all sincerity, I know how easy it is to get the wrong number in the wrong quote, but you managed to do both.

Mr. Bounsall: I got the wrong year in the first communication and corrected it.

Hon. Mr. Miller: I wrote you a letter dated June 9, which I think is today if my dates are correct -- tomorrow being the 50th anniversary of the United Church and I knew that was June 10.

Mr. Bounsall: I send my letters out according to those kinds of communications in my calendar as well.

Mr. Ferrier: I thought you would have a United Church pin on your lapel.

Hon. Mr. Miller: If I could just get some of you fellows on our side.

Mr. Chairman: I wonder if we could return to the estimates?

Mr. Bounsall: No nonconformists welcome over here.

Mr. Ferrier: Why haven’t you got one, Mr. Chairman?

Mr. B. Newman: Open this with a prayer, Mr. Chairman.

Mr. R. S. Smith: Tell them to go off and open their own churches.

Hon. Mr. Miller: May I quote your question in Hansard of May 28:

“Mr. Bounsall: A question of the Minister of Health, Mr. Speaker: Is the minister aware that a regulation in the Public Health Act -- Public Hospitals Act -- proclaimed last year requires Hospital workers absent from their job for more than three days to report to the public health nurse in the hospital’s health service?”

As is often the case, I listened to part of your question without defining the difference between the two parts that didn’t jibe. Public health nurses are a specific type of nurse generally, in my mind, placed in the medical officer of health’s employ.

Mr. Bounsall: Did I say public health?

Hon. Mr. Miller: Yes, you did and that is the part I am afraid I misinterpreted.

Regulation 101-74 of the Public Hospitals Act -- that was the one you were referring to -- indicates that where a hospital employee has been absent from his work because of illness three or more days he shall report to a registered nurse in the employ of the employee health service before returning to work.

There are two reasons for it but most important, from a hospital point of view, was to ensure that the person returning to work was well enough to return to work.

Mr. Bounsall: Understood.

Hon. Mr. Miller: That was the issue. I understood, after a little checking with Queensway after our discussion the other day, that there had been discussions between management and union to clarify the issue and to make sure it wasn’t being used in any other way. Our purposes are clear -- if a person is coming back to work to a hospital after three or more days’ illness they should have their state of health checked by the nurse before returning to station. That could just as easily apply, in retrospect in reviewing the situation, to a patient who saw a doctor as to one who did not.

The secondary issue, of course, would be to make sure that the person had been ill. Traditionally, that would have required the doctor’s certificate but I think it can be understood that sometimes it is not deemed necessary to call a doctor. It is a bad cold or something of that nature which is easily diagnosed by the patient. The fact remains we have this regulation in place so that people coming back to a hospital will be checked through before returning to station.

I think on that basis it can be verified and justified. If it is being misinterpreted or misused or used as a negotiating instrument, I, like you, would not be pleased and I think that point we can jointly talk to somebody about it if it is being abused.

Mr. Bounsall: Maybe that is what we should do down at the Queensway. My proposal was if one simply had a current doctor’s certificate, whether or not the doctor defined the illness, saying they can return to work, that should substitute for an inspection by the RN in the employee health service or the referral by her to the staff doctor.

Let’s make it dear, in the one instance we are talking about it is not the RN who does the hassling; the RN has been told this group of employees goes to the staff doctor. It is the staff doctor who does the hassling but she has been instructed to send them.

Hon. Mr. Miller: I don’t know that but I mu willing to say it is possible. I understood it had been negotiated and resolved at Queensway.

The next question was ambulance service branch and the amalgamation in Metro. That is correct, it is not yet in place. We are negotiating with the private ambulance operators for takeover. There is, naturally, no necessity to negotiate with the Ministry of Health for the takeover of services.

I understand employees’ rights are being protected; their contracts are being honoured -- this is correct -- until such time as they have been red-circled or whatever we have to do if their salaries are in excess of the Toronto rates, until such time as the next contract is negotiated for all the employees, I assume, under one bargaining agent.

I assume, and I am told, that the choice of that bargaining agent will be made conforming to the rules and regulations under the Ontario Labour Relations Act. I am not sure whether CUPE or CSAO will be the winner; that is really of little consequence to me, as I am sure it is to you. That should be resolved in the traditional ways which have been used for many years.

I can only say we are doing our best to protect those rights the employees had negotiated in this process. Our interests were to meet the recommendations of the consultants and the needs of the area for one integrated ambulance service with better response time. That is my comment, Mr. Chairman.

Mr. Bounsall: Could I ask a couple of other questions on that? Does the minister have any idea when the amalgamation will take place? What date is he aiming at on this?

Hon. Mr. Miller: June 30.

Mr. Bounsall: And what’s the mechanism? Are you taking over the privates and then taking all the privates in Toronto; and is it all going to be sorted out at that point?

Hon. Mr. Miller: That’s our own staff, our own ASB people, the ones that we currently have as civil servants working for the Ministry of Health. The other ones are still in negotiation because as you know we haven’t yet resolved the buyout prices for the Toronto ambulances. This is being discussed at the present time. They suggested the Land Compensation Board. Lawyers are now negotiating terms for the takeover and the appraisal of the fair values of the businesses we are buying out indirectly through Metro with Ministry of Health funds.

Mr. Bounsall: Further on this, then your employees are going to Metro on June 30, but the other five ambulance or privates will not be going until the prices are settled. So you would have six different groups arriving at six different times into Metro.

Hon. Mr. Miller: I suspect that the decision on the five independents will probably be made as one. I don’t know that but I would think they would be. There are certain negotiations going on by Metro, with at least two of them to rent space from them, utilizing the existing ambulance key posts.

It’s a bit premature. We are not involved directly in those negotiations. In effect, we are the financiers, not the negotiators.

Mr. Chairman: The hon. member for Nipissing.

Mr. R. S. Smith: I didn’t think we were going to make it. I’ve been waiting for two days.

Hon. Mr. Miller: Think of me.

Mr. R. S. Smith: You are getting paid for it.

Hon. Mr. Miller: I am getting paid for it?

Mr. R. S. Smith: You are getting paid extra for this.

Hon. Mr. Miller: After income tax deductions, I am worse off.

An hon. member: I think you are tax deductible.

Mr. Ferrier: You had a chance to take that lodge over the weekend.

Mr. Chairman: Order, please. The Chair finds the financial status of the minister most interesting but I would hope we would get on with the estimates.

Mr. R. S. Smith: Fine, Mr. Chairman. I have four or five questions, not to do with the minister’s personal financial status whatsoever, but to do with the financial status of some of the hospital services in the province and some particularly in my community.

The minister mentioned earlier that my community, Hamilton and some of the other communities had led the way in the rationalization of services. I can remember 13 years ago being on the committee in North Bay that was established to try to rationalize the services between our two hospitals. Since that time there has been a great amount of rationalization of services, not without, should I say, great stress on the community itself at times. I think that for that rationalization of services the community has paid in a number of ways. I think those differences that did come about and were overcome over that period of time were worthwhile.

We then come to the point where we do have a fairly good rationalization of services although there are still some areas where rationalization could take place and there are still those people in the community, notwithstanding what the ministry might or might not do, who do see new areas where rationalization can take place, such as in the area of admittance where some people believe that admittance in both hospitals could be done in one area and the people then sent to whichever hospital is providing that service.

There is no question that that would be another area of saving to the province as a whole, though not to the community anymore because we can’t talk about saving to the community, since the minister says if the community had to pay for it they’d be up in arms, and there is no question about that.

Coming from an area that has gone through the trauma of rationalization of services, I feel this minister has now placed on that area and on other areas that have done the same thing a penalty because he has said to those areas that have cut the cost of services to the bare minimum that they still have to cut two per cent more. You have ether areas in the province where there has been no attempt at all to make any type of real saving in this area. They’re told the same thing: “You cut two per cent” They can’t cut the two per cent without affecting their services. Those areas that have done a decent job in the whole question of rationalization of services really feel a two per cent cut in services much more than an area that has done a poor job.

In effect, what you’re doing is penalizing those areas of the province that have done a good job, while to those areas that have done a bad job, you’re saying: “You cut two per cent.” And they have lots of fat in their budgets. It’s not very difficult for them to rationalize a bit and to cut that two per cent. I think that that is very unfair insofar as the global budget is concerned.

I would like the minister to explain to me why the areas that have done the most are now the areas that are going to have the most difficult time to meet this two per cent cut. Why isn’t there some kind of a sliding scale to provide an incentive, insofar as the global budget is concerned, to these areas that have done something positive? I’d like him to answer that question first.

Hon. Mr. Miller: There are lots of ways we can rationalize services apart from the integration of the delivery part of the service. You’ve integrated, I believe, obstetrics and pediatrics in North Bay. Is that correct?

Mr. R. S. Smith: And many other types of services. Do you want me to name the five or six different areas where that applies?

Hon. Mr. Miller: Sure, I’d be glad if you would.

Mr. R. S. Smith: I can start off by saying, first of all, that we rationalized the laundry service. Then we rationalized the laboratory service and some other services associated with the laboratory service. There has also been isotope rationalization. It’s not only a question of obstetric services; all of these other things have been rationalized, and there has been more of a difference in the community, perhaps more than the one you mentioned. That’s the one that caused all the problems. There’s no question about that. It causes problems in every community. We all know that.

There are other areas of services that have been rationalized there that haven’t even been touched in many other municipalities across this province. There’s no reason why those hospitals should now have to suffer extra to meet two per cent cuts that can be easily taken by other communities that haven’t rationalized.

Hon. Mr. Miller: First of all, I mentioned earlier that we hold out North Bay as an area that we’re proud of as a result of the local willingness to help us resolve the problems. You’ve just told me, even better than I knew, just why we should. I see this happening in other areas. I’m beginning to see it happening in Ottawa to a degree. Certainly Kingston is coming along, as I mentioned.

I don’t totally disagree with the concept you’ve expressed about the unfairness of an across-the-board two per cent constraint. As a matter of fact, in the middle of last summer, when we were discussing ways and means of obtaining some efficiencies within the hospital system, our ministry began by believing that selective reductions were the best means of achieving these savings, on the assumption that certain hospitals had more room to trim costs than others. That’s basically what you’ve said.

Mr. R. S. Smith: Right.

Hon. Mr. Miller: We dealt with their association, who pointed out to us that that had a number of disadvantages; that the Deutsch study, I believe, was going on right then and that it was government’s job to make an overall request. After two or three days of pretty constant negotiations, the association representing the hospitals of Ontario accepted a two per cent overall budgetary constraint.

Later in the fall or early winter -- I’ve just lost track of the exact timing -- Dr. Deutsch issued his report. In that he said that any system of funding hospitals that takes last year’s figures and adds or subtracts a fixed percentage for all hospitals in the province was unfair to some in the long run, if carried on indefinitely. I agree with that -- I accept it completely -- because workloads in given hospitals vary as the population load changes. Many other factors influence it.

Last year we took the two per cent off the basic 1974 submitted budget. You know that. It was roughly $20 million. We then added whatever the negotiated and inflationary costs were for that specific hospital for 1974 to come to the 1975 budget. Added to that were the contractual obligations that the hospital had for this coming year. So we made a variation around the province, hospital by hospital, according to the specific negotiations it had carried out.

Mr. R. S. Smith: You are only talking about one part of their costs -- although it is the major part, I grant you.

Hon. Mr. Miller: Of the hospital?

Mr. R. S. Smith: Yes.

Hon Mr. Miller: We didn’t just allow for salaries; we allowed for the inflationary purchase costs of that other 20 per cent of the hospital service costs -- or probably 15 per cent by now -- that was not labour. I think about 80 per cent is labour, in round figures. Experience told us pretty accurately how the overall purchase costs of goods had changed. The fact is, they change much more accurately than labour.

So those adjustments were made on an actual basis, rather than a theoretical basis. Hospital budgets have climbed roughly 30 per cent to 40 per cent over the year. The accumulative total by the end of this year may be as high as 40, over a two-year span.

This, then, didn’t penalize them too much in the total. A hospital like mine in Bracebridge would have to find $50,000 in round figures. We left it up to each hospital to decide how those savings would be made; whether by vacancy in staff -- by just not keeping staff replacements up to scratch -- whether it was by internal savings; or whether by change in services. Because one of the things the hospitals warned us was that not every hospital could effect the savings simply by administrative means, that some hospitals might have to curtail services.

Mr. R. S. Smith: That’s right.

Hon. Mr. Miller: Now, that is something that I think some hospitals have played with, but those are in the minority. I would say that in the main the hospitals of this province have been extremely willing and co-operative in their attempt to meet that two per cent constraint.

We then looked at Deutsch’s comments and said, yes -- although I don’t think this has been an official position -- there should be some sort of periodic review of the individual hospital on a detailed analysis basis. I think that is something we will see come into effect before too long. Each hospital would be reviewed -- whatever it is, four or five years -- on a detailed line-by-line basis to see what their real needs were, based on community needs at that point. Hopefully, that is going to achieve the results.

You know, the only constraint on the hospital from my ministry is in terms of the money it spends. I don’t blame them for this because the pressure on the executive of the hospital board is to deliver more and more services. Why? Because there is nothing charged against the tax base of the municipality.

You can imagine how roads would be in a municipality, or sewers or social services, if there were no property taxes. The demand would be staggering. But the moment a local tax is levied, there is a great deal of local interest in the cost of the services. This does not apply to health. We say it should not. But one must realize in the absence of a local constraint that the Ministry of Health has the responsibility to police the total amount of money that can be spent. I am sure you don’t want us to waste money on the hospitals. We were told probably two per cent could be saved -- maybe it was four; maybe it was five; maybe it was three -- but at least we effected a two per cent saving.

Mr. R. S. Smith: You sure did. You effected the two per cent saving but the point I’m making is that in so doing those hospitals which had been going along with your programme of restraint or had led the way ahead of you and your ministry are the ones suffering the most by that two per cent. You say to me -- and I understand what you are saying -- that over the next four or five years you are going to have to even this out. Deutsch says there should be a review of each hospital so we make sure no hospital is suffering because of that.

But there are hospitals suffering because of that and they are in the areas where rationalization of services has taken place, when they’ve cut as far as they can cut. They’ve done that to assist our ministry and to assist us as taxpayers. But the thanks they get for it is the same treatment as the hospital which has done nothing or has not attempted on the same scale at least. This is what is very hard for them to understand and very hard for them to accept.

You say this was negotiated with the Hospital Association. That’s fine but the Hospital Association, although it may represent the hospitals in total, does not represent the hospitals as individual units and the day it does is the day there is no more autonomy at the local level. God bless us, there is not enough there now and there is less and less each year. You know that as well as I. When you get into that area of discussion you leave me right out in the cold because I don’t accept that as the place for negotiation for each individual hospital.

Hon. Mr. Miller: I appreciate that; I would say to you this, though. If by amalgamation of two departments or by centralized laundry a certain cost saving was made, that doesn’t mean the efficiency savings we are looking for were made in terms of what personnel may have been surplus to the balance. I’ve had a goodly number of very sincere, dedicated chairmen of hospitals in to see me in the last few months about this issue.

Mr. R. S. Smith: I don’t say rationalization is the whole story.

Hon. Mr. Miller: No, I’m just saying these are often hard-nosed local businessmen who, running their own business, would chip a dime off anything they could to make a buck. They’ll come in and tell me there is no way that hospital with 250 staff can save two per cent. I look back in my own life and I say I had a staff of 16 in the car business; when I lost money I knew of no way I was going to save but I had to because if I didn’t I went out the door. I suggest that the pressures on a businessman are not on federally and provincially subsidized things like hospitals. Sadly enough I have the duty of reminding those same people from time to time that we need the same kind of cost cutting approach in the hospitals they manage as those of us who are in private business, like you and me, have to apply to our own businesses to stay alive.

Mr. R. S. Smith: All right, that’s fine. I accept that principle just as you put it. But to be competitive or to be fair you’ve got to make each one do the same thing and you are not doing that and that’s where you are wrong.

Hon. Mr. Miller: I’m getting there.

Mr. R. S. Smith: You are getting there but for those who are away ahead of you there is no salvation. By the time you get caught up those hospitals are going to have no services left whatsoever and the people in those areas are really going to start to suffer, if you continue the way you are now to get there.

I have two or three more things I want to bring up. That was just the first one. The second one I think we discussed on your opening remarks the other day and that’s insofar as physiotherapists are concerned. You brandished the book with the number of physiotherapists across the province which I’ve never seen, and you said they were here and here and here and here and all over the place. They are all over the place but mostly they are in the hospitals.

If you want to make a rule -- here we get back to rationalization of services -- why don’t you rationalize your physiotherapists and say they are always going to be in the hospital or that services across this province are going to be the same for everybody and there will be physiotherapy services outside of the hospital setting as well? Why does one area of the province have this type of service and another not? Why is it in one area of the province, if a person works during the daytime, he is forced to take time off work at cost to himself to get physiotherapy treatments whereas in some other area he can make his appointment outside of the hospital setting for 5, 6, 7, 8 or 9 o’clock, and get those services? In my area, for a person to have physiotherapy services three days a week or something like that, it may well cost him in the area of $50 or $60 out of his pocket in salary. I don’t think that’s fair. Beyond that, I don’t think it’s fair that the physiotherapists are placed in a position where in some areas they are allowed to practise, as are all the other paramedical professions, and in other areas as individuals they are not allowed to practise outside of the hospital setting. I would like the minister to explain that type of rationalization to me.

Hon. Mr. Miller: It’s not very easy to explain. I know for the last few years we have been very reluctant to create more fee-for-service therapy units around the province. On the other hand, we have had a number that were in existence and were doing a good job and in the main they have been allowed to carry on. It has been our assumption that it was a type of service that could best be delivered in terms of cost in the hospital or in hospital-based operations. It’s not possible to deliver all the physiotherapy services in hospitals because, as you know, some of it is related to home care specifically to patients who don’t leave the home.

We are trying to expand that side of the physiotherapy service rather than slow it down. We have in this year’s budget, physiotherapy for nursing homes. This is a new endeavour because in the past we have been bringing people from the nursing homes to the hospitals for physiotherapy, often by ambulance. I have listened to some fairly logical arguments on that in the last two years and had asked my staff to try to get it in this year’s budget and apparently they did manage to do that.

I think I answered this question the other day, probably in either a question period or in the first part of my estimates when you were talking about physiotherapy, by saying that at a time when fee-for-service in general was being questioned by many people, as the best means of delivering services, we have been reluctant to expand one discipline more in that field when for most people the service can be delivered most efficiently and at the lowest cost in the hospital. It can’t be for all. We are recognizing those who are still in the business and exceptions will be made from time to time as a good argument is made on behalf of that group.

Mr. R. S. Smith: I would just like to point out that the ministry certainly expanded the services for the chiropractor a few years ago when it included it under OHIP. Of course, there are differences of opinion as to treatments by the chiropractor and the physiotherapist. I wrote the minister a letter on that and he said he hadn’t received anything from the chiropractors in regard to physiotherapy service so I sent him a copy of the presentation they had made to him and then I didn’t hear back from him. In fact, I don’t think I’ve heard back yet, and that is some three or four months ago now. Perhaps we might get some replies if we were a little more abrasive in our letters. I guess that’s what we have to do.

Obviously there is a difference of opinion here insofar as services of paramedicals are concerned. I would like to ask the minister where does he stand in regard to the new legislation that is going to be forthcoming, maybe sometime in the future. I don’t know when. It is supposed to be here by now. Where does he stand insofar as the other paramedical services are concerned and insofar as physiotherapy and chiropractors are concerned? Why do we have one group where some of them are making over $100,000 a year from OHIP, plus charges above that? It is beyond me why they are allowed to charge beyond the OHIP payments whereas the medical profession or anybody else is not. Yet the physiotherapists who have professional training as well are not allowed a fee for service.

It’s very difficult to understand. You either have a philosophy or you don’t have a philosophy, but you don’t have it for some and not for the others. This seems to be the way all the way through your ministry. It’s different for different areas, it’s different for different groups of people; there’s just no continuous philosophy of the delivery of health services. As Eddie would say, it’s the whole ball of wax. Just throw it up in the air and whatever comes out, that’s what we’ll do today.

Hon. Mr. Miller: I’ve been rationalizing a few of the discrepancies in the system, and there are some. To pretend there aren’t would be ridiculous. Optometry was one of our COCO benefits -- chiropractic, optometry, chiropody and osteopathy. Okay? Those are the COCO benefits that are in the group that you talk about as being different from fee-for-service, or not totally paid for by OHIP. There’s an indemnity paid toward those services per year. There’s a limitation on the amount you can get. It’s not an opt-in, opt-out situation. In other words, the chiropractor has had the right to claim part of his fee from us up to a limit of $100 per patient per year.

We’ve just finished drafting the chiropractic part of the health disciplines bill with the chiropractic college. It’s in review with other disciplines. I was hoping it might have even hit the spring session. I don’t think it will. I have taken optometry, though, and managed to rationalize it on the simple basis that the optometrist performed certain services that, if rendered by a licensed physician, would have been paid for by OHIP. On the assumption that the optometrist is qualified by law to perform those services I said there should not be a differentiation in the patient’s rights to those services whether provided by an optometrist or a physician. The regulations have been changed in those cases. The optometrists are now opt-in, opt-out, with exactly the same kinds of rights as physicians would have had.

That’s step one in the process, but the optometrical part is pretty well into the health disciplines bill now. I trust, as we get the scope of practice defined for physiotherapy, for chiropractic, for chiropody and for osteopathy, we will have an opportunity then to look at the payment mechanisms that go with those disciplines and perhaps have a chance to improve them so there won’t be discrepancies from the patient’s point of view.

Mr. R. S. Smith: In the one letter of reply I did get from you, you said that there was a working party. That almost sounds like something from Russia, but anyway --

Hon. Mr. Miller: There is a working party, yes.

Mr. R. S. Smith: -- this takes the place of commission or committee or something else. It is made up of representatives of the executive of the Ontario Physiotherapy Association and the Ministry of Health. They “are holding meetings at present with the objectives of working out suitable arrangements for the provision of physiotherapy services in the province.” That letter is now six months less eight days old.

Hon. Mr. Miller: Mine or yours?

Mr. R. S. Smith: Yours, this is your letter to me of Dec. 17. What has that working party done and what conclusions have they come to?

Hon. Mr. Miller: I can’t recite by memory all the things it has done but it has done quite a bit. It got the optometry part straightened out.

Mr. R. S. Smith: No, this has got nothing to do with that. It’s a working party made up of representatives of executives of the Physiotherapy Association --

Hon. Mr. Miller: Physiotherapy, okay.

Mr. R. S. Smith: -- and the Ministry of Health. I hope they’re not working on the optometrists.

Hon. Mr. Miller: They may be.

Mr. R. S. Smith: Let’s not have the physiotherapists working out for the optometrists.

Hon. Mr. Miller: I wasn’t listening to you for a second, obviously.

Mr. R. S. Smith: Oh, obviously.

Hon. Mr. Miller: First of all, they have managed to get two rate increases for the physiotherapists.

Mr. R. S. Smith: Yes, but they’re not allowed to practise, so what good are the rate increases?

Hon. Mr. Miller: There are quite a few of them practising. If you saw the millions of dollars going out, I think you would appreciate that.

Mr. R. S. Smith: I can’t find one in my area for miles.

Hon. Mr. Miller: May I send the regulation over to you for you to peruse in case there is? I don’t know which one would be yours and which one wouldn’t be, but you can peruse it and see.

Mr. R. S. Smith: I’m telling you --

Hon. Mr. Miller: We are working with the association in a number of areas. I got a brief from the physiotherapists just yesterday on certain aspects of it and I sent it on to staff. By the way, I want to make one comment to you. I’m sorry when you don’t get an answer to a letter. I’m embarrassed by that fact. I have asked staff to make sure that letters from members are answered promptly and sent back to me for signature because, as you know, in the main they require technical response. I say to you, and I am sure my staff will listen, that I expect the letters from members to get prompt attention when they are sent to them for response.

Mr. B. Newman: I wish you could tell some of your colleagues that.

Mr. R. S. Smith: I am just looking over this booklet you sent over, “The Health Insurance Act, 1972.” In part one, approved physiotherapy facilities, there is no mention of any in my area. In part two, which is to provide home treatment only, there is one in my area. So we have one who can provide it in the home only, but none who can provide it in his office or for people to make appointments to go and see him.

Under part one, we have all these very great places that are significant by the fact that almost every one of them is represented by members of this Legislature who don’t sit on this side of the House. There is not one area represented by a member on this side of the House that has physiotherapy treatment in part one. I just point that out.

Hon. Mr. Miller: Well, I take some exception to that, Mr. Chairman.

Mr. R. S. Smith: Well, I am just telling you.

Hon. Mr. Miller: There is no political patronage in that list.

Mr. R. S. Smith: I am not saying there is patronage in that list --

Hon. Mr. Miller: What are you saying then?

Mr. R. S. Smith: I am just saying there are methods of choosing areas that will be served which are different from the norm might be.

An hon. member: Probably about six or seven.

Hon. Mr. Miller: Is there one in Muskoka?

Mr. D. W. Ewen (Wentworth North): North Bay has everything up there.

Mr. R. S. Smith: Is there anybody living there? I thought you had such a small population that they hardly had to vote.

Hon. Mr. Miller: There are very few of them, but they know for whom they should vote.

Hon. A. Grossman (Provincial Secretary for Resources Development): With that statement, they will know for sure.

Mr. R. S. Smith: That’s such a pocket borough, we’d starve to death up there.

Hon. Mr. Grossman: Getting worse; they’d never elect a Liberal now.

Mr. R. S. Smith: No, there are none in Muskoka. Just a minute now; there are so many small towns up there, there might be one stuck some place.

Hon. Mr. Grossman: Have you got something against small towns?

Mr. R. S. Smith: No, nothing at all. They are nice places; I live in one.

Hon. Mr. Grossman: What have you got against them?

Mr. R. S. Smith: It’s Toronto I’m worried about.

Hon. Mr. Grossman: Remember that, Margaret -- we will tell the Liberal candidates in Toronto.

Mr. R. S. Smith: I am sorry to take up the time of the House looking through this list, but I have never seen it before. I didn’t know it existed; I guess I should have, though.

The only one I can see in northern Ontario in the first section is one in Sudbury. I’m sure he is having a great time serving all those 700,000 people in northern Ontario. Anyway, in the second section, there is one in my area, but he is allowed to provide home treatment only. He can’t open his own office or provide the services that are available elsewhere.

If you look at this list, it becomes obvious that there are places that have treatment facilities that others don’t have. Basically I disagree with that. I think if you are going to provide the services, that I, as a taxpayer, and the rest of my people, as taxpayers, have the same right as the taxpayers who live in part one of this list. Either you are going to provide the service or you are not. I don’t expect the minister to reply, because I don’t think there is a reply, other than the fact that it may be rationalized someday.

The other matter that I wanted to bring to our attention is something I read about in a tabloid form paper that I picked up in the airplane one day, and then I read about it in the Toronto Star. I wasn’t well aware of it, nor am I yet well aware of the total situation. It has to do with the approach that was taken by a Dr. McGoey and Medical Inns, and then the refusal of the ministry to grant him a licence. In fact, I don’t think the second facility ever did open; it went into bankruptcy, as I understand it, before it opened.

But all though the information that I could find it appeared that he was of the opinion that he would, in fact, be granted licences for the second Medical Inn that he built in Scarborough, which was based on the fact that he had provided a service in Don Mills for some period of time, which proved to be most satisfactory and which proved to be less costly, in fact, than that which could be provided in other government-controlled or government-owned services.

As I understand it, he was prepared then to move to some kind of public ownership or public control of the Medical Inn, but this was not taken into consideration by the ministry or the government. Also, beyond that, a number of people from my area had gone to his first service in Don Mills.

Hon. Mr. Miller: Medical Place.

Mr. R. S. Smith: Medical Place, yes. They had been more than well satisfied with the service they got there, and they were in and out in much less time than it was indicated to them by their medical practitioners in our area that they would have to stay in the hospitals.

I looked into it further and I found that there are claims made by Medical Place that, in fact, for the type of services they were providing, instead of an average of 10 days’ stay the average stay was less than three. I would think that this would be one of the areas that would have been very attractive to the ministry insofar as the cutting of coats is concerned.

I couldn’t understand why we would pass the bill apparently in 1973. This was after they had made all their contractual arrangements in the building of the Medical Inn in Scarborough. A bill was then passed to amend the Private Hospitals Act so that no more private hospitals would be allowed, but this was after that group had gone ahead and made contractual arrangements to build in Scarborough. Up to that time, there were claims on both sides that they had received encouragement and discouragement from the ministry. Of course, Dr. McGoey and his group claim that there was encouragement from the ministry, and the minister claims, as I understand the two articles and the one letter which I think was published in the Toronto Star, that he had been advised, not by letter or anything like that, that likely he would not receive a private licence.

There was a letter from the minister that finally went out to him -- I presume after the passage of the bill in January, 1973 -- that, in fact, the licence would not be issued. But since they had entered into the contractual arrangements for the building and the facility by that time, they had no choice but to go ahead in the hope that the ministry would either change its mind or take it over in some method as a public general hospital.

The rationale, as I understand it, for the opposition to the granting of any of this type of licensing or of the taking over of it as a public general hospital, is that it would throw out the whole balance that had been established for the Scarborough area insofar as number of beds and all this is concerned.

Actually, in fact, the Medical Inn was built not only to service the specific area in which it was built but also to service the many areas of the province from which it had been drawing patients in the other location, which was more or less a pilot project. A great number of people came to that other facility from many points in the province.

I am not sure of the admissions and where they were from and all this type of thing, but it became apparent to me that a number of people in my area were patients at the first one and could not understand why the second one was not granted a licence, because they found it to be a good high-quality service. They had been given to understand, as I had been given to understand by some of the literature I have, that it was a savings to the province insofar as the treatments themselves were concerned.

I’d like the minister to comment on this.

Hon. Mr. Miller: Yes, I’m very familiar with this problem. I met with Dr. McGoey, would you believe, as recently as 10:30 this morning, I think it was.

Mr. R. S. Smith: That’s pretty current.

Hon. Mr. Miller: Yes. It’s a long, involved story. I was not the principal, nor was my deputy, in most of the detail.

Mr. R. S. Smith: I realize that.

Hon. Mr. Miller: I can’t speak with the assurance that what I say is true and even as of today I have been trying to verify some of the inconsistencies in the story. I am seasonably sure that the Ministry of Health is correct when it says at no time was any permission ever granted for the creation of that hospital. In fact, before it was built there is a specific letter from this deputy to Dr. McGoey stating it should not be built and would not be licensed if it was. That letter is on file.

Mr. R. S. Smith: Excuse me, is that the letter dated January, 1973?

Hon. Mr. Miller: That’s right.

Mr. R. S. Smith: That was after they had made contractual arrangements?

Hon. Mr. Miller: The fact remains they were well aware that contractual arrangements for a hospital in the province could not be made without permission to create it. It’s like building a nursing home. You can’t build a nursing home and come to us and say, “Give us a licence.”

In each case, you have to gain the right to create the specialized facility first. Does it really make any sense to you in a system where we are trying to close existing public hospital beds in the city of Toronto or have them unfinished such as we have in Scarborough, to allow another operation to start up, independent of the existing publicly-owned system? Does it make any sense to allow an operation to skim those types of jobs it wants to do, leaving the more complicated for the public hospital to look after when the capacity exists within the public hospital system?

If you have ever been a municipal councillor or have found a person who has built without a building permit -- all of us do; all of us have people who, once in a while, are satisfied that win, lose or draw, they’ll get their way.

I have no question about the capacity, capability and sincerity of Dr. McGoey. At no time have I questioned any of those things. He’s a professional man. I simply say he believed, as far as I can tell, that if he built that building he would be licensed. He felt, and I believe him when he says this, he had been encouraged to build it. That is one of the dangers of not saying no to people.

Mr. R. S. Smith: That’s one of the dangers in not using letters.

Hon. Mr. Miller: There were letters. There were letters which talked about seeing plans and things of this nature, but you realize the staff were dealing with a rather unusual circumstance. They asked for certain information but at all times, I understand, he understood he had to have the right to go ahead. I don’t know the history of Medical Place but I have reason to believe that it was also created without permission. Can anybody confirm that for me? The words “forced situation” has been used.

Mr. R. S. Smith: I am sorry I --

Hon. Mr. Miller: Many aspersions have been cast at us for making the decision not to license that facility. We reviewed it half a dozen times. We brought the three hospitals of Scarborough together with Dr. McGoey, I would think back in mid-winter, before the foreclosure.

We asked them if they could take over the operation of his facility, as he suggested, as part of the public system. Each declined. Each said it was satisfied with the present bed capacities. We looked ahead and saw the existing space already built in the Scarborough area. We looked at our obligations to Grace Hospital currently downtown which has, I believe, either bought or located land in that general area -- with our approval -- so that when the population expands, that hospital would be built. We came to the conclusion that our first responsibility was to the public system. Since this hospital had been built without permission -- perhaps in the absence of a specific denial, but at least without permission -- then we could not license it.

Mr. R. S. Smith: I accept the principle upon which you base your decision. I find it difficult, though, to put that together with the philosophy of this government, even though I think it has moved far away from that philosophy in the health field. And I congratulate it for moving away from its ancient philosophy. You know, it was back in another century. But the thing I would like to ask you is: Can you tell me if the services that are being provided by the clinic new in existence, and are apparently covered by Ontario Health Insurance Plan -- whether they came into effect in a proper way or not, I really don’t know -- but are those services costing us less than if they were performed within the general hospital system?

Hon. Mr. Miller: I haven’t got into an argument about the rights or wrongs of private enterprise hospitals, because I even said to Dr. McGoey today that I really wanted to reserve my personal opinion about privately-owned hospitals for some future time.

Medical Place still operates as a private hospital, as do a number of other private hospitals around the city and around the province. They are restricted by the legislation currently on the books, so that they may not expand. I don’t even have discretionary authority, if you read the statutes. They simply may not expand. That was because of our existing problems with the public system; the problems of overbuilding.

I would like to think that there may well be a pause and a cause for review, once we have sorted out some of the urgent problems with the public system. It is not going to happen in a year or two, though, because our problems are not of a short-term duration. I am, and profess unashamedly to be, a free enterpriser.

Mr. R. S. Smith: Oh, you are not -- no more than the man in the moon. You might have been when you were selling cars, but not as Minister of Health.

Hon. Mr. Miller: I still apply some of my principles. We still have privately-owned nursing homes. We still have ambulances operated by other than the state.

Mr. R. S. Smith: Yes, and you have to wait three-quarters of an hour for them.

Hon. Mr. Miller: Oh, come on now. You have got the best ambulance system in North America, and you know it.

Mr. R. Haggerty (Welland South): The most expensive.

Mr. R. S. Smith: I am not going to get into that question with you, but I waited three-quarters of an hour in this building for one -- so just put that in your --

Hon. Mr. Miller: All right, then something went wrong.

Hon. Mr. Grossman: They just don’t like politicians.

Mrs. Campbell: That is your emergency service.

Mr. R. S. Smith: That’s real emergency service. I could have crawled there quicker.

Hon. Mr. Miller: Now, don’t tempt me tonight. Don’t get me being irrational.

Mr. R. S. Smith: Well, you make me irrational. Well, that’s fine. I am not going to argue with you about your philosophy, because I think you are rather fuzzy on it.

Hon. Mr. Miller: Oh, come on.

Mr. R. S. Smith: That is being very polite. You know fuzzy is not a very strong word.

Hon. Mr. Miller: Fuzzy Wuzzy was a bear.

Mr. R. S. Smith: Yes, but anyway, you still haven’t answered my question as to whether you do believe that these services could have been provided cheaper in this way. I am not one of those --

Hon. Mr. Miller: I will answer that; you got me carried away with my favourite topic, free enterprise.

Mr. R. S. Smith: Which you talk about but don’t follow.

Hon. Mr. Miller: Yes.

Mr. R. S. Smith: Okay.

Hon. Mr. Miller: The incremental costs of delivering a unit of service in the public hospital system are very low. The basic cost is the maintenance of the system. We do not pay a hospital on the basis of services rendered, but on a global budget. So when the system is in place, the incremental cost is so low that it is virtually add-on expense to let somebody else provide that service, regardless of the per diem rate they may calculate. Now, when we calculate a rate in the public hospital system, it is an average rate for all services rendered in that hospital, including all medicines, all surgery, all supplies, just so much per day. That is so much easier, from a bookkeeping point of view, than the system of our friends across the border that there’s a tremendous saving on overhead right there.

Mr. R. S. Smith: Do you realize the way it used to be here and the way it is now?

Hon. Mr. Miller: We simply say that as long as the current system has the capacity to provide those services, then any payment, at whatever rate it may be, to somebody other than the publicly-owned hospitals is an incremental cost.

Mr. R. S. Smith: In other words, you take into consideration any payment outside of that to a general hospital as if that service could be provided for this much within the general hospital system. Is that right? That’s blatantly ridiculous.

Hon. Mr. Miller: I could have accountants argue for years on it. All I know is that I have to pay out bucks out of my pocket if somebody else does it, and if the public hospital system does it it’s already in the budget.

Mr. R. S. Smith: What you’re saying, in effect, is that it doesn’t cost a nickel to provide one extra service. That’s just impossible for anybody to accept.

Hon. Mr. Miller: The fact is the budget of a hospital is predicated upon the overall average utilization of that hospital. They win, lose or draw according to the actual utilization. So, really, if one looks at a hospital and decides what savings are effected by not having a patient in a bed on a given day, they are almost zero. They are the costs of linen and food, or of dressings, or of drugs, but those are a small part of the total cost of the operation of the hospital.

Mr. R. S. Smith: Why do you set a per diem at all then? The obvious point then is you don’t have a per diem. The obvious result of that argument is that there’s no way that you should ever come to a per diem.

Hon. Mr. Miller: The per diem is really an artificial figure.

Mr. R. S. Smith: Yes, that’s what I’m saying.

Hon. Mr. Miller: Sure it is. But, you see, 99 per cent of the people are insured. From whom are you collecting a per diem anymore? A per diem is paid to a private operator, it is not paid to a hospital.

Mr. R. S. Smith: Yes, but the global budget is paid to the hospital.

Hon. Mr. Miller: Yes, but it’s not based on a per diem.

Mr. R. S. Smith: And it’s all dollars, no matter whether you do it on a global basis or whether you do it on a per diem basis.

Hon. Mr. Miller: You’ve lost track of the exercise. Seriously, you have.

Mr. R. S. Smith: I’m sure I have.

Hon. Mr. Miller: If Toronto General Hospital is getting $40 million this year, it will get it whether you have surgery there or not, period. If you go to Medical Place instead of the Toronto General, and have a leg operated on, we will send $300, $400 or $500 to them by cheque, in addition to the $40 million Toronto General would have had. So we have spent money because you vent there.

Mr. R. S. Smith: And you do not believe that you would have to have any extra services if Medical Place was not in place?

Hon. Mr. Miller: Probably not.

Mr. R. S. Smith: And if all these other private hospitals closed up, there would be no extra cost to the taxpayer? In fact, that cost would be written right off?

Hon. Mr. Miller: A good deal of it would be.

Mr. R. S. Smith: In that case you have no other alternative but to close them all up, because it’s a blatant waste of money, to follow your argument through to its logical conclusion.

Hon. Mr. Miller: I tend to agree with you.

Mr. R. S. Smith: And it’s an irresponsible --

Mr. I. Deans (Wentworth): Why do you keep bobbing up and down?

Hon. Mr. Miller: Because he’s exacerbating me.

Mr. R. S. Smith: You may not agree with this; it’s irresponsible for you to sit there and say that you tend to agree with me and do nothing about it.

Mr. Deans: He’s not sitting, he’s jumping up and down.

Hon. Mr. Miller: I don’t think I want to admit that in public. There are a number of cases --

Mr. Deans: What is it you don’t want to admit?

Hon. Mr. Miller: I knew that would stimulate your curiosity.

Mr. Deans: You’ve got to believe it. At this time of the day on a night like this anything would stimulate me.

Hon. Mr. Miller: Please stay on that side!

Hon. Mr. Grossman: Next vote!

Mr. Deans: I would have said “nearly anything.”

Mr. R. S. Smith: Mr. Chairman, I think that’s going a little too far.

Hon. Mr. Grossman: Care to call that one a draw?

Mr. Chairman: Order.

Mr. R. S. Smith: So we come to the obvious conclusion then that there’s only one thing to do, you’re either in or you’re out, and the minister has to make up his mind whether you’re in or you’re out as far as private or public provision of service is concerned. If you are going to go that much farther, I suggest that running this extended care on a private basis is almost a farce because there we will get into some argument as to who is selected for what, let me tell you.

Mr. Chairman: The member for St. George. I assume you are speaking on vote 2901?

Mrs. Campbell: I am speaking on the same vote everybody else has been speaking on. I am delighted to be able to come back and find we are at the same place we were when I left a few days ago.

Hon. Mr. Miller: Try me next Monday.

Mr. Deans: Are you available?

Mrs. Campbell: I was a little afraid I might not be able to get some of these things in because you might have passed the vote.

Hon. Mr. Miller: I may have just passed Orillia.

Mrs. Campbell: I can see we are never going to pass the vote.

Not too long ago in this House, I asked the minister --

Mr. R. S. Smith: Everything from soup to nuts.

Mr. Chairman: Order, please.

Mrs. Campbell: -- if he could tell us what provision was being made, either by the advice of his ministry or in any other way, to those hospitals which were border hospitals and which had been alerted by the United States -- the various states on the border -- that they might be curtailing their activities because of the malpractice insurance situation. The minister, in his usual frank way, simply said, “No” in answer to the question and sat down. I had thought he might perhaps have given us an answer to that one because it does seems to me it has some bearing on the hospitals in the border cities of this province. That is one thing I wanted to know about.

Hon. Mr. Miller: I have an answer for that if you can just wait a second.

Mrs. Campbell: You did get an answer?

Hon. Mr. Miller: Yes, I did.

Mrs. Campbell: Thank you. I will sit while you look at that.

Hon. Mr. Miller: It is not here. You can carry on and I will give you the answer later.

Mrs. Campbell: The second thing --

Hon. Mr. Miller: Carry on.

Mrs. Campbell: The second matter I would like to discuss briefly with you is the funding for Bloorview Children’s Hospital. For some years I have felt that this hospital was doing a very fine service in caring for young people. However, recently I have been alerted to the fact that there are those who have been on staff who have a deep concern that the emotional interests of these children may not be being served adequately.

I am not presuming to make a judgement on this matter but I would invite the minister to tell me whether or not it is a fact that this ministry commissioned a study and whether or not that study has been completed and was somewhat negative in this area. If this study is available, I would invite the minister to table it so we may all have the benefit of that report.

One of the things which is bothering me is the kind of thing which comes about with the minister’s philosophy about the right of hospitals to order their own affairs. I want to reads into the record a memorandum under date of June 14, 1974 which went to all employees from Roger L. Sheeler, the administrator of this hospital. And it says this:

“I recently learned of a group of individuals who had been meeting for several weeks without the sanction of my office. The seriousness of such cannot be underestimated, and as a result, one individual has been discharged from our employ and all other participants seriously reprimanded. I wish it to be known that future occurrences, whether subversive in nature or otherwise, will not be tolerated by either myself or the hospital governing board. All participants in future, whether they are innocently involved [whatever that means] or participating freely, will be automatically discharged from the employ of this hospital and reference to such will be made in any letters of recommendation. Thank you.”

I would very much like to have your comments on that kind of a memo going out to professional staff of a hospital, who simply wished to meet to consider their concerns and to prepare a report for the board of that hospital, in view of the fact that this hospital was moving from its location into a new location and enlarging its services. And, certainly to me, if that is subversive then really I don’t know where we have all been for an awfully long time. However, that is something I would like you to comment on. I think I am losing the minister.

Hon. Mr. Miller: Never.

Mrs. Campbell: I think I am losing all the rest of you, too.

Mr. Dukszta: No, Margaret.

Mr. Deans: When you drive the minister out, that’s it.

Hon. Mr. Miller: That was my dihydrochlorothiazide.

Mrs. Campbell: I think this might be a good point for me to stop and perhaps get some answers to those questions before we rise and report.

Mr. B. Newman: Put your glasses on, Frank.

Hon. Mr. Miller: I forgot them.

Hon. Mr. Grossman: He is having trouble; it is written like a prescription.

Mr. B. Newman: I will lend you mine.

Mr. Deans: That’s not so bad, but he wrote it himself.

Hon. Mr. Miller: I really am having a bit of trouble reading the note, in all honesty. Usually you type them.

Mr. Deans: It is getting late.

Hon. Mr. Miller: No, it’s okay. It is not the size that is bothering me. I was expecting this question during question period; that is why I knew there was --

Mrs. Campbell: You got it during question period and you didn’t have an answer.

Hon. Mr. Miller: I had some more data back on it afterwards.

First of all, it was my understanding that the doctors in New York State were considering some type of removal of services, but they had made the statement that they would not withdraw their services for emergency purposes.

Mrs. Campbell: That’s right, but others.

Hon. Mr. Miller: We have contacted the hospital in Niagara Falls. They haven’t anticipated a serious problem and they don’t seem to see any change in the patient load at the present time.

I think it is one of those things where we have to be prepared to co-operate to a degree. I would hope that if the reverse situation ever happened we would get the same kind of understanding from the other side of the border, or from another province. Every so often somebody comes to me and asks us to consider the limitation of, say, Quebec residents coming into Ontario. I point out that for every Quebec resident who comes into Ontario there is probably an Ontario resident going into Manitoba, for example, or, in the northern part of Ontario back into Quebec, or some areas in northeastern Ontario. So I am very reluctant to see us refuse services, but we have to be ready for it if it comes. The import of the message we’ve got back is that the hospitals in that area feel they are able to cope at the present time.

On Bloorview, I don’t know that I have any specific comment except to say I’ll try to find the information and see if I can give it to you later in these estimates, probably on this same vote, on some future day. On the final comment, regarding hospital management, I would need to know -- and I’m sure you would want to know yourselves -- both sides of the story.

The memo does sound pretty autocratic, and yet I have no idea what circumstances led to the writing of that. Management has a right and a duty to manage, and there are times when this is sorely tested and, I might say, particularly by professionals. I’m not talking about the hospital field; I’m talking about the professional vis-à-vis management, because with our level of education has come a growing belief that this level lets us tell the boss what to do. I suspect at times that the staff of such institutions as hospitals, made up in the main of highly trained, intelligent, educated, dedicated and sometimes stubborn people, gives the managers some very real management problems. I would like to hear both sides before I make any judgement on a memo like that, to see what precipitated it.

Mrs. Campbell: Mr. Chairman, it would have occurred to me that nowhere at all could anyone order people to cease and desist from the right of assembly if that’s what it is. I thought that that at least was an inalienable right --

Hon. Mr. Miller: Not necessarily at work.

Mrs. Campbell: He doesn’t say they were work and they weren’t taking time out of their work. What I am saying is I thought that that would be self-evident, but if the minister wants to study it, that will be fine with me.

Hon. Mr. Miller: Please send me copy, will you?

Mrs. Campbell: I’ll send you a copy; yes, I shall. There are two other points I want to mention. Regarding ambulance services, I thought I had waded through all the intricacies of the ambulance services as they pertained to Metro Toronto. But I have a letter here from a gentleman who wishes me to help him, and I guess everyone else in this Legislature, to raise money to buy an ambulance for Upsala --

Hon. Mr. Miller: I have my ticket.

Mrs. Campbell: -- which is 90 miles from the nearest hospital and ambulance service. Is this the way they run the ambulance service in that part of the country? When you insisted -- and you did insist -- on taking over all the ambulances from the ambulance operators in Metro, wouldn’t it perhaps have been a good idea to have provided an ambulance service to a place 90 miles from the nearest hospital and ambulance service?

Mr. Deans: Why don’t they have an ambulance?

Mrs. Campbell: Why should they have to go out and provide this service by this means?

Hon. Mr. Miller: It would be great to have every service available in every community of the province, and you and I would aspire towards that. We have a number of isolated or small communities where it’s economically impossible to provide many of the services -- and ambulances are just one. In the north, we have provided volunteer services in a number of communities and we’re trying to expand this as we study each one. We also have air ambulance services for the most severe cases in many of these areas. Within the limitations of the money we have, we’ve been doing our best to cover most of the areas. I agree -- and I’m sure if the member for Thunder Bay (Mr. Stokes) were here, he would be on his feet telling me of a number of communities in his area that are underserviced. That is true. I simply have not yet got adequate answers to the question of supplying all services to our sparsely-settled parts of the province.

May I move that the committee rise and report?

Mrs. Campbell: Mr. Chairman, could I just finish a point there, and then I will be happy to leave it alone. The only comment I have is that this ministry went in and clobbered the private ambulance owner in the city of Toronto. If you needed the funds, would it not have been better to have provided ambulance service where there wasn’t any, and then buy out the Toronto ambulances or provide the publicly-owned ambulances for the firms in Toronto?

Hon. Mr. Miller: That is an interesting argument from a resident of Metro Toronto, because you can recall last summer this was a very emotional issue in the city of Toronto -- the question of response time within the city.

Mrs. Campbell: It certainly was -- I don’t think it is any better than before.

Hon. Mr. Miller: I would suggest that many provinces --

Mrs. Campbell: The minister should look at the hierarchy there.

Hon. Mr. Miller: -- would like to have the 12½-minute response time, or whatever it is in the city -- certainly in the city of Toronto. Rather than saying any more, Mr. House Leader, may I suggest that the committee rise and report?

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 very little progress and asks for leave to sit again.

Report agreed to.

Mr. M. Cassidy (Ottawa Centre): Casting aspersions on the work of the committee.

Hon. E. A. Winkler (Chairman, Management Board of Cabinet): Mr. Speaker, I have called the business of the House for tomorrow. On Thursday, if we do not complete that list, we will continue with it. We will add to that item 7, Bill 77, and also item 14, Bill 98.

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

Motion agreed to.

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