SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION
SANDWICH COMMUNITY HEALTH CENTRE INC
SERVICE EMPLOYEES UNION, LOCAL 210
ASSOCIATION FOR PERSONS WITH PHYSICAL DISABILITIES OF WINDSOR AND ESSEX COUNTY
CANADIAN MENTAL HEALTH ASSOCIATION, WINDSOR-ESSEX COUNTY BRANCH
WINDSOR AND DISTRICT LABOUR COUNCIL
ESSEX COUNTY DISTRICT HEALTH COUNCIL
ESSEX COUNTY PHARMACISTS' ASSOCIATION
WINDSOR AREA CAW RETIRED WORKER COUNCIL
HEALTH SYSTEM LABOUR ADVISORY COMMITTEE
CONTENTS
Monday 15 January 1996
Savings and Restructuring Act, 1995, Bill 26, Mr Eves / Loi de 1995 sur les économies et la restructuration, projet de loi 26, M. Eves
Sandwich Community Health Centre Inc
Isabella Cimolino, executive director
Service Employees Union, Local 210
Ken Brown, president
Hôtel-Dieu Grace Hospital
Armando DeLuca, chairman of the board
Frank Bagatto, CEO
Association for Persons with Physical Disabilities of Windsor and Essex County
Taras Rohatyn, executive director
Canadian Auto Workers-Canada
Peggy Nash, executive assistant to the president
Canadian Mental Health Association, Windsor-Essex county branch
Pamela Hines, executive director
Thom Morris, volunteer
Windsor and District Labour Council
Gary Parent, president
Nick LaPosta, secretary-treasurer
Essex County District Health Council
Jo-Anne Johnson, chair, implementation committee
Hume Martin, CEO
Essex County Pharmacists' Association
Yvonne McRobbie, president
Dave Malian, president-elect, Ontario Pharmacists' Association
Sal Cimino, district 11 representative, Ontario Pharmacists' Association
Fred Netherton; Art Kidd
Essex County Medical Society
Dr Albert Schumacher, member
Dr Ian McLeod, president
Windsor Area CAW Retired Worker Council
George Johnson, chair
Les Batterson, past chair
Health System Labour Advisory Committee
Pierina DeBellis, co-chair
Valerie Walter, co-chair
St Joseph's Hospital
Stephen Fuerth, chair
STANDING COMMITTEE ON GENERAL GOVERNMENT
Chair / Président: Carroll, Jack (Chatham-Kent PC)
*Carroll, Jack (Chatham-Kent PC)
Danford, Harry (Hastings-Peterborough PC)
Kells, Morley (Etobicoke-Lakeshore PC)
*Marchese, Rosario (Fort York ND)
Sergio, Mario (Yorkview L)
Stewart, R. Gary (Peterborough PC)
*In attendance / présents
Substitutions present / Membres remplaçants présents:
Caplan, Elinor (Oriole L) for Mr Sergio
Clement, Tony (Brampton South / -Sud PC) for Mr Kells
Ecker, Janet (Durham West / -Ouest PC) for Mr Stewart
Johns, Helen (Huron PC) for Mr Danford
Lankin, Frances (Beaches-Woodbine ND) for Mr Marchese
Also taking part / Autre participants et participantes:
Crozier, Bruce (Essex South / -Sud L)
Duncan, Dwight (Windsor-Walkerville L)
McLeod, Lyn (Fort William L)
Pupatello, Sandra (Windsor-Sandwich L)
Clerk / Greffière: Grannum, Tonia
Staff / Personnel: Fenson, Avrum, research officer, Legislative Research Service
The committee met at 0859 in the Ramada Inn, Windsor.
SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION
Consideration of Bill 26, An Act to achieve Fiscal Savings and to promote Economic Prosperity through Public Sector Restructuring, Streamlining and Efficiency and to implement other aspects of the Government's Economic Agenda / Projet de loi 26, Loi visant à réaliser des économies budgétaires et à favoriser la prospérité économique par la restructuration, la rationalisation et l'efficience du secteur public et visant à mettre en oeuvre d'autres aspects du programme économique du gouvernement.
The Chair (Mr Jack Carroll): Good morning, everyone. It's nice to be in Windsor. You probably won't believe this, but I used to live in this city a few years ago.
Interruption.
The Chair: Anyway, we are happy to be here. We're here to listen to the concerns of the people of the city of Windsor. We have several groups going to present to us today and hopefully they'll get an opportunity to do that.
Oh, I'm sorry, Ms Lankin.
Ms Frances Lankin (Beaches-Woodbine): Thank you, Mr Chair. I just wanted to make note of the fact that I have filed with the clerk two motions: one dealing with the committee coming back to Windsor to hear from those people who've not been heard from, and another dealing with a demand that the government file the amendments to this bill. Those motions have been duly filed with the clerk and I'd be prepared to move them at a time where you schedule them for debate.
The Chair: As probably has been our custom, out of respect for our presenters, we'll deal with those at our lunch break, if that's satisfactory.
SANDWICH COMMUNITY HEALTH CENTRE INC
The Chair: The first presenter this morning represents the Sandwich Community Health Centre: Isabella Cimolino, who's the executive director. Isabella, you have a half-hour of our time. Questions, should you leave time for them, would begin with the Liberals and would rotate around the table.
Mrs Isabella Cimolino: Thank you and good morning. The thrust of this presentation and its primary focus is on process, process as it relates to the Sandwich Community Health Centre and consequently the impact of Bill 26 on these processes. It will be brief in deference to those who are following me, and I will even read the presentation as opposed to ad libbing because when I ad lib, I tend to go over time.
To this end, attached to the presentation is the mission statement of the Sandwich Community Health Centre and the latest copy of its newsletter, Health Smart. From that mission statement you'll find that we're a community-directed organization that works with its community in the achievement of optimum health, looking at physical wellbeing as well as others, and we do so from a primary care perspective, as well as focusing on health promotion and diseases prevention. So with that in mind, I will now go through the presentation itself.
Since its official opening in November 1989, the centre board and staff have worked with the community to determine its health status as well as ways in which this could be improved, including how, working collaboratively, we can make Sandwich a better place to live.
Focus groups, town hall meeting, needs surveys which involved completion of questionnaires door to door, for example, are a number of the ways in which we obtained public input upon which to develop strategic plans and operational plans which assisted us in making the decisions necessary for the deployment of resources, both human and financial.
We have paraphrased an old Chinese proverb which says, "Tell me and I will forget; show me and I will remember; involve me and I will understand." I think that latter part, the involvement and the understanding, are what is critical to today's times. We're long past the time where somebody knows better and imposes upon the people whatever they think happens to be best for others.
It's not necessarily the easiest way to proceed, but in the long run it's the most gratifying. When we do put together a program, it's one that's attended because the people we're serving have helped us develop it. They then have ownership in it, and that means they then go out and bring in the parties who can best benefit from whatever we have developed.
In bringing common sense to health care in December 1994, the Progressive Conservative Party stated, "The public should be a key player in determining local community health care priorities." It's suggested that the provisions of Bill 26 totally contradict this particular statement.
Our clients are served by a team of health care professionals which includes physicians, nurses, social workers, a chiropodist, a dietitian and health promotion specialists. The administrative support to this is two people, an administrative assistant and myself, so we can't say we're heavy in administrative costs. Clients provide explicit consent to the Sandwich Community Health Centre, both when they first become our clients and then through different processes, as we deal with external organizations, they become even more specific to ensure that the client has some sort of control and some sort of knowledge and some sort of input into what is about to happen to them.
The implied consent that permeates Bill 26 which allows the minister or designate to access client records is of great concern to the centre. It detracts from the notion of assuming greater control over self and thus has the potential to nullify clients' participation with respect to decisions regarding their health, not to mention, I suggest, a breach of current standards of confidentiality.
On a microscale, the services in a community health centre are integrated. This integration of services must occur at a macroscale to ensure the development of a system of health and health care in order that we better serve clients' needs efficiently, appropriately and cost-effectively. The centralization of authority in Toronto will jeopardize this integration, will deny communities the opportunity to set their own health and health care priorities and thus design a system which will address these priorities.
Another one is, as we look at the section that deals with independent health care facilities, that a community health centre is currently incorporated under the Ontario Business Corporations Act and we're governed by a volunteer board of directors. Much of our work is done in committees, with our directors, residents, clients and staff working together for the betterment of the community as it relates to health. The provisions of Bill 26 as they relate to independent health facilities have the potential, we suggest, to render this volunteerism obsolete because there exists the possibility we could be declared an independent health care facility. This is of concern to us.
There are other provisions of this bill upon which we could comment, but I think the previous examples give you an idea of the concerns we have. There are others here today who will speak to the other areas that are of concern to us, which are the Ontario drug benefit plan and things that the physicians will be addressing, things specifically from their perspective.
No matter how I read that bill and no matter how I would put the "mays" rather than the "shalls" and all the rest of it, to all intents and purposes it has every appearance of being a power grab of leviathan proportions and it is moot as to whether the end actually justifies the means. I think we have to look very closely at that.
We do have some recommendations, and probably I could have gone an awful lot further with these, but again, I defer to time and perhaps the opportunity to answer questions from the members of this committee. But we will certainly send the message that we have to resist the temptation to centralize authority in Toronto. It's not just the centralization of authority; it's the kind of authority that's being centralized.
I would hate to think that one person sitting down there can make a decision as to the health care that I'm receiving from my family practice physician or whoever else I happen to be getting that from. They don't know me, they don't know anything about me, they don't know anything about my health, so why should this person be making a decision? I will rely on making the decision with the input from my practitioner, whoever that may be, and on that basis I think my health will be better served.
So we have to look at the centralization in Toronto. Toronto doesn't always know what's best for the rest of Ontario. They might think they do, but we know you really don't. We are quite diverse, we really are. There's no place to allow communities to plan their own local health system. We have to allow communities, in conjunction with medical societies and the Ontario Medical Association, to determine the requirement for physicians of all stripes so that there will be family practice physicians, specialists and what have you.
Here I emphasize the local end of it because it has to be done on a health status basis. We have to look at the health of the communities being served and make a determination from that. If, say, in Windsor we need more orthopaedic surgeons than some other area might need, so be it. But it's only the local communities that can make that determination, working with their physicians and coming up with a plan so that then, when people go into medical school -- this is only a suggestion, by the way; the Sandwich Community Health Centre's thinking certainly isn't anybody else's necessarily -- they know what's needed and they know where the jobs are. It's a better way of controlling it than suddenly pulling the rug from under somebody's feet and saying, "You don't have a billing number any more." I would suggest that is not a terribly appropriate way to proceed.
0910
If any of you were watching Canada AM this morning, there is a report that has not been released yet -- this is a pre-release -- that has to do with the migration of Canadian physicians to the US, but part of it also deals with the suggestions and recommendations from a diverse group as to the practice of physicians in Ontario. It struck me, as I look at this planning thing particularly, that for every two physicians who go to the States, one comes back. But it was a comment I heard made, "Well, Canada has too many physicians anyway." Now, you wouldn't know that from necessarily Essex county, and I may add Kent county, because we certainly do not have an overabundance of physicians and our physicians consequently work extremely hard.
The point was, I thought it was such a comment that just emphasizes the fact that we have to plan, and planning needs diligence in conjunction with the service. But move the decisions closer to where the services are delivered, to the front-line workers, and that of course includes physicians, includes nurses and includes all of these people who directly serve Ontarians.
We ask that you support the integration of services at the local level. If all health care providers work together cooperatively, the efficiencies will occur. They can't help but occur if they're working closer together.
You must respect their clients' confidentiality; and although I say that, I now move into another section where somehow or other we move to the technology to develop a smart card that will protect this confidentiality.
If in Scotland I can access my bank here in Windsor or in Chatham, Ontario, surely we can come up with something that would protect the confidentiality of the client. But, because of the client tracking system inherent in that process, then we can better serve our clients, and if there's any misuse of the system it will be identified, whether that misuse is by the person receiving the services or the person providing the services.
To suddenly go out and start trying to find abuses of the system -- I worked in government service for an awfully long time, both in Britain and here, in the sense that I've usually worked in the public, if not directly as a civil servant, and usually these abuses are greatly magnified as opposed to the reality. The things that are set up to stop them are usually worse than what they're trying to stop.
I think also that it better serves, and more importantly, clients in that they won't receive inappropriate medication. I hear our physicians speak sometimes as I'm walking by. They go to a walk-in clinic, they get a prescription that's not an appropriate prescription and then have to try and undo what has happened in that particular environment; or a walk-in clinic has sent somebody to a specialist without consulting with their family practice physician and a letter comes back to the family practice physician saying: "We don't know why this person was here. She should never have been there in the first place." So I'm suggesting there are other ways of doing things, and perhaps we should be looking at the smart card, rather than scrapping it, as a possibility.
I would certainly suggest that the Progressive Conservative Party adhere to the processes, values and beliefs, with respect to process, as you set out in the Common Sense Revolution and your health care bill of rights, one of these rights being that Ontarians have the right "to participate in decision-making regarding one's own health and the right to treatment free of discrimination and which recognizes one's privacy, dignity and individuality." With all due respect, Bill 26 is a total contravention.
These are your words that I have read from the various documents coming from the PC government when it assumed power. I took it upon myself to read all these things to have an idea of what would be happening to us.
As I said, there are other things I could focus on, but I'll let others do that, and I'm sure they will. But there is one thing I was thinking of this morning which I should have put in there. Canada has a unity problem sometimes, but one thing that struck me was that when they took a poll of Canadians coast to coast, regardless of province or where people lived, 82% to 84% supported our medicare system. That is a very high percentage.
There's already private coverage to the extent of somewhere around 22%. I was just thinking this morning, how far do we want that to go? With all due respect, I suggest that the percentage of privatization, if it has to occur at all, has to be limited and it certainly has to never exceed the public part of it. I believe health is a right, and health care is an extremely important part of health, and probably most of the people across this province and across this country would agree with that. The poll certainly suggests that. I throw that in although it's not in the brief, because it is of concern to me.
All that's left for me to do is thank you for the opportunity to make this presentation, but I would be remiss in not saying a special thank you to the loyal opposition and the New Democratic Party, who have made these hearings possible.
Mrs Sandra Pupatello (Windsor-Sandwich): For the information of committee members, Sandwich Community Health Centre is one of the examples that would be continuing should the Win/Win proposal ever come into place in this area, specific to our health services in Windsor-Essex county where savings in health and hospitals was to be redirected into community health services. Your organization is one of those examples. What does this bill do in addition to the fact that the Minister of Health has not continued to be committed to the win-win proposal for Windsor? How do you see this being affected, compounding the problem especially where your clientele are concerned?
Mrs Cimolino: With respect to our clientele, I don't have a crystal ball to see where the directions are going, but I've certainly indicated the processes involved in the community health centre. That could go by the board. My experience has been, as I look over the past eight years -- we opened officially in 1989 -- to see the differences in the community and work with them. We do access federal dollars, working with the community to address things like environmental needs and also our healthy mothers/healthy babies program. There's going to be an announcement on Wednesday from Mr Rae with respect to federal input into that process.
Depending on the road taken, it could be adversely affected, but we could also possibly benefit. Because we are an integrated service, we're all paid by salary; that includes physicians. I'm usually a perennial optimist, but this line from the poetry of Robert Burns keeps coming through my mind, "An' forward, tho' I canna see, I guess an' fear!" That is from the poem To a Mouse. It keeps coming up. It could be negative, but I see it also as a positive. I'll certainly, as an individual, do everything I can on behalf of the clients we serve to ensure that whatever adverse effects occur are as minimal as possible, working with the community.
Mr Bruce Crozier (Essex South): Thank you for your presentation. Notwithstanding the fact that the Conservatives gave their solemn oath not to cut any funding from health care, we see now that about $1.3 million, earmarked to reduce the deficit, is going to come from health care, without any plan that we can see. When we have downsizing in medical services, in hospitals, where do you see community health centres in this situation at the present time, when funding is definitely going to be reduced for health care yet there's no plan out there for how that is going to be shifted to community health centres and how they're going to be funded?
0920
Mrs Cimolino: With respect to our community health centres, we've already seen the impact of early exits from hospitals and that type of thing. You don't have home care. The family practice physician is still in charge of that, so consequently, as it moves into the community, even if it might be VON or somebody of that ilk providing the service, the impact is great on our physicians to deal and to give the direction.
That's only the start, and I think it will get worse if there are no resources allocated to the community sector to do that. That's probably what Sandra was thinking of in terms of the promise that if we had any savings from the hospital sector, it would be reinvested into the community, one which is now in jeopardy and it will all go into the same pot. In fact, we will have a plan in Essex county. I don't want to steal the thunder of the district health council, which is coming later this afternoon; they will be able to address that much better than I. But we are already feeling the impact, and we're trying to do the same.
Now, we still have a similar amount of dollars -- we've been most fortunate -- and I think that is a recognition of the work we do. But the impact on services is great, and we are looking very strenuously at the moment how to reorganize internally to address the much greater demand on our services.
Ms Lankin: Thank you, Isabel. It's a pleasure to see you again. I highly recommend to the government members of the committee, if they get a chance to come back to Windsor, to visit your community health centre. It's an incredible operation, located in a school, well integrated into the community. I remember well the opportunity I had to tour it. The work you do is very important and serving an important constituency in the Windsor-Sandwich area.
I want to also address the issue of community participation and community control and community planning for our health services. Here in Windsor you went through a process to come together to determine the direction of not just hospital services but health care system restructuring, which I think is important.
This bill sets out a new process: a minister who can make a decision any time he wants about hospital closings; a hospital restructuring commission that has no terms of reference, no controls on its powers, that can implement anything it wants; and nothing in the legislation that relates it back to the work of local planning processes and reports, such as the one here that was led by the district health council.
The government gives us all sorts of assurances that that's what it intends, but this is the same government that has withdrawn the commitment that was made to Windsor to reinvest the dollars from the hospital savings into the community to ensure that there is a seamless system.
We're interested in seeing the government amend that section of the bill to give a very clear linkage that what the minister and the hospital restructuring commission are going to do is based on, has some relevance to, the local community planning process that communities themselves undertake and the decisions they make for themselves. Would you be supportive of that kind of amendment and could you speak about what that might mean in terms of this community and resources into community services?
Mrs Cimolino: I would be 100% supportive of that position. I've been involved in the process you've just described since 1991, first of all as a citizen and then as part of the district health council. I'm now chair of the community restructuring segment of that process, and exciting things are emerging from that community process. Again, I don't want to speak too much, because the district health council will be making a presentation in that regard.
But we have a planning vehicle, and they're called district health councils. The money is already going into district health councils and they are working with their community. The format could change; I'm not saying that. But use the vehicles that are already there. Communities are at different stages in this. I think we're a wee bit ahead of some of them, because we were invited to speak to the Metro Toronto District Health Council. Anything that keeps the planning, the decision-making at the local level where they have a firsthand knowledge of the needs of the community, looking at it from a needs perspective, ie, health status and all these things, yes, it's the only way to go.
If we have, as this person said, and I've heard it before, too many doctors in Canada, obviously we haven't planned well, and it's hardly fair to the people entering medical school, the profession. It's already happened to teachers and to so many other places, that the jobs just aren't there. That's a rather difficult situation. Are we as Canadians going to train doctors so they can go to the States? I don't think that's terribly acceptable and I don't think half the physicians would find it terribly acceptable either.
Ms Lankin: The other area you raised in your presentation was concerns about the Independent Health Facilities Act. I'm sure you know that the current legislation has in it a provision that gives a preference for Canadian-owned, not-for-profit delivery of services. The government is taking that provision out. I can't read anything into that but to open up the door to competition from for-profit, foreign-owned. Otherwise, why would you remove that provision? In fact, government members across the way said in other communities last week: "So what's wrong if someone wants to come from Korea or the United States or wherever and run it and make a bit of profit? If they're doing it more efficiently, then great."
I have grave concerns about services to people being turned over to the for-profit sector and I have grave concerns about what that means in terms of our medicare system and the values in our communities that are exemplified through our commitment to medicare. Can you comment on that from a Windsor perspective? You're very close to the American system across the border.
Mrs Cimolino: This is the town that was first in so many things. We had the Windsor medical association. The unions in this area have very much been advocates of the non-profit delivery of medical services. As I stated earlier, we have to look very closely at that and we must not, cannot allow ourselves to be taken over by the for-profit and end up like our friends across the border, where it's said that 52 million people do not have any medical coverage and a great many more don't have satisfactory coverage, and this is in a country where they spend more money on health per capita than any other country in the world. Do we want that? I would suggest not, and certainly they're not the values and beliefs I hold as an individual, albeit a naturalized Canadian citizen, but I'm in Canada because Canadians think similarly to me, although not quite the same, because I come from a British tradition.
Mr Tony Clement (Brampton South): Thank you for your presentation. It was very thoughtful and certainly has given us some things to think about.
I just wanted to talk about a couple of areas of your presentation. First of all, as Ms Lankin has already raised, you feel very strongly about the need not to centralize the authority in Toronto, and I couldn't agree with you more on that. I've been drawing to the attention of some of the presenters who've raised that issue before the fact that in Bill 26 there's no mention of district health councils, which some people view with alarm, but what that means is that the provisions currently in the legislation on district health councils still apply, so district health councils are still there to advise, to plan and to make recommendations.
If we made that more explicit, if we drew the connection between district health councils and the hospital restructuring, do you think that would satisfy some of your concerns?
Mrs Cimolino: If you did make things more explicit, certainly we could understand and it would not be subject to the broad interpretation it currently has. But any legislation that denies the right of appeal to whomever -- my background is that I have a law degree. I find that so offensive because now I'm subjected to the interpretation of one person or maybe even two, without any recourse to anybody.
What one intends and how it's interpreted are so different. I sat through the Municipal Act that was just written, and it was pulled apart by law students with the writers, and all they could say was, "But that's not the intent." That is the English language. This is an interpretation this language could stand. You must have appeal or some way of getting interpretation of that, and the more explicit you can be, the better.
Mr Clement: Can I talk a bit about the disclosure of medical records? You raised the issue of your concern over deeming to disclose automatically. Under the current legislation, you are deemed to disclose as well, and in fact the new legislation under Bill 26 restricts the conditions under which you're deemed to disclose. But I acknowledge that perhaps must be a bit more calibrated, made a bit more specific, maybe made more anonymous. I want your comment on that.
0930
You've mentioned the smart card. The Minister of Health and the Conservative caucus very much believe in a smart card as well and we would like to implement that technology. But you've got to do a bit of a balance between the smart card and the technology and how that intersects with keeping medical records confidential. Could you comment on those two aspects of your proposal?
Mrs Cimolino: I agree totally there has to be in this technology some ways of putting checks and balances. I don't understand why we can put a man on the moon, a man someplace else, and yet we can't do something like that. There has to be a way of doing it. We are in the technocratic age. We are going to be exposed more and more to these things. It behooves us very early in the process to develop these opportunities for confidentiality because we are going to have to live with it for an awful long time.
Mr Clement: So you see no contradiction --
The Chair: Thank you very much, Mr Clement.
Thank you. We appreciate your interest and your presentation this morning. Have a good day.
Mrs Elinor Caplan (Oriole): Mr Chairman, can we get a few more chairs for accommodation? People are standing and waiting in the hall and I think there is room in the room for some more chairs, if that would be possible. Could you see if that could be arranged?
SERVICE EMPLOYEES UNION, LOCAL 210
The Chair: Our next presenter represents the Service Employees Union, Local 210, Mr Ken Brown, the president. Good morning, Mr Brown. Welcome.
Mr Ken Brown: Thank you and thanks to my few friends I brought along with me this morning. On behalf of the 4,000 members of Service Employees Union, Local 210, employed in health care facilities in Essex-Kent, Lambton, Huron and Bruce counties, we welcome this opportunity to express our views on Bill 26 as it impacts on health care.
At the same time we must state our objection to the obvious intent of this government, which is to pass the legislation by the end of January with little or no regard to the input to be received at these hearings. The whole process, frankly, seems undemocratic.
With the introduction of this bill the government is proposing sweeping and fundamental changes without adequate public debate. It has become apparent in recent weeks that no one, including members of the government itself, has had adequate opportunity to study the bill and how its passage will affect our society.
The Premier talks to us about the need for less government, and yet the unifying theme of Bill 26 is to gather greater unprecedented powers into the hands of government ministries and the Ontario cabinet. In the words of Thomas Walkom in a December 2, 1995, article in the Toronto Star with respect to this legislation and its process: "In the world of rational order, there is no room for dissent and precious little role for the elected representatives of the people. The government marches on...."
As it relates to health care, the omnibus bill creates a new health act and a Physician Services Delivery Management Act and amends the following: Ministry of Health Act, Public Hospitals Act, Independent Health Facilities Act, Ontario Drug Benefit Act, Prescription Drug Cost Regulation Act, Regulated Health Professions Act, 1991, Health Insurance Act, Health Care Accessibility Act, Pay Equity Act, Hospital Labour Disputes Arbitration Act and other interest arbitration legislation.
Some of the substantial changes in the bill include:
A rollback on pay equity for women.
The deregulation of drug prices and the introduction of user fees for the Ontario drug benefit plan.
The increased power of cabinet and Minister of Health over hospitals and doctors. Under this bill the Minister of Health would be able to close hospitals, appoint a supervisor to take over hospitals or tell individual hospitals what services they can or cannot provide.
The repeal of existing laws giving preference to Canadian-owned, non-profit health care providers and the removal of a public tendering process. It would appear that the door is open to American for-profit companies to set up clinics in Ontario.
The opening of the door to new user fees for a wide range of health care services including hospital services.
New rules for bargaining with hospital workers, forcing arbitrators to consider the ability to pay and to further consider the possibility of service cuts in deciding wage levels.
Sweeping immunity of government at all levels from the legal challenge.
The absence of an appeal process for health care providers or citizens.
It is our belief that no sector will be as significantly affected by Bill 26 as will be health care sector. It will surely impact the quality of care in a negative way. It will profoundly damage publicly funded medicare and encourage the privatization of health care. It is an attack on the elderly, the poor and all of those in society most in need of quality care. It permits and even encourages extra billing and violates the Canada Health Act.
If this legislation is enacted, we will see a rapid encroachment by the private sector looking to make profit on illness and disability. We need only look to the US to see a shining example of that type of health care system, where an estimated 44 million people have no health care coverage and another one third of the population is underinsured.
The United States is the richest country in the world. They spend more money per capita on health care than we do, but in the end only provide quality care to the rich, create huge profits for insurance companies and health maintenance organizations and leave an estimated 60% of their population either uninsured or underinsured. We do not believe that most Ontarians want this kind of health care system.
Schedule F of the legislation, health services restructuring, provides the government with arbitrary power to close public hospitals and to invite private profit-making corporations to open licensed fee-charging facilities in Ontario. It allows for the introduction of user fees and extra billing practices and, in our view, firmly establishes two-tiered medicine. The changes to be implemented under this schedule are an attack on the principles of the Canada Health Act.
Schedule F amends the Public Hospitals Act, the Private Hospitals Act, the Ministry of Health Act and the Independent Health Facilities Act.
The Public Hospitals Act: Significant components:
Bill 26 will give the minister virtually unlimited power to dictate every detail of the hospitals, including the funding, operation, closure and amalgamation of hospitals.
It fundamentally changes the democratic community governance structure of community boards of directors of hospitals. The minister has the power to override decisions of the community boards of directors without their input.
It ensures that fiscal and budgetary responses alone can close or amalgamate hospitals without regard to the impact on quality of care.
It can direct hospital supervisors to implement the minister's decisions and to take over the powers of the local board of directors.
Bill 26 protects the minister, investigator, hospital supervisor and board of directors from any liability as a result of hospital restructuring.
Funding: Under the old Public Hospitals Act, sections 5 and 6 gave the minister the power to give provincial aid to the public hospitals as defined by regulation. In Bill 26 these sections have been repealed and replaced with clauses giving the minister discretion over when, how much and under what conditions the minister will give grants, loans and/or financial assistance. He also has the power to require repayment and to reduce or terminate grants and loans. His only criterion is that he must consider the public interest.
The new section 6 gives the minister the power to close hospitals, order hospital amalgamation and specify the services to be delivered by a hospital if the minister deems it in the public interest. The effect of these provisions is to give the minister significant discretion to decide all hospital funding matters without regard to any of the objective or limiting criteria contained in the present regulations.
Public interest: "Public interest" is used throughout schedule F. The definition of "public interest" is added to the Public Hospitals Act in section 9.1. The clause states that the minister and cabinet are not limited by these matters and can consider "any matter they regard as relevant."
The list includes the quality of management and administration of hospitals; the quality of care and treatment of patients in the hospitals; the proper management of the health care system in general; and the availability of financial resources for the management of the health care system and for the delivery of the health care system.
The availability of resources is entirely a matter of priority. The Minister of Health may well find less resources available for health care because more is needed to cut the income taxes of the well-to-do.
Section 9.1 and amended section 13 also protect the minister and cabinet from any legal liability from any decisions as a result of their direction or level of funding.
0940
Ministerial power to close, merge or make other directions: Bill 26 fundamentally alters the relationship between public hospitals and the government. It replaces the independence of hospitals and the communities with the overriding control of the Minister of Health and cabinet.
The courts have ruled that, under the existing Public Hospitals Act, the minister cannot act for fiscal or budgetary reasons alone or without regard to the effect on patient care in deciding to close or amalgamate public hospitals. However, under Bill 26 the minister is empowered to order the closure and amalgamation of public hospitals whenever the minister considers it is in the public interest. The bill also provides that no amalgamation can take place without ministerial approval. In making decisions, the Minister of Health is authorized to take into account any matter he or she regards as relevant, including the availability of financial resources.
Under the bill the minister is also given power to direct a hospital to provide specified services and dictate the extent of the services. The minister also has the power to make any other direction related to the hospital that the minister deems in the public interest. In effect, this section of the act grants the minister the power to virtually dictate any aspect of the operation of public hospitals.
When ministerial directions are given, the bill provides that the board of a hospital must carry out the direction. Throughout all of this, the minister and cabinet are insulated from any legal liability with respect to any direction given to the hospital or the effect of any funding decision.
Powers of investigation and supervision: The power of cabinet to appoint investigators under the Public Hospitals Act has been expanded under the bill to allow investigators to investigate any matter related to the hospital, again where cabinet considers it advisable in the public interest to do so.
Under the existing Public Hospitals Act, an investigator could be appointed "to investigate and report on the quality of the management and administration of a hospital" and "the quality of the care and treatment of patients in a hospital." New section 8.1 adds "or any other matter relating to a hospital where the Lieutenant Governor in Council considers it in the public interest to do so."
In addition, Bill 26 authorizes cabinet to appoint a hospital supervisor whenever cabinet considers the appointment to be in the public interest. In the former Public Hospitals Act there was a requirement that an investigator's report first be completed and considered for a 30-day period.
In Bill 26 the powers of the supervisor are expanded. Instead of providing advice or direction to the hospital board, the supervisor now has the exclusive right to exercise all of the powers of the hospital board. The supervisor can now completely take over the board of directors or the corporation managing the hospital. Previously, under the existing Public Hospitals Act, the board or corporation had the obligation to follow the supervisor's advice. Now, if the boards resist ministerial direction, they can essentially be removed from office.
Also previously, the supervisor was required under the Public Hospitals Act to report from time to time to the minister. Now he is required to follow directions issued by the minister with respect to the supervisor's powers which themselves are virtually unlimited.
Again, the bill protects investigators and hospital supervisors from liability for any action or omission.
Physician appointments and privileges: Section 32 of the bill gives the minister the power, with the approval of cabinet, to make regulations including the appointment of physicians and the requirement for each hospital to submit a "physician human resource plan." These provisions, taken together, give the minister and cabinet potentially unlimited control over fundamental decisions relating to the appointment of physicians in public hospitals and, accordingly, over the ability of physicians to work in public hospitals and of their patients to have access to their services while in a hospital.
In addition, the bill provides that cabinet, by regulation, could prevent physicians from using the courts for damages for refusal, alteration or termination of their appointments or privileges even if the hospital is not closing. Physicians also do not have any right to appeal.
It also gives the power to the minister to make regulations concerning hospital subsidiaries, hospital foundations and the disposition and/or purchase of hospital assets. Large amounts of dollars are sitting in these funds and no one knows what will happen to them when hospitals close or merge.
Once again, the bill extends to hospitals immunity from any liability.
Private Hospitals Act: The significant components:
The minister has the power to close or terminate any grant of any private hospitals without notice.
Hearings or rights of appeals have been repealed.
The minister is protected against liability.
In schedule F the minister amends the Private Hospitals Act to give the minister the power to revoke a private hospital licence at any time, and to reduce or terminate any grant, loan or other financial assistance, without notice, where the minister considers it in the public interest.
No hearings or rights of appeal presently provided under the Private Hospitals Act would apply. Again the minister is immunized from any legal liability as a result of closure or a funding decision.
The Ministry of Health Act, significant components:
Bill 26 establishes the Hospital Services Restructuring Commission whose mandate is to implement the government's agenda on hospital restructuring.
The commission is totally protected from any liability in implementing hospital restructuring.
Section 8 of the Ministry of Health Act deletes any references to district health councils.
Bill 26 repeals section 8 of the Ministry of Health Act.
The old section 8 established the Ontario Council of Health, which is a senior advisory body to the minister on health matters. It also established the district health councils and outlined their functions. Finally, it provided direction to DHCs in respect to first nation or aboriginal communities.
The new section 8 does not mention district health councils. The removal of the references in section 8 of the district health councils makes it very unclear as to the government's intention for the DHCs and the relationship between them and the Health Services Restructuring Commission.
I heard a comment to the last speaker on that point. Although we've had our difficulties with the DHC and the reconfiguration process in Essex county, clearly without that kind of body to do what we've done in local planning, we certainly would not have accomplished what we have managed to accomplish with regard to the health care restructuring, the amalgamation of four hospitals into two in this community in the last four years.
Section 8 is replaced with a section that creates the Health Services Restructuring Commission. This group will be appointed by the Lieutenant Governor in Council and can be assigned duties by regulation under terms and conditions determined by cabinet. There are no restrictions on the duties of this commission. The minister could delegate this authority to the council, who will be empowered to carry out restructuring in whatever way he deems appropriate.
The Independent Health Facilities Act, the significant components:
Bill 26 expands the definition of independent health facilities to include any facility or service that the minister defines through regulation.
It allows for the expansion of independent facilities licensed to charge a facility fee over and above what they receive from the government for insurance services. This is called extra-billing.
It repeals all preference to non-profit or Canadian operators, thus opening the door to private American or profit-making corporations to open licensed, fee-charging facilities in Ontario.
It removes the requirement for public tenders and allows the minister to send a request for a proposal to one or more specified persons.
Under the existing Independent Health Facilities Act, services covered by the act can only be provided in licensed health facilities. Generally speaking, these services presently covered by the act include various diagnostic, surgical and other services provided in outpatient clinics, for which facility fees are paid by the Ministry of Health.
Bill 26 proposes changes to sections of this act which challenge our ability to maintain a universal, accessible, not-for-profit, publicly administered health care system in Ontario.
In Bill 26, the terms "facility fees" and "independent health facility" are redefined to allow for a charge or fee to be made for any service designed by the minister and includes any facility the minister defines through regulations.
Independent health facilities can be expanded far beyond their present use in the system and will be permitted to charge fees to insured persons. This also is extra-billing.
The definitions for "health care" and "health record" are repealed, and in subsections 3(2) and (3) "insured service" is changed to just "service." This allows for deinsuring services and implementing user fees in other parts of Bill 26.
The Americanization of our health care system: The bill repeals the language that directs the minister in the Independent Health Facilities Act to give preference to non-profit Canadian operators and to solicit proposals for new facilities from the general public.
Under Bill 26, this requirement would be repealed. Instead, the minister can direct that a request for proposals be limited to one or more specified persons. This raises the real possibility that for-profit US health care providers will be licensed to provide health services in Ontario. American corporations are extremely interested in our health care system. They call it the "unopened oyster" and care for the elderly is referred to as "mining grey gold."
0950
Under the act, there is no obligation to notify those who submit unsuccessful proposals or to give reasons for the decisions. There is no right to a hearing or appeal. In addition, there is no appeal process if the minister refuses to designate a health facility, if the director refuses an application for relocation or if the minister revokes licences or eliminates services. While there is no right to appeal, the minister and the director are protected from liability for licence decisions.
These changes allow the Minister of Health to handpick corporations or individuals who will be able to open up businesses and franchises of health care clinics that charge people money. In tandem with the massive cuts to hospital services, it seems that the new legislation will allow health care gaps to be filled by more private clinics or organizations intent on making profits from the sick and the elderly.
If you've got my presentation and you're following along, pass over the next section and go down to the bottom of that same page, to "Limitations on Physician Affiliation." The bill also empowers cabinet to make regulations governing the terms and conditions of affiliations between physicians and independent health facilities so that physicians can only operate out of or work in licensed facilities in accordance with whatever requirements are established by cabinet.
Power to set fees and amounts payable: The bill empowers cabinet to unilaterally determine, by regulation, the fees and other amounts payable in relation to the operation of an independent health facility under the act. Cabinet also has the power to set the amount of fees at zero. As well, the minister has the power to set off or deduct against future payments amounts that in the minister's opinion should not have been paid for any reason prescribed in the regulations, with no right of appeal provided. This means that if a doctor provides a service that later the government decides was unnecessary, the doctor will not get paid for providing that service. This process could lead doctors to hesitate in sending people for assessments and so on.
The Chair: I just want to make you aware, Mr Brown, that you've got about 10 minutes left. So you can use it as you see fit, okay?
Mr Brown: Okay. In that case, I will move on to the issues more relevant to our workers. I want to go to page 25, schedule J, the amendments to pay equity, and complete from there.
Bill 26 amends the Pay Equity Act. Effective January 1997, it repeals the proxy provisions. An estimated 100,000 low-paid women in such areas as nursing homes and day care who work for employers with no male-dominated job classes will have their right to fair pay abolished. The pay equity increases that had been agreed to for several thousand nursing home workers in this province prior to the repeal of the proxy provisions were modest at best. The repeal simply punishes these working women that were at the lower end of the economic scale to begin with.
Schedule Q contains amendments to a number of acts involving interest arbitration. Our particular concern, of course, is the Hospital Labour Disputes Arbitration Act. The bill amends legislation governing interest arbitration in the fire, hospital, police, public service and school board sectors. Previously, the Legislature determined that, given the essential nature of the services provided, the terms and conditions of collective agreements must be determined by a process of compulsory interest arbitration rather than through recourse to strikes or lockouts.
The traditional criteria used by arbitrators to determine wages in the public sector is comparability with employees performing similar work for the same employer, with other employers in the public sector or with employers in the private sector. This ensures that wages for employees governed by interest arbitration in the public sector follow freely negotiated settlements in those sectors where the parties have the right to engage in free collective bargaining and with the right to a strike or lockout.
However, Bill 26 requires arbitrators to consider certain criteria when making decisions. These criteria include the employer's ability to pay in light of its fiscal situation and the extent to which services may have to be reduced if the current funding levels are not increased. One of the fundamental objectives of interest arbitration has been to replicate as closely as possible the results of free collective bargaining without having to worry about work stoppages or strikes or lockouts in those essential service areas. The requirements imposed by Bill 26 on arbitrators will make it impossible to achieve that result. With the requirements of this bill, arbitrators will be nothing more than agents of the government sent out to implement government budgetary measures. Arbitrators have historically held that such workers ought not to be required to work at substandard wages and working conditions because of government budgetary decisions. It will be virtually impossible to protect public sector workers from such a plight with these new requirements imposed on arbitrators.
There is a common acceptance among arbitrators and labour relations experts that arbitration boards must be independent of pressure or guidance which could skew their reasoning in favour of one party or the other. The award should result in something both parties to the collective agreement feel represents a balance of their interests. It is up to the arbitrator to independently weigh the evidence presented by the union and the employer and to come to a decision.
The criteria in schedule K constitute a significant interference with the independence and integrity of the arbitration process, requiring boards of arbitration to consider government criteria in awarding collective agreements. Arbitrators have stated that basing an award on ability to pay could render the interest arbitration process largely irrelevant, since the use of ability to pay could allow the government and employers to unilaterally determine wages and benefits by simply allocating a fixed or reduced amount for employee compensation in their transfer payments or budgets. It also would undermine the independence of arbitrators and the integrity of the arbitration process.
With that, I'll go to the last page, the conclusion, and try to leave a few minutes for questions.
The information contained in this submission pertaining to the legislation and its effect is based on documentation provided by the Ministry of Health, the Ontario Health Coalition, the NDP Ontario caucus, Ontario Coalition of Senior Citizens, the Ontario Federation of Labour, the law firm of Sack Goldblatt Mitchell for the legal opinion on Bill 26, and various newspaper articles.
The opinions expressed are those of this union and in support of opinions expressed by the Ontario Health Coalition, the Ontario Federation of Labour and others who have made presentations. Due to constraints of time and resources, we have touched only on the particulars of the legislation we find most troubling.
We believe the impact of this bill is much too broad and far-reaching to be dealt with in a single piece of legislation, and that at the very least it ought to be broken down into three or four more manageable parts, and that public consultation of several months ought to be held on each of those parts. Ontarians deserve that much before such institutions as hospitals and other health care facilities and in fact our entire health care delivery system is so fundamentally altered and in some cases dismantled.
The Chair: Thank you very much, Mr Brown. You've left these politicians with their biggest challenge ever, and that is an opportunity at one short question.
Mr Rosario Marchese (Fort York): Mr Brown, thank you for your thorough presentation. You covered my question to some extent with your last remarks. It seems to me quite clear that when the public has an opportunity to respond to this bill, they have a great deal to say, and you, along with all the other deputants, have had a great deal to say.
There's nothing wrong with governments proposing things. There's something definitely wrong with governments trying to shut out the public from speaking to those proposals, and that's what this government tried to do. Do you believe that people have had an opportunity, obviously, to review this document or do you think -- and I think you've answered -- there's definitely more room for people to read this document and respond to it?
Mr Brown: I wonder if the people closest to it really understand the full implications of it. I know I've spent a lot of time on it in the last couple of weeks and I'm sure there's more to it than I've seen. But I agree wholeheartedly that we're down a path that very few people understand.
Mrs Janet Ecker (Durham West): Thank you very much for a very detailed presentation and brief. Under previous governments we've closed, according to some estimates, almost 9,000 beds, the equivalent of 30 small hospitals, with the resulting layoffs. That has been done through funding cutbacks, the closure of the beds, with previous governments. Do you believe that's the appropriate way to restructure the health care system, or do you think it would be more appropriate to restructure it based on locally planned restructuring plans and recommendations?
Mr Brown: Well, I think in the examples of the areas where we're working, there is a lot of local planning. In Essex county, Kent county, Lambton county there have been studies of the hospitals. The labour movement has historically supported true health care reform, and we certainly have pointed out over the years to all three governments in power where there are waste and inefficiencies in the system that could be eliminated without impacting on the quality of care.
Mr Dwight Duncan (Windsor-Walkerville): I wonder, Ken, if you could just go into, for the members of the government, what happened with our reconfiguration, where it was when this government took office, and why your union can no longer support the process, and delve into your answer a little further.
1000
Mr Brown: As I indicated in my presentation, it was not without our difficulties with the principals here in working with the DHC. We had a lot of problems along the way, but it was a locally driven process where we had input from virtually all stakeholders in the system, including the community, the hospitals and workers.
Where it really came off the rails and where the labour movement decided to walk away from it was because of the attitude of this government that after three years of planning for what we had to do in the reconfiguration process in order to save an estimated $25 million a year in hospital budgets, there was a capital expenditure involved, and the attitude of this government was, "Those capital dollars have to be reduced." We weren't told by what amount, just that they had to be reduced: "Come up with a new plan." They wanted us to redo something that had taken three years to put together, put a couple of artificial deadlines on us to come up with something new, and then at the end of all of that, after rushing us into something last fall, as I understand it there is still no formal answer as to where we are with that.
So we were at the local level with a commitment to the capital funding necessary to save those dollars; we were moving along and overcoming our difficulties. When the government came in and put the capital funding in jeopardy, the process, from our perspective, became one of implementing saving money and not focusing on the other aspects that we were about, which was enhancing our ability to deliver care and do it more efficiently.
The Chair: Thank you, Mr Brown. We appreciate your presentation. I just want to assure you that the committee will read those parts of the brief that you didn't get a chance to go through this morning.
HÔTEL-DIEU GRACE HOSPITAL
The Chair: Our next presenters are from Hôtel-Dieu Grace Hospital: Armando DeLuca, chairman of the board. Good morning, gentlemen, and welcome.
Mr Armando DeLuca: I'm chairman of the board at Hôtel-Dieu Grace. I've served on the board since 1988. The material is being circulated. It's rather succinct. It covers two main points which we would like to make today.
I've been chair since April 1, 1994. That's the day that ministerial approval was reached with respect to the alliance agreement between Hôtel-Dieu and Grace. This is important in terms of our being here. As a community volunteer, I feel I'm part of a large number of volunteers who donate their time and energy to ensure that hospitals are responsive to the communities they serve.
I'd like to address the committee on two general areas: the need for hospital restructuring, and a more equitable distribution of health care resources, particularly in our community.
The hospitals in Windsor and Essex county, as has already been pointed out, recognized the need for hospital restructuring in 1991, when the hospitals supported in principle the vision statement which was prepared by the hospitals in collaboration with the Essex County District Health Council. The conclusion reached was that Windsor and Essex county would be better served by two state-of-the-art acute care hospitals rather than the existing four.
As a result of the studies conducted in collaboration with the DHC, the hospitals agreed to pursue voluntary mergers and alliances consistent with the plan approved by the DHC and the Ministry of Health. As a result of this voluntary agreement, the city has two hospital organizations on four sites. Once the necessary renovations and constructions, as recommended by the hospitals and the DHC, are completed, we will be able to voluntarily close two acute care hospital sites in this community. This remarkable achievement was accomplished through extensive collaboration and participation by community volunteers, front-line workers, hospital boards and the DHC. It was done without the need for a hospital restructuring commission.
We do recognize, however, that in some communities voluntary agreements may not be possible and the powers of the restructuring commission may be required as a last resort. We are pleased that the powers in section 6 of schedule F are time-limited for four years and will end on March 31, 1999. The statute will assist in hospital restructuring while at the same time preserving for the future the fundamental principle of voluntary governance.
We have also reviewed the Ontario Hospital Association recommendations 1 through 10, and they're appended to the material, and these were presented to you on December 18, 1995. We concur with all of those recommendations, including the provision "that the statute make it clear that the minister's decision to close or amalgamate a hospital is based on the public interest" -- those are not little words but very important words -- "and that his power to close or amalgamate should be exercised only after receiving advice from a district health council or other planning body. As part of the planning process conducted through district health councils, hospitals must have an opportunity to submit their views and be heard."
The next major point in our submission is on the more equitable distribution of health care resources. The material will show that by comparing Windsor-Essex county to southwestern Ontario and indeed the province, we haven't fared very well.
The success of hospital restructuring which will result in the voluntary closure of two acute care sites in Windsor will depend on the timely approval of the $72.4-million capital plan which has been recommended by the Essex County District Health Council and the hospitals. This capital investment will provide for the necessary building renovations and new construction to accommodate emergency departments, critical care areas, ORs, renal dialysis, perinatal care and diagnostic services. The existing acute care buildings cannot accommodate the additional patient workload without this construction.
This committee should note that hospital restructuring provides an opportunity for equitable distribution of resources. Although Essex county has a high incidence of disease compared to the rest of the province, it has one of the lowest per capita operating expenditures in the province. The chart shows that southwestern Ontario is 12.8% above the cost per capita in Windsor and Essex county over the last 10 years. The disparity increases from 1983-84 to 1988-89, yet even with these low per capita operating costs, Essex county refers only 5% of its population to teaching centres because we provide many of our own tertiary services such as major trauma, neurosurgery, neonatal intensive care and cardiac catheterization.
In addition, with respect to capital spending for hospitals we are also below the average compared to southwestern Ontario and the rest of the province. As you can see from the chart, Essex county spends $200 per capita compared to southwestern Ontario at $410 per capita. We therefore urge the committee to support the capital investment needed for hospital restructuring in Windsor, which would not only achieve the closure of two acute care hospitals but would also help to offset the imbalance of hospital capital investment in this community compared to the rest of the province.
1010
We'd like it to be noted that we support the Minister of Health's statement to redirect savings from hospital restructuring to community programs, based on provincial priorities and allocated through the Ministry of Health rather than through a local allocation process. Recognizing that Essex county has one of the lowest operating health expenditures in the province, additional investment in community health programs should be based on the needs of the population and current expenditures compared to other communities in Ontario. Windsor and Essex county should receive its fair share of operating dollars. We know that those needs will be considerable in the community program area.
Thank you for this opportunity to address you. In the event you have any questions, I am here with Mr Bagatto, who is the CEO of our institution. Someone in the audience asked that we speak on behalf of the other institution as well. We'll do our best.
Mrs Helen Johns (Huron): Thank you very much for your presentation. I appreciate your being here today. Having lived in Windsor for a few years, I know that the hospital system and the health care system here have special needs as a result of being a border town also. I appreciate your time in talking to us.
I was wondering if you could just comment on your charts on page 3 for a minute. Can you tell me why you're using data from the 1980s and, at the latest, 1990? Can you tell me the formulation that went into those charts and why those numbers are from that time frame?
Mr Frank Bagatto: We took that information from the Orser commission. That's the only information we have. I've been encouraging others to seek that kind of information, because I think it's vital to the community. But obviously we don't have the total picture, so we relied on the Orser commission for the data.
Mrs Johns: Can you tell me, from your gut feeling and being in the community, would the data that we would present, looking at 1994-95 data, be somewhat the same as this or are there major changes within the time frame of five to six to seven years?
Mr Bagatto: Without giving evidence, so to speak, from my information I can confirm that it would probably be an increasing disparity, given the accelerated increases in complexity of patient care that we're providing in this community.
Mrs Johns: Last week we were in Timmins, Thunder Bay and Sudbury, and this week in Windsor. Those four geographical locations are basically forerunners in the hospital restructuring, having their DHC reports done and starting to combine services in areas. I was interested that you said you believe that some communities would not be able to come to agreement and we needed to have those powers. Can you tell me why you believe that, or how the process differed in Windsor, that you got community approval and other places may not?
Mr DeLuca: We all know what we read, and we have a sense from what we read that the difficulties in Toronto, for instance, will be considerable and the process may drag on. The commission may be helpful in moving that process along more quickly.
Mrs Johns: So as much as the commission may not be needed here, you can see times and time frames where it may be needed.
Mr DeLuca: Perhaps.
Mrs Ecker: Thank you very much for your presentation. Coming from a region that actually has lower per capita health spending than Windsor, I can appreciate -- in ours the problem is due to the growth we have in our particular region. As you note, you have unique needs because of the disease rate you have here. I think that underscores what's very important about the fact that there are unique needs region by region.
I would like to just mention that while the legislation, Bill 26, does repeal section 8, and I know the previous speaker had mentioned this, subsection 8(1) of the old Public Hospitals Act, which does have the district health council powers and recognition, is still in the legislation, because we quite agree that those regional restructurings, based on local recommendation, are very, very important. What was the secret of your success in terms of being able to get consensus?
Mr DeLuca: I think that's so. Labour, at least in our institution, was very much a part of the process. From the beginning, we involved our front-line workers. Mr Brown and a number of his colleagues as well were present at town hall meetings; he wasn't at our institution, but Mr Bagatto had town hall meetings weekly in the hospital. One of the fundamental principles we articulated was that we hoped to achieve the downsizing without impacting the lives of the health care workers who had chosen this vocation as their life's work. We thought we could do it with attrition and early retirement and without impacting the workers who keep the institutions going, and there are thousands of those. That, plus an enormous amount of goodwill on the part of the volunteers, who devoted countless hours to this very commonsensical approach to reducing from four acute care sites to two and the efficiencies that would flow from that.
Mr Crozier: Mr DeLuca, I need your help on recommendation 1, where you agree with the OHA. Many of us agree with sunset clauses for a wide range of legislation, but I need the reason why you support this clarified for me. You say: "In this way, the statute will assist hospitals and the government in the restructuring of the hospital system, yet at the same time preserve for the future the fundamental principle of voluntary governance."
If you believe in the principle of voluntary governance -- I might compare it to, if you believe in the principle of democracy -- why would you agree it could be suspended for four years and then brought back?
Mr DeLuca: In our view, there's a reaffirmation of voluntary governance in that it has a built-in time frame. It may be, provided that the public interest is maintained throughout this interim period, that the process, the savings, will be moved along a little more quickly than they might otherwise be, without sacrificing the public interest, yet we're coming back to the same system of voluntary governance. It isn't off the table totally.
Mr Crozier: You just don't have any for four years.
Mr DeLuca: I wouldn't go that far.
Mr Bagatto: The intent -- hopefully, and we have no guarantee -- is that if there's stalemate in the community, which is not the case in Windsor, maybe this commission's powers would be used very, very sparingly. That's our hope. Maybe it's naïve on our part, but only when there's a stalemate and nothing is moving.
Mr Duncan: You gentlemen were so integral to the reconfiguration process in this community. Would you be concerned if there was a loss of local ability to deal with these issues? Would you reaffirm today that a locally driven solution is indeed a better solution?
Mr DeLuca: Yes indeed. I would.
Mr Duncan: Any advice to members from communities that haven't gone through this process about the pitfalls and things to beware of in the reconstruction process?
Mr Bagatto: In my view, the most difficult problem is time. In this community we started in 1991, and I don't know how other communities will deal with the major operating dollar reductions without a restructuring plan. This is why we need a restructuring plan to be implemented, so we can achieve the budget reductions that will be imposed on us through this government.
Mr Duncan: So there are going to be budget reductions imposed by the government? We were told there wouldn't be.
Mr Bagatto: We're going by the Treasurer's statement.
1020
Mrs Pupatello: The Conservative members keep mentioning the DHC and how the bill doesn't change its role. The reality is that the DHC never did have legislative power, nor is any given or taken away, although the Minister of Health is on record now as saying that the DHC will be reverted in terms of its advocacy role, that it's going to be taken away or is going to be told it's doing even less. How do you feel, given the role it played in the restructuring in Windsor-Essex county?
Mr DeLuca: From what I read, I hear the minister say that he sees the DHCs as advisory bodies, that they are his eyes and ears at the local level. We don't see that as changing, and we see it as helpful.
Mrs Pupatello: Do you think we're in an underserviced area?
Mr Bagatto: I'm concerned that we're the community with the largest population in Canada without a teaching centre, and are two hours away from a teaching centre for tertiary services. I recognize that some centres on the periphery of Toronto are in a growing population and perhaps have a cost per capita less than Windsor. But I worked in Richmond Hill many years ago, and you're within half an hour of tertiary services. In Essex county we have a population of 350,000 people and we deserve the same level of care as other parts of the province.
Ms Lankin: Thank you very much, gentlemen. I appreciate your presentation and I thank you and others who have been involved in the process here in Windsor for the fine work you've done in that restructuring plan. I hope it proceeds to be implemented as it was planned and that the Minister of Health doesn't use his new powers in any way to impose on you solutions that are not satisfactory to your community.
I say that and it perhaps sounds a bit facetious, but there are good reasons for it. Already we have seen the minister determine that notwithstanding previous commitments, the capital dollars commitment that would have helped the reconfiguration from four physical plants to two is gone; the commitment for the operating dollars to be reinvested in your community -- even though I recognize you say "provincial priorities," but I think you're hoping you would be a provincial priority -- is not rock-solid any more.
We've seen a community in northern Ontario where there was a complete and unanimous recommendation from a district health council on the issue of governance of their hospitals where one hospital had fought that all the way through; the local community had the support of the ministry and the minister previously, and now the new minister has pulled the rug out from underneath the local process and that hospital has won out.
In Ottawa, the community believes it has a process that is coming to a conclusion, but one hospital came forward to present to this committee and say: "We don't need to listen to the community. We don't need amendments in the legislation that say the DHCs should be involved. The minister is accountable; the minister should do this." And when I said, "If you can't reach a consensus in Ottawa, who should the minister listen to?" the chair of the board in that case said, "Us," a large facility.
I should say the only facilities I have heard come forward and be overwhelmingly supportive of this, all the powers being in the hands of the minister, are large specialty or teaching facilities. We know there are few in number; we know they take 40% of the hospitals budget. We know they are the jewels in the crown and are very important in our system, but we also know they get the ear of the minister. If I were a community hospital or a community service looking to see that restructuring and reinvestment from hospital dollars into the community, I'd be a bit worried about all the powers as they are and that they be used as judiciously as you are hoping they will be used.
Mr Marchese: "Don't worry. It'll be all right."
Ms Lankin: "Trust me," right? This legislation is underscored with big words: "Trust me." I have to say, with this current government, I personally don't.
In your brief you said you are pleased that the powers in section 6 of schedule F are time-limited for four years. In general, you're looking for sunsetting of powers. The minister has indicated that he will sunset -- if we ever see the amendments -- the Health Services Restructuring Commission. We believe it is necessary that the extraordinary powers be sunsetted, and I think you are indicating support for that.
Specifically, I would like to ask you about a couple of amendments we've been trying to convince the government it should consider. As to the power of supervisors to go in and take over hospitals, where it's in a closure situation perhaps those extraordinary powers you would support. Where it's a question of the quality of care or concerns around that, do you not think the due process of an investigator's report and an opportunity to respond should be maintained? And would you comment about the issue of the Minister of Health being able to impose physician resource plans on hospitals, which seems to me to be a little too much micromanagement.
Mr Bagatto: We're concerned about that; in the interests of time, we didn't want to repeat the submission made by the OHA. We're concerned about extending the powers of a supervisor, really suspending the powers of volunteer boards based in the community. Those powers should be sunsetted as well, if they're going to be implemented. In essence, we're concerned that the volunteer hospital boards are responsible for the quality of care, yet a supervisor can overrule that responsibility. They're accountable, yet the supervisor can make changes and not be accountable. We're very concerned that they're not legally accountable.
Ms Lankin: You indicated that you support the concept of hospital operating dollar savings being allocated based on provincial priorities, but you do stress an investment in community care. We have seen some mixed response so far from the government. Not a lot of what they're taking out has been earmarked for reinvestment, but even at that, for example, one of the areas of reinvestment was in cardiac surgery. I don't know this to be true, but I will tell you that three people in the health care, hospital sector have told me the government got duped big-time in terms of the cries from the cardiac network -- you know, that sometimes high-tech, powerful voices get the money. That's not exactly reinvestment in community care. I'd like you to talk about that, because I worry when it's provincial priorities that the squeaky wheel gets the grease.
Mr DeLuca: I know Frank will have more to say, but the minister had published in our local paper a letter responsive to this question. As I read his statement, he was focusing on community issues across the province as opposed to reallocation at a local level.
Mr Bagatto: Determination of need is vital, and it has to be done with the medical profession, the employees, the community, and it can't be done arbitrarily; it has to be based on data from district health councils and the work being done across the province to determine, what are the population's needs? Again we're hoping for objectivity in determining those needs.
Ms Lankin: You have a lot of hopes riding on this, let me tell you.
The Chair: Thank you very much, gentlemen. We appreciate your being here with us this morning.
The Chair has had one too many cups of coffee this morning, so I'm going to have to take about a three-minute recess.
The committee recessed from 1028 to 1032.
The Chair: Okay, folks, the emergencies have been taken care of so we can get back to work.
ASSOCIATION FOR PERSONS WITH PHYSICAL DISABILITIES OF WINDSOR AND ESSEX COUNTY
The Chair: The next group is the Association for Persons with Physical Disabilities of Windsor and Essex County. Good morning, sir, and welcome.
Mr Taras Rohatyn: Thank you very much. Good morning, ladies and gentlemen. I am the executive director of the Association for Persons with Physical Disabilities of Windsor and Essex County, more commonly known as the APPD.
We appreciate that the association has been allowed to present its concerns to this committee, and I ask the committee members to refer to the brief distributed by the clerk. Of course, I will not read the entire presentation but will highlight a number of elements, issues, and association programs. I will present a number of individual case profiles to you and in each case demonstrate the effect of the changes contemplated through Bill 26 and the diminished quality of life that will ensue. To conclude our presentation, I will then refer the committee members to a series of recommendations that we truly hope will be considered by the committee.
In order to understand our association, I wish to very quickly highlight 57 years of history. I'll do that in two paragraphs. I refer to page 2 of our brief, specifically the last two paragraphs.
The APPD was formerly known as the Cerebral Palsy Association and has had a varied history since its inception in 1938. We have been a strong community player since that time. In the early 1960s we took over an existing workshop from the March of Dimes, renamed it in 1978 to be called Participation Industries, in advance of Participaction, and we relocated to a 25,000-square-foot facility in that year. The board realized very early, and they were very proactive, that the workshop, as it existed, was not beneficial to a number of individuals who wanted to work in society. With an agreement with the General Motors of Canada transmission plant, we actually created a business called Participation Press Assembly Centre, or PAR PAC. In 1987, that business received the quality of excellence award for its small parts production.
During those 10 years from 1981 to 1991, we had significant growth also in our residential programs. We were the first in Ontario to create what was called an independence training department program -- a life skills program where people learn how to live in an apartment and move to a community.
In 1984, we commenced an outreach attendant care program -- workers going into a person's home, assisting them with their activities of daily living.
In 1991, the flip side of it: a respite program to give the caregivers relief.
In 1994 and 1995 we expanded our services into supportive housing.
Specific details of our vocational residential programs are outlined in the brief and are expanded on, and I do not wish to go through them today, but they are on page 3 through to page 8.
We employ 130 personnel today. We service nearly 250 adults with physical disabilities with their activities of daily living, but unfortunately we also have approximately 250 individuals on our waiting lists.
I ask the committee to turn past the appendices. The appendices are very specific. For those who may not have had the opportunity to deal with our particular types of services, they deal with activities of daily living and provide definitions on what has been accepted by both the federal and provincial governments as definitions in dealing with disability issues.
We'd like to highlight, however, a number of individuals we provide services to currently, and there is a variety of them. I'll provide you with a very short little background and then indicate to you what the potential effects of Bill 26 will be on them.
The first, and I will not go through each one, we've initialled as B.D. I'll call him Brian for the sake of a B at the present moment. He's a male who's 28 years old with spina bifida. Medically, he's susceptible to skin ulcers, urinary tract problems and a history of kidney stones. Overall, his income for the entire year through FBA is $680 a month or approximately $8,160 a year. I challenge anyone in the room behind me and in front of me and to the sides of me to attempt to live on that income. However, Brian has done reasonably well.
Brian is very, very involved in recreational activities in the city. He in fact may end up on the Olympic team for people with disabilities in weight-lifting, and that is his second life. His first is his desire to work. Brian had the opportunity through our supported employment program to find a job in the community. He did extremely well; in fact came off of FBA and became a taxpayer. Unfortunately, and it had nothing to do with Brian nor did it have anything to do with the job, this major national chain had to lay off that particular division across Canada and Brian was affected, like everyone else was. Brian had to come back into the system, had to go back to where he was, and that hurts. His quality of life diminished fairly substantially.
What we envision, unfortunately, with some of the contemplated changes and some of the discussion, and again not all of it is known, nor is it fact at the present moment, but because Brian is involved within the health care system through prescription drugs, through the use of the health facilities, if there are additional costs, whether they be called copayments or whether they be called user fees, whatever the terminology itself, it will adversely affect that $8,160 a year that he already has.
1040
There are other ramifications also. Indications already are, locally, that there are changes to the parallel Handi Transit system; that there is a diminishing of hours of service; that there is a diminishing of the number of rides available because of potential budget cuts, nor do we know whether it is through the transfer payment process, whether it is at the local level or whether it is a decision. However, there have been changes.
I challenge anyone -- should they wish to leave today and pick up a taxi and go home, they can do it. In some instances with the parallel transit system, you have to book a week to two weeks in advance to go out with the boys for a drink. That is not acceptable. If there are additional fees imposed, if there are increases in the transit fare, if there is a diminishing of services -- not 12 o'clock midnight pickup, but 10 o'clock -- quality of life will be diminished.
I would ask committee members to refer to the second individual profile. This is a young lady, a female, 28 years old, S.L. -- "Susan" for the sake of a name at the present moment -- who is a quadriplegic with some upper trunk and limb control. She also has a problem with a urostomy. We provide you with a brief description of her medical situation, her income and her accommodation.
She lives in a supportive housing complex, where her personal activities of daily living and attendant care needs are supplied for by our association. She's a very interesting young lady, who became employed this year. After 30 years of living at home, after being taken care of by her parents, she had moved off into the community, was able to upgrade her grade 7 education over the last few years, received her high school degree and then became employed. Unfortunately, it was with one of the crown agencies that has been disbanded locally, and that income has been lost to her. It was her first real job. She would like to move on in school. Unfortunately, there are many barriers, obviously, in the education system, from the beginning right through to the higher institutions of learning.
She uses a large amount of prescription drugs to maintain her medical health. Because of a lack of income in the process of moving from gainful employment to UIC, she will go back into the family benefits, the Gains-D. She will be back at a level of $8,000 to $10,000. Any $2 additional copayment, user charge, will have a negative impact.
She also falls into the process and the problem of the parallel transit system. That is her only means of transportation. She is actively involved in numerous committees, advocating very strongly on disability issues both locally and provincially. Again, if there are additional costs, if there is a minimization of service, it will affect her life dramatically.
She would like to be re-employed. She would like to move on in education, but she realizes that she has to have additional education. If there are increases in tuition fees and there is no reciprocal funding available through any kind of source, she will not be able to move forward. We provide a summary of her potential and of the problems that we have and that she has in the general summary.
I'd like to skip by the next case profile and move on to one individual we have. The second line indicates "Independence Training Apartment Program." M.L., 34, female, left-side stroke, left hemiplegia. This young lady was gainfully employed with the city for a number of years. She has a degree. Unfortunately, a tragedy occurred: a stroke which left her with severe physical disabilities. This is not out of the ordinary in our world.
She has, and had, a fairly substantial income. She has disability pension coming in and Canada pension plan. So she falls well above the norm for general benefits or Gains-D. That income excludes her for a number of things. What she would like to do is get back into the life that she had previously, and the chances are slim to minimal.
However, her major goal is to walk again, and I think that is very important to her. We've brought her, fortunately, into the system in a non-subsidized apartment and are retraining her in the life skills that she lost because of her stroke. Part of the problem is that should she succeed within our training apartment program, she will go on a very substantial waiting list for supportive housing programs. She will require attendant care services, probably over a 24-hour period, and the list itself is very, very dramatic.
She now has to use the parallel transit system, and again, I've indicated to you the problems that are occurring and that potentially will occur. Her needs for prescription drugs at the present moment are quite dramatic. She is one of the few who will probably be able to afford, because of her disability, through the insurance that she is receiving, to pay for a portion of it. However, at a point in time, that will run out. She will still have a relatively substantial income, but the $100 deductible and the pharmaceutical fees will have an effect on her life.
The last two individuals I would like to speak of are under our central Y housing supportive program. If you see, I'm leading you through our programs and where the individuals themselves are and what the impacts will be.
C.K.: We'll call her Cindy. She's a 39-year-old female with an arterial malformation and uses a manual wheelchair. She takes six different medications and independently pays for supplies for urinary problems, and the six medications are on a monthly basis. This does sustain her, without any question. But the additional cost of the urinary supplies because of the urinary problems is fairly substantial. Quite a while back, a lot of this, through the ADP, was covered. That has disappeared. Our local social service department had an emergency fund for those who might not be able to afford. I suggest that within the first three months of the year that fund is depleted, and I don't think Windsor is an exception. It is just a matter of dollars.
She does reside in a supportive housing program. She came through the system, our system, the entire system, and has been able to move to independent living. We provide her with the arms, or the legs, that are necessary and the assistance with activities of daily living. She attends swimming. It is very important to her. She attends church functions. She attends special events that we hold in the community halls.
If the transit system is to increase costs and diminish its activity, that will have an adverse effect on her. If transfer payments are reduced and municipalities are put into a position where they have to bring in some type of fee for recreational facility usage, this will affect her life quite dramatically. She would like to move on to an additional, a different, supportive housing unit, but unfortunately again, there is not an availability within the city or within the county.
The last individual I would like to refer to is two pages over. This is an individual, G.B., in the attendant care outreach program. She's 39 years old, chronic leukaemia, osteoporosis, osteonecrosis -- there is a definition of what osteonecrosis is -- and spinal damage. She lives with her son, 10 years old, in the county. She was widowed in 1991 and she has no other family. She supports herself and her son through FBA, the Gains-D, and in 1992 her gross monthly income was $1,014 a month. Again, we're dealing with an individual with about $12,500 in gross income. She's permanently disabled because of her condition.
She is attempting to have increased homemaking because her condition is disabling and in fact is degenerating, and receives approximately 12 hours weekly through the home care program. There are quite a number of personal goals, and one of the most important in dealing with quality of life is functioning at the optimum level that she can. She wants to care for her son, but there is a question mark at this present time of a 10-year-old boy and a mother who may not have the services available to her to move forward. She'd like to remain independent in her own home. She'd like to have an increase in the outreach attendant care program, activities of daily living, and additional homemaking. Those are not available because of substantial waiting lists.
1050
The problems themselves are a little more systematic in this particular case because there is a very large demand for the services that we provide, like organizations across the province, but at the same time the question mark of where some of the dollars will be coming from. We have heard very, very strong statements that there will be a reinvestment in community; however, there have been a number of questions raised in the process itself. If the reinvestment does come, we will be more than happy and willing to accept it because of the people who are waiting.
I would like to ask committee members to refer, on the grey sheets, to the recommendations that we have. There are only six. They're very broad and they're very general. We could not be as specific as a local association. We don't have the resources to read through 2,000 pages, but we at least have the 211 pages that we're able to refer to.
We ask that the committee recommend to cabinet:
-- That there be an extension of the time frame proposed for the enactment of the bill to allow for further discussion and dialogue regarding the impact and consequences, and specifically for our group, for persons with physical disabilities. We deal with the adults.
-- That serious consideration be given to excluding or exempting all adults with physical disabilities from all aspects of Bill 26 whose gross income is less than $25,000 a year.
-- That serious consideration be given to including provisions which will not allow municipal or other government or regulatory bodies to impose, in the broadest sense, fees on adults with physical disabilities whose income level is below $25,000. I just refer, as examples, to libraries, recreation, refuse collection.
-- That serious consideration be given to provisions being included in the bill that ensure that transfer payment reductions stipulate and guard against any reductions being directed to local parallel transit systems for persons with physical disabilities.
-- That serious consideration be given to the enhancement of funding levels for supported employment programs which in the longer term will provide work opportunities and the entitlement of paying taxes for adults with physical disabilities.
-- That serious consideration be given to the enhancement of funding levels for supportive housing programs and second-stage housing for battered women with disabilities, whether by delaying or deferring action on provincial housing authorities or the not-for-profit housing sector, or by providing appropriate incentives to private landlords to build new apartment complexes or renovate existing apartments to barrier-free units for adults with disabilities.
Ladies and gentlemen, 16 out of every 100 Ontarians have a physical disability. Statistically, looking at the committee makeup, a minimum of two of you will require within the next decade the services that we provide as an association. You may today be comfortable with your income level and options concerning your quality of life and that of your family. However, the future for each of us is unknown. You may conceivably become a case profile study, as presented today, in the not-too-distant future.
We realize the provincial debt is an enormous burden on each citizen, but we ask that you be sensitive to those who will be dramatically and adversely affected by the proposed changes through Bill 26.
A Chinese proverb suggests: A man who removes a mountain begins by carrying away small stones.
Mrs Pupatello: We heard from those representing persons with physical disabilities during the general government committee hearings on employment equity. It was interesting that they mentioned that every one of us is only years away from having some form of disability ourselves in terms of things that happen to us as we get older.
They also mention that of all they see the government doing, it's especially hitting those with physical disabilities, whether it's through those on welfare, the housing cuts, the housing projects that have been cancelled, especially those with supportive housing. That wasn't given any additional look; that was cancelled outright. There's the second-stage housing for battered women, because so many of those women are disabled. There's a high incidence of abuse among disabled women. And of course there's the employment equity that was thrown out outright. How do you see that in comparison to the sweeping things that affect those with disabilities in Bill 26?
Mr Rohatyn: I think they're parallel, but I also think there has to be consideration for each specific process that we're talking about.
With the process of employment, I think one has to consider that if the proper services are available, if the proper backup is available, what you will end up with is a working Ontario, off of benefits, off of disability pension, and providing income not only to themselves but, through taxes, to the province of Ontario.
It is difficult to be able to say that there is an equality within the system itself. This goes back for generations. This is not an issue of just today or just of what has happened in the last little while.
Individuals want to work, but individuals with disabilities are the same as anyone else: Some will, some won't, some do and some don't. If the mechanisms are not available within the education system to provide them with support, if the educations are not available to them in institutions of higher learning, through colleges and through university, and if they are not available within the workplace, then individuals with severe and moderate physical disabilities have no chance of employment, not only yesterday, but in the future. I use that as an example specifically. There are many, many other issues besides.
Mr Marchese: I have two questions, Mr Rohatyn, if I can get through them.
The first one has to do with the kinds of things the Conservative government has said with respect to employment equity and, as well, the Advocacy Act. With respect to employment equity, they said it was too intrusive and it was too draconian. They're about to repeal the Advocacy Act that we passed because they argue it's too intrusive and it's too draconian.
It's incredible to me that they can say that about other bills and at the same time introduce a bill that is the most dictatorial bill that we in the House have ever seen. Not only does it give powers to ministers to close or to merge or to make other directions with respect to hospitals, but it absolves them of any responsibility, and the scrutiny that we wanted was almost abolished had we not done what we were able to do here, giving people an opportunity to do this. Do these powers give you any comfort whatsoever?
Mr Rohatyn: I think we have to be very cautious in almost anything. I would like to suggest that when the entire employment equity was brought forward, we did speak to it and the Chair at that point asked, "What do you want?" I said, "Let's not be passive. If you want quotas, put them in writing," and we in fact suggested that the quotas be in writing, that there be a percentage of employment which includes people with physical disabilities, and then we defined for that minister and that Chair at that time what our definition of "physical disability" was. We were quite specific on that.
Mr Marchese: I wanted to make a statement then to remind everybody that in the Common Sense Revolution they indicated that seniors and people with disabilities would not be affected. We have seen in many ways that they have, and this bill proposes a user fee that will affect seniors in a very big way and affect people with disabilities in a serious way as well.
Mr Rohatyn: That is why we in fact raised the individual issues from the various programs that we have.
Mr Clement: Thank you very much for your presentation. I note that your organization is funded by the Ministry of Health, I think to the tune of over $2 million a year, and that you're also funded by the Ministry of Community and Social Services. The figure I have is over $450,000. Is that fair to say?
Mr Rohatyn: Correct.
1100
Mr Clement: I find that interesting, that you've got two different ministries doing funding for particular programs and then you've mentioned with the case studies how your clients intersect with Health, with Housing, with women's issues.
I'd like to put this question to you. I wonder whether you'd like to expand your recommendations a bit, because it seems there's a whole bunch of different ministries interacting with your organization and with your clients. Is there perhaps a way to restructure the way government does its job so that more of the money actually goes to the individuals affected rather than some of it perhaps getting taken up by overadministration and overcompliance and what have you? Is that something that you've turned your mind to?
Mr Rohatyn: There has been, in fact, a series of actions that have occurred over the last little while where government has moved to individualize funding for attendant care services. It's a pilot project at the present moment. I think for a segment of society it will be quite beneficial, but that individual must be a doctor, a lawyer and an Indian chief in that whole genre of what is being said, to be able in fact to be an employer, and that is not fit for everyone. They become an employer of their attendant services and they fall within all the legal liabilities and ramifications that follow as an employer. So it's a small group of individuals who would be able to benefit from that.
We are multiministry-funded. There are more funders than just the ministries themselves, United Way included, and there are our businesses. So we have a variety of funding and dollars coming into the association.
The problem is that our recommendations were fairly broad because we, unfortunately, didn't have the time, nor do we have the resources, to be able to get into the detail. We will be submitting, hopefully through the board of directors, further recommendations through the committee itself for scrutiny in the future.
The Chair: Thank you for your input. We'd be happy to consider any recommendations you forward to us.
Ms Lankin: Mr Chair, with that suggestion to the individual that we'd be glad to consider those further suggestions, you'd better get them in by the end of this week because we start clause-by-clause next Monday and a week after that the whole bill's passed.
CANADIAN AUTO WORKERS-CANADA
The Chair: Our next presenter is from the Canadian Auto Workers, Peggy Nash, assistant to the president. Good morning and welcome to our committee. You have a half-hour of our time. Questions, should you leave the opportunity for them, would begin with the New Democrats. I'll ask you to identify yourselves for Hansard and then the floor is yours.
Ms Peggy Nash: I'm the executive assistant to the national president of the CAW. With me is Catherine Gilbert, legal counsel to the CAW national union. You're being handed now a copy of our brief. I'll be referring to the brief but I will be making other comments as well.
The CAW is well known to the community of Windsor. We represent more than 200,000 members across Canada, about 130,000 in the province of Ontario, and in addition about 40,000 retired workers throughout our union.
The issue of health care is fundamental to working people. To be free of the fear of losing everything as a result of catastrophic accident or illness and to have more or less equal access to quality health care regardless of income have been of central importance to workers' lives over the last three decades.
As early as 1950 our union negotiated medical, hospital and surgical insurance in Canada. We were the first to do so. This was followed in 1968 when we first negotiated dental insurance. Both of these developments set the standard for group prepaid health care. However, we believe strongly in a universal health care system. We don't believe that the provision of health care should be tied to one's place of employment.
The dramatic policy changes contained in Bill 26 constitute a major and disturbing threat to working and poor people in this province. This bill aims to undo social advances that working people have achieved throughout the 1960s and 1970s. At stake are the living standards and the basic security of our members along with those of thousands of other working people in this province.
This government seeks to make these extraordinary changes without proper public debate and consultation and without the mandate of the people of Ontario. The Tories in their Common Sense Revolution promised to protect health care, and we don't believe that that's what's happening with Bill 26.
Our presentation deals with three areas. The first is the issue of democracy. We ask the question, what's happening to democracy in the province of Ontario?
In the Common Sense Revolution document you said, "The political system itself stands in the way of making many of the changes we need right now." We think they were prophetic words. The entire process surrounding the introduction of Bill 26 has revealed this government's contempt for the democratic system in this province.
We want to add our voice to the outrage over the inadequacy of these hearings. The only reason we're having hearings is because the opposition parties forced the government to hold hearings. We're sitting today in a packed room in this hotel. Clearly there is intense public concern about what's being proposed through Bill 26. These hearings are inadequate. There are hundreds who want to be heard and cannot be heard before this committee. We think it's a shame.
We have to ask the question, why are you afraid of debate? Why don't you have the courage to defend your views publicly? What are you hiding? We believe that the government should not be permitted to dismantle the health care system as set out in Bill 26. It should certainly not be permitted to do so by anti-democratic legislation that gives cabinet, appointed officials and ministers unlimited powers to make decisions affecting the delivery of public services and the operation of public institutions without public scrutiny, debate or community input.
Bill 26 would ensure that the public is left unaware and outside the democratic process that would allow them to even discover, for example, that they will soon pay for numerous health services, that services will be reduced or eliminated in their communities and that they'll be prevented from using services which are now universally available. We believe these proposals have much less to do with balancing budgets or reducing deficits and much more to do with Conservative ideology.
Bill 26 contains numerous schedules which involve over 40 pieces of legislation. We use the example of the bill's impact on our public hospitals to illustrate our concern about the lack of democracy. The changes contained in schedule F to Bill 26 give the minister virtually unlimited powers with respect to funding, operation, closure and amalgamation of public hospitals. Further, health care decisions once made by hospitals and communities that they serve will now be controlled by cabinet and the Minister of Health. Our hospitals will no longer have an essential independence from government.
Funding: The minister will have unlimited authority to decide all hospital funding matters. These changes clearly present the scenario that this government will find less resources available for health care because, for example, more is needed to cut income taxes for the well-to-do.
Hospital closures and governance: The minister will be able to close and amalgamate public hospitals whenever the minister considers it in the public interest to do so. Currently the minister cannot act for fiscal or budgetary reasons alone or without regard to the effect on patient care in deciding to close or amalgamate hospitals. No public consultation will be necessary now before the minister can exercise this new power.
The minister will have the power to override decisions of the boards of directors without their input. The minister will have the power to direct a hospital to provide or stop providing services. They'll have the power to dictate almost any aspect of the operation of public hospitals.
It also appears that Bill 26 may allow hospital boards to override and ignore contractual obligations, including collective agreements. This is probably in violation of international labour treaties such as ILO treaties, of which Canada is a signatory, and is absolutely anti-democratic.
Finally, throughout the health-related sections of this bill, the cabinet, Minister of Health, hospital supervisors and boards of directors are protected against any liability or court challenges. Yet the health care providers and citizens are not provided with any opportunity to have input into decision-making or any vehicle to appeal these decisions.
We understand that there are amendments being considered, especially concerning the right to privacy. We want to see any proposed changes or regulations that are being considered along with this bill. Why should we have to wait until after this bill is passed? Again, what is the government hiding? We believe this is a fundamental question of democracy and that Bill 26 and the manner in which it's being brought in is contrary to our democratic traditions.
In summary, on the question of democracy, we believe that one way or another, people will be heard, and governments ignore the people at their peril.
1110
The second area we want to address is the right to privacy. The violation of a citizen's right to privacy was not contained in the Common Sense Revolution, to which the Harris government often likes to refer as proof as its mandate from the people of Ontario.
It's hard to think of information that is more sensitive in nature than our personal medical histories. It almost defies belief that this government is actually trying to pass legislation that would override the right of citizens to have their personal medical histories held in confidence, without public hearings, scrutiny or debate. The personal information could include information from patient diagnoses, hospital records and prescriptions, such as details about mental health, medical history, ancestry, genetic makeup and more.
Citizens will have little or no recourse or protection when personal information is disclosed. This information belongs to the citizens of Ontario; it is not the government's property. We would do well to remember that it was the issue of disclosure and misuse of confidential medical information that led to the resignation of a Minister of Health in the previous government. This government is apparently seeking to legalize just such a violation of an individual's privacy by the minister.
We are also very concerned that the government seems to be intending to contract out aspects of OHIP administration to private companies. Private companies which are not accountable could obtain contracts and thereby possession of and the ability to use or disclose our confidential medical information.
After concern was publicly expressed by many, including Ontario's privacy commissioner, the minister said that changes may be made. No details have been given with respect to any measures, nor any assurances that changes will undergo public scrutiny. Again, these changes should be seen now so that they can be debated by the community, the public, before the bill is voted on.
The third area we want to discuss is the whole question of dismantling medicare, and we have to begin by asking the question, why, at this time in our history, when we are producing so much more, more than ever in the history of our society, are we eroding the programs that our parents and grandparents built?
We don't believe it's just an issue of the deficit. Banks are making record profits, more than $5 billion this past year. Company profits all over are high. CEOs are making record salaries and bonuses. This is more about transferring wealth from workers and the poor in our society to the wealthiest in our society.
We believe that one of the greatest rights in a caring society must be the right to have decent health care. Years ago, we chose a system designed to make sure all Canadians would have universal access to health care regardless of financial resources. Medicare is perhaps our most cherished social program.
This government's Common Sense Revolution, your document, was explicit in sending a clear message to the voters of Ontario that health care would not be touched. It was described as one of the "top priorities -- essential services that Ontarians want to see protected." The Harris government promised not to cut health care spending, playing on the concerns of the population that it's far too important.
It is absolutely unacceptable for this government to attempt to change the health care system in this province to a two-tier health care system where the more wealthy will be provided with a much different level of care and treatment. The end results of these changes contained in Bill 26 are declining quality, user fees and privatization in key areas of the health system.
Medically necessary services: I want to speak to the fact that these can now be deinsured. The Health Insurance Act currently requires that OHIP cover all medically necessary services provided by physicians. Bill 26 gives the power to decide which medical services will be insured, under whatever conditions or limitations the cabinet may establish by regulation.
This power will enable the government to limit access to services which are now covered by OHIP. It may even decide not to cover some services which are now considered medically necessary but which they perhaps consider to be too expensive. The government can differentiate on the basis of any other criteria it determines.
Incredibly, the cabinet will be given the power to determine the type of services provided to persons of "prescribed age groups." What can this possibly mean? Could this mean that somebody over 65 or perhaps premature infants needing open-heart surgery would not get the services they require? Is the government now going to make value judgements based on age?
Decreasing insured services is another route to two-tier medicine. The wealthy never have to worry about a lack of universal health care. They'll always be able to afford health care. It's working people, the average person in Ontario, who need universal health care coverage.
User fees: The Common Sense Revolution clearly promised "No new user fees," but what do we find in Bill 26? New user fees and the power to create more.
Hospitals to charge patients: Bill 26 would give the cabinet the authority to make regulations to allow hospitals to charge patients user fees for any hospital-based insured service. The government did not tell the public, when introducing this bill, that hospitals could soon be permitted to charge for emergency room visits, drugs, use of operating or obstetrical delivery rooms, nursing services, tests, accommodation and meals. An administrative fee of up to $150 may also be charged to patients.
This is absolutely unacceptable. There can be no doubt that such fees will act as a deterrent. Let's be clear: Only the poor and the working poor will be deterred from obtaining the medical care they need.
Other changes repeal the language which directed the minister to give preference to non-profit Canadian operators. This raises the real possibility that for-profit American health care providers will be licensed to provide health services in Ontario and to charge patients for this service. We're talking about bringing in Americanized health care.
This government has never received a mandate from the people of this province to launch such an attack on universal, accessible health care. It's a shame on this government that it's introducing this.
User fees for prescription drugs: Under Bill 26, the government introduces user fees and gives the cabinet the power to unilaterally increase the fees as well as to change the method by which the fees are charged.
The government tells us today that a fee of $2 will apply. In addition, depending on income, a $100 deductible per senior per year will be instituted for benefits under the act, plus the full cost of the dispensing fee even where the $100 deductible has been reached. But we have no assurance that the fees won't be significantly increased tomorrow and we'll have no opportunity to be consulted with respect to such increases.
What we're talking about is another example of a two-tier health care system. First the government makes deep cuts in the income provided to the poor; then it increases the cost of their medical care.
This bill will also give cabinet decision-making authority over which drugs are eligible to receive reimbursement under the plan. Cabinet will consider any matter it believes advisable in the public interest, specifically including the cost of the drug, in determining whether to list the drug. Medical necessity or other health criteria do not necessarily have to be considered.
Where user fees were introduced in other provinces, studies have shown that visits to doctors by the poor and the numbers of prescriptions filled by seniors declined. As a result, we may find that the poor stop using important drugs such as insulin or heart medication.
These user fees place the blame for costs of the drug program on the poor and on seniors. It's like a new tax on the poor and on seniors. User fees are not cost-cutting measures; they are new revenue sources that hit the poorest of society the hardest.
Deregulation of drug prices: If this government deregulates drug prices, it would be the only province in Canada to do so. The price of drugs will surely increase, particularly in remote or small, rural communities. It will have an impact on our members' benefits packages, because it will increase the cost of supplementary health insurance benefits. But on top of that, nearly 2.5 million people in Ontario have no insurance to cover drugs. Clearly there will be a huge impact on them. These changes will also hurt seniors and low-income families and individuals, including the working poor. Prescription drugs must be affordable to all.
1120
In conclusion, I remember that in the mid-1980s this country debated whether to be part of the Canada-US free trade agreement. Overwhelming concerns were raised about the necessity to protect our social programs and health care system. Canadians were assured that our social programs were not for sale, that they were part of Canada's sacred trust. Yet less than a decade later, we find ourselves before this committee responding to Bill 26, an anti-democratic piece of legislation which seeks to dismantle medicare eroding the universal, accessible health care system upon which Ontarians rely.
Bill 26 will change for the worse our communities, our public institutions and the care ensured the elderly, the sick and the poor, without public debate or accountability.
If this government believes there are problems in our current health care system, it should consult with those who work as health care providers and administrators and with communities and individuals served by them.
If this government wants to start altering what is probably considered our most cherished social program, it must do so only after commencing broad consultations with the people of this province. If it had done so before setting out its hidden agenda in Bill 26, for sure it would've learned that the people of this province will not stand for the dismantling of our medicare system.
We call on the government to withdraw Bill 26 and for this committee to make that recommendation.
We welcome any questions.
Ms Lankin: Thank you for your presentation. I don't have questions so much as a couple of comments. I sat through hearings all through northern and eastern Ontario last week on the health sections of the bill, and I heard the government members say over and over again to groups such as yours: "We're listening. We're out here because we want to hear from you, and we're listening."
Then I come here today and I see this crap out on a table that says, "Ten Great Things About Bill 26 That You Won't Hear From The Vested Interests." You're here today and these people are listening to you, but in their minds you're a vested interest, the people who are out here watching this are vested interests, and they don't want to hear from you or listen to what you have to say.
They also put out a whole bunch of things they call myths, and it addresses the democracy you talked about. For example, they say it's a myth that the government tried to sneak Bill 26 into the House without any debate. Let me tell you, I, as the Finance critic, and our leader and the Liberal Finance critic and their leader and many other opposition members were locked up in the pre-economic statement lockup when they brought this bill in, unprecedented.
They say that as an omnibus bill it's not unprecedented, that there have been many more. There has never been an omnibus bill that dealt with policy issues like this. It has always been housekeeping. Their comparison to NDP legislation is pure misleading of the public in a way that is certainly not credible, but is not worthy of anyone attempting to govern the province of Ontario.
They say, "Myth: The PCs tried to ram this bill through with no debate or public input." They call that a myth. Here we are, one week before we go into clause-by-clause, and we haven't seen the amendments from these people. No one's going to have any public input on what they're proposing in amendments. I imagine we'll get them at the last minute, like we got the bill, and be expected to deal with it, understand it, vote on it and they'll ram it through. They'll do whatever they want.
This is a fundamental denial of democracy in this province. Your brief has hit it right on. The people here have made it very clear that they want to have a say. We have two motions coming up, one urging this committee to recommend that we come back to Windsor, the other urging that the amendments get tabled. I hope the government members will listen to what they've heard here today and to you and will support those motions.
Mrs Ecker: Thank you very much for your presentation. I'm sure if we were to bring in amendments before we had heard from all the many people coming forward with very useful suggestions, the opposition would quite rightly come down on us for not listening to the rest of the presentations.
As an organization with a lot of experience and expertise in negotiating good health packages, insurance packages, drug and dental service packages for your members, in many cases excellent packages above and beyond what some people have access to in the public system, one of the issues in financing those kinds of insurance plans, I understand, is cost control, difficulties with increasing costs. We've heard from some people who have come before us that, for example, with seniors there have been serious problems with the overprescribing of drugs they don't need. One figure was something like 30%; the seniors groups were telling us that. One of the other presenters earlier today talked about the need for a smart card so we could, in their words, better track patients' or clients' use of the system.
The statistics indicate that in one particular month we had, for example, 7,000 individuals who went to see five or more family physicians in one month, which I think most people would see as pretty serious. So if -- just a second --
Ms Nash: If I can address the overprescribing --
Mrs Ecker: Excuse me. Just let me put the question. Based on your expertise, how do we go after those kinds of concerns in the system without some access to information, with appropriate confidentiality protections? How do we do that without some sort of access to the information?
Ms Nash: Very simply, what you should do, before you bring in something heavy-handed like this legislation, is talk to the people concerned. For example, in the CAW we have a program of medication awareness that we have negotiated with some employers and brought in with many of our seniors' chapters. It starts off basically educating citizens about difficulties in using medication: about overmedication, about keeping old medication. It's a preventive way, it's non-intrusive, it's cost-effective, and it would work one hell of a lot better than giving American companies access to our confidential medical records.
Mrs Caplan: I want to congratulate you on an excellent brief, an articulate and a passionate one. I agree with your concerns and also hope that the government is listening, although I fear it is not. We have been demanding and requesting and cajoling and asking for this bill to be split to allow for public scrutiny so people can fully understand what this bill is doing. We've been asking for and demanding and requesting the amendments that they're going to bring forward. We had one press release from the minister almost immediately after the tabling of the bill and the start of these hearings suggesting that there would be an amendment on sunsetting of powers. We don't know what they have in mind, and I think it's tremendously unfair that people are coming here not knowing what the government intends. We see news reports with statements from Mr Clement suggesting that there will be substantial amendments, and I have requested repeatedly, during these hearings, that we have a chance to look at what they have in mind.
I want to assure Mrs Ecker that we would appreciate seeing those amendments as soon as you are proposing them. We would not criticize you for tabling them; in fact, we would thank you for allowing us to see what you have in mind, because that is due process and democracy. To suggest you're holding back on them because we might criticize you -- we would only criticize the amendments if they didn't repair some of the damage in this bill. We would not criticize the tabling.
Second, again I would like to ask -- this is a request, Mr Chairman -- the government to let us know who produced this crap. Who paid for it? Who produced it? It is misleading, it misrepresents the reality of Bill 26, and in fact it is full of lies.
If it was produced by the provincial Progressive Conservative Party, the people of this province have a right to know; if it was produced by government, the people have a right to know; and if it was produced by your caucus people, we have a right to know who produced this. The only word for this, Mr Chairman, is crap, because it is full of lies and it is intended deliberately to mislead the people who are attending these hearings and coming forward with genuine concerns.
Mr Duncan: Mr Chair, your staff person was passing them around.
The Chair: Mr Duncan, Mrs Caplan has the floor.
Mrs Caplan: I yield to my colleague.
Mr Duncan: Who paid for that, Mr Carroll? One of your staff members was passing them out here. You ought to be ashamed of yourself. You're cutting back health care dollars and you're passing out Tory propaganda. Shame on you.
The Chair: Can I just correct the record? It was not one of my staff people handing out that brochure.
1130
Mr Duncan: One of your Tory caucus staff members. Let's clarify: one of the whiz kids. Who was it? Who paid for that?
Interjections.
The Chair: Thank you very much, ladies. We do appreciate your presentation today.
We now have two motions to deal with. The next group has withdrawn its presentation, so we do have two motions to deal with as put forward by Ms Lankin. Would you like to deal with those one at a time, Ms Lankin, please?
By the way, just for the information of the people on the committee, Ms Lankin had requested in Thunder Bay that the comments made by Dr Kotalik, a bioethicist we heard in Thunder Bay, be copied for the members of the committee. Hansard has done that for us and they are being circulated.
Ms Lankin: I appreciate that. Mr Chair, could you indicate the procedure for dealing with these two motions so we're all clear on time limits?
The Chair: Our standard procedure is that we've had five minutes' debate, one person per motion.
Mr Marchese: Five-minute debate and a few people can participate?
The Chair: One person is what it has been, okay?
Mr Clement: Oh, they can split it up any way they want.
The Chair: I'm just looking for all-party approval on this. I'll do it any way you want.
Mr Marchese: Five-minute debate.
Ms Lankin: Five minutes to be split up.
The Chair: Five minutes be split up per party?
Ms Lankin: Yes, and again, I reserve the right --
Interjections.
The Chair: I assume that all of you want to hear what Ms Lankin has to say. She has the floor.
Ms Lankin: That's a big assumption, Mr Chair. I just wanted to indicate that I will be splitting my time with Mr Marchese and I will be saving a short amount of time at the end to wrap up.
The first motion I am placing before the committee:
Whereas there has been overwhelming public interest in Bill 26 and that 42 groups and individuals have requested to appear before the standing committee on general government in Windsor, which far exceed the 15 spaces available today for hearings;
I move that this committee recommends to the government House leader that when the House returns on January 29, 1996, that the order with respect to Bill 26 be amended and that the bill be returned to the standing committee on general government so that further public hearings can be arranged for the community of Windsor;
Further, that this committee recommends that the three House leaders meet as soon as possible to discuss this issue.
Mr Chair, you know how strongly I feel about this. The opposition had to go to extraordinary lengths to get public hearings that would go out of Toronto in the month of January to give people time to develop their presentations, to understand the bill and to come forward in their home communities to be able to present the regional issues and regional concerns. So it wasn't just the Toronto-based process that would have happened had we proceeded with the government's intention to have it wrapped up before Christmas.
May I also say that at the time in which all three parties arrived at an agreement with respect to the schedule of hearings, none of us knew what the overwhelming public response would be or that the numbers of people and groups and individuals who have applied to appear would do so.
Mr Chair, you well know in these two weeks of committee time that the two committees are travelling, there are over 1,000 groups or individuals who have applied for less than 300 hearing spaces. If this government is truly listening, as it says it is, it would listen to the vast majority of presenters who have come forward and who have said: "Slow this process down a little bit. Let us have some more time for public debate. Listen to the people." That's what we have been hearing.
May I say that the opposition has made this offer before to the government and I repeat it today on behalf of the New Democratic caucus. We are prepared on January 29 to pass those few sections of the bill that you absolutely believe have to be done in order to meet your fiscal agenda crisis that you have set out. The vast majority of this bill deals with long-term policy changes which have immense implications for the province of Ontario and deserves to be under public scrutiny, to be seen, to be known, to be understood and to be debated by the public before legislators come to the final decision-making with respect to these changes.
I urge the members of the government to listen to the words in the resolution, to understand that we will not be making the decision. We are simply urging the House leaders to meet to discuss this. They will make that decision. Please, listen to what you've heard from the presenters and please be part of this committee's recommendation to pass that information on to the government House leader so that we may have a proper debate about what democracy is in this province and how this bill should be handled and we might hopefully see a return to communities like Windsor so the public can have a full say about what they think this government should do with this bill.
The Chair: Mr Marchese, Ms Lankin didn't split her time evenly with you, so you have about 30 seconds.
Mr Marchese: Quickly, we have learned a great deal. We know that the interest is very great. We know that written submissions are inadequate because they enter into the world of oblivion. We know that one doctor in Peterborough said he could only understand a third of the document, meaning this document is completely incomprehensible even to those who are most literate. People need time, civic participation, in order to be able to influence. The direction of where this bill is going is critical, and therefore people need more time to be able to read and debate this bill.
Mr Clement: I regret that I cannot support this motion. The reasons are as follows. I believe the process is working very well, at least on the government side of the committee.
Interjections.
The Chair: Mr Clement has the floor. We allowed Ms Lankin to speak. Let's allow Mr Clement to speak too.
Mr Clement: I'd like to report to the committee that as a result of this process, by the end of this week, both sides of the standing committee will have heard, by my calculations, from close to 750 presenters, with a diversity of views. They are obviously not all favourable to the government, I concede that, and I actually welcome that. Although some people might not agree that I have that emotion, I welcome the criticism, I welcome the analysis, I welcome the ability of people to give us some very critical points of view and some very worthwhile suggestions, quite frankly.
Mr Marchese mentioned the rushed atmosphere that some of the presenters mentioned, but there have also been some very high-quality presentations. People have had the time to review the legislation, to come up with worthwhile recommendations, and I can at least say, from the government's side of this perspective, the recommendations are being taken very, very seriously and we want to improve the bill. Bills can always be improved, whether you look at them for five days or 500 days, and we can improve this one.
My final point would be this: Ms Lankin mentioned that she understands the fiscal exigencies the province faces, but there is also a health care situation that we face, a situation where, because of the way we spend the money, $17.4 billion, we spend some money in areas where it doesn't make sense: for administration, for heat and light, for hospital beds that don't have patients. And yet there are many other areas, and Windsor-Essex is a prime example, where there is need for more resources, for the mentally and physically handicapped, for palliative care, for long-term care. We want to fund those things too. But in order to do so, we have to make the changes that are necessary.
Interjections.
Mr Clement: We need to make the changes that are necessary, and I would say this: If we hold off even for one more month, that means $720 million more going to interest on the debt rather than into the health care system, and I for one am not going to sit here and let that happen.
Mr Duncan: Absolute disgrace.
Mrs Caplan: That's a misrepresentation of what this bill does and you know it.
Ms Lankin: January 30, it's all over, is that what you're saying? No more deficit?
Interjections.
The Chair: Is this a combined presentation by the Liberals or does one of you want the floor?
Mrs Pupatello: I'd like to address especially Mr Clement's comments that he's just made. The reality is, and everyone in this room knows it, that we wouldn't be sitting here today if Alvin Curling, the Liberal member, hadn't sat in the House. As a matter of fact, if he hadn't sat that night in the House, where the rest of us joined him for the balance of the evening, we wouldn't have gone to any communities. We wouldn't have had the ministers themselves realize that amendments are required to this bill. We would have passed a bill in its entirety the way it was presented, and you and I both know that's totally inappropriate.
1140
Moreover, I want to tell you that in the limited time that we have had here, we have had the audacity of some groups come here who have just the day before been government spokespeople and now sit there actually speaking to government as if they are not some kind of vested interest. Today we've got another indication of that.
Why is it that this kind of propaganda doesn't have any indication of where it was printed? The Conservative Party didn't print this. You're $5.5 million in debt, so it couldn't have been a party printing. Could it have been printed at Queen's Park? I think we need to know the answers to that. You've got the nerve to sit there and talk about public expense for public hearings, and you don't consider this a blatant waste of taxpayers' money and you don't have the nerve to put the fact that it was printed at Queen's Park on this.
I just want to tell you that anything we can come out with today is going to indicate further public hearings. We spent all day yesterday afternoon at the Fologar Furlan Club listening to more folks who didn't get on the list today. Every time we have a new group speak, we find something out about this bill that even the Conservative members don't know.
So I just want to tell you that, you, Mr Clement, and every other Conservative member who's here understands the value of public input. Every new group that has spoken will elicit some other nuance of this bill that none of us realized in terms of its impact and potential impact on the communities, in particular in the area of health. You are in a community that has been devastated by this government. You have put off making decisions on the reconfiguration of hospitals for this area for months. You are changing all of the attitudes here for health. You're literally dismantling this before the bill is even passed.
This kind of action, as it stands now in Bill 26, will only serve further to destroy health in particular in Essex County. You've got command now, you are government. You have the power to allow us to have further public input, and we are asking you to consider further public input on this bill. Do not let this go through. All of the people of Essex county are asking that of you today.
Ms Lankin: Very quickly, Mr Chair, I have a list here of all of the groups who were denied standing before this committee. It includes groups like the Essex County Board of Education, Essex County District Health Council, the medical society, the Ontario Healing Arts Radiation Protection Commission, Windsor and District Chamber of Commerce, the Windsor Area Action Group, the Windsor academy of radiologists, the Windsor and district council of CUPE, Windsor Women's Centre, on and on and on.
Mr Chair, in addition to this, there are all those groups who didn't get their application in in time because the ads were in the newspaper over the Christmas holidays who haven't had a chance to come forward. There are many people here who approached me this morning and said they would like to be on but they just found out about it as the hearings last week started on the other half of the bill.
I say again to the members opposite, if you are truly listening to what people have said, you will understand that there are portions of this bill that will fundamentally change the value of our health care system in this province, the values that underscore the Canadian medicare system that so many people fought for so may years to build, and you will allow public debate to determine if that in fact is the way the people of this province want this new government to take us.
Don't be afraid of debate. Don't be afraid of what the public has to say. Take the time to listen. You will only end up with better legislation as the result of that.
Recorded vote.
The Chair: Ms Lankin has asked for a record vote. Just to explain to the audience, there are only two members here, the way the committee is structured by the Legislature, Ms Lankin and Mrs Caplan who have a vote; three members on this side.
Ayes
Caplan, Lankin.
Nays
Clement, Ecker, Johns.
The Chair: The motion is defeated.
Ms Lankin, your second motion.
Ms Lankin: Thank you, Mr Chair. In light of the fact that again the government members refuse to pass on to the government House leader the need for further hearings on this, and in light of the fact that this means it is clearly their intent to proceed with the bill as is scheduled for passage on January 29, my second motion reads as follows:
Whereas there are only five days remaining for public scrutiny on Bill 26; and
Whereas the public interest in this bill has been overwhelming; and
Whereas the vast majority of presenters to the standing committee on general government have recommended major changes be made to the bill;
I move that this committee recommend to the government House leader that the 95 individuals and groups that requested to appear before the standing committee on general government in Windsor be given the opportunity today to see the government amendments to Bill 26.
Mrs Caplan: You can't vote against that.
Ms Lankin: Mr Chair, Ms Ecker said earlier that if we were to table the amendments before we've listened to all of the public input we would be criticized for not having let the process unfold.
Ms Ecker, I know that you have been around legislative processes a long time and I know you know better than that in terms of the process that has always been followed by all governments, that where at all possible amendments are shared with the public and with members of opposition as soon as they are in a draft form so that we can give you input as to whether or not those amendments in fact address the concerns. It has always proceeded that way because governments have the resources of large legal departments and bureaucratic departments of advice to help those amendments be drafted, and opposition parties, as you know, have research staff in small numbers and rely on legislative counsel who are very overworked this week, trying to put together potential amendments. It is always the procedure that government shares those amendments so that the opposition knows whether any areas have been taken care of and what further areas or refinements to their amendments may need to be done.
On Monday, when we start this process and we must file those amendments, we have no further time to deal with this, other than trying in committee to deal with amendments. Both committees are going to be put back together in one room to deal with this whole bill and all the amendments over the course of one week. We will be scrambling, trying to deal with the amount of them. It is absolutely imperative that you provide us with this information.
Last week I heard over and over again the three of you saying: "We're listening. We want to continue to listen next week and then we'll develop our recommendations."
Interjection: They're not even listening now. Look at them.
Ms Lankin: You know something? I almost was sympathetic to that until I found out from a very, very reliable source inside government that your government dealt with a package of amendments at the policy and priorities board of cabinet early last week. You've already got them passed and approved and you're not sharing them with anyone. This is intolerable. You will repeat next week in clause-by-clause what you attempted to do before Christmas in terms of ramming this through without proper examination, without proper comment and without proper due process. I implore you to support this motion.
The Chair: Ms Lankin's giving you a lot of practice at 30-second statements, Mr Marchese.
Mr Marchese: It's all I need, Mr Chair. Just two comments. The first one is that enough presenters have presented, on the whole, many common amendments that we have a sense of the kinds of amendments that the government members can bring forward.
Secondly, it's important to get the amendments they have in mind so that we have a good sense of what they're listening to and what direction they're going into. Without that, we will not know what they're listening to as the deputants make their presentations.
We would be very helpful to them, it seems to me, in terms of making suggestions to the amendments they're making, so that once they're presented there will be greater agreement among all parties if they did that. If they don't do that, it'll be a problem. So we urge them to give those amendments now so we have a sense of what they're listening to and what direction they're going into.
The Chair: Thank you, Mr Marchese. Mr Clement.
Mr Clement: Again, I thank Ms Lankin for the motion. I'm with you about 95% of your motion, so I'd like to discuss at the end the problematic part.
With respect to the policy and priorities committee of cabinet, as the member well knows, they very rarely deal with precise wording of amendments. So it is not accurate to say that there is precise wording, but there are amendments being considered by the government. I will confirm that for the public. There's nothing to hide here. We are looking at potential amendments.
Mrs Caplan: If there's nothing to hide, table the amendments.
Mr Clement: From my perspective, may I say that Mrs Ecker, Ms Johns and myself are very sympathetic to the argument that these should be presented as soon as humanly possible, because they should be part of the discussions as soon as we can do that. So I don't disagree in theory with your motion.
1150
Mrs Pupatello: That doesn't do a thing for us, Tony.
Mr Clement: I think what we have to do is, right now we're just starting the process of amendments internally so that we have a comfort level as committee members with that process as well. I think I can make a verbal commitment that as soon as they're in a draft form that we can share with this committee, we will share them, believe me, with this committee.
The only word in Ms Lankin's motion -- I haven't conferred extensively with my colleagues -- the only thing I think theoretically that causes us problems is when she says "be given the opportunity today." We can't do it today. If you wish to amend your motion, Ms Lankin, to say "as soon as possible," you have my vote on this motion.
Interjections.
Mr Clement: Can I ask Ms Lankin whether she's going to amend her document to that extent? It's a friendly amendment but I'd like to ask in good faith for a response.
Ms Lankin: I can assure you that if you defeat this motion today, I'll give you another opportunity tomorrow to pass it.
Mr Clement: Fair enough.
The Chair: Are you finished, Mr Clement?
Mr Clement: Did you have something to say, Mrs Ecker?
The Chair: Quickly.
Mrs Ecker: I'd just like to say that Ms Lankin has pointed out that I have been involved in previous legislative procedures, and I have. I have received big chunks of amendments on a Friday night that we had to respond to by Monday morning, and didn't like it then. That's why the minister has given the commitment that we will be releasing amendments as soon as we can possibly do that. But we also want to make sure that we don't miss the good points that are being brought forward by many of the groups that are here, which you yourselves have said are good points. We want to make sure we do them right.
Mr Crozier: To respond to a couple of things, certainly with this motion the real intent behind it is, I believe, that we should be able to get to the amendments and we should be able to understand the government's direction as quickly as possible.
Again, the excuse has been given that the government doesn't want to put any amendments forward because they don't want to miss some of the good presenters. Well, quite frankly, it's not unusual for amendments to be tabled at the beginning of hearings on a bill. It's not unusual for amendments to be tabled partway through, and then if there are other presenters who, let's say, give another opinion, then you can amend those amendments.
Mrs Caplan: Or withdraw them.
Mr Crozier: Or withdraw them. Thank you. To say the process has to wait until everyone's been heard from I think is untrue and unfair. Maybe it's not untrue, but it's unfair.
I'd be willing to bet, fellow committee members and ladies and gentlemen, that these amendments will not be tabled until the very last minute. I am in fact willing to stick my neck out far enough to suggest that there won't be significant time to review these amendments. But I don't think there'll be any meat to a lot of these amendments. I think there will be a great number of them. In fact, we have a pool going -- and we invite the government to join it -- as to how many amendments there will be.
Mrs Ecker: I'll take a bet.
Mr Crozier: So I suggest there will be lots of amendments, but it's the quality of the amendments that really counts, not just the number. I don't want anyone to be smokescreened by the fact that there will be a great number of them. In fact, I suggest that this legislation is so poorly written that the legal department has been scrambling to correct and to bring forward amendments in just the way it's been drafted, notwithstanding what anybody has said before this committee.
We had a bill just before the House broke in December that was two pages long, had eight sections, and the government tabled six amendments. If you translate that into a bill of 211 pages long -- I suggested at that time that some of the legal staff that's advising and drafting these bills would have a little difficulty with a two-car funeral, I suspect.
So I think you're going to have to consider the real context of these amendments and the fact that there is going to be very limited time. I suggest that with the number of amendments that will come forward there won't even be enough time to discuss each one of them and that they then will be simply accepted as tabled.
Mrs Caplan: That's not democratic.
Mr Crozier: Mrs Caplan says that's not democratic, and I agree -- but we've heard from many, many presenters who have said the whole process is undemocratic -- partly because, and I think it's misleading to some extent, this information says: "Well, we offered 360 hours of hearings. The opposition didn't like that. We only took 300." They offered 360 hours. It was going to be in Toronto. It was going to be before Christmas. You were going to go through till midnight. We've heard from disabled people in Windsor and London and Kitchener and Niagara Falls and in the north who wouldn't have been able to get to Toronto. So the point is, the whole process would have been very undemocratic had we not taken the steps that we did.
I would also ask the government to please understand what people are asking for. They only want to know where you're going, what direction you're going to take, are you listening, and they just want to know this ahead of time. So please table those amendments.
The Chair: Ms Lankin, a final sum-up.
Ms Lankin: Again, I'll try to be very brief, Mr Chair. May I say to Mr Clement that I appreciate his sentiments of support for the intent of the motion. The reason that I don't find it satisfactory to amend this motion to simply say "as soon as possible" is because I got a clearer commitment than that from the minister.
On the very first day of hearings in Toronto, on December 18, I put the question to the minister, would he commit to this committee that we would receive copies of the amendments that he was proposing, because he'd already talked about one that first day, prior to going out on the road on public hearings so that the public knew what areas the government was intending to amend? They could comment on the nature of those amendments, whether they were satisfactory, and if they resolved the concern, we didn't have to keep talking about that issue and we could concentrate on other issues.
I quote to you Health minister Jim Wilson's own words: "We have no interest in holding amendments back. I found that frustrating when I was in opposition actually and I couldn't understand why the government, when a good point was made and agreed upon, would wait till the last day to put in amendments and continue to get hammered day after day, witness after witness, when they're already intending on doing it."
I point out to you that you are continuing to get hammered day after day, witness after witness. We know there are areas where you are going to make amendments. Share them with us. Let us decide collectively with the public whether you've addressed concerns. Be, as a government, facilitative of the process in terms of producing the best legislation, not a barrier to it.
So I stand by the motion that I put forward and I do indicate to you that I will repeat this motion every day, because I believe this committee should be making a firm statement to the government House leader that the government has been mishandling how this bill has been proceeding.
The Chair: It's now time for the vote.
Ms Lankin: Recorded vote.
Ayes
Caplan, Lankin.
Nays
Clement, Ecker, Johns.
The Chair: The motion is defeated.
Just a couple of things before we break for lunch. I do want to compliment the audience and thank them for allowing us to hear the presentations. We do appreciate the fact that you don't always agree but we do appreciate your attention in allowing us to get the presentations done. We recess until 1 o'clock.
The committee recessed from 1159 to 1300.
CANADIAN MENTAL HEALTH ASSOCIATION, WINDSOR-ESSEX COUNTY BRANCH
The Chair: Good afternoon, ladies and gentlemen. Our first group this afternoon is the Canadian Mental Health Association for Windsor-Essex, represented by Pamela Hines, executive director, and Thom Morris, who's a volunteer. Good afternoon and welcome to our committee. You have a half-hour to use as you see fit. Questions, should you leave time for them, would begin with the Liberals, and the time would be shared evenly. The floor is yours.
Mrs Pamela Hines: On behalf of the Canadian Mental Health Association, Windsor-Essex County Branch, I want to thank you for the opportunity to present some of our views regarding Bill 26 for your consideration.
Canadian Mental Health Association, Windsor-Essex County Branch, is an incorporated, registered, non-profit charitable organization locally established in 1971. This year we are pleased to be celebrating our 25th anniversary in providing mental health services in this community. We are one of 36 branches in Ontario having membership with our provincial and national associations.
The Windsor-Essex county branch has approximately 240 active volunteers that provide direct program support as well as board and committee services. The branch has a rich history of providing mental health services in this community through education, prevention, advocacy and support services. The programs and services provided by the Windsor-Essex branch are funded by government grants, the United Way and supplemental fund-raising activities.
The Windsor-Essex branch has supported the efforts of the Canadian Mental Health Association, Ontario Division, in recommending deficit reductions as a target for the government during pre-budget submissions over the past several years. We acknowledge that major changes are required in the health care system. It is essential that we create a cost-effective system which makes the best use of our resources to meet the needs of individuals coping with mental illness and their families. To that end, the Windsor-Essex county branch has been working in cooperation with the local district health council, community partners, consumers and families to plan and implement creative options to cope with the economic environment and improve services.
Our comments to the committee in response to Bill 26 will be limited to the potential impact on consumers in the mental health system with a view to identifying possible changes that will limit the risk of implementing measures that could be counterproductive to a fiscal plan which is balanced with providing responsible mental health services.
It has been documented in reports by all three political parties in the last decade that there is an urgent need to restructure our mental health system to shift from a dependence on hospital beds to a community-based model. The community system has been characterized as underfunded and fragmented. Funding is centred on provincial hospitals and psychiatric units rather than community services. We believe it is essential that cuts to the mental health system are not made solely for the purpose of short-term gains but rather in the context of an integrated approach, such as the excellent strategic plan outlined in the government document Putting People First.
Extensive local planning has been conducted to implement principles of mental health reform consistent with the government's fiscal plan. The Windsor-Essex system reconfiguration is recommending that psychiatric beds be reduced from 115 to 90. The London and St Thomas Provincial Psychiatric Hospital amalgamation proposes the closure of one site and the possible reduction of 240 beds. Historically, bed reductions have seldom been offset by strengthening community services. We encourage the government to support the recommendation of the Provincial Psychiatric Hospital Restructuring Committee that no downsizing of beds occurs until such time as the local communities have a plan and the resources to provide appropriate supports and services to this population.
Local mental health services are underfunded and overburdened with demands for services that cannot be met because of prior deinstitutionalization and increasingly limited access to hospital services that are streamlining and narrowing their mandate to accommodate budget reductions.
The Windsor-Essex mental health community is unanimous in supporting the recommendation of the Provincial Psychiatric Hospital Restructuring Committee to explore a decentralized option of the transfer of specialized beds and services to communities such as Windsor. With the planned closure of acute-care beds in Windsor we have the capacity to accommodate these services, and it is opportune to incorporate such a move in our local planning process. We are prepared to take responsibility for providing these supports in our community and believe it would be cost-efficient and significantly improve access, availability and quality of service.
We recognize that there will be no new dollars. However, it is essential that dollars be reallocated in the mental health system. The retention of any saving from the restructuring and downsizing of psychiatric beds to fund the government deficit or to finance a tax break would further erode essential services for individuals coping with psychiatric disabilities, putting vulnerable people at risk with inadequate and/or no supports. This could prove contradictory to the government's fiscal agenda if more costly and inappropriate services such as the justice system are accessed as an alternative.
Reallocation of dollars alone will not improve services. How those dollars are spent will be vital in determining a positive outcome. Resources must be designated to strengthen community organizational processes. We need support and the tools for organizational development activities, such as human resources, volunteer programs, strategic planning, financial management, information and communication technology, as well as research that will assist us in determining the program models for the best outcomes for consumers.
Bill 26 extends considerable ministerial powers and authority. While we recognize that decisions must be made to effect changes, we are concerned about the process. We believe that health services are strengthened when stakeholders are involved in the planning and design. We can benefit from the knowledge and expertise of professionals, volunteers and those for whom the services are intended, to provide creative solutions. We believe the mechanism for full consultation is already in place under the auspices of the local district health councils which make recommendations to the government. Following consultation, we recognize priorities must be determined, but this should not occur without the benefit of full participation.
The mandate of the Health Services Restructuring Commission is vague but appears to be specific to hospital restructuring. We believe that hospital restructuring will only be implemented successfully if considered within the context of the planning and enhancement of community services. We encourage the government to examine the process of the Windsor-Essex reconfiguration, which shifted from a hospital to a health system model.
Each community has its unique concerns, and what works in Toronto may not be appropriate for other jurisdictions. We suggest that the government focus on the conceptual model and criteria to help mental health evolve and establish a decentralized governance system in which local communities determine how best to meet the criteria in their jurisdictions.
Community organizations are dependent upon supplementary fund-raising to provide a broad range of services. Locally, the casino has already impacted on bingo revenue for many charitable organizations, increasing the competition for limited charitable dollars. Bill 26 will permit hospitals to establish crown foundations for fund-raising purposes. We are concerned that this will threaten the fund-raising efforts of the United Way and other community organizations already dependent on this revenue. In the mental health system, this would be paradoxical to the shift from institutions to community services by further eroding acknowledged underfunded services.
1310
The Windsor-Essex branch recognizes the value of services contributed by volunteers, and we are pleased by the government emphasis on the usage of volunteers. The breadth of services provided by the branch is greatly expanded by our volunteers. Involving mental health consumers in a variety of volunteer activities has also provided meaningful activity for individuals to integrate in the community. These activities would be greatly enhanced if the government would support the utilization of volunteers by providing resources to recruit, train and support an effective volunteer program.
In the Health Insurance Act, schedule F, hospital privileges, Bill 26 requires new specialist physicians to be affiliated with a facility in order to obtain a billing number. This measure reinforces the affiliation of psychiatrists to the hospital system without providing any incentive to share their expertise with the community-based system which is the recommended future direction for mental health services. Many community-based services do not even have access to sessional fees for consultation services. To provide effective community mental health supports to reduce the dependence on beds, it is essential that community-based services have access to psychiatrists for program design, clinical direction, staff education, case conferences, planning and consultation.
Medical advancements in the development of psychotropic drugs in the 1960s made it possible to consider supporting individuals coping with mental illness to live in the community rather than asylums. Canadian Mental Health Association, Windsor-Essex County Branch, is concerned with the proposed changes to the Ontario drug benefit plan.
Medication is frequently a key factor in the recovery process and the ability to support mental health consumers successfully in the community. Medication complaints for some mental health consumers is already a challenge in establishing a consistent routine, particularly because of frequent unpleasant and adverse side-effects. The proposed changes would set up additional barriers that may reduce or preclude availability of necessary medication.
CMHA, Ontario Division, made a presentation to the committee in Toronto. We fully support its presentation and have attempted to focus ours on the local perspective. The issues regarding the changes to the drug plan are of such paramount concern to the Windsor-Essex branch that we will reiterate those points already made by Ontario division.
Many mental health consumers are prescribed several medications and some receive them on a weekly basis to diminish the potential for overdose. This means that a person with a psychiatric disorder who is on social assistance could, under the proposed changes to the Ontario drug benefit plan, be paying a $2 dispensing fee once per week. This is a prohibitive amount for an individual on social assistance.
I'm going to skip some of these points for the economy of time, but they are in your report.
The mental health reform process has emphasized moving the psychiatric population into the community and assisting them to lead meaningful lives. Equitable access to the medications they require is part of sustaining a psychiatric consumer in the community. Our organization hopes and expects the government will make this possible, consistent with the principles in Putting People First.
The Windsor-Essex county branch offers a wide range of supports to individuals coping with a mental illness. These supports cannot be provided in isolation of availability and access to basic needs such as adequate housing, education, social supports, transportation and employment opportunities. Absence of these basic needs will severely limit the recovery process.
In summary, the Canadian Mental Health Association, Windsor-Essex County branch, acknowledges the need to reduce the public debt. We believe economic efficiencies can be achieved while improving services with a redistribution of dollars in the mental health system. We are prepared to continue to work collaboratively to achieve these goals in the process of mental health reform. Thank you.
Mr Crozier: Thank you, Mrs Hines, for your presentation. I would like to take you back to page 2 very briefly and ask for your comment about the third paragraph, where you say, "Historically, bed reductions have seldom been offset by strengthening community resources." Unfortunately, we've heard that this has been what has happened; there wasn't enough planning prior to moving to community-based care.
There has been this recommendation by the provincial Psychiatric Hospital Restructuring Committee not to do any downsizing until that's done. Can you comment on that, as well as, with your suggestion in the next paragraph, I suppose, if they are going to do downsizing and not plan for community-based, that you can use acute care beds that are closed in Windsor as an example. But do you still see moving away from any kind of institutionalization into community-based care?
Mrs Hines: There will always be a need for specialized hospital beds for psychiatric care. At this point in time, there is no cure for mental illnesses such as schizophrenia. It can be a very debilitating disease and the nature of the illness may require some individuals -- not all -- to occasionally be hospitalized for stabilization. But with the advent of medications that can help to reduce some of the symptoms of psychiatric illness, it is possible for longer periods of time and, in some cases with some individuals, to do it and provide supports without lengthy hospitalization.
Our suggestions at the provincial Psychiatric Hospital Restructuring Committee were that in amalgamating St Thomas and London Psychiatric hospitals, communities be provided enough time to plan for any repatriations of individuals who were formerly hospitalized to be given appropriate supports in their local communities. We would like to have the opportunity to make sure those community services and supports are in place before any further reductions in beds.
The decentralized option we're talking about here is that we would like to be able to provide even the specialized care in local communities where that's possible. Rather than Windsor residents who require the specialized services of a psychiatric hospital going to St Thomas or London for those supports, perhaps we could look at decentralized options; in other words, maybe 80 tertiary care beds in the Windsor-Essex area that are administered from the combined hospital of St Thomas and London, but in the local community. We possibly have the beds available here because of the restructuring locally.
Mr Marchese: Thank you for the presentation. I want to touch on a few things that you've mentioned and want your comment.
We have heard from a number of people who deal with a lot of different clients who are very vulnerable, generally speaking, on the effects the user fee would have under the drug benefit plan. Some people talk about the $2 fee, the general fee, and for those who make over $16,000 you'd have a $100 deductible and the dispensing fee.
But what some others forget is that as this government gives municipalities and others more tools, there will be more user fees. Municipalities will impose them, hospitals will impose them, doctors will impose them, and independent health facilities will also impose user fees. So when you add the accumulated effect of those fees, it will have, I would think, a devastating effect on the consumers you deal with on a regular basis. Is that not the case?
1320
Mrs Hines: One of the points that I made later on in the presentation was that people who are mental health consumers also need access to public transportation and adequate housing, and there are concerns that if things like subsidized bus passes and the subsidies to the rest homes, those kinds of basic needs, are also attached with user fees, it may become very difficult to support individuals with mental health problems in the community.
On the drug issue, I'd just like to point out that $2 does not sound like a lot of money, but many of our consumers may be on five to maybe 15 different prescriptions to deal with different side effects and the nature of their illness. So you're not just talking about the dispensing fee for one prescription every three months; it's a cumulative effect.
Mr Marchese: I agree. Part of the fundamental flaw, in my view, is that the user fee assigns blame to those who have to get prescriptions, and it almost assumes affordability. Both of those two assumptions, in my view, are false. It communicates a sense that seniors who need drugs, for example, are the ones to blame for having to get that prescription. I think that's not so, and a number of people have shown that. Do you have an opinion on that as well?
Mrs Hines: I think the important thing in terms of drugs or any other user fees -- one of the suggestions has been that individuals on social assistance can go out and find additional employment to make up the difference. With our population, because of the nature of their illness, sustaining ongoing employment in the community is very difficult. Again, that's another area where perhaps in terms of supports we need additional supports to help in terms of job readiness and the supports they need to maintain even minimal employment hours.
Mr Marchese: As I read Bill 26, or at least parts of it, and hearing a number of deputations, I see nothing in this report and this bill that helps community services or helps to strengthen community based health services. So I'm not sure that I would have any hope that this government necessarily, through this at least, will hear you.
You pointed out on page 4 a problem: "In the Health Insurance Act, schedule F, hospital privileges, Bill 26 requires new specialist physicians to be affiliated with a facility in order to obtain a billing number. This measure reinforces the affiliation of psychiatrists to the hospital system without providing any incentives to share their expertise with the community based system." That's yet another example, in my view, if anything, that what's contained in this does not support what you're after but rather weakens the kinds of things that you would like to see this government doing. Is there anything in this bill that you see might be helpful to you?
Mrs Hines: I think that what is happening in terms of hospital restructuring right now is that if there is consideration that the money be redirected as opposed to put towards the deficit, this could be a mechanism for shifting to a community based system. My understanding is, and my hope and expectation is, that the community investment fund will be confirmed and implemented by this government. But these are the issues that we would like consideration given to in regard to mental health.
Mrs Johns: Thank you very much for your presentation. I appreciate it. I would like to just confirm, to go forward from where Mr Marchese finished off, that the government has been showing that it will be investing in community services. We've been investing in dialysis machines, we've been bringing back a number of our Ontario residents who have been in the States as a result of a prior brain injury, we're doing measle immunizations. I know that's only the start, but that is a reallocation of dollars within the health care system and into the community.
I'd like to thank you for recognizing the need for change in the system. I think we all want change to make the health care system better for all of us.
In the previous government, what happened was that they had to delist some drugs off the formulary twice. I think they delisted 130 different drugs the first time, which resulted in $20 million in savings, and the second time I think it was 110 drugs, resulting in $37 million in savings.
To me, delisting drugs off the formulary is a 100% user fee, if you will, because the person then has to pay for it totally themselves. It was our government's vision that this isn't the way we wanted to go with that, that we were looking for some alternative to be able to keep as many drugs on as people needed and at the same time allow for new drugs to come on because there's such change in drugs, as you know, in mental health and in AIDS and a number of different areas.
Are there any other recommendations you would have if the copayment won't work in your area? You obviously -- well, maybe -- don't like the delisting either?
Mr Thom Morris: One of the key components is looking at populations that are at risk and that had been identified that are at risk and look at some generic envelope funding perhaps to help address those types of population; rather than look at a generic or universal system, look at some partitioning for some populations that are at risk with some specialized funding mechanisms to assist them in ensuring that they can remain out in the community rather than ending up in a costly hospital bed.
Mrs Johns: I heard you suggesting that to downsize the beds in the institutions, we had to make sure that the community was ready to accept these people and had the funds to be able to do that. You then proceeded forward with suggesting that the district health council was probably the best person in the community to decide how to proceed with that. Was that part of the district health council's plan in the restructuring of the hospitals, or would this have to be a separate plan for the district health council of Windsor and Essex county?
Mrs Hines: The local district health council has a mental health committee and certainly has done a great deal of planning locally with respect to mental health reform and working in cooperation with the proposed downsizing of the psychiatric hospital. What I'm suggesting is that we already have that mechanism in place for consultation. We recognize that just as this committee is consulting right now, you will not be in a position to implement every single recommendation that everybody gives. Decisions have to be taken. What we're suggesting in terms of the process is that the consultation, when you've already got the mechanism in place, is very key to the success of the process.
The Chair: Thank you. We appreciate your presentation and your interest in our committee process.
WINDSOR AND DISTRICT LABOUR COUNCIL
The Chair: Our next presenters are from the Windsor and District Labour Council, represented by Gary Parent and Nick LaPosta. Good afternoon, gentlemen.
Mr Gary Parent: Thank you, Mr Chairman. I'm the president of the Windsor and District Labour Council. To my right is Nick LaPosta, secretary-treasurer of the Windsor and District Labour Council.
Before I get into my brief, I want to say how disappointed I was that obviously there was a group that did not show up, the Silent Majority. I think, Mr Chairman, that you can be well advised that you are hearing at these hearings from the silent majority, that being us. I believe you used that time. Even though it was entertaining to see the debate as it related to the motion, I think it would have been better spent if you'd had the additional representation made by one of those groups that could not have made representation.
I also want to make a comment if I may before I start pertaining to something that was said today, and that's from the Hôtel-Dieu Grace board as it relates to the proposal on provincial government funding being directed from the centre. I guess I have some problems with that theory in having the real faith that that money was going to be spent in the communities that do need it and how it would be determined which community would get it. I say that because we have before the government today a proposal. And as we have heard testimony here today -- I would hope that the members are well versed with the Win-Win scenario that took place in this particular community, and we have put forward to your government proposed savings of the amalgamation that your government is sitting on, holding this community hostage as it relates to better health care reconfiguration that this whole community sat in.
Mrs Ecker asked this morning, "What makes this community so great?" Just let me say, Mrs Ecker, it's consultation. Your government refuses to consult with the people of Ontario, and I'm saying to you that if you want a better health care system, then extend these hearings so that you can consult with more people.
We have before us the omnibus bill that we dealt with last week as it relates to the general items and when we're dealing today on the whole question of health care, I can say, Mr Chairman, and to the committee as a whole that I think you are fortunate. You have the expertise of two ex-Health ministers sitting with you to probably and hopefully give you advice that you will adhere to. They have gone through it, they have experienced what your government now is going through. Listen to them, listen to the people of Ontario and don't listen to a circle of whiz kids who are dealing and going through your government and putting forward in this government some ideological differences that we feel are going to be detrimental to the people of Ontario.
First of all, we want to say that we are expressing our profound opposition to the content of the omnibus bill and in particular, the sections pertaining to health care and also to the undemocratic process with which it's being foisted upon the citizens of Ontario.
It repeals existing law giving preference to Canadian-owned, non-profit health; it deregulates drug prices and introduces user fees and deductibles for seniors and social assistance recipients, two of the most vulnerable sectors of our society.
If you want to really talk about the silent majority, I suggest you, as members of this government, talk to the constituencies of the poor, the seniors and the elderly and the sick in your particular respective constituencies to see if you're travelling down the right path.
It grants government, this Tory government, enormous arbitrary power over doctors and strips away the negotiating rights and agreement of the Ontario Medical Association. This bill, in our opinion and in fact the opinion of many other Windsor residents, is a clear indication that this government favours the American for-profit style of health care. Well, we in Windsor-Essex county want to state loud and clear to this committee that we want no part of for-profit health care, as our health care is not for sale in Windsor-Essex county or the province of Ontario.
I want to say that here in this community, and this has been -- and contrary to what, and I've had this argument and discussion before with some of my colleagues -- God bless Tommy Douglas -- but the health care system in this province started right here in Windsor, Ontario, with Windsor Medical. It was the first prepaid medical in the province of Ontario and in fact, in Canada and I just want to say that when you attack the health care system, you are attacking a deep-rooted system we in Windsor-Essex county carry very near and dear to our hearts.
We are prepared to fight this government and any other government every step of the way to make sure it doesn't happen now or in the future. The government committee members might say that these are very harsh words and that this is not what the proposals in Bill 26 really mean. Well, let's just examine what we have found to be included in the bill and maybe you will see why we, and many others, feel the same way. I'll ask Nick to continue on with the presentation.
Mr Nick LaPosta: Thank you, Gary. Bill 26, as it amends the Ministry of Health Act: The first thing that makes us suspicious is what we find in the new section 8 of the act. There is no reference to district health councils and, if they are still to be left in existence, what exactly their relationship would be with the newly established Health Services Restructuring Commission which, as we interpret, has no restrictions on its duties.
Even though we in the labour community have not always had a good relationship with the Essex County District Health Council, we are of the strong belief that there should be a cross-section of the community represented on a body, such as the district health council, to make sure the citizens of Windsor and Essex county have the best health care services available, as Bill 26 amends the Public Hospitals Act. In Bill 26, sections 5 and 6 have been repealed and replaced with clauses giving the minister discretion over when, how much and under what conditions the minister will give grants, loans and/or financial assistance. He also has the power to require repayment and to reduce or terminate grants and loans. His only criteria are that he must consider the public interest. This new section 6 also gives the minister the power to close hospitals, order hospital amalgamation and specify the services to be delivered by a hospital if the minister deems it -- deems it, mind you -- to be in the public interest.
Under their definition of "public interest" is a phrase stating "availability of financial resources for the management of the health care system and for the delivery of the health care system," which is then, in our opinion, when the Minister of Health may well decide to make less resources available for health care because more is needed to cut the income taxes of the well-to-do.
Amendments to the Private Hospitals Act: In schedule F of the act, it is amended to give the minister the power to revoke a private hospital licence at any time and to reduce or terminate any grant, loan or other financial assistance without notice where the minister considers it in the public interest. No hearing or rights to appeal presently provided under the Private Hospitals Act would apply.
Amendments to the Independent Health Facilities Act: Under the current act, services covered by the act can only be provided in licensed health facilities. Generally speaking, these services presently covered by the act include various diagnostic, surgical and other services provided in outpatient clinics for which facility fees are paid by the Ministry of Health.
The proposed changes to sections of this act, which repeal all preference for the non-profit or Canadian, in our opinion, challenge our ability to maintain a universal, accessible, not-for-profit, publicly administered health care system in Ontario. The minister can under Bill 26 direct that a request for proposals be limited to one or more specified persons. This raises to us the real possibility that for-profit US health care providers will be licensed to provide health services in Ontario. As we all know, American corporations are extremely interested in our health care system. They call it the "unopened oyster," and care for the elderly is referred to as "mining grey gold." The proposed changes allow the Minister of Health to handpick corporations or individuals who will be able to open up businesses and franchises of health care clinics that charge people money.
We are also very concerned that Bill 26 gives the minister the power to collect and disclose patient information for the purposes of administration of the Independent Health Facilities Act, the Health Insurance Act or the Health Care Accessibility Act and would encourage this committee to abandon these proposed changes.
Amendments to the Ontario Drug Benefit Act, schedule G: The amendments of this bill introduce copayments and deductibles for the most vulnerable in our society, they being the sick and the elderly as well as those recipients forced on to our social assistance rolls. It also gives the cabinet the power to increase these user fees at any time, which in our opinion will not reduce the need for prescription medicine but will reduce the number of prescriptions that will be filled. Because of their limited incomes, they will have to make the choice between food, shelter or medicine. All of this, in our opinion, will increase the need for crisis intervention, hospitalizations, longer-term treatment and other social services.
We say to this committee in the strongest terms, examine what your government is doing, as user fees are not cost-cutting measures but rather new revenue sources which create more wealth for the drug companies at the expense of hitting the poor of our society in this province, which, by the way, will be the only province, we believe, that will not be regulating drug prices.
1340
Amendments to the Health Insurance Act and the Health Care Accessibility Act: In the amendments to the Health Insurance Act, we see the removal of the term "medically necessary," which means many services could be delisted. Differences could exist among the care provided by hospitals, independent health facilities and private hospitals. The government could easily differentiate on the basis of age, severity of illness and any other criteria the government determines in order to delist services.
You may say this will never happen, but when we look at subsection 11.2(4), which states that such service may be prescribed "only if they are provided to insured persons in prescribed age groups," which we interpret, as an example, could mean that no one over 70 receives a bypass or that a person with Alzheimer's will not be treated for pneumonia. The possibilities are unlimited, in our opinion, and what these changes suggest is the slippery slope to the problem of what is sometimes called the burden of an aging population.
We feel with the ever-increasing pressure to cut costs and get patients out of hospital, government officials and health care providers could make value judgements based on age, which we believe to be totally unacceptable.
The amendments to the Health Care Accessibility Act provide cabinet with the specific authority to make regulations prescribing insured services for which hospitals would be entitled to charge an insured person.
While presently hospitals are charging patients for a limited range of insured services -- for example, copayments for certain chronic care services -- the bill will give explicit statutory authority for cabinet to make regulations which would permit hospitals to charge patients user fees for any hospital-based insured services, including those presently covered by OHIP. Examples of user fees would include accommodation and meals, necessary nursing services, laboratory and other tests, drugs, use of operating or obstetrical delivery room, and emergency room visits.
And if this isn't enough, the bill also authorizes an administrative fee of up to $150 which hospitals may charge patients. This is completely unacceptable. The people in this province who are poor, who cannot pay the rent and feed themselves, certainly do not have $150 if they are hospitalized, especially since living with a marginal income increases risks of illness and emergency situations.
Mr Parent: As we stated in the beginning, we would try to explain to this government and to this panel why we not only as a labour community but on behalf of every citizen, that silent majority in the Windsor-Essex area, especially on behalf of those who have not been allowed to express how they feel about this bill and how drastically they will affect our health care system in this province.
We see the amendments of this bill doing nothing more than Americanizing our health care system, which would absolutely not be in the best interests of the residents of the city of Windsor or the county of Essex or the province of Ontario. As we stated before, our health care is not for sale.
We ask this committee, as many others have asked and will be asking, to allow these hearings to be extended because of the complexity of the issues and the seriousness of the consequences that would occur as a result of the implementation of Bill 26.
If you care about yourself, your parents, your grandparents, your children and your grandchildren, you will agree with most of the people appearing before you that yes, these issues are very complex and that they do need more time to be examined to determine just how these proposed changes will affect the people of this province in the future in their daily lives.
I ask this committee, particularly the government members, to travel down our riverfront to the east along our beautiful waterfront. There is a park on our waterfront that is very appropriate that you should stop at. It's called Stop 26. You should go and visit it.
Mr Marchese: I have a comment and Frances Lankin has another question. Someone in Peterborough said -- it was a deputation of three people -- that this act goes far beyond the traditional ideology of the Conservative Party. In fact many of us have observed that this party is no longer the party than many might have recognized. It is unrecognizable, and when you look at Bill 26, it does indeed alter the democratic process to an autocratic one. Both in terms of process and content we see a very radically different Conservative Party.
If you look at Bill 26, and you've enumerated many, it gives incredible powers to ministers, to cabinet, and it's a whole list of what can and can't be done, usually what cannot be done by someone else. Alterations to the tendering and licensing process, restrictions on relocation, minister's power to revoke licences or eliminate services, immunization from liability for licensing decisions, minister's authority to disclose health information, limitation on physician affiliation -- there are pages and pages and pages of what powers they have and the limitations they impose on other deliverers of services around the whole issue of health.
In my view, it's incredible. This is why we have said people need time to review the document as you've done, because many people don't realize what's contained in Bill 26. There's a hell of a lot. So I'm supporting your call for further discussion on this matter.
Ms Lankin: I wanted to pick up on one of the points in your presentation, sort of expand it. You talk about services that can be provided to a group depending on their age. In the old act the reference to that which was there, which allowed things like breast cancer screening programs to women over age 55 to be established, or whatever, had a protection which said it had to be done in accordance with the Canada Health Act. It has been removed and there's now no protection in accordance with the Canada Health Act.
Mrs Ecker: That is not true.
Ms Lankin: Well, the section with respect to prescribing by age has been moved to another place in the legislation.
My concern is that what we see here is the ability to impose user fees, the ability to do things outside of the Canada Health Act that lead to a very different health care system. Labour has been in the forefront of the fight for our medicare system and the values reflected in that and what that means in terms of values in our communities. I just don't believe there has been a debate in the public that we should be moving away from that. I wonder if you could comment on that from a Windsor labour perspective. I'll just leave it open for you on that.
Mr Parent: I believe, obviously, that we would much rather be debating this in the open for many more months because we believe it deserves that attention. I can only share with you that I had the opportunity to speak to a group last week of mostly seniors. It happened to be at a Kiwanis club meeting and the discussion was around this whole bill. You cannot believe the amount of concern that is before those people as it relates to what is going to be taking place if this legislation goes through as it is.
I hear the government members, continuously all morning and again when you made a comment, on the whole question of that's not what it says. I guess what we need are those amendments you talked about earlier. If they have some things that are going to clarify some of the things that have been put forward, those things should be tabled so they do become part of the public discussion and consultation process we're under right now.
I share your concern that being in the dark as you are, can you imagine what we would have been like if we had not had these hearings? It would have gone on if it were not for Alvin Curling and what he did. I can only say again that I wish he had a bigger bladder because maybe we could have got an additional few more weeks on the whole question.
1350
Mr Clement: Thank you for your commentary. I thank Ms Lankin for recognizing the point that the so-called age discrimination section was in the old legislation as well as the new legislation. She and I disagree on the impact of removing the Canada Health Act references. I argue that the Canada Health Act still supersedes. I guess she and I are going to have to argue that and hire lawyers or something.
I had a couple of particular questions about your brief, if I might, because some things you said jarred me and I went back to look at the bill and I just want to pursue it a little bit.
You say on the second page of your brief that the first thing that makes you suspicious is what you find in the new section 8. You say there's no reference to the district health councils. In fact, in the old section 8 there was no reference to the district health councils. The reference to the district health councils was in section 8.1, which is a separate section from section 8 and is not amended or repealed.
If you do have the opportunity to take a look at the old legislation, I encourage you to do that, but if my interpretation is correct, would that go some way to satisfying your concerns?
Mr Parent: No. The problem we have, whether it's 8.1 or 8, is that the linkage has to be made on the whole question of having district health councils be part so that there can be some community input into any decision-making as it relates to restructuring or the whole question of health care service delivery in this community. We see that as not being in this current bill.
Mr Clement: That's a fair point, but I did want to make it clear that the district health councils still exist in the new legislation.
You also say later on in your brief, with respect to amendments to the Health Insurance Act and the Health Care Accessibility Act, that we removed the term "medically necessary." I'm not sure what you're referring to when you say that, because I don't think we do that. Do you have an exact section that you're referring to?
Mr Parent: I don't have it in front of me, but I can certainly bring to your attention where it is and where it was removed. I will do that.
Mr Clement: That's fair. If I can take a guess, I think what you may be referring to is the definition of "insured services," which in the old legislation had a bunch of mumbo-jumbo which included "medically necessary" and in the new legislation --
Interruption.
Mr Clement: That's a legal term. In the new legislation it just says "`insured services' means services that are determined under section 11.2," so technically you're right. We have removed the term "medically necessary" services. But then if you refer to 11.2, it does reference medically necessary services. If that's the section you're worried about and, if my explanation is correct, does that go some way to alleviate your concerns?
Mr Parent: No, it doesn't, because again, if you look at 11.2, as we said, in the groups I believe --
Mr Clement: I know I'm putting you on the spot. I apologize.
Mr Parent: No. This is what consultation's all about.
Mr Clement: Page 92.
Mr Parent: It provides to "insured persons in prescribed age groups." That again leads us to believe the "medically necessary" part of it has been removed and you're isolating people in different age groups.
Mrs Ecker: It's right there. "The following services are insured services for the purposes of the act.... Prescribed medically necessary services rendered by physicians." It's very clear.
Mrs Caplan: Have you changed the definition of "medically necessary"?
Mrs Ecker: No, we haven't.
Interjections.
Mrs Ecker: It's the new act.
The Chair: Mrs Ecker, this is Mr Parent and Mr Clement having a conversation here.
Mrs Ecker: Sorry.
Mr Clement: I just wanted to raise those points just so we were all sort of rowing in the same direction and we understood what we were saying. I take it from your brief that you don't like the tax cuts. You think they're going to go to the rich. You don't want the tax cut at all.
Mr Parent: We have gone on record as stating that we feel the tax cut, as it has been allocated and has been stated by your government, is not going to be a fair tax cut across this province and it's at the expense of the poor.
Mr Clement: You acknowledge, though, that anyone who files an income tax form will get a tax cut.
Mr Parent: I guess I can say personally, from my point of view, keep my tax cut that you're going to give me and give it to the poor and the less advantaged in this province.
I don't think the people of Ontario elected this government to give this tax break to the more affluent, the ones that can afford it, because it's not going to be the $16,000 wage earner or the one on social assistance that you've just cut. It's not going to be the ones under $20,000 that are going to get a tax break. It's going to be the more affluent in this province.
Mrs Pupatello: I have a question for Nick. You and I were on a hospital board not too long ago and so we were personally seeing the kind of changes that were coming about in hospitals as a result of restructuring.
I wonder if you could comment on this: (a) that this government was elected on the promise of not cutting health care, but you and I have both seen what hospital administrations are now having to surrender to to try to effect cuts because the money is not there, even though they were elected on no cuts to health care; and (b) because in our Win/Win for this area redistributing services to community base and perhaps not hospitals the labour community was more comfortable because even though there may be some shifts in labour from hospitals, you knew that the funding was being moved to community base you had some kind of sense of assuredness that people too would be moving but there would be jobs in community-based services.
This government has not kept its promise on moving to community-type services. Can you comment on the group you represent in that area?
Mr LaPosta: Thanks, Sandra. First of all, I want to tip my hat to a group that was here earlier and did make a presentation, and that's the Hôtel-Dieu Grace Hospital board. At least they came down here to make a presentation. Although I don't necessarily agree with everything they said, they were at least here, which is one step more than what the hospital board that I currently sit on is doing.
I personally believe the reason they're not here today is because they have yet to hear from this government what is happening with the moneys that they have requested through the reconfiguration and the downsizing of the two hospitals into it. They're afraid that if they were to make their voices heard in this committee here, out into the public, more damaging information would probably come down through the financial aspect of the dollars that they are waiting for. As we sit here, no official notice has yet been given to the hospital boards as to where they're at with the money that they requested.
Secondly, in reference to the reconfiguration process and helping our community to be prepared for the shift from hospitalization to community-based staying at home -- to answer that question frankly, that's been going on for the past two and a half to three years anyway, and the community is not prepared to receive all those people who are already being cut and put back into the household, back out on to the streets.
The problem is that the more they keep requesting funds to get, for example, the district health council and all these service groups together to prepare themselves for this, there are people out there right now as we speak with no place to go, no health care and no system in place to catch them. That's the truth. That's what's actually happening.
Although we're sitting here and asking for more time, more hearing, more debate, it's because this government is asking us to take a leap of faith with them, the same leap of faith they asked us during the election. We all know what happened during the election. They haven't kept one promise that they said they were going to keep, such as no cuts in health care. That's the biggest promise that they are breaking to date.
The truth is we want these hearings out and into the open to discuss such things as Mr Clement brought up, for example, where there is a difference of opinion. But the difference of opinion should be for the betterment of all Ontarians and all Canadians, not just those who are looking for a handout from the government.
The Chair: Thank you very much, gentlemen. We appreciate your presentation.
ESSEX COUNTY DISTRICT HEALTH COUNCIL
The Chair: Our next group, the Essex County District Health Council, is represented by Jo-Anne Johnson, the chair of the implementation committee, and Hume Martin, the chief executive officer. Welcome.
Ms Jo-Anne Johnson: We're delighted to be here today, and I will start the comments by giving you some of the background and accomplishments of the district health council to date. The district health council was established exactly 20 years ago this month in 1976, so we're celebrating our 20th birthday this year. Our mission is to promote the development of an integrated health system through action-oriented health planning.
In the early 1990s, in conjunction with the Ministry of Health, we established a steering committee of local volunteers to develop a plan for hospital reconfiguration. Those volunteers consisted almost 50-50 of providers and consumers. The idea was spawned at the Essex County District Health Council but was quickly supported by the Essex County Medical Society, the hospitals, labour and other health professionals.
1400
We quickly found that hospital reconfiguration could not be developed in isolation from community agencies providing auxiliary health services, because it was presenting an incomplete picture.
In 1994, the health system reconfiguration plan was completed, the first comprehensive plan in Ontario. We have since then seen a reduction from five acute-care institutions in Essex county down to three through voluntary mergers. Reconstruction plans for two of these acute-care sites are completed and we are currently waiting for capital funding to proceed building. Two other sites are slated for closure. One will physically close and the other will be a consolidation point for all long-term-care beds. Savings will be realized with these closures two years from start of construction.
In 1995, with the Ministry of Health again, we embarked on a community study which will be completed in September 1996, producing plans for the reconfiguration of the community health sector, and we will then be ready to actually develop an integrated health system for Essex county.
We have begun development of linkages and working agreements between agencies, institutions and broader community partners. In 1995, for example, the district health council, in conjunction with the Windsor-Essex health unit, produced a joint, comprehensive health profile for Essex county, providing important data for our immediate planning purposes. I have brought a couple of copies of that report, if anybody would be interested in taking a look at it.
In 1996, the hospital unions in Essex county, six different unions, developed landmark agreements with the three existing hospitals and each other covering unprecedented transfer and seniority rights clauses. This contract is now a model for the entire province.
We have the pieces in place to develop an integrated health system. We have done this by taking the initial support of hospitals, medical people and health professionals and labour and we have broadened that support to the general public by involving consumers in every DHC-sponsored committee, subcommittee and task force. We have involved the public through public consultation, fora, and through consumer-led, community-specific meetings to provide information to and gather from the public.
Our DHC can now boast that we have over 500 volunteers involved in DHC planning and educational activities. Out of this broad-based process, we have developed broad public support for an integrated health delivery system.
Essex county is ready to make change. We just need the capital dollars and continued government support to serve as a demonstration site for an integrated health delivery system, and I might add, in a strategically timely manner for the province's needs.
Mr Hume Martin: I'm the chief executive officer with the district health council. What I propose to do is to build on the presentation made to you in December by the Association of District Health Councils of Ontario and make four observations in terms of the impact of this legislation, as well as four recommendations in terms of things the committee might wish to consider.
The four observations are, first of all, that the authority of the Health Services Restructuring Commission, in our view, will be needed in some Ontario communities which have not achieved a voluntary restructuring plan. We don't think it will be necessary in all, but certainly we see that in some communities this will be the case. We note that this commission in essence was recommended by the Metropolitan Toronto District Health Council in terms of its report.
We do believe that the Ministry of Health approval of a $48-million capital grant recommended by the Essex County District Health Council for the two remaining hospitals in Windsor will prevent the need for this legislation being applied in Essex county. When I say $48 million, that assumes there will be $24 million raised locally, and that does constitute the $72 million that will be needed to take the four hospitals and fit them into two remaining acute-care sites.
A third observation is that while Bill 26 appears to provide greater authority for local municipalities to integrate services, it appears also to centralize decision-making in the health sector. It provides no framework or mechanism for integrating health services at the local level. We believe this is contrary to trends in terms of organizing health care across Canada and, for that matter, North America where integrated delivery systems are emerging as a model. Even in an environment like the United States, which we all agree is not appropriate in terms of not having a single-payer model and a universal health system, it is working in places where there are whole populations being served. It's proving to have a tremendously beneficial impact on the health of those populations.
Finally, we would note as an observation that the Health Services Restructuring Commission does not have authority for broader health system restructuring issues, in our view. It would be more aptly described in the legislation as hospital services restructuring as opposed to health services restructuring.
In terms of our recommendations, the first is that we ask that the committee and the government recognize the urgent need to promote the development of integrated delivery systems at the local level. If it would help, we have operationalized a definition, which is taken from the literature, that we feel would guide our thinking on this issue. We define an integrated delivery system as: "A network of organizations" -- in other words, it's not a single board, it's a network of organizations -- "that provides or arranges to provide a coordinated continuum of services to a defined population" -- and in the case of Essex that would be the population of 350,000 in Essex county -- "and is held clinically and fiscally accountable for the outcomes and health status of that population."
Our second recommendation is that the vital importance of integrating primary care and physician services with local integrated delivery systems be recognized as critical to their success. We believe health should be a non-partisan issue. We also believe that previous governments have struggled with the whole notion of how to integrate primary care into the series of reforms that certainly were very evident under the last government. We urge the new government not to ignore the need to integrate primary care into the full system.
With that in mind, we encourage the committee to take a look, if it hasn't already done so, at the work done by the chairmen of the colleges of family medicine in Ontario and the university faculties of family medicine. They have really put together some exciting recommendations in terms of how primary care can be integrated. They point out, for example, that 93% of all residents of Ontario can name who their physician is. We believe that with that kind of recognition, all members of the population could be rostered with primary care organizations, and that more than anything might lead to the kind of integrated delivery systems that we think ought to emerge.
Our third recommendation -- and this was referred to by the Windsor and District Labour Council -- is that provincial workforce adjustment policies must be in place before health system restructuring recommendations can be fully implemented. It's absolutely vital that these kinds of policies be in place and clearly understood and that the funding mechanisms be clearly understood so when we do downsize the institutional sector, which we're right on the edge of doing in Windsor and Essex county right now, we have the policies in place that will ensure that clinical teams stay together, that will ensure that the community health sector, which should continue to grow in size notwithstanding the budgetary restraints, will be able to benefit from some of the skills associated with these people who have given so much in the hospital sector.
Our final recommendation is that successful hospital restructuring cannot occur in the absence of a strong, well-integrated network of community health services. We strongly believe that some of the savings from hospital restructuring must be reinvested at the local level on the basis of district health council needs-based plans.
1410
With that in mind, we would urge the committee to recognize that district health councils should be recognized in the legislation, both in terms of any recommendations that go to the proposed Health Services Restructuring Commission and, for that matter, any community reinvestment that will be directed at those communities that are relatively underfunded, like Windsor and Essex county, and that have taken the initiative to restructure and downsize their institutional services.
With that in mind, one of the thoughts that occurred to me, in listening to the discussion earlier today, was that Bill 173 passed by the previous government did amend section 8.1 of the Ministry of Health Act -- I believe that legislation is still on the books -- and that legislation described the functions of district health councils very specifically. Clause 4(c) of that legislation specifically said, "The functions of a district health council are...to make plans for the development and implementation of a balanced and integrated health care system in the council's geographic area," and that is what this district health council has been struggling to do over the last four to five years. Thank you for this opportunity.
Mrs Ecker: Thank you very much for coming forward with an excellent presentation and some very excellent suggestions.
As you probably are aware, other provinces, when they got into the restructuring exercise, actually passed legislation to completely scrap all hospital boards across the entire province, which we didn't think was a very appropriate way to go. We recognized that the voluntary boards and the hospital boards are important components of the system, as are district health councils, which are very much a component of the system. As you probably know, under section 8.1. in the current legislation, which is not being changed, the DHCs have the power "to advise the minister...", "to make recommendations on the allocation of resources" for local areas, "to make plans for the development and implementation of a balanced and integrated health care system..." and "to perform any other duties assigned to it under this or any other act or by the minister." I think that is very clear.
What I think I hear you saying, however -- there are three things, and I just want to bounce them off you to make sure I'm hearing what you're saying. First, you would like us to increase the power of the district health council in effect by giving it specific status in terms of basing restructuring decisions on those recommendations.
The second issue -- did I understand you correctly that you would actually like us to broaden the mandate of the commission to include community-based services in terms of the restructuring as well as hospital services?
Sorry I'm getting into a lot of points, but the final point was, given the fact that the minister has agreed to sunset the commission within four years and some presenters here have said they think that's appropriate, do you believe we can get the restructuring within Ontario done? Given the experience you've had out here, can we get the restructuring done which everyone recommends and agrees needs to be done within that four-year time frame?
Mr Martin: In answer to your first question, I don't think the issue is so much strengthening the mandate of district health councils. The strength of this district health council in Essex has been that we have been a neutral body made up of volunteers from the community who are here to serve the best interest of the community and not any specific stakeholder in the health care system.
The thrust of these remarks was to encourage the government to promote the development of an integrated delivery system that does need to have primary care, mental health, long-term care, acute care, rehab care all connected in a comprehensive way.
The issue of mandate for district health councils does need to be clarified. It needs to be specified clearly what that mandate will be. But I'm not sure I would use the word "strengthen." We have had a role that has been well recognized and well supported, and if that continues, I think we will have the tools necessary to do the work.
In terms of broadening the mandate of the Health Services Restructuring Commission, I view that commission as representing a major centralization of authority, and I don't think it makes sense, necessarily, to broaden the mandate of that committee to include community-based services. I think the tools are there without that additional legislative mandate. But what I do believe is that the government has to provide envelope funding, probably at the local level, to ensure that the integration that has to happen will happen.
Mrs Caplan: Nice to see you. Excellent presentation. I can only imagine the frustration that you have when you've got a plan and it's ready to go. In the context of the total resources spent in Windsor-Essex county, waiting for those capital dollars must just be driving everyone nuts: "Here is the plan. The community did it itself." I thought you were very diplomatic when you said you don't need the hospital restructuring commission. You're absolutely right that it's about hospitals; it's not about any kind of restructuring of health care.
We've heard very clearly from the minister that it is his intention to turn back the clock on the district health council mandate. My question is this: Was your mandate 20 years ago the mission that you've put forward for us today? Would you have done 20 years ago, not that you were there at that time, but do you remember -- as I recall, DHCs were advocates in the community for add-ons.
Ms Johnson: Actually, we can see our mandate broadening daily and changing. I've spent now two and a half years at the health council. I have seen nothing but change and a broadening of our mandate. That broadening is coming basically from the community and from the partners. They're looking for direction. They're looking for somebody to sort of be not necessarily a central authority but a central coordinator-facilitator type of thing. That's the growing role of the health council in Essex county. I don't know that that's happening in the rest of the province, but it's certainly happening here.
Mrs Caplan: I agree entirely with your desire to have that mandate clarified as part of the process of this legislation, because in the absence of that process and the fact that the minister's been very clear about returning the district health councils to the role of 20 years ago, it would be a terrible setback for community participation.
The second point I wanted to make was, I very much support your definition on the network of organizations providing innovative services. To me, that that's the definition of a comprehensive health organization.
Earlier today there was a discussion about allocation of resources that would come from savings. I guess I hear you very clearly saying that the local community can tell you what's going to work in their community, and it's the centralization of power that we see in Bill 26 that runs contrary to that local coordination that's needed. Is that a fair categorization?
Mr Martin: In our case, certainly we are in the middle of a project called improving community health. We will have recommendations ready by late this summer in terms of where funds should be reinvested. We think it's important that some of the reinvestment should be made on the basis of local decisions and we think that those will be better decisions if done on that basis, provided it's consistent with provincial policy, and there's no reason why that wouldn't be the case.
Mrs Caplan: The last point I'll make, and then I'll turn to my colleague, is that I was the person who was there when your discussions on reconfiguration began. I am saddened personally to see Windsor not held up as a model for the province and encouraged and supported. I despair that you've been put through the agony that you have over the last year. I hope they will just get on with using you in a positive way as a model and as a reward to your community that has done it all by itself.
Mrs Pupatello: I wanted a quick question, Hume. This morning's presenters from one of our hospitals indicated that, "Redirect savings from hospital restructuring to community programs based on provincial priorities and allocated to the ministry rather than through a local allocation process," which is sort of opposing my thought and yours that in fact it should be done on a local level. Can you give me a quick comment?
The final summary is that this government did get itself elected on the basis of no cuts to health care -- you have to agree, then, that there have been cuts in health care -- and they were also elected on the basis of returning 10% of casino profits to a city like ours. We could get our reconfiguration done in 480 days, if that were the case. That was pointed out to me by my colleague. I just wanted to throw that out; but specifically, local decision-making in the reallocating of community service dollars, if you could comment.
1420
Mr Martin: Certainly. I think there's been a bit of a misconception in terms of the history of this. The Win/Win report always suggested that there would be $22 million reinvested in community services, which was roughly estimated as being 10% of the savings coming from the hospitals when they consolidated on two sites. In fact, the Win/Win report suggested that might be an underestimate of the kinds of savings that would accrue, and in fact research coming out of the United States suggests that anywhere up to 30% savings can be reinvested with proper integrated systems and the removal of duplication.
Mrs Pupatello: Yes. That was before the 10% cut.
Ms Lankin: I'm going to follow along the same lines. You might have a chance to combine what you were going to respond to Sandra's question with mine. I'm finding it almost amusing when I go from community to community and hear each of the communities say, "Well, we're actually proceeding fine with our restructuring and we have consensus and we know where we're headed, but you may need these powers for other communities." So I support the powers that are there.
Let me tell you my concern about the powers as they're set out. The restructuring commission doesn't have any terms of reference. There's no mandate set out and there's no limit on its power and there is no linkage to the reports or the processes driven by local health planners, usually, through a DHC-led process. I've heard assurances from the government, "Well, that's what we intend to do," but that's not at all clear in the legislation. I can give you very quickly examples of where the minister has in fact come into communities which were well on their way to implementing consensus reports and the actions of this new Minister of Health have in fact stalled the implementation of those reports because he has taken steps that have broken down the consensus. So I feel a need to see the terms of reference in the mandate and the linkage set out to ensure that there's a framework for what we're doing.
A last comment on that: I'm sorry, but I don't know what this government's philosophy is with respect to restructuring of health care. It's not clear to me at all that they're looking at determinants of health. If I look at everything else they're doing in terms of cuts they're making, where they're making them and the effects on people's health -- not determinants of health. It's not clear to me, given that the early reinvestments that are being made are in extension of cardiac care and other services in hospitals, as important as those are, that they believe in the shift from institution to community or from illness treatment to illness prevention and health promotion. They haven't told us what their framework for restructuring is other than to save bucks and to reinvest it: "We'll save them now and we'll reinvest them some time in the future." Could you comment on the proposal for those kinds of linkages to be built into the legislation?
Mr Martin: In terms of the linkages, we do believe there should be reference to the commission being required to consult with local district health councils before using the powers that are assigned to it in the legislation. So there should be that linkage with local planning.
In terms of the question around reinvestment of savings, the current government has said that the health envelope is sealed. We believe that even though clearly there have been reductions announced for hospital budgets that are going to be very difficult to manage but which we, as a community, are in a much better position to manage because of the steps that have been taken by the hospitals and the medical society and the district health council, within a year or two there will be that reinvestment possibility surface, given the government's commitment to keep the envelope sealed, and we believe we will be in a good position to make advice in terms of that reinvestment on the basis of the current project we're involved in. We hope, again, that the government will give us that possibility, because we believe that the recommendations will make a lot of sense, in terms particularly of areas like children's mental health, women's services and children's services.
Ms Lankin: In fact, if the total restructuring reports aren't adhered to, if it's only the downsizing of hospitals and saving of the money and not the reinvestment in the community, in many communities there will be very large gaps in this system. These people are looking in those reports to relocate services from institution to community. I understand that you've heard that commitment that the health care envelope is sealed and that you believe in that commitment. I hope your belief is well placed.
Let me ask you a question. The word around Queen's Park these days is that a section of the Ministry of Community and Social Services, particularly dealing with children and children's mental health, whatever, will be moved from that ministry over into the Ministry of Health and that its budget, downsized as it is, will be brought over with it and that in fact that will be subsumed within this $17.4 billion; in other words, a dramatic cut to the actual health care budget. Would that meet your belief of what the government's commitment to seal the envelope is?
Ms Johnson: If I may, Hume is an employee of the government; I'm an appointee.
Ms Lankin: No, he's an employee of the district health council.
Ms Johnson: I don't think he should be put in the spot of answering that. As far as the commission is concerned, I myself had some serious thoughts about the lack of any kind of mandate or organizational structure or goals set forward. That left me wondering what that commission would be all about. But I would issue a word of caution, that if in fact the government plans on using that commission to go in and ram through hospital restructuring and/or any kind of community restructuring, I don't think that would work. Quite frankly, after two and a half years on the health council, and knowing all of the skills and the careful structuring that had to take place in order just to bring all the partners to the table and get them to begin to talk to one another and build some trust, because there was no natural trust that had ever been built between the institutions and the agencies, and all of my time at the district health council has been spent working on those types of endeavours, a commission that comes in from outside and lays down the law and says, "Here's what we're doing. Go do it," I suggest would not result in successful results.
The Chair: Thank you for the presentation. We appreciate your involvement in our process.
Mrs Caplan: As is our practice, I would like to place a question at this time to be answered. This presentation raised the issue of provincial workforce adjustment policies and suggested the need for a transitional fund. Given the fact that the government cancelled the workforce adjustment fund as one of its first acts upon assuming government, my question is whether there is an intention of the government to bring forward provincial workforce adjustment policies; and secondly, whether it is going to reinstate the workforce adjustment fund in order to support the restructuring as contemplated by Bill 26 and, if so, when we can expect to see that.
The Chair: I'm not sure the Minister of Health can answer that question, but we'll certainly direct it to them.
Mrs Caplan: He probably couldn't, and that's why I have the worries about this bill.
Ms Johnson: I'd just like to make a parting thought or comment. That is part of the necessary structure for restructuring the community. You cannot do that without the labour people. The people whose jobs are to work in the hospitals and work in the agencies absolutely will not come to the table. In fact, the labour people in this community have left the table because they could not trust what was happening with the government when the government refused to give us the $109 million which was the original commitment. Labour has left the table here, and you will not even get them at the table in the rest of the province if there is no money and no planning in place.
The Chair: Thank you very much.
1430
ESSEX COUNTY PHARMACISTS' ASSOCIATION
The Chair: The next group is the Essex County Pharmacists' Association. Good afternoon. Welcome.
Ms Yvonne McRobbie: Good afternoon, Mr Chairman, ladies and gentlemen. I am the president of the Essex County Pharmacists' Association. With me are Tim Coughlin, president-elect of our association; Dave Malian, president-elect of the Ontario Pharmacists' Association; and Sal Cimino, our district 11 representative of the Ontario Pharmacists' Association. We are all practising community pharmacists here in Windsor. We have been asked to speak to you on behalf of the board of directors of the Essex County Pharmacists' Association, representing the 160 community and hospital pharmacists of Windsor and Essex county. The goals of our organization are: (1) to serve the public, (2) to serve the profession of pharmacy and (3) to provide continuing education for our members.
We recognize and agree with this government's need to bring Ontario spending under control. We have, however, grave concerns that some measures put forward in Bill 26, the Savings and Restructuring Act, will not be in the best interests of the public, especially those in greatest need, seniors and social assistance recipients. We are pleased to be able to express our concerns to you at this public forum. The areas of concern that we would like to address are: (1) the introduction of copayments, (2) the deregulation of drug prices and (3) the limitation of a formal negotiation process with the pharmacists of Ontario through the Ontario Pharmacists' Association.
Copayment: Under this bill, seniors earning less than $16,000 and couples earning less than $24,000 and social assistance recipients will pay a copayment of $2 for each prescription filled. Seniors earning over these amounts will pay the first $100 in prescription costs each year per person and then the Ontario drug benefit dispensing fee of up to $6.11 per prescription.
We are concerned that the proposed system will result in the following: (a) a financial hardship to seniors on a fixed income and social assistance recipients, (b) an increase in non-compliance of medication therapy, which may lead to higher-cost health care interventions, (c) an increase of stockpiling of medications, and therefore an increase in wastage, (d) concern of privacy issues and (e) the cost to implement and monitor this program.
First of all, financial hardship: Already a community pharmacist on our board has reported being approached by one of his senior patients who is quite fearful of the impact of this legislation on his health care. This senior has an income of $16,200, which is slightly above the cutoff for the $2 copayment. He presently requires 45 prescriptions per year. Under this legislation, his medication copayment would be approximately $350 per year. If his income was $200 less, then he would only pay $90. This senior now must make a decision to reduce his income or do without some of his medication.
Residents in nursing homes are subject to this $2 copayment, also with a limited discretionary income of approximately $100 per month. These seniors must make all their personal purchases, including clothing, possibly incontinent supplies, personal care items and now prescription copayments with this income. The average nursing home resident receives five medications monthly, but it is common for some to be on 10 or more per month with chronic illnesses like Parkinson's disease, diabetes, congestive heart failure and high blood pressure. This could easily take up 20% to 25% of the residents' monthly allowance in copayments. Often in these instances the physician may require changes to dosages and drugs in order to get the appropriate medication therapy and regimen. This may become quite costly to these individuals.
Non-compliance: Copayments will not reduce the need for medication. Seniors and social assistance patients who have high blood pressure may think they do not need their medication because they feel well. As a result, if left untreated, more serious health problems may occur that could result in hospitalization and increased costs to our health care. Low-income parents of a child having a chronic illness such as asthma may decide not to fill certain medications due to cost, which may result in repeated hospitalization. Should the physician treating a patient in a nursing home be required to make a medical decision in a patient's treatment that could jeopardize their care on the basis of cost? United States statistics indicate that the cost of non-compliance is tremendous: $25 billion in hospital admissions and $5 billion in nursing home admissions.
Stockpiling and waste: The average price for medications filled under the Ontario drug benefit plan is $33.40. This consists of the cost of the drug of $27.31 and a professional fee of $6.11. As you can see, $6.11 represents just 18% of the total cost, while 82% is made up of the cost of the medication. Much of the cost to the Ontario drug benefit plan has increased due to the cost of the medication itself and the introduction of newer, more expensive drug treatments, especially for cardiovascular and gastrointestinal diseases.
It is understandable that someone who has to pay a $6.11 copayment would want as large a quantity as possible. If you look at a popular antihypertensive medication with once-a-day dosing costing $1.02 per tablet, a 100-day supply would be $108.41. The senior pays $6.11 and finds that after a couple of days he or she cannot tolerate the side-effects and discontinues the medication. This treatment failure has cost the Ontario drug benefit program $102.30. The remaining tablets will likely end up in the medicine cabinet cleanup and be destroyed. Something else will be required for the patient so another drug will be prescribed. Will this one work, or must we try a third or fourth medication? Medications are discontinued for a number of reasons, including ineffectiveness, side-effects, dosage change due to change in medical condition, and drug interaction with new drugs added to the therapy.
The Essex County Pharmacists' Association, as a public service, has conducted a medicine cabinet cleanup annually over the past 15 years. In each of the past five years we have collected 14,000 unused prescriptions for destruction, with a value of $215,000. Approximately $60,000 was paid for by the Ontario drug benefit plan. This would represent the $2 copayment for 30,000 prescriptions. This is only what was brought into our pharmacies in a two-week period. What remains in seniors' homes or in nursing homes as a total of unused medication is unknown. There are more cost-effective ways of saving this money rather than putting the burden on seniors.
1440
In this area, we applaud the government's initiative to limit quantities dispensed to 100 days and we would encourage the government to discuss with the Ontario Pharmacists' Association the concept of trial prescriptions. This would greatly reduce waste and save health care dollars. In a study in British Columbia in February 1993, a seven-day supply trial prescription program showed that over 50% of prescriptions were never filled after the initial prescription was taken.
Privacy issue: In my local pharmacy, I can see two senior neighbours coming in at the same time to pick up their prescriptions. I charge one $2 and I charge the other $6.11. Clearly, the message to them under this two-tier system is that they are in two different income categories.
Implementation: How will the government accurately determine each senior's income and have this input into the pharmacy network by June 1, 1996? How will any updates be monitored and changes implemented? What will this cost? How can seniors be sure that the right copayment is being charged? How will nursing home patients pay for this medication?
We believe this government's introduction of copayments for prescription drugs will not reduce health care costs for the future. We believe substantial savings can be realized through the introduction of trial prescriptions and elimination of waste. A more equitable program may be developed, much like an insurance plan in which seniors could join with an annual premium. If further measures were required, then consider Mr Harris's fair share health care levy as proposed in the Common Sense Revolution where individuals are asked to pay a fair share based on income.
Our local Council on Aging has asked that we express their concerns as well on the issue of copayment:
"The Council on Aging, Windsor-Essex county, is concerned about the changes being made to the Ontario drug benefit plan. The fear is that older adults might choose to extend their prescriptions by taking them less often or eliminating them, thinking that they don't feel `that bad.' This is because of the `minimal fee.' In the long run, there will be an increased cost to the health care system because those who might have been easily maintained on medications in their own homes will now be hospitalized. Seniors are the province's greatest resource and have contributed to its development over many years. They deserve the best and most equitable health care system available. This is not to ignore the difficult economic times we face, nor to underestimate the impact of the health care budget on the overall economy. We must be careful, however, to look at the full picture and decide whether pennies saved today will cost dollars tomorrow."
Deregulation: Health care costs should be fair and equitable to all Ontario residents. Under the proposed changes, the government will continue to set the price for a drug product by an agreement with the manufacturers for drugs dispensed through the Ontario drug benefit and Trillium programs. It will eliminate any restrictions on the price that drug manufacturers can charge pharmacies and hospitals for products to be dispensed to non-Ontario-drug-benefit patients. This means that independent pharmacies, chains and hospitals will have to bargain individually with drug manufacturers, and some will get better prices than others.
Is it fair for consumers in one part of the province to pay more for a prescription that others? How much is fair? Will prices go up or down with deregulation? If prices go down, wouldn't it make sense for the government to deregulate drug prices for everyone, including the Ontario drug benefit program? If prices go up, who bears the cost?
There are about 2.5 million people in Ontario with no drug insurance. Fifty-five per cent of Ontario residents have some type of private insurance. However, price increases will affect the benefit packages the employer can provide. If government by definition has the best available price for medication, why not keep this accessible to all Ontario residents?
Negotiation process with the Ontario Pharmacists' Association: Under the proposed changes, the government will eliminate the negotiation process with the Ontario Pharmacists' Association, or OPA. The government will unilaterally set the maximum professional fee for Ontario drug benefit program prescriptions by regulation.
The Ontario Pharmacists' Association represents over 4,500 pharmacists in Ontario practising in independently owned or chain pharmacies, hospital pharmacies and industry. The government has not attempted to negotiate with OPA under the present legislation. Instead of eliminating the process, we would ask that an attempt be made to have the negotiating process work for both parties. We also think that a forum to discuss other issues would help both parties. Some of these topics are cost containment, trial prescriptions, intervention programs, drug utilization reviews and drug information services.
In Essex county, we have conducted an intervention study to determine the extent and type of interventions that community pharmacists make and to estimate the benefit in economic and health care terms. In an eight-month study, 1,348 interventions were documented. Of these, 222 had a cost savings of $10,820. In Essex county, we also have formed a Pharmacy Task Force on Prescription Cost Containment, bringing together all the stakeholders -- physicians, employers, union leaders and benefit consultants, as well as pharmacists -- to explore ways of containing and/or reducing costs to employers. Employers seek us to help them with drug utilization reviews and suggestions to make their drug benefit plans more cost-effective.
Would it not make sense for government to work with the Ontario Pharmacists' Association to achieve long-term control of costs of the Ontario drug benefit program? OPA has the tools to help. Pharmacists in Ontario need a voice that will speak on their behalf in order to improve the level of pharmaceutical care to the consumers of this province. We ask that the Ontario Pharmacists' Association be that voice.
In conclusion, we would ask that you amend Bill 26 in order to: (1) eliminate copayments as proposed and utilize cost savings and, as proposed by the fair share cost levy, if necessary, (2) maintain fair and equitable drug costs for all Ontario residents, and (3) create an effective process through the Ontario Pharmacists' Association for the profession of pharmacy to have a voice in their future and that of the drug benefit program.
Mrs Pupatello: I understand from a group of pharmacists speaking yesterday that in fact no members of the Ontario Pharmacists' Association were consulted in any manner at any time prior to Bill 26 becoming public knowledge. I'd like you to confirm that, and also tell me the differences or changes you anticipate as a small drugstore, or not one of the large chains. What are the changes? What's going to impact you in terms of a business, given that the Conservative Party is supposedly in favour of business, and particularly small business? What happens to small business pharmacies when you do not have the huge buying power of the large chains and the drugs become deregulated? Of course, we anticipate that drug prices go up. What kind of pressure are you under to absorb that copayment so that your clients are coming back to you etc? Would you comment on both?
1450
Mr Dave Malian: Yes, I can do that. We did meet with the Minister of Health back in September, and at no time during our discussion with him did he indicate to us what changes were going to be occurring to the Ontario drug benefit program. As a matter of fact, he indicated to us that he was very supportive and he would like our help in decreasing costs. We were not consulted at all regarding these changes.
On the question about smaller pharmacies, I don't know. I don't think anybody really knows. The concern we have with deregulation of drug prices is that the independently owned pharmacy in Wawa, Ontario, may not necessarily have the same price advantage that the pharmacy in London or Toronto would have. So we're concerned about some of those smaller independent pharmacies having that same type of competitive advantage.
Mrs Pupatello: I'd like to put those same questions that you've asked on the table so that we may get answers from the minister: How will the government accurately determine seniors' income and have this input into the pharmacy network by June 1, 1996? How will any update be monitored and costs and changes implemented? What will this cost, and how can seniors be assured that the right copayment is being charged? How will nursing home patients pay for these medications?
Those are such valid questions, I'd like to have those tabled and a response from the ministry as soon as possible.
Interruption.
Mrs Pupatello: Oh, I think they had lots of discussion with that group. Thank you.
Mr Crozier: I'd like to go a little further into deregulation. I'm concerned about those who have been emphasized and what it's going to cost seniors under the Ontario drug benefit plan, but what about all those people out there who aren't covered by a drug plan, who may be seniors, who may be the working poor, and what deregulation may do to them because they don't have the Ontario drug benefit plan to bargain for the cost of their prescriptions? Where do you see deregulation going, in your professional opinion?
Mr Malian: We're quite concerned that we think deregulation will increase drug prices. We think that if the government felt the same way, then they would have deregulated the prices on the Ontario drug benefit program too.
Mr Marchese: I want to thank the group for the submission and the number of suggestions that you have made. I know that in Peterborough a number of pharmacists have said very much the same thing in terms of what it would do under the whole issue of user fees, for example. You outlined and defined six areas where you have concerns, and I hope the government members will take that into account.
Also, I'd agree with your conclusion that "Instead of eliminating the process, we would ask that an attempt be made to have the negotiating process work for both parties." It's my belief that when people are working together, we have better solutions, and that when governments act unilaterally, we have problems, not just for yourselves but for everybody else affected.
You raise an interesting issue about trial prescriptions which interests me. Would it mean that if you give a prescription for seven days, the individual doesn't have to go back to the doctor and you would fill them automatically, or would they have to visit a doctor again?
Mr Malian: No. The whole point of trial prescriptions -- and we do have studies, as Ms McRobbie has indicated, that have been going on here in Canada, in British Columbia. In the trial prescription program, a physician would write a prescription and the pharmacist would only fill a week's supply. It gives the patient some time to adjust to the medication and also to find out whether the medication was helpful. If the patient didn't feel comfortable, then they certainly can go back to their physician and another medication would be chosen. If after seven days they're feeling good, then the complete medication would be filled.
Mr Marchese: I understand, yes. I personally find that very attractive. My mother is 84 years old, and I know often doctors prescribe many pills. She takes them, takes them home and sometimes realizes the effect of it is either good or not good and she may not take them any more. So we have a whole load of wasted pills. I think it's a very useful suggestion to pursue.
You didn't comment on other areas of this document that I know you might have wanted to; I'm not quite sure. I appreciate that you covered areas of interest, but is there anything in this document, Bill 26, that you want to speak to generally with respect to whether it contributes to the betterment of our health system or not?
Mr Malian: We found it difficult to just take the pharmacy portion of that document and try to understand that. But we have concerns, as a citizen of Windsor, of the whole Bill 26. Yes, we do.
Mr Marchese: It's a very good point again and it brings me back to the comment the doctor made in Peterborough, again, when asked a similar type of question. He only understood a third, I believe he said, of this entire document. This man is quite literate. It obviously means there's a hell of a lot of incomprehensibles here, meaning people need a great deal of time to understand them. The fact that they're so complicated makes it impossible for people to participate.
Thank you for your submission.
Mrs Johns: Thank you for your presentation. I don't know if you were here when I asked the last question, but I asked one of the previous presenters about the delisting of drugs from the formulary. I'm sure that many of you were pharmacists in 1993 when the last delisting happened. Can you comment on the effect of the delisting that happened in 1993 with your clients, which basically implies a 100% user fee, versus $2, when considering taking drugs less often or eliminating them altogether from their portfolio of drugs that they take?
Mr Crozier: Because they're going to put them all back on.
Mr Malian: Sorry. Can you just repeat that for me again? I'm sorry. I want to make sure. We're talking about delisting of products from the formulary that's been occurring since the program first began, not just in 1993.
Mrs Johns: It's happened a number of times; that's right.
Mr Malian: The formulary is an ongoing process.
Mrs Johns: So one of the things we could have done was we could have delisted drugs off the formulary and not charged the copayment. What we did was we decided to charge a copayment. In your statement you suggested that their taking drugs less often or eliminating them would be one of the results of the $2 copayment. I want to know if that was a result of the delisting also.
Mr Malian: No, delisting's been going on since the program began, back in the early 1970s.
Mrs Pupatello: The Davis era.
Mr Malian: The program is an ongoing program. Products are delisted and added to the program consistently. So whether it's 1993 or 1980, drugs have been added and brought on, and that will not change. Now, whether you delist more products -- then you might as well not have a formulary any more. They've delisted enough products now that the formulary is actually quite small in comparison to community-based formularies.
What I'm trying to say is that delisting has been going on since the day the program began. We've added drugs and we've deleted drugs, or the government.
Mrs Johns: Do you want to add to that?
Mr Sal Cimino: Yes. Dave makes the right point. A lot of the deletions were not to save money. A lot of them were because drugs have changed. We've got new drugs. Why use something old that doesn't work as well?
In today's formulary, I think the last deletions, on a personal view, were done very well in the sense that lifestyle drugs were hit somewhat, where you're taking a drug three times a day now rather than when it was once, but that was a bit of politics and a bit of savings of money. Just a few of those happened. The other ones were basically because the drugs are new that were developed, and they work much better than the ones that were developed 30 years ago. That's why the deletions occur. It may cost more, because developing a drug today is a hell of a lot more than it was 30 years ago.
Mrs Johns: I just want to ask you a question about the medicine cabinet cleanup. Every place we've been, people have talked to us about it, collecting lots of unused prescriptions, $215 million I think you said.
Ms McRobbie: Thousand.
Mrs Johns: That's $215,000 brought in during two weeks. If we went to a trial prescription like you're suggesting, you've outlined what's good about it to the consumer of the product. Can you outline the cost there would be to the taxpayer for that?
Mr Malian: Under this present legislation, we know if this goes through you won't have anybody to speak to on this, okay? If you're interested in trial prescriptions, then I hope the negotiation process with the Ontario Pharmacists' Association will be able to continue, because if not, you won't have anybody to talk to about it.
We feel trial prescriptions can save costs in the long run for the taxpayer. BC has an excellent pilot program out right now and studies are coming back right now showing a considerable cost. If you'd like, we can get that kind of information for you. We've asked. We've told the minister we have that information, and so far they haven't looked at it, I guess.
The Chair: Thank you for your presentation this afternoon. We appreciate your interest in our process.
While our next presenter is coming forward, we're going to have just a quick three-minute recess.
The committee recessed from 1500 to 1503.
FRED NETHERTON
ART KIDD
The Chair: Folks, if we can get back to the table, we'll listen to Dr Netherton, our next presenter. One of the dangers of a recess is that it takes a little while to get things back under control, but we're almost there.
Dr Fred Netherton: Thank you for allowing me to speak today. I'd like to start by saying that I did meet Mike Harris about three years ago and I was impressed; I thought he was sincere and interested in Ontario. But I don't agree with his bill. I agree that Ontario has some problems and some changes are necessary. I also understand that the government wishes to get the bad-tasting medicine out of the way early so they can bring on the sweets in a few years. However, I do not agree or understand why the last 30 years of progress have to be destroyed to accomplish this.
In reading excerpts from Bill 26, the most often heard phrases are "the minister would have the power" and "no right of appeal." The bill contemplates all power at one point, with no right of appeal, no assurance of job security and no due process of law.
I was born and raised in Ontario and always felt that the government was here to serve the people, not the people to serve the government. Ontario is a diverse province with problems varying with the different areas. In Essex county, we have made great strides in improving efficiency and saving money in the health care system while maintaining excellent patient care. Since 1991, the hospitals and physicians have restructured health care in Essex county. We have gone from about 1,200 beds down to the 700 range with no loss of programs. This has only been possible because of cooperation and trust between the hospitals and physicians. I feel that Bill 26 will certainly destroy this spirit of cooperation.
As a radiologist, I have three specific concerns. The first one is concerning the Independent Health Facilities Act. X-ray offices are independent health facilities. We are inspected twice a year for X-ray safety and every five years for everything else. We are like a hospital that has an accreditation inspection, only our inspections are not voluntary. I feel we are overregulated as it is.
To set up an X-ray office takes anywhere between half a million and one and a half million dollars and can employ up to 20 people. It's very labour-intensive. This is a very large commitment to make if there is no assurance that you can stay in business after the end of the year. With Bill 26, any office can be closed at any time with no right of appeal -- always with no right of appeal. It is reasonable to close facilities that are a danger to patients or that are substandard; it is not reasonable to dangle my livelihood on a political fishing line that can be cut at any time.
Not only will Bill 26 close facilities for any political or non-political reason, but it will allow the minister to have any specific person open any facility anywhere the minister chooses.
Taken together, this sounds as if we'd better get one of my partners involved with each political party to try and cover our bases. These changes will obviously lead to open political patronage, as far as I can see. I would suggest that clinics be opened or closed only on medical grounds: medical safety to close them, medical need to open them -- nothing else.
The section on removing limitations on foreign for-profit operators is also a great concern. Right now, 50% of outpatient X-rays are done in private offices. I feel the government probably could get the job done cheaper if it did contract all outpatient services to an American, for-profit HMO, but the foreign firm is going to have to make money. I think they make about 30%, though I may be wrong. So what are they going to do? They're going to demand the closure of existing offices, which the minister can do with the existing legislation. This would produce great hardship on physicians but also on the hundreds of secretaries, receptionists and X-ray and ultrasound technologists we employ. HMOs from the States do not hire the same numbers back again. They would probably do it with about 50% of the number we use. There goes a large number of jobs. The other large group to suffer would be patients. Convenience, with local and rapid diagnosis, would definitely be lost.
I would expect a Conservative government to help private enterprise, not kill it. Why would anybody want a foreign firm to take money out of Canada, and why would you want to kill jobs that keep the money and taxes in the community? I suggest that the preference for non-profit Canadian operators be maintained.
The third concern is over the necessity for a specialist to be affiliated with a facility. I'm not really sure on my reading whether this means it has to be a hospital. If it does, it's going to create a problem. Twenty per cent of Ontario radiologists work only in private offices. Actually, in Windsor, there are five groups with private radiological offices, and only one has a hospital affiliation. Patient care would not be served by forcing these doctors to work under the auspices or at the convenience of hospital administrators. With the powers of the College of Physicians and Surgeons watching us and ordinary market forces, I feel confident that so-called specialist affiliation will not add anything to medical care and should be dropped.
I'd like to introduce Dr Art Kidd, who also has a few comments, and then I have a few at the end.
Dr Art Kidd: Thank you for allowing me to speak today. I wish to comment on a few general aspects of Bill 26, the Savings and Restructuring Act.
To introduce myself, I am currently an endocrinologist who has been practising here in Windsor, my home town, for 15 years. I have been chief of medicine at both the Salvation Army Grace Hospital and the Hôtel-Dieu Hospital for a total of eight years. I have served on and chaired virtually every possible committee at those hospitals, and I have been the chairman of the research ethics committee for the local cancer foundation for five years. I am the former president of the local Academy of Internal Medicine, and I am the immediate past-president of the Essex County Medical Society, which represents over 400 physicians.
My appearance today is simply further evidence that I am committed to quality health care in Windsor, Essex county, Ontario and Canada. I am here because I believe that many elements of schedules F, G, H and I which impact on the provision of health care will undermine the health system it is intended to improve.
1510
It is not my intent to reiterate in any detail the many concerns that physicians have with Bill 26. You have already heard many times about our fears for the confidentiality of our patients' charts, fears about interference with the patient-doctor relationship, fears of bureaucratic second-guessing of physician practices, fears of absolute ministerial control of hospital or physician services and fears about the intent to repudiate previous collective agreements with the Ontario Medical Association, to name just a few.
I would like, however, to provide some local perspective with regard to these issues. This community, through its district health council, has been engaged in a process of voluntary reconfiguration of both hospital and community health services to improve efficiency. This has been a long and difficult process and much has been achieved through the strong efforts which have required mutual trust. The Essex County Medical Society has taken an active role in promoting these changes because we believe in promoting efficiency and cost savings for local health care. Incidentally, we do 95% of all health care right here in this county.
The Essex county society has concerns, however, that the new ministerial powers granted by this act would threaten the cooperation, as different institutions would see it to their advantage to gain favour with a minister who is able to unilaterally determine which hospital or organization will provide which services. The minister could also designate which physicians could work at a given site, effectively negating the importance of local experience and expertise.
The concept of remote manpower decisions is especially frightening in light of our experiences during the reconfiguration process. Repeatedly, we have noted locally that data emanating from the ministry and other consultants are badly flawed and do not accurately reflect Essex county situations. In virtually every situation, the data overestimate the number of physicians working in our county. Some of these errors are understandable and forgivable, but some are incomprehensible.
I may occasionally make a mistake in counting, but as someone with 25 years of experience in medicine and someone with six kids, I think I can accurately estimate the gender of each and every one of my colleagues. With this in mind, I have been unable to find in my county the female obstetrician, the female ophthalmologist, the female otolaryngologist and the second female general surgeon who are listed as practising with me, according to central Ontario reports, but I have not yet resorted to surreptitious surveillance of the surgeons' changeroom.
On a more serious note, these same statistics indicate that there are over 230 physicians doing family and general medicine in Essex county. Our Essex County Medical Society would estimate, with reasonable accuracy, that the maximum number of such practising physicians would be about 175. That's a number far below the recommended standard of 241. Our new county residents know this by the difficulty they experience in finding a family doctor upon arriving here. Similar difficulties are experienced by established residents who lose their existing physicians through retirement, death or, most commonly, through relocation to the United States. The faulty data used to make manpower distribution decisions from afar could create a disaster. Local physicians have always worked to lure appropriate generalists and specialists to fulfil local needs. Now that role would be totally frustrated.
I would respectfully remind the committee that other parts of Bill 26 have received praise for the transfer of powers and responsibilities to more local government. I therefore find it appalling that in the critical area of health care Bill 26 shifts incredible powers away from the local, responsible bodies to the Ministry of Health, where there is real potential for their misuse, either inadvertent or deliberate, in the absence of local accountability.
A further concern I have is that schedule I proposes to eliminate all previous and existing government-OMA agreements. In that scenario, the government would be in clear violation of the accessibility provision of the Canada Health Act of 1984, which mandates that medical practitioners must be compensated via a process which includes negotiations with a dispute resolution mechanism. If schedule I comes to pass, what am I, as an honest Canadian, to do? Which level of law should I obey? Will I be forced to go outside an apparently illegal system? Difficult choices lie ahead.
Lastly, I would like to comment on a report which I heard on the CBC news today, and I admit it may be inaccurate, but it was indicated that there was an offer to sunset the law after four years, presumably after completion of the government's goals. I must protest the hypocrisy of this approach. If this is a good law, then it should be a good law in the hands of any government. Rather than establishing a sunset for this law, I would suggest that it not be allowed to see the dawn of day.
Dr Netherton: I'd like to continue. My largest concern as a physician basically is the castrating of the OMA. With the bill as it stands, the OMA would not be able to negotiate with the government on behalf of the doctors of Ontario. The statement, "Trust me, I'm from the government, I'm here to help you," is meant as a joke. I don't believe it, and I don't think many people across society believe it. The government cannot decree from on high where I should work, how much I should work and how much I should be paid. That is the Communist way, not a Conservative way.
I hope that doctors are finally angry enough that they will not let the government split them into many small factions to be devoured or fed to the wolves as they see fit. I'm not a negotiator and I have limited time for family and non-medical pursuits. I can't negotiate a salary with government. I think maybe it's time we have to talk to CUPE or maybe the CAW.
The government really can't believe that it can govern by decree and get the so-called best bang for the buck. This keeps going through society. In the 1950s, a doctor of mathematics actually, Dr Demming, was laughed out of America and went to Japan. There he showed that to make a strong, efficient, profitable company, the workers had to tell management what was the most efficient way to perform the job, and look what happened in Japan.
The government's biggest asset in producing a viable, effective health system is the health care workers, if they'd only listen. Sometimes they think they listen and dump an area of responsibility on them. Suddenly we are responsible for a new area, but they forget to give us any power to accomplish this. The best example is the past government and the social contract. It made doctors responsible for utilization, but they refused to give doctors any power to control utilization. Decrees from above without worker input equals a mess. Responsibility without power equals frustration. We are either partners in health care or we are adversaries in health care.
The government may have the best interests of Ontario at heart, but I don't feel that Bill 26 will work. There's too much power. Personalities, greed and human jealousies will all undermine any good intent unless safeguards are built in. After passage of the bill, the powers -- we've already gotten through that, so I'll skip that if I may.
If the bill passes as is, it will really only be one more slide on the downward slope medicine continues to take. I, as a physician, can ensure that my mother will always get a CAT scan when she needs it. My children, my grandson, as well as Mike Harris's family, will always be able to see specialists when they want to. The majority of Ontario citizens, however, will have to put up with longer lineups, more rationing and outdated care.
One of my four children happens to be extremely intelligent, I think. He has always talked about going into medicine as his field until about a year or so ago. Now he doesn't talk about it any more. I think he's so intelligent that he's changed his mind. He will now find a new area to excel in. Not only are we losing existing doctors but the best new ones will never be. The sad part is I feel that the people of Ontario will continue to accept whatever government gives them for free and will never know how good medical care could have been.
Mr Marchese: Thank you for your presentation. I know there are a lot of areas to cover, and you covered quite a few. I want to ask one question on the issue of billing number restrictions. You talked about it briefly.
I recall the members of that government introducing Bill 7, which repeals the Employment Equity Act. They said it was a very draconian act, that the job quotas contained in that were abhorrent to them. What they're doing here in this area is very authoritarian, very draconian. In fact, the cabinet and the minister have the unilateral power to force a doctor to practise in a particular geographic area, to prevent physicians from practising unless they agree to perform services specified by the minister, and it imposes numerical quotas, determining how many physicians can practise in a particular geographic area.
1520
We think these matters should be settled with doctors by negotiation. What they're doing here through this is not negotiation, and it moves from a democratic process to an autocratic one. You may have commented on it, but I'm not sure whether you would like to add some more in that regard.
Dr Netherton: If I may, I agree. I feel that the problem with underutilization or doctors not being where they're needed runs to seeing responsibility without power. I would suggest that the government tell the OMA: "We have a problem. I want you to solve it. I'll give you the powers that you need to solve it." But you can't ask us to solve a problem without having the power. I think that we could do it, and a lot better than they're suggesting.
Ms Lankin: I do appreciate your presentation. I know that from time to time over the years, with various governments, there have been points of contention between the medical profession and government, but I don't believe I have ever seen the medical profession both so angry and so demoralized as the tone of the presentations that I've heard during the course of these hearings. In part, I don't think it's helped by the government putting out propaganda like this that says, "Ten Great Things about Bill 26 that You Won't Hear from the Vested Interests." Gentlemen, I suggest they're talking about you and other presenters who are coming forward who are criticizing them as being vested interests.
One of the things I know about the medical profession is that to a large degree, particularly in hospital settings, they are patient advocates, and I want to ask you about the process of revocation of hospital privileges. We know under the bill, where a hospital closes, that there's an absolute right to revoke, and under the old legislation there's a very complex set of reasons for revocation and appeals of that. In a sense, it's to ensure that the CEO doesn't have unilateral power over hospital privileges and that doctors who speak up and who rub CEO the wrong way can't be just dismissed.
In the new legislation, under regulations, there's a provision that the minister can set out any other circumstance in regulation he wants that can be treated just like a hospital closure and in which all of the protections in the act wouldn't apply, and that he can set out by regulations what procedures would apply. I don't know what those circumstances are going to be and/or what procedures he's going to put in place. Does the OMA know? Have you been given any information? How do you feel about the fact that if you speak up, you could be next on the chopping list?
Dr Kidd: If I may be allowed to reply, I find that particular aspect of the bill frightening, as I said, even on a personal basis. It is the role of the physician to always be his patient's advocate, and sometimes that patient is a singular person and sometimes it represents a group of persons with a common problem.
One can envision through this situation that they've set up, where the hospital must provide a roster of physicians that meets the minister's approval and that there is the ability to unilaterally take away privileges when it meets the interests of the public, that the physician would be afraid to be the advocate within the hospital setting if that physician's livelihood rested with his hospital privileges.
The best example I could come up with off the top of my head would be if a new orthopaedic surgeon advocated the use of a better but more expensive prosthesis. He might advocate this to the point of making angry the bean counters in the administration office and, lo and behold, a new manpower study may show that they don't need quite as many orthopaedic surgeons as they used to and therefore the young advocate suddenly loses his privileges and his ability to practise in that hospital, and perhaps that town.
Mr Clement: Ms Lankin on occasion astounds me. When she said that doctors should be patient advocates, it was her government that instituted the Advocacy Act, as we all know. So I think we are seeing a shift in position with respect to that.
Ms Lankin: I don't think so. Mr Clement, I can speak for myself.
Mr Clement: I know you can, Frances.
Can I just get back to what I see as a fundamental dilemma that you are facing and, if I can be so bold as to say, I as a Conservative looking at the system face as well. If you came at me and argued, as you have done, that there should be greater say of the providers in terms of utilization, push it down from the bureaucracy, push it down from government, down into the community, down into the patient-client relationship, you know what? I agree with you, although nine other presenters here today don't want to see any such radical shifts in the health care system. They like the status quo when it comes to that sort of relationship.
Mrs Pupatello: That's not fair, Tony.
Mrs Caplan: That's not true. That's an unfair categorization.
The Chair: Mr Clement has the floor.
Mr Clement: I'm being provocative again. I apologize. But I guess my question to you is, that's one point of view that is a pressure on the system which is knocking us off the status quo. But there are other people -- and I as a Conservative also understand this point. If I had my way, if we could run a perfect health care system without the government being involved, believe me, that would have my vote. But given that there's a consensus that the government should be involved, I as a Conservative also want to act on behalf of the taxpayer. You know, it's the taxpayer who pays your salary. It's the taxpayer who collects your bills. It's the taxpayer who ensures that the system runs, because people wanted the government involved and we represent the taxpayer. That's what government does. So how can we reconcile your point of view that we should be pushing down, you should have some control over utilization? That's what you said. How do we reconcile that with my responsibility as an elected representative to the taxpayer who pays the bills?
Dr Netherton: I think you're right; I advocate from the bottom up. If you read any of the CQI or TQM or whatever all those things are, you don't tell a worker how to do it; you ask him how to do his job efficiently.
Mrs Caplan: Exactly. Quality management.
Dr Netherton: What you've done with this bill is, it's too large. You couldn't ask the workers, you couldn't ask the bottom line to submit changes and improvements in five years. It's just too big a bill. You're trying to change too many things. The way you're going about it, I don't think you're going to be able to do what you want to do.
What you want to do is improve the system. Unfortunately, you have to take somebody's advice, and I think that somewhere along the line you've gotten bad advice.
Mr Clement: Fair point.
Mrs Pupatello: I have a quick comment to make before I address your question.
Mr Clement needs to understand what city he's in today. For him to suggest for a moment that the people who presented here today are in favour of the status quo -- you've got to be kidding.
These people from the city of Windsor have been looking for change for years, have been working towards change, and your government has let us down. We do not want status quo, and for you to suggest otherwise, that is just inappropriate behaviour on your part.
Mr Chair, you've got to keep these members contained in terms of their attitude as well.
In terms of you representing the taxpayer, you had 37,000 people at Queen's Park on Saturday. Those are all taxpaying people. Does that mean you're going to reinstate the $400 million you've lobbed from education? I don't think so.
Mr Clement: Do you have a question for the presenter?
Mrs Pupatello: I certainly do.
Mr Clement: If you want to carry on a debate, we'll do it afterwards.
Mrs Pupatello: The point is that you are representing taxpayers and these are taxpayers. Just remember who really are the taxpayers here.
I'd like to ask a question for those who presented, very quickly. We're concerned that you're going to have potentially the minister's ability to just shut down the radiologists' facilities. There's another way to close you down, and that is by changing the levels of payment, because the bill also allows for the minister, with no medical support, to make decisions that determine what fees should be paid. So you'll have death by a thousand cuts: You'll just continually get paid less and less for the various services, so it'll just run you out of business and allow the Americans to set up posts here, which is a quiet way to put you out as opposed to shutting you down. I submit that this government has been, above all, brilliant in political strategy, and that is where you're going to see the changes coming. It's going to be that death by a thousand cuts, because they'll implement their own social justice and morality by changing levels of service. That was pointed out to us yesterday as well. Do you have a comment?
Dr Netherton: I have a quick comment. I think medicine has been dying the death of a thousand cuts since I got into it about 30 years ago. This is just accelerating the procedure. I agree, but I they could have shut X-ray offices down for many reasons at any time with the existing legislation and the rules they have. They don't need more.
The Chair: Thank you very much. We appreciate your presentation and your interest in our process.
1530
ESSEX COUNTY MEDICAL SOCIETY
The Chair: The next group is the Essex County Medical Society, represented by Dr Ian McLeod.
Dr Albert Schumacher: Mr Chairman, ladies and gentlemen, thank you for giving us the opportunity to present to this committee on behalf of our colleagues, the members of the Essex County Medical Society, and our patients, the residents of Essex county.
I'm a general practitioner in Windsor, a member of the society, as well as a member of the board of directors of the Ontario Medical Association. With me is Dr Ian McLeod, president of the Essex County Medical Society.
For the past seven weeks we have been intensively studying the proposed legislation, with great difficulty, due to its scope and severity. Its effects are far-reaching and, we believe, extremely detrimental to the health care system we have helped to build in Ontario. I'll ask Dr McLeod to address his concerns before making some recommendations.
Dr Ian McLeod: The very first thing I'd like to open with is to say that I do represent a special-interest group. Do you know what that interest group is? The people of Essex county. I have some prepared remarks and I have some extemporaneous remarks I want to make.
I wrote an article for the Windsor Star and I'd like to read it into these minutes, if I may.
"On November 29, 1995, when Bill 26 was introduced, few of us could have envisioned the depth and breadth of the changes proposed. If passed, the bill will vest the government with unconstrained powers, allowing them to rule by decree, often without opportunity for public scrutiny, debate or even input from the community or local stakeholders.
"This is being done under the banner of fiscal responsibility and more efficient government, but is inherently dangerous since these powers are broadly granted without conditions traditionally provided to ensure political accountability and effective recourse through the courts.
"From the medical perspective, it is lamentable that their solution, in addressing real health care delivery problems, damages what is good in the system. The astonishing new controls proposed over physician mobility, remuneration and practice patterns will adversely affect patient care."
Some examples, if I may. I've got to tell you that there may be some repetition here, but it's because we all arrived at the same conclusion in our own different ways.
"Physicians could be asked to personally pay for the cost of medical tests and specialist consultations, if some bureaucrat deems specific care to have been medically unnecessary." I asked the people of Essex county: "What will that do to your `complete' physical and preventive disease management such as mammography? What if you want another medical opinion?"
This moves us back decades to a time when the cost of a test could be more important than the patient's needs. Our system is the envy of the world, where doctors can take care of patients, thinking only of these needs. I think the people of Ontario would find it offensive that anyone would be personally responsible for the cost of medical tests under the guise of being medically necessary.
My first question is, what is the definition of "medically necessary"? Is it the preservation of life? I would think so. Is it the prevention or detecting of disease? I would hope so. But what if it's done just to relieve anxiety, to offer reassurance? Medicine is not just a science, it's an art. It's called the healing art.
What about that terrified 35-year-old female who comes into my office? She perceives a breast lump. I may not agree. I try to give her my reassurance, but I look in her eyes and I see the terror; her mother may have had breast cancer. And I do what I'm supposed to do -- I practise the healing art. The healing art in this case means ordering the mammogram, and although it may be deemed medically unnecessary in the sense of some plugging in of a scientific formula, it is part of medicine. We deal with patients in a holistic manner. It isn't just an organ I deal with; it's the person with that organ. And damn it, as long as I am a physician, I am going to treat people in a holistic manner and I am going to order that mammogram.
"It is proposed that no new physicians be allowed to set up medical practice in a `well-serviced' area. (Historically, Essex county has been incorrectly labelled well-serviced.)" It's been pointed out that there's potential here that no new physicians may come.
Fleshing out Art Kidd's speech, we appear to have three neurosurgeons on that list. In reality there are only two. That female obstetrician he couldn't find; she left four or five years ago from the Leamington area. It's my opinion that having been dealt with in the past as a well-serviced area, and with my perception that this government doesn't listen, there is a grave danger that this false impression will be continued.
"Malpractice copayments are to be cancelled. This tradition was started about a decade ago instead of a pay raise." Do the people of Essex county know "that the income generated from the first 120 babies delivered will just go to pay an obstetrician's malpractice insurance? Most rural obstetricians only deliver about 120 babies per year, rural family doctors even less. The implications are obvious."
When I started medicine in 1974, the malpractice insurance for family physicians and specialists was $50 per year. By 1986, an obstetrician was paying $4,900 per year. This year, he will be asked to pay $23,340 per year. When I started delivering babies, I got a little under $200 in the mid-1970s. Now the fee is $240-odd. It doesn't keep pace with the times, does it?
What about an orthopaedic surgeon? He will be asked to pay $22,440; a neurosurgeon the same. We're small business people. We have to ask ourselves, can we afford to offer the service? What a terrible position to be put in, to decide whether you can afford to offer a service. This is not why we came into medicine.
"Hospital-based physicians (surgeons, anaesthetists) could lose hospital privileges without reason being given or legal recourse."
Again, this has been given very vocal and clear direction by Dr Arthur Kidd ahead of me. I could only re-emphasize one or two things. By putting a specialist in a position where he may lose his ability to earn income and feels threatened by an administration forced to balance budgets, there is a double whammy. It is proposed in this bill that billing numbers for specialists be tied to hospital privileges or institutional privileges. In other words, the possibility exists that a specialist may be unable to practise medicine, particularly if he makes too much noise. Ladies and gentlemen, welcome to the feudal system of the 20th century. This is a 13th-century, medieval mentality.
"User fees on senior citizens for their drug use. This is one area where economic issues must be tempered with compassion. No Ontario citizens on fixed incomes should be forced to decide if they can afford medication."
1540
This bill states that if you earn $16,000 a year, you pay $2 for a prescription, and $2 and $2 and $2 and $2, and it will all add up. Should we be putting people in a position where they may have to make a choice between rent, medication and food, even if it is tuna? There's another level here too. What about that group of people, low-income, perhaps working part-time, no benefits, no drug plan? What a wonderful time to bring in the deregulation of drug costs. Thank you very much.
I'm not done. That comment was directed towards the government.
"Disclosure of confidential medical information." This has been well worked over by previous people, but I'd like to point out a couple of facts. First, the government has stated it needs this in the bill so it can monitor physicians to make sure there's an appropriateness between billing and service rendered. Well, I humbly submit that there are plenty of long-standing regulations in place between the College of Physicians and Surgeons and the monitoring agencies of OHIP to deal with this. If that was the major reason, why did they slide in that other little phrase, "and for release of information for any other purpose prescribed by cabinet." Wow. Where will that lead us all?
Lastly, one that really, really concerns me is taking our fee schedule away from the OMA. Traditionally, the pot has been set up so that we internally decide what a hip is worth, what a cataract is worth. The minister will be empowered to dip into the schedule. This probably doesn't sound like much, but's going to allow him to use the schedule as a tool for social policy. Think about this. If some government, maybe not this one, feels there's not enough access to abortion, he could increase the fee. If, conversely, he felt there was too much access to abortion, he could reduce the fee to zero. I'm not taking one side or another on this issue. It's a very controversial issue. What I'm saying is, should any minister, any government, be given this type of power?
"The above is only a partial list of my concerns regarding Bill 26 and its effect on patient care.... Suffice it to say, if passed in its present form, this bill decertifies our `union,' the Ontario Medical Association, by taking away representation rights, cancels contracts, eliminates grievance procedures, allows termination of employment without giving cause and bans legal recourse."
Would the CAW put up with this with the Big Three?
"It is a black day when any government elects to fracture the traditional agreement processes between patient, doctor and government in the management of health care and elects to go it alone.
"Mike Harris has sadly forgotten that evolution is healthier than revolution," and has given a whole new meaning to the term "code blue." Thank you for allowing me to present our case.
Dr Schumacher: In response to the call from the opposition this morning for someone to do work on recommendations and amendments, we've put a little head time into this. I'm going to give a little preamble, and I'll make specific reference to schedule I. The medical association in the past has been able to negotiate agreements with all sorts of governments. In fact, we negotiated not less than five agreements with the NDP, and as difficult as that was, we managed to do it. We have been trying to do that with this government and have been unsuccessful.
There are five pieces of legislation that will be affected by the Physician Services Delivery Management Act, schedule I. These include the 1991 OMA-government framework agreement of April 1991, the 1993 OMA-government interim agreement and the physician sectoral agreement of August 1993.
As a result of these agreements, physicians have helped to decrease OHIP utilization from the double-digit range of the late 1980s to the 3% range per year. Three factors that raise these costs and that continue to go on must be kept in mind.
The first is that the population of Ontario increases by 1% every year, mostly through immigration. It is not my colleagues and I having these children; they're put upon us. And they're usually not children; they happen to be adults and they have their share of health problems. The second is the increase in availability of new technology, such as MRI scanners, mammography, bone density scanners and laparoscopic technology, which again accounts for an increase of 1% a year. The third is our aging population, which again accounts for a 1% increase per year.
Physicians have lived up to their obligations in paying for this, including the clawback which currently runs at 10% of our billings.
The government has unfilled obligations, which have been successfully appealed and subject to orders by the referee of agreements to give back to the OHIP pool $30 million, plus $1 million a month, for just one of the ongoing violations.
The government wishes to rid itself of its obligations while keeping the bad parts. It does not even wish to live up to court awards to the generic drug manufacturers. Are the bondholders going to be the next told that the government will not live up to its financial obligations?
The OMA does not believe that any group in society is prepared to exist totally at the whim of the government and to have no ability to represent itself to the government and be recognized. Agreements which are entered into in good faith should be respected.
We urge the government to continue to recognize the OMA as representative of Ontario physicians. We believe that the government should be willing to enter into agreements and to honour and abide by them.
Speaking now on behalf of the president and the board of directors of the Ontario Medical Association, I recommend the following amendment to schedule I. This does not in any way imply endorsement of schedule I or any other aspects of Bill 26.
The recommendation is to replace all of the current wording with wording that would incorporate the following principle:
We would like to see the existing agreements in subparagraphs 1(2)1i, ii, iii and iv of the schedule to be terminated only upon negotiation and execution of a new agreement by the OMA and by the government of Ontario which would replace the said agreements.
We continue to work intensively and will be presenting other amendments to this committee at other opportunities, albeit limited, during the coming week.
Mrs Ecker: Thank you very much, doctors, for taking the time to come forward today and bring forward some suggestions. If I understand you correctly, you have some concerns about the OHIP general manager's powers to make a decision about "medically necessary."
Dr Schumacher: That's right. That's absolutely correct.
Mrs Ecker: How is it done now under the Health Insurance Act?
Dr Schumacher: Medically necessary services have been largely unchanged under the act and the fee schedule for many years. They came up to a review. In fact, there was a delisting panel that looked at a number of recommendations during the last government which removed a small number of services, probably to the tune of about $12 million.
Mrs Ecker: I'm not taking about the delisting exercise. I'm talking about the general manager of OHIP deciding what's medically necessary in terms of payments.
Dr Schumacher: Currently the general manager of OHIP does not have a purview to decide what is and what isn't medically necessary.
Mrs Ecker: Well, it says here in the Health Insurance Act, "General Manager...all or part of such services were not medically necessary." There is that "medically necessary" phrase in the new legislation. You can make an argument that the general manager shall refer the matter to the Medical Review Committee at the college, which you've mentioned, to determine medical necessity, but the college has told us that the Medical Review Committee as currently structured is not working. They have suggested that we need to look at some changes and to try and streamline and make that process better so that it can go after difficulties.
If we were to streamline the Medical Review Committee in some fashion so that we don't get physicians tangled up there for two, three, four and five years, would that help to address some of the concerns that you've talked about with the general manager?
Dr McLeod: In terms of a philosophical point of view, we have no problems with peer review, and that is the bottom line. But we want it to a be a peer review.
Mrs Ecker: Okay. Do you support the activities of organizations such as ICES?
Dr McLeod: Absolutely.
Mrs Ecker: How would you advise the ministry to share health information with organizations like ICES to do the good work they do without the minister having the power to make agreements to disclose information?
Dr Schumacher: I believe that since its inception by the last government and the OMA, ICES has gotten off to a good start and has been working very well, and I believe that the results that have come forward already, the ankle study, the hypertension guidelines and other things that have been put forward, have been done independent of the current government.
1550
Mrs Ecker: There is also some power of agreement for previous ministers under the Health Insurance Act to collect, use and disclose personal information. But as I understand it from people who are in the field who want to expand the ability of the system to manage better, to do more outcome measurement, we have to make sure that we're collecting it from all the facilities out there that are providing health care. The experts tell us we need to do that, and I guess the question is, how do we do that and have that information available to make better clinical outcomes and judgements without sharing or having access to information in some manner?
Dr McLeod: There is no argument that there are areas for improvement in the science of medicine, and we would all agree there are clinical guidelines that have to be put in place, when to order thyroid, blood tests and so on. What I'm trying to bring out in my presentation is that there is more to medicine than just simply the science --
Mrs Ecker: I'm well aware of that, very much so.
Dr McLeod: -- and that there is a danger of being penalized for practising the art of medicine.
Mrs Ecker: It's certainly not the intention to penalize you for doing that.
Mrs Pupatello: I just wanted to put on record that Mrs Ecker's comments give the impression that the College of Physicians is being supportive of this legislation and using managers --
Mrs Ecker: That's not what I said, Mrs Pupatello.
Mrs Pupatello: It certainly is, and I think it's incumbent on you --
Mrs Ecker: Quote me accurately, please.
The Chair: Mrs Ecker.
Mrs Pupatello: I don't want her cutting into my time either, Chair. Anyway, it's inappropriate for you to suggest or try to trip up people who are speaking here as if the college in fact is supportive. They are not, and it's inappropriate on your part to do so.
Mrs Ecker: I did not say that.
The Chair: Mrs Ecker.
Mrs Pupatello: Secondly, I'd like to ask a specific question. Are we underserviced in terms of doctors' services here? And give me a brief on the history of doctors leaving this area -- let's just pick the last five years -- and what you expect will happen when this bill is passed on the 29.
Dr McLeod: Before this bill even became part of the landscape, there were approximately 25 physicians who left this county over the last five years, probably -- would you say a 60-40 split? --
Dr Schumacher: Correct.
Dr McLeod: -- specialists to family physicians.
The political climate has worsened. I cannot support this in fact but I have heard through my colleague that a large percentage of the graduating class at the University of Toronto is seriously considering going south and that figures of 75% to 80% have been bandied around within our milieu.
It certainly will not improve the likelihood of keeping people here, but I will also say to you that, in talking to a number of my colleagues, they want to stay for now to fight the good fight because we are members of Ontario. We feel that we've got a good system. We feel that we can maintain this system and improve it. If we all work together through negotiation, through settlement, through cooperation, perhaps we can come out at the other end with a decent system.
Mr Crozier: Thank you, doctors, for taking your time to come to us today. I want to bring up the point about the privatization. There is in the act, as I'm sure you're well aware, certain indemnity for the minister, for the director and inspector and assessor. Everybody seems to be indemnified in this act except for the practitioner.
Is that a concern of yours, that notwithstanding that this act may go through as it is and that certain information may be made available to the government that we are not comfortable with, that still doesn't prevent someone from taking it to court and suing you? With that thought in mind, may it also, in your opinion, encourage some practitioners not to include all the information on a chart that you normally would; in other words, frighten them from really recording the information that you normally would? Can you give me some sense of that, how you feel about that?
Dr Schumacher: I think I can answer that question for you. We already have fear from patients who come into our office, and they ask us outright, "Will this information be recorded?" and can we possibly not include it in the chart. We have an increase in off-the-record applications, so to speak, for advice, whether it be about their family, their family's history of mental illness, their own concerns about mental illness, sexually transmitted disease. There's a whole gamut of things that go on our in offices which have no business outside our offices.
Yes, I think you will see more. You will go back to the days of smaller and smaller charts, back to the days of my grandfather when the entire medical record was kept on a cue card. It's very difficult to transmit and to keep up a decent record, to let one's colleagues know what's going on, but you're going to go back to one-word consultations.
Ms Lankin: I listened carefully to Mrs Ecker's questions and while she did not specifically state that the general manager under the previous plan could determine medical necessity --
Mrs Caplan: She implied that, absolutely.
Ms Lankin: -- you have to say that the questions might have given that perception to some of the people listening, because it was the perception that I had of what she was intending.
I just want to make it very clear that under the old act the words were very, very clear that "where...it appears to the General Manager on reasonable grounds that...all or part of such services were not medically necessary," he "shall refer the matter to the Medical Review Committee," who will make that determination and the recommendation back. Of course, in the new act, the Medical Review Committee is cut out unless the physician takes extraordinary acts of appeal up to that process. It's the general manager, ie, someone in OHIP and not necessarily a professional or a doctor or a peer review, who would be making that determination.
Now, in order to make that determination, I would think first of all you have to have the professional qualifications, so let's put that aside. The government has argued it needs access to patients' records in order to get at the issue of fraud and that this all comes together with the general manager being able to send his inspectors in and take the files out of your offices and determine whether or not you have defrauded the OHIP system.
Just now we heard Mrs Ecker say we actually need to disclose the information in those patient files so that ICES, the Institute for Clinical Evaluative Sciences, can do its epidemiological work in the development of clinical guidelines. My recollection of that, having been somewhat involved in the establishment of it, is that they don't need to go into patients' records to do their work. In fact, within OHIP already there is the ability from doctors' billings to look at the number of procedures billed in any geographic area, compared to other geographic areas, and to sit down and peer review with physicians. When you find out that in eastern Ontario they're performing more C-section births than vaginal births, you sit down and you talk about why and what are the practice decisions that are being made. Through that process, you develop clinical guidelines which you then share and you have peer influence.
Why would David Naylor or anyone else at ICES need to go into a patient's file to determine what the epidemiological support is for the development of the clinical guidelines of practice?
Dr Schumacher: You're quite correct. Currently, they have more HMRI data that they've used and still have to use to keep them busy probably for several months or years.
Ms Lankin: That's the hospital management records information.
Dr Schumacher: That's correct. It's clean of any personal information. It's certainly managed and supervised by professionals in that area, and from what we can see since we established ICES, we can't see any major leaks yet.
Ms Lankin: Here's one of the problems I have and it was my frustration this morning around the amendment. We keep being told the government is going to amend the privacy area because of all of the concerns, and yet they keep sitting here and defending the reasons for these changes. We don't know what the amendments are. If they would table the amendments we could determine if they've taken the privacy commissioner's advice and we wouldn't have to waste our time talking on that issue any more. We could go on to other areas. Let me just ask --
The Chair: Thank you, Ms Lankin. Thank you, doctors. We appreciate your interest in our process and your presentation today.
WINDSOR AREA CAW RETIRED WORKER COUNCIL
The Chair: Our next presenters are the Canadian Auto Workers retirees, represented by George Johnson, who is the chair, and Les Batterson, who is past chair.
Good afternoon, gentlemen. Welcome to our committee. You have a half hour of our time to use as you see fit. Questions would begin with the Liberals, should you allow time for them. The floor is yours.
1600
Mr George Johnson: My name is George Johnson, and I'm the chairperson of the CAW retirees and seniors. We represent some 45,000 CAW retirees and seniors. We also believe we are speaking on behalf of some of the seniors and retirees who couldn't make it to the table today. We want to present our views to this committee and our concerns.
Until the government has had time to develop a coherent strategic approach to the transformation of public services, is the only instrument available a meat cleaver? The Common Sense Revolution reference to health care clearly states, "We will not cut health care spending." Under "Fair Share Health Care," it clearly states, "Under this plan there will be no user fees." Were these promises earmarked to catch the voters' attention and, if elected, to weasel out of? We sincerely hope not.
Physician-prescribed medication is clearly a part of health care to seniors. Statistically, under schedule G, 86% of persons over 65 are affected by disease in one form or another. One of the major concomitants of growing old is susceptibility to one or more chronic illnesses such as heart condition, strokes, arthritis, hearing impairment, high blood pressure and diabetes. Unlike an automobile, where parts can be replaced when worn out, when human organs begin to wear out, they often must be maintained with drugs. Imposing copayments under Bill 26 will mean that patients living in or near poverty will face financial barriers to getting the medication they need.
Our recommendation is that you raise the minimum income levels of $16,000 and $24,000 to $35,000 to $40,000 annually. We want to stress to this committee and to the government, to set the record straight, that we do not believe in user fees at all, by any name. But if you are insistent on introducing them, do not apply them to people who have to decide whether to fill the prescription or eat, knowing they cannot afford to do both.
Second, we submit that the use of generic drugs will lower costs to the drug plan substantially. Your government should implement legislation which states that generic drugs must be used in all cases where the physician and pharmacist recognize it as adequate to do the job for that particular patient. Physicians are not opposed to prescribing generic drugs if they are of high quality and comparable to the original drug. The federal government, as of September 1, 1995, implemented a generic substitution plan for all its employees, saving the government millions of dollars in drug costs. A similar plan has been introduced in British Columbia.
Third, your proposal to deregulate drug prices in Ontario seems to be contrary to your cost-cutting ideology and is a nonsensical exercise, given the needless additional cost this would inflict on Ontarians as well as on your government. There is no question that drug prices would immediately increase, creating more costs to the drug benefit plan. We recommend deletion of this proposal.
Fourth, many older citizens suffer from several diseases and may visit more than one physician. It then becomes very possible for them to suffer from physician- or self-induced problems as a result of overmedication or an incompatible combination of medications that interact or produce unfavourable reactions. This costs the system needlessly, both in terms of drug costs and hospital costs. We recommend that the ministry concentrate on developing better mechanisms for physician tracking of their patients' medications; for example, that the family doctor prescribes all medication in consultation with any specialist a patient may be receiving treatment from. Further, your government would be wise to expand drug awareness programs like the one established by the Canadian Auto Workers to train seniors to be aware of the dangers of overmedication and to take charge of their own bodies.
Prior to any funding cuts to hospitals, the Ministry of Health should consult with the citizens who will be affected by such a move, especially through the local district health council. The ministry should not have the unilateral right to determine what is in the public interest.
The patient and appropriate health care providers should be the only ones to have access to any patient's personal health records. To send in government inspectors to probe patients' medical records is a direct violation of the Ontario information and privacy act. Notwithstanding the disclaimer in the bill, should this type of information get into the wrong hands -- and it would -- it would be harmful to the patient. For whatever reason, can you justify invading the privacy of the citizens of Ontario?
The French government has arbitrarily decided to deny or severely restrict access to dialysis treatment for patients over 65. Further, no one that age or older is considered for a bypass operation.
You have included in Bill 26 provisions for the Minister of Health to unilaterally determine what constitutes unnecessary services and deny paying doctors for services rendered. We are aware that there are demanding patients out there, but this responsibility does not belong to the Minister of Health or his bureaucrats, and if implemented as recommended in Bill 26 will only serve to undermine the confidence the citizens of Ontario have in our present health system.
We recommend that the Ontario Medical Association be mandated to establish standards, guidelines and regulations for the provision of health care services in conjunction with the Ministry of Health and then be responsible for their enforcement among its members.
The ministry has already implemented limited access to home oxygen for patients. We would like to cite two cases we are aware of to illustrate the profound hardship this new regulation has imposed upon individuals. I've been asked not to name the individuals, but I will give you their case histories. This is from a daughter about her mother.
"My mother is 78 years old and is in the advanced stages of a disease called pulmonary fibrosis. This is a horrendous disease in which you eventually suffocate to death due to the lining of the lungs becoming hardened, forming cysts and tumours within them. There is no treatment available and her only comfort is the 24-hours-a-day oxygen she receives from her concentrator in the large portable tank in case the hydro was turned off.
"I am appalled by your government's decision to allow her to be denied funding due to your guidelines that she requires oxygen only during exertion. Does this mean she will have to spend the rest of her life lying in bed so as not to exert herself? Her movements are so limited now that I can't imagine what will happen to her. It is absolutely unthinkable to say she does not meet your criteria. It will be $345 a month for her to rent the concentrator and the large portable tank will cost her $215. She lives on old age security and CPP, which is less than $1,000. How could she possibly pay for this oxygen?"
Second, this gentleman is 44 years of age. He has pulmonary fibrosis, interstitial lung disease, has lost 65% of his lung function, is diabetic, has severe angina, one kidney functioning, and not too well. He's an epileptic. He was told that his oxygen will be cut off. He has only $1,360 a month and he would have to pay $250 a month for his oxygen requirements. His doctor says that if he cannot afford it, he will have to hospitalize him, at $452 per day. Where is the rationale?
These cases are examples of the hardships created by even the smallest changes in the health system, and they are indicative of the necessity of using extreme care and caution in moulding reforms. The system did not become faulty overnight and quick and dirty resolutions will not satisfactory solutions.
We trust that the minister will take a serious look at our remarks today with respect to the ramifications of the proposed Bill 26 and its effects on the seniors and retirees of Ontario and other people of similar circumstances who are unable to present their case before you today.
1610
Mr Les Batterson: Mr Chairman and committee members, I appreciate the opportunity to appear before you. As George pointed out, I am the vice-chair of the Windsor Area CAW Retired Worker Council.
My colleague George has outlined many of our concerns with regard to the health care section of Bill 26, and you have heard similar and other concerns from a broad cross-section of people across Ontario.
Since our medicare program is supported by a large majority of people in Ontario and Canada, I would first like to outline its beginning. I am old enough to remember when people did not get needed health care or went broke trying to pay for it. It was initiated in the Ford strike of 1945 and consolidated in the 1954-55 strike. We were also fortunate to have progressive doctors in Windsor who established Windsor Medical Services, which we incorporated into our program. The success of this program brought about Physician Services Inc in other parts of the province and made pre-paid health services available to many in Ontario.
Tommy Douglas legislated health care in Saskatchewan and it spread across Canada. We worked to bring health care to all the people of Ontario and our program became part of the Ontario health insurance plan. Hopefully, if we know history, we won't repeat it. With a long history of having adequate, affordable health care, it is obvious why we are concerned about the passage of this omnibus bill without adequate time to study and amend it.
My second item is the matter of a mandate. Regardless of unofficial polls, the election is authentic. Mike Harris received 45% of the vote, but when coupled with the high percentage who didn't vote, it means that 55%-plus, a majority, did not vote for him. Surely this must be considered. Also, Bill 26 was not discussed during the election and possibly would have made a change in the results.
My third item troubles me as a veteran and this being the end of the 50th anniversary of the Second World War. In 1934, Adolf Hitler put through legislation that negated the German Parliament. It surely doesn't seem the appropriate time to pass this omnibus bill, which would have much the same effect on our provincial Legislature.
We believe that the Ontario voters believe they were electing legislative members who would openly deal with the governing of all of Ontario in the provincial Legislature. From your hearings it is obvious that this unwieldy omnibus bill, particularly the health care sections, needs more study and reworking before it is passed. January 29 is too soon. We urge members of provincial Parliament, of all parties, in the best interests of the people of Ontario, to make this happen.
We once had what we think they're trying to give us back. We had private health care back when we established the first programs. It didn't work then, it isn't going to work now, and it isn't working in the United States.
Mr Crozier: Thank you gentlemen. I applaud you. You're seniors who could sit back and say, "I'm retired; I'll live out my years comfortably and not complain about this," but I think you also see that you may not live out your years comfortably if you don't complain about it.
In any event, I want to see if I understand something and if you understand it the same way. The government has made it a solemn promise that they will not cut one cent out of health care. We know they will be taking $1.3 billion and applying it to the deficit. It's their own figures.
Mr Johnson: That's not one cent.
Mr Crozier: That's not one cent; you're right. If they were to spend $17.4 billion for four years, that would be almost $70 billion they'd spend on health care. But if they spend $1.3 billion less for those four years, they're only going to spend about $64 billion. Now is my math wrong or do you think that over that period of time, at $1.3 billion a year, they're breaking a promise not to take one red cent from health care?
Mr Johnson: I definitely agree. I think if you go back a decade ago, we were spending $70 billion on health care, if I'm right. So it hasn't changed a lot. So to take $1.3 billion out of health care, something has to be taken out from giving to the people of Ontario.
Mr Crozier: So you and I aren't going to be fooled --
Mr Johnson: No.
Mr Crozier: -- if at the end of the period of time we look back and they spend less than $69.6 billion, are we?
Mr Johnson: No.
Mr Crozier: Do you know that of this money that's going to be given back in a tax cut they're going to borrow every cent of that?
Mr Johnson: No.
Mr Crozier: Because at the end of the term of this government -- in fact they're saying now they won't be able to balance the budget as soon as they thought -- the deficit will increase from around $100 billion to $120 billion. So they're not fooling us there either, are they, when they have to go out and borrow the money to give back to those who can afford it better than you and I?
Mr Batterson: Unfortunately, they're playing with the wrong problem.
Mr Crozier: Would you like to help them with what problem they should be playing with?
Mr Johnson: I think one thing is that it's going to eventually get worse because the last unemployment figures have shown that jobs in Ontario have not increased, and the only place that you get revenue is from people working. So if the job market is down and it keeps decreasing, your revenue is going to fall. So where are they going to get their revenue to put this 30% tax -- he might be a P.T. Barnum --
Mr Crozier: Well, they're going to borrow it, sir.
Mr Johnson: There's a sucker born every minute.
Interjection: Through job creation.
Mr Johnson: Yes, well, they've only created 17,000 jobs in the last three months. So --
Interjections.
Mr Johnson: But they're going to borrow it. So if they borrow it there's going to be an extra cost for borrowing the money, right?
Mr Crozier: Certainly, $5 billion. So wouldn't you, rather then borrow the money for that tax cut, take a closer look at what they're doing to health care and to what it's going to do to your future health care?
Mr Johnson: Yes, absolutely.
Mr Crozier: The point I'm trying to make, though: There are different ways to get at the same problem. We all want to reduce the annual deficit. We all want to eventually eliminate the debt.
Mr Johnson: But don't do it on the backs of the retirees and the sick and the underprivileged.
Mr Crozier: He has said it better than I, Mr Chair.
Ms Lankin: I couldn't agree with you more and I do believe there are alternatives that could be pursued. But I want to touch on a couple of points you raised which I think go to the issue of universality of medicare and the preservation of our medicare system. A couple of these points are technical and I just want to set up my argument for you.
I believe earlier, and I'm sure Ms Ecker will correct me if I'm wrong, but there was a presentation that talked about the change in the definition of insured services, and the person was worried about deletion of the reference to medical necessity. Ms Ecker had pointed out that in the new act under 11.2 in fact the reference to medical necessity was there: prescribed services that are deemed medically necessary. In fact, it was Ms Ecker, because I immediately piped up and said, "Yes, prescribed," and I provoked her, and I shouldn't have interjected, but she came back at me and said, "Yes, and it was prescribed in the old act too."
1620
Well, as I am prone to do, I'd like to correct the record. I just want to point out that in the old act under the definition of insured services, those services in health care facilities or hospitals such as set out in regulations and prescribed were insured services, and then all services rendered by physicians that are medically necessary were insured services, and then other health care services rendered by practitioners under conditions set out and prescribed.
It used to be that all medically necessary services by doctors by the legislation were deemed insured. In order for something to be uninsured, unlisted, there was a process to go through with a panel looking at it and determining whether it was no longer medically necessary. I'll give you a good example of something that was delisted. I'm not arguing that that's the right strategy in health care, but something that was delisted. Other than in situations of prisoners of war camps who had tattoos, removals of tattoos were determined not to be medically necessary -- but by a process -- and those were delisted. There was a process. Now it's what's deemed by the minister and set out, and I find that a troubling shift in terms of the decision-making process.
You mentioned the process of determining services by age. Under the old act, and I have said very clearly, it was under the rules of the Canada Health Act. It's now been moved. The government may choose not to take on the federal government and have a war around money, but before they couldn't do it around services by age, because the Ontario law said "under the Canada Health Act"; now they can.
There's a lot of talk about core services, the Oregon model, determining what's going to be paid for, what's not going to be paid for. I fear this is a complete undermining of medicare and a shift in values of universality, moving things out to the for-profit sector, and we see the ability of American companies to come in. You're pioneers of our medicare system, and I'd like you to comment on that and reflect on that. It's important from the values of our community.
Mr Johnson: I don't think at any time we ever questioned whether it was necessary or not, the medicare. If you needed it, the doctor prescribed it. I can look at myself, for instance. I suffer from arterial fibrillation, and it's controlled by medication. Once a year I have to go for an echo-sound and I have to go for a treadmill test. Now, each year there's no change. So what the present minister is saying is, "If there's no change, then this is not necessary any more, so you're not going to get it." That's the point that really is bothersome to many seniors. It's preventive. I could play the devil's advocate and ask, how many scans were positive that were taken? So are you going to go back and because they're all positive we're going to charge everybody? Because they were all positive, they weren't necessary? I don't think we should get into that type of a program, because it's going to undermine the whole medicare system.
Mrs Johns: Thank you very much for your presentation. Your recommendation about the substitution for generic drugs is part of Bill 26. That's part of what we're talking about doing in Bill 26, so I appreciate you bringing that up.
The other thing I just wanted to bring to your attention before I ask a question was that local input and planning is something we believe is very important to hospital restructuring and health care restructuring, and it's not something that we intend to do without a lot of consultation with the people of the community.
I have a story about a specific individual, just as you did, and this specific individual is my mother, who is 76 years old, a senior, one of the people you're representing today. In 1994, she needed valve surgery and couldn't get into the hospital. As a result she was left at home with my father, who was deaf, and they lived very far from a hospital. We were very worried about them.
To me, the system wasn't working in 1994, it wasn't working probably before that, and it's not working today. I believe that there have to be changes so that seniors don't have to wait that kind of time for heart surgery, valve surgery, pacemakers; that things have to be done to change the way the system works. Can you comment on that for me?
Mr Batterson: No way. I have a pacemaker. When I needed the pacemaker, the doctor said, "You need this." He told me in the morning and they put it in in the afternoon. I had no waiting. I also want to point out, when my wife needed surgery -- maybe we're better off down here in Windsor, because we've looked after our health care system.
Mrs Johns: You must be.
Mr Batterson: I'm very proud of what we've been able to do in the city of Windsor. I might point out it's only because we've had the complete cooperation of the doctors as we worked through from Windsor Medical into the OHIP program. We have had very few problems.
Mrs Johns: So there's no waiting for heart surgery.
Mr Batterson: There are some people, yes, but, unfortunately, it's one of those things that I guess if there's too many people, you have to wait your turn.
Mrs Johns: So you don't think there should be allocation of dollars to be able to get people into heart surgery quicker if they're waiting?
Mr Batterson: Certainly, if there were other places where they can be moved to, we hope that's part of the system.
Mrs Johns: I believe that's what we're trying to do with this bill: to manage the health care more effectively and move resources, scarce resources which are dollars to the areas that we need to have them in.
Interruption.
The Chair: Come on, folks. These gentlemen have some interesting answers. I'd love to hear them.
Mr Batterson: I'd just like to close on one thing. One little problem nobody discusses is, I was recently at a Canadian Labour Congress conference and the chairman of that conference pointed out that he'd done a study on the five years that we had unemployment less than 5%. We had balanced budgets. That's something maybe you should be looking at.
The Chair: Thank you, gentlemen. We appreciate you coming and making your presentation to us.
Ms Lankin: Mr Chair, I'd like to place a couple of questions on the record. I was wondering if the Ministry of Health would provide the committee members with information about how the cardiac surgery registry works; and if in fact a physician recommends that a cardiac surgery patient is of an urgent nature, what the turnaround time is on that. It's my last recollection that it was done within three weeks or less. If it's elective, then that's the doctor's determination.
Secondly, I was wondering if the Ministry of Health could inform us how taking $1.3 billion out of the hospital system is going to help Ms Johns's situation with respect to her concern about waiting lists for cardiac care surgery.
HEALTH SYSTEM LABOUR ADVISORY COMMITTEE
The Chair: Our next presenters are Valerie Walter and Pierina DeBellis from the Health System Labour Advisory Committee. Welcome to our committee.
Ms Pierina DeBellis: Good afternoon. I'm Pierina DeBellis. I'm co-chair of the LAC. Next to me is Valerie Walter.
On behalf of the Health System Labour Advisory Committee, I would like to thank the standing committee for hearing our presentation today. However, I would be remiss if I did not point out our dismay at the government's attempt to ram this huge bill through with little time, almost no consultation. Given the scope of the document and its ramifications to the people of Ontario, it is inconceivable that Mr Harris could possibly feel that democracy has been served with three short weeks of hearings. With the one slotted position today at 11:30, I feel it's quite appalling that that spot wasn't filled. There are over 100 people who asked to be heard, and that spot should have been filled.
I therefore would like to join the recommendations of those before me who have urged this government to commit to a true consultation process, probably six months, wherein the voices of all could be heard and not just a chosen few.
The Health System Labour Advisory Committee was formed during the initial planning stages of the Essex county health system reconfiguration project being directed by the district health council. At that time, there existed a recognized need to provide labour's input into various aspects of health care reform contemplated under the project, and our positive role in assisting in the development of what was to become the Win/Win report is well documented.
1630
Currently, representation on the LAC includes hospital, community and consumer representatives, and they are from the following organizations: CUPE, the Canadian Power Engineers and Skilled Trades Union, IBEW, OPSEU, SEU Local 210, and the Windsor and District Labour Council. As such, we speak for several thousand health care workers and consumers in Essex county. Unfortunately, we have recently withdrawn our support of the reconfiguration project, primarily due to the current government's decision to renege on promises made to this community. Notwithstanding this, we continue to be advocates for true health care reform in this community.
It is understood that the focus of today's presentation is to be on health-related matters, and our submission will primarily deal with this. However, it cannot be overstated how other sections of this bill have a direct and negative impact on the social fabric of this community, and thus the health and welfare of all who reside here. The current cuts to social services in income, housing and child care benefits have placed an already enormous burden on those least able to survive the blow. When seniors and lower-income citizens are faced with additional spending challenges in contemplating a host of user fees for everything from garbage pickup and library cards to health care services and lifesaving medicine, it does not take a brain surgeon to imagine the devastation that may follow.
One of the most disturbing elements of the Ministry of Health Act is the deletion of section 8 with respect to the establishment of district health councils and its replacement with a section that creates the Health Services Restructuring Commission. The specific mandate of this commission is yet to be defined by regulation, but it is clear that it will have the power to implement such government objectives as forced hospital closures, all without public consultation at the local level. While the current system of appointments to the local DHC is not without its flaws, one must certainly expect that local bodies would be more responsive to the needs of the community than such a commission will be. The lack of reference to DHCs in this bill gives rise to the real expectation that they may have reached their sunset years. Given the role that the local community members and the district health council have played in developing a restructuring plan that was, at least in its conception, to have provided a blueprint for the province, it is totally unacceptable to even contemplate removing our local district health council from the ministry's scheme.
Despite the problems that have recently arisen with the implementation of the Win/Win report, mainly by reason of the minister's refusal to ensure retention of savings for needed community supports, the labour advisory committee is still committed to the fundamental principles contained therein. The promises made to this community cannot be breached. We would not stand idly by and watch the work of several years go down the tubes under the direction of the Health Services Restructuring Commission.
The changes put forth under the Public Hospitals Act are sweeping in their scope and impact. Previously, sections 5 and 6 of the act gave the minister the power to fund public hospitals, as defined by regulation. However, Bill 26 replaces these sections with clauses that give the minister discretion over what criteria for such funding will apply. The only criterion that must be considered is that of the public interest.
Section 6 of this act will now give unilateral power to close hospitals, order amalgamations and specify services to be delivered, all under the so-called public interest. The ministry has already made it clear that it thinks inpatient services are excessive, so Bill 26 will impel hospitals to perform more treatments and procedures on an outpatient basis and to achieve smaller and smaller length-of-stay ratios, a trend we consider to have already produced unhealthy results. Under this approach, patients will continue to be pushed out of the system too quickly or denied appropriate levels of care.
When Essex county volunteered to close two acute care hospitals, it was promised that the savings would be reinvested in sorely needed community services. The ministry thus far has failed to heed warnings from physicians and providers of acute and community care services that hospitals cannot be closed and bed utilization significantly reduced without a network of community supports. In fact, far from honouring the commitment for approximately $22 million per year, the minister has chosen to announce that 18% of the hospital budgets will be clawed back in the next few years, with no reassurances that any funding will enhance community care, which only causes us concern about the already dangerous levels of health care that are being provided and ensuring patients will not be dumped on the streets, sicker and sicker, with nowhere to go for required health care services.
Previously, the minister was precluded from making any decisions on the basis of financial reasons alone without considering the effect on patient care. What is particularly disturbing about this bill is the enshrined definition of "public interest," which now includes the availability of financial resources and, for that matter, any other matter the minister and cabinet rely on as relevant. Of course, if the minister chooses to direct less funding towards health care in an attempt to meet the promise of tax cuts for the wealthy, he will legally be protected from the consequences of the decision made.
In case that isn't enough to set our heads spinning, the minister now has expanded powers to appoint investigators and supervisors whose scope of investigation includes "any other matters relating to a hospital where the Lieutenant Governor in Council considers it in the public interest to do so." Should the hospital board resist the direction of this supervisor, they can essentially be removed. Once again, full legal protection is afforded to all.
The LAC sees the changes to the Independent Health Facilities Act as not only a foot in the door, but a wide-open door for private, for-profit American corporations to enter the health care business in this province. For Bill 26 redefines independent health care facilities to include any facility or service that the ministry defines by regulation. Furthermore, this bill eliminates all preference for non-profit or Canadian operators and allows the minister to invite proposals for new facilities from whomever he chooses. American corporations have for some time now dreamed of cracking the "unopened oyster" -- that is, the Canadian health care system -- and of providing care for the elderly, which has been termed "mining grey gold." Changes to this act bring their dreams and our nightmares a frightening step closer to the light of day.
These changes set the stage for expansion of independent health facilities in the system and permit them to charge fees to insured persons, ie extra billing. Furthermore, the definitions of "health care" and "health record" are repealed, and references to "insured" when referring to services deleted. This sets the stage for deinsuring services and implementing user fees contemplated in other sections of Bill 26.
Changes to this act also may result in a breach of confidentiality of patient records, for it gives the minister the power to collect and disclose patient information for the purposes of administration of this act. Once again, when the so-called public interest is at stake, the right to confidentiality of patients' private medical information is up for grabs, with no legal recourse to those affected.
Ms Valerie Walter: The changes outlined in schedule G heave the most dire consequences on the sick, the elderly and the poor, while providing immeasurable benefits to huge international drug cartels. Presumably, such companies as Star Kist and Oscar Meyer will also do well.
Under amendments to the Ontario Drug Benefit Act, seniors and social assistance recipients will be expected to absorb new user fees, regardless of their income levels and realistic ability to pay. The Tories promised that there would be no user fees and that services to seniors and the disabled would not be touched. The changes to the act belie these promises, and once again place the greatest tax burden on these most vulnerable people.
The minister has put himself in the position of overruling physicians and pharmacists when it comes to determining what is medically best for the patient, for under this act patients will be responsible for paying the difference between the generic drug and that prescribed by their physician, even if the generic drug is unsuitable for that patient. Medical necessity or other health criteria will no longer have to be considered. Cabinet will now be able to establish their own clinical criteria in determining what will be covered. In fact, the minister may consider the total cost when designating or removing the designation of a drug product. I wonder if the cost of human suffering will be part of his deliberations.
It is clear that user fees will not reduce the need for prescription medicine. Rather, they will limit the ability of seniors and those of limited means to actually fill prescriptions for what may be lifesaving medication. The true culprits in the rising costs of the Ontario drug benefit plan -- the high cost of drugs compounded by the federal government and Bill C-91, and overprescribing by physicians -- will remain untouched, and once again it is the innocent victims who will be expected to pay.
1640
And speaking of the high cost of drugs, the Tories in their wisdom have seen fit to render Ontario as the only province no longer regulating the cost of drugs. The legislation removes any concept of a public process for setting the price of drugs and for determining other matters related to the Ontario drug benefit plan. To the government's contention that this deregulation will actually lower the price of drugs, we can only respond that hallucinogenics are obviously too easy to procure. With high costs of drugs under regulated prices, can we really expect the huge drug companies to suddenly get an attack of compassion and lower prices when under deregulation the sky's the limit?
Under schedules H and I, significant changes are made. Once again the minister is given tremendous powers to determine what he considers to be "medically necessary" services. Previously, the Health Insurance Act required OHIP to cover all medically necessary services provided by MDs as negotiated with the OMA and defined by regulation. However, cabinet will now be authorized to decide what services will be insured "under such conditions and limitations as may be prescribed."
Payment of fees will be decreed by cabinet, thus removing any negotiating capability of the OMA. The fees could vary for different classifications of physicians and practitioners, and fee schedules altered in almost any manner considered appropriate. Furthermore, accounts submitted to OHIP by physicians for services that were not deemed to be medically or therapeutically necessary could be denied.
The impact of these amendments on services provided in hospitals and health facilities is also worth noting. Despite the fact that the bill defines prescribed services, they too must be rendered under "such conditions and limitations as may be prescribed." Ultimately, these provisions may be used to limit access to services now covered under the Health Insurance Act, for no other reason than that they are deemed too expensive. Criteria may also be set in determining what is considered necessary, and provisions are in place to ensure that "such services may be prescribed only if they are provided to insured persons in prescribed age groups." Let the pogroms begin.
Of course, this section of the act, as do many others, gives the minister and the general manager of OHIP the power to collect and disclose patient information for any "purpose as may be prescribed." This could lead to the ministry contracting out aspects of OHIP administration, thus providing personal medical information to private corporations. Just think of the consequences of this ability of private corporations to access medical records. Think of the insurance claims that will be denied or access to insurance that will be limited. In all this, once again, the minister and general manager are exempt from prosecution as a result of their disclosure.
The power over physicians in this act and in the new Physician Services Delivery Management Act is truly mind-boggling and an affront to democracy. Not only will fees be prescribed by government, but regulations may require physicians to make contributions to OHIP, impose retroactive fee reductions, restrict billing numbers and force the physician to practise in a particular area. While giving the government the power to completely avoid all legal obligations with the OMA, Bill 26 continues to hold the OMA to those obligations the government decrees upstanding. The effects of these and other acts will give the Minister of Health and cabinet absolute legal authority to dictate the terms under which physicians provide medical services in this province.
While the LAC is on record as stating that changes must be made that deal with overprescribing and referral patterns that may contribute to the inefficiencies and waste in the health care delivery system, this totalitarian approach is completely unacceptable. What it will only serve to do is drive experienced physicians out of the province, and in Windsor we are particularly vulnerable to the threat of our MDs packing their bags and heading south. The health system reconfiguration project was to have offered a better deal to this community: comprehensive yet streamlined services in both the hospital and community care sectors, greater satisfaction for front-line staff, and, through these, the ability to attract qualified physician specialists such as neurosurgeons and obstetricians who are sorely needed. We ask you: What physician in her right mind would even think of considering a career move to this province, given the severe limitations that are being placed on all matters affecting a physician's practice?
Unfortunately, the list of affronts perpetuated under Bill 26 just gets longer and longer, for under the Health Care Accessibility Act cabinet is given direct authority to regulate extra-billing on insured services. This could mean a host of user fees on virtually everything from breakfast to bedpans, with unlimited capabilities for recouping huge reductions in hospital funding at the expense of the patient unfortunate enough to require care.
For example, it has been suggested that hospitals may be allowed to charge a daily user fee to patients in acute care beds awaiting placement in a long-term care facility or nursing home. Patients therefore will be made directly responsible for having been put on a waiting list for services that have been chronically underfunded as a result of government spending policies.
We are not amused.
Ms DeBellis: The decision to remove the proxy method of pay equity evaluation effective January 1, 1997, will have a profound effect on some of our members, for example, nursing home employees, who most likely will have no male-dominated job classes of employees to which they may compare. These workers are traditionally the lowest-paid in the health care field, and the decision of this Tory government to snatch away the only opportunity for fair pay that these hardworking health care providers are likely to achieve is met with contempt by members of this committee.
In the health care sector, the amendments contained in schedule Q are reflected in changes to the Hospital Labour Disputes Arbitration Act. Bill 26 sets new criteria for arbitrators to consider ability to pay and service levels when issuing their award on interest disputes.
Considering that funding in the public sector is determined by ministry policy, it would be a simple matter for the government to pre-determine pay and benefits long before the negotiating process even begins by cutting hospital budgets. Employers as well could unilaterally budget for wage freezes or concessions, as Bill 26 will virtually eliminate any incentive they may now have for entering into true collective bargaining.
As early as 1965, an arbitrator, Harry Arthurs, in an award concluded that consideration of ability to pay would make the interest arbitration process a sham. Despite this, Bill 26 now gives arbitrators the right to reduce services, lay off workers and anything else deemed necessary to meet the budgetary requirements.
Historically, public sector workers have been deemed to perform essential services and thereby denied the right to strike. Under changes to the Hospital Labour Disputes Arbitration Act, these workers will no longer be able to rely on a relatively balanced system of determining what is fair through the arbitration process. Arbitrators will be forced to become agents of the Harris government to deny collective bargaining rights to so-called essential public service workers.
Given that this current government is in the process of introducing measures that will eliminate thousands of hospital workers, it seems ludicrous to hold on to the myth that Mr Harris considers them essential by anyone's standards. It is therefore the contention of this committee that any or all legislation forcing compulsory arbitration on public service workers, including health care workers, be repealed so the parties may exercise their democratic rights to collective bargaining through the option of resorting to strike and lockout mechanisms.
Ms Walter: In conclusion, Bill 26 is nothing about fairness. It's not about controlling a wayward deficit or about health care or tax reform. What it is simply is a blatant attempt to gouge the pocketbooks of those least able to afford it: the sick, the elderly and the poor, including little children who have committed no sin other than having had the misfortune to be living in Ontario during this regime.
It is purported to be about the relinquishment of government powers and the devolution of these powers to the local level. However, while it certainly devolves responsibility for funding far from Toronto, it sets up such an amazing array of unilateral, unimpeachable powers that one must wonder if we're now living in a police state.
It is an assault against working people, who are the backbone of this province and of their communities, who have shed blood, sweat and tears in their efforts to establish the social programs that have made this country so unique.
It is the selling off of essential services to for-profit private corporations that care little about what is best for the citizens of this province but care greatly for the bottom line.
1650
It is about the betrayal of the people of Ontario, who were fed a string of lies during the heat of the election campaign and who were innocent enough to believe these empty promises.
It is about a government that is willing to put itself above the law and deny the citizens of this province the right to appeal and to their day in court.
People will die because of this bill. I repeat: People will die, the ultimate price to pay for this government's irresponsible policy.
Seniors faced with user fees for drugs while on a limited income will have to make the choice between lifesaving medicine and other necessities of life, and some will die.
The elderly, too sick or infirm to care for themselves at home and awaiting placement in a nursing home, may find their lifelong savings eroded by hospitals forced to offset their own budget reductions with user fees. Some patients, in desperation, will go home, despite their medical need, and some will die.
Hospitals will be forced to achieve smaller and smaller target rates for bed utilization and patients will be dumped on the streets sicker and sicker, with no community supports in place, and some will die.
Mothers suffering the effects of cuts to welfare, housing and child care benefits will face additional user fees for drug and hospital services, not to mention municipality-applied user fees for a variety of necessary services. They will be forced to choose between medical care and shelter or food for their children, and some children too will die.
It is a sham. It is a disgrace. It is a crime. In the name of decency, in the name of democracy, in the name of God, we urge you to scrap this unholy bill.
Ms DeBellis: Along with our presentation, we do have petitions. Petitions have gone out for the last week. We have over 1,000 signatures that we'd like to present to the committee today.
Ms Lankin: Thank you very much. Reading this propaganda again, it says, "Myth: Bill 26 was written without consultation or input from those affected," and it says, "Reality: Before drafting Bill 26 each minister held extensive consultations...." Would I be right in guessing that no one consulted with you?
Ms DeBellis: No.
Ms Lankin: I thought I might be right. Of course, I know why: because you're a vested interest group.
Ms Walter: Yeah.
Ms DeBellis: Right.
Ms Lankin: Let me talk about your vested interest and the folks you represent. I'm kind of tired of hearing people marginalized in their opinions, sort of denigrated because they're a vested interest, and particularly labour. This government is so anti-labour. It's so clear.
Labour has been an integral part of the restructuring in this community. Sure you had problems here and there and you fought for your points of view, but you participated and you believed in the process and you believe restructuring has to take place.
I find it amazing that with all of that participation and goodwill, they'll just turn around and sort of say, "Well, on the other hand, okay, we're going to attack you from another front that we didn't even talk to you about, like changes to the arbitration act to impose ability to pay." They obviously consulted with somebody with respect to that, hospitals and municipalities, I suspect.
And we know that over and over again, in 1985, when the Tory government introduced wage guidelines and put ability-to-pay criteria in legislation, arbitrators rejected it, because they said essentially, from their point of view, ability to pay is the willingness to pay. How can they tell whether a municipality's going to raise taxes or not or take it out of salaries?
Nursing home employees in for-profit nursing homes: The employer decides how much profit goes to the bottom line, and what's left over they go to arbitration. Who are the employees of the for-profit nursing homes, and what does this mean without pay equity protection and with this new legislation on arbitration?
Ms Walter: I guess what it means is that the people in nursing homes, who are traditionally the lowest-paid health care workers, will have, under the cuts and everything and under the backlash from the hospital restructuring, more and more heavier-care patients to care for and nothing out there to ensure that they get a fair and adequate wage for the services that they're providing.
Mr Clement: On page 4 you say, "American corporations have for some time dreamed of cracking the `unopened oyster' that is the Canadian health care system and of providing care for the elderly, which has been termed as `mining grey gold.'" Since this has been the third time in the labour briefs that we've heard today that we've had that terminology and probably about the 10th time the committee has heard that, I'm just curious: Which American corporations are you talking about who have said "unopened oyster"?
Interruption.
The Chair: Please, I think these ladies can answer the questions.
Mr Clement: Did you have a name of an American corporation?
Ms DeBellis: I don't have any names.
Mr Clement: So where does this paragraph come from? Where did you get this paragraph from?
Interruption.
Ms Walter: Well, this is more important. First of all, I think American Liberty has made it very clear that they are interested in health care. There are advertisements already on Windsor television for insurance corporations to cover health care in Canada. Our brief was compiled from a number of sources, including the Ontario Health Coalition, the OHA, we've looked in the regulations, we've looked in the Sack Goldblatt -- is that --
Mr Clement: And Mitchell.
Ms Walter: -- assessment.
Mr Clement: A legal brief, right. Could I just turn to page 3 for a second? You talk about how we are advocating the closure of 38 Ontario hospitals that we have declared redundant. That's in the third paragraph. Sometimes, when we Tories talk, we talk about the 9,000 empty hospital beds which are the equivalent of 38 small-sized hospitals in Ontario that we're still paying the heat, the light, the administration for and how we want to restructure the hospital system so that we can deliver the health care services to where it's truly needed. Is that what the reference is?
Ms DeBellis: Once again, that was from our document and this was over and above, that there are 38 hospitals to close.
Mr Clement: Well, that's false.
Mrs Lyn McLeod (Fort William): I very much appreciate the thoroughness of your brief, and if the government is so convinced that it's advocating open and consultative processes even when it comes to new independent facilities, we might wonder why there is no request for proposals. They're not even going to invite people to make proposals so they can look for what might be the best offer.
Your brief is so thorough I'm not sure what to touch on. I think there's maybe one thing that you haven't specifically mentioned and that I think is worth mentioning, and that's that this is a bill that comes from the Minister of Finance. This is a finance bill. I'm sure you're as frustrated as we all are when you hear the government members talk about restructuring the health care system in order to be able to do important things like shortening the list for heart surgery when you know this bill is not about health care restructuring, it's not coming from the Minister of Health, and in fact it makes the Minister of Health subservient to the Minister of Finance. So this is about taking $1.5 billion out of health care and about giving themselves the powers to make the cuts fast, and I don't believe you can make a case that you're going to have a better insurance of shorter lists for cardiac surgery when you arbitrarily force the closing of hospital beds by taking $1.3 billion away from the hospitals.
I share the concerns you've expressed in your brief, and one of the things you've touched on that not all presentations pick up is that when it comes to closing hospitals, the Minister of Health is actually putting himself beyond the law. He's not even governed by regulation under the hospitals act.
You've mentioned the importance of the district health council and local input. I'm surprised Mr Clement didn't use his time to talk about the fact that the district health council --
Ms DeBellis: He already did.
Mrs McLeod: -- hasn't been sacrificed yet. That's perhaps to come in amendments to future acts. But there's no guarantee of local input, and as you have noted, there's no guarantee of the dollars that are saved by restructuring coming back into a community. I guess I'd just like to ask you to comment a little bit more. This is a community that's gone through a lot of anguish in looking at hospital restructuring in order to save dollars and in order to make sure some of those dollars go into community care. What do you need in a community to have an incentive to bring about real savings, not arbitrarily forced savings?
Ms DeBellis: I want to say at first that this bill has nothing to do with improving our health care system.
Mrs McLeod: You're right.
Ms DeBellis: Far from it. With restructuring, labour was part of restructuring, the Win/Win book, and you bring the stakeholders, you bring all the parties together, and it's amazing what can be accomplished. We are true partners. Looking at labour as, "Oh, here they come, a vested group," we're not only -- we are looking out for our members but also for the consumer. We're consumers as well; we use health care, we use a lot of the programs and services. But we need commitment from the government. If you want people to stay in hospital a lot shorter time, you've got to have the community services out there, because people are falling though the cracks; they're doing it now. We have the elderly, we have the poor. They are the first ones who are going to get hit. We need to have community services.
The Chair: Thank you very much. We appreciate your presentation.
1700
ST JOSEPH'S HOSPITAL
The Chair: Our last group for the day represents St Joseph's Hospital in Chatham. Welcome.
Mr Stephen Fuerth: I'm the chairperson of St Joseph's Hospital in Chatham. With me today are Richard Kuhn, chief executive officer of St Joseph's Hospital; Linda Millard, assistant executive director of patient services; and Bonnie Wooten, a member of our board of directors.
On behalf of St Joseph's Hospital in Chatham, thank you for the opportunity to address the committee with respect to Bill 26. We made the decision to seek out the opportunity to appear before the committee because of the potential impact of the bill on the delivery of health care in our community. We believe it is important that in its deliberations on this bill, the government has the benefit of a broad range of views concerning the bill from the public and from the various providers on such a fundamental issue as health care. The comments offered today by St Joseph's Hospital are intended to give the government some constructive feedback on the provisions of the bill as they affect community hospitals.
The concept of fundamental community planning and restructuring of service delivery of health care in our local community is certainly not an idea new to Kent county. Throughout the past several years, St Joseph's Hospital has been an active participant in the efforts of our community to come to grips with declining provincial funding, downsizing, and the efforts to rebuild a system that is sustainable for the foreseeable future. These efforts began several years ago in negotiations with other Kent county community hospitals concerning the rationalization of services and has extended more recently to our participation in the study of our local health service with the district health council, the Kent county hospitals, public health, and representation from labour and from medical staff. St Joseph's Hospital has also been involved in a strategic partnership with local municipalities, school boards and sister hospitals known as KAAG, Kent area administrators group, for the express purpose of maximizing use of taxpayers' dollars.
The board of St Joseph's has demonstrated throughout these efforts its commitment to plan for change, and its appreciation of the need to find new models for the delivery of health care. There is a commitment by our board to develop new relationships with the other deliverers of health care in our community, including our sister hospitals, physicians, our hospital workforce, community agencies and the public itself. In the meantime, we have managed our resources carefully and prudently and we have opened our processes to be more open to the public and therefore more responsive and accountable to our community, while at the same time ensuring that the standard of care in our programs remains of the highest quality.
St Joseph's Hospital acknowledges the vital provincial interest in the delivery of care in our hospitals, and as we struggle with the need to maintain our present level and quality of the services we provide to the public in our area, we also understand that we have to do so with fewer financial resources from the provincial government. Indeed, all our planning efforts over the past five years have been based upon fewer real dollars coming from the province, and we fully understand that we have likely only seen the tip of the iceberg in this regard.
Our hospital has worked cooperatively with the provincial government in local restructuring studies in this time of fundamental change. Our purpose in coming today is to make constructive comments about the form chosen by the government with respect to future provincial participation in the local planning and decision-making processes.
The province of Ontario ensures the fulfilment of its health care responsibilities in large part through small community hospitals throughout Ontario. For example, St Joseph's Hospital in Chatham has continued a long history of identifying local needs, implementing new programs and services in response to these particular health care needs, and in the course of doing so, raising capital from the public to meet the fiscal requirements that the development of these new programs inevitably brings. In doing so, we have had to cope with limited resources and foster strong commitments and close working relationships with our customers, which include our patients, staff, physicians and community agencies. This is the challenge for community hospitals, but it is also one of our traditional strengths and a resource well worth preserving.
This leads us to our first recommendation for consideration by the standing committee. We believe it is inevitably healthier for the small community, and the solutions more viable and sustaining, if the decisions about local needs and the utilization of local resources, including not only the physical and financial resources but also the human resources, are left to the community itself. While we understand that there is always a potential for honestly held beliefs of dedicated community members to develop into an impasse with respect to potential solutions for fundamental change, it is also true that decisions made in Queen's Park are not always easily accepted at the community level. As a preliminary step, therefore, the province ought to facilitate a resolution to local impasses by using its expertise and persuasiveness in uncovering compromises at the local level. If more conclusive provincial input should be necessary, either through the Health Services Restructuring Commission or otherwise, we believe that such an extraordinary provincial intervention should be accountable and subject to a fair and equitable process.
Therefore we make the following recommendation: In order to ensure accountability for decisions concerning fundamental structure and major change in service delivery, the Health Services Restructuring Commission act in an advisory capacity only to the minister, who shall ultimately be responsible and accountable for such decisions.
In the event that the government chooses the vehicle of the commission to effect provincial policy in local communities, then as an alternative we would make this recommendation: that the commission be held accountable for its decisions and conduct its deliberations in a fair and open process, including with it the obligation to give those affected reasonable notice of its intent to act and an opportunity for a full and fair hearing. In doing so, there ought not to be immunity for the commission in its decision-making processes.
The next area I want to talk about is merger, closure and amalgamation, what I call the extraordinary remedy. The proposed powers in Bill 26 with respect to closure, merger and amalgamation of hospitals by the commission, the writing of hospital bylaws and the requirement to provide certain services and level of services represent a significant and extraordinary change in the relationship between the purchaser of services, which is the province, and the local community providers. We believe the government appreciates that such extraordinary remedies have the potential of striking at the heart of the community hospital and can result in the nullification of the hospital's very mission and purpose.
The loss to the local community by the exercise of such extraordinary remedies would be great and would include the following: potentially the loss of a valuable community charitable trust with a proven record of providing health care services and raising capital for the benefit of the local community; and also a real sense of loss and a corresponding harm to the social fabric of the local community.
1710
In this regard we recommend to this committee that you consider the following: that the exercise of such powers as amalgamation, merger, closure of hospitals, replacement of trustees, writing of bylaws and dictating the services to be provided take place only after a full and fair deliberation exercised with due process.
We understand that in terms of making provisions for these powers, the government is prepared to consider a sunset provision with respect to their exercise, and we wish to state our very strong support for such a termination to the existence of such powers. We also strongly recommend to the committee that the extraordinary powers given to the supervisor also be subjected to the same sunset provision. If there is no light at the end of this tunnel, we are concerned that there's going to be little incentive for local initiative, unless the government clearly enunciates closure with respect to these provisions.
There is little indication in the bill of the basis upon which the government intends the minister, the commission or the supervisor to act, other than what it considers to be in the public interest. This is indeed a very broad brush, and if the province wishes to maintain the restructuring process as a cooperative effort, it would be very useful for the government to enumerate what it means by "the public interest." We understand the government intends to exercise its discretion out of a concern for its fiscal responsibility, and in that endeavour you have the support of our hospital. We understand the need to find solutions to the problems created by past spending practices and what some might view as largess in funding hospital care, and we affirm to this committee that it is a strong Catholic principle to be prudent and careful stewards of the taxpayers' dollars while at the same time meeting community needs.
However, we also believe as a community hospital that it is also in the public interest that the quality of care not be impaired in the rush to save money. For the past several years we have had to struggle with this very issue as the level of provincial support has dropped for our hospital. The issue is how we maintain services and the quality of those services with fewer dollars. We believe that to date, community hospitals have met those challenges responsibly, and if the province wishes to engage in the fundamental restructuring this bill contemplates, we would suggest that the level of services and quality be part of the criteria. In addition, as a community hospital we are also concerned about the availability of services in our community and whether basic medical services will continue to be available locally. The trend to regionalization is one which, in our opinion, must be resisted for access to basic levels of primary care, and accessibility ought therefore to be an additional criterion.
We have not attempted to enunciate all the relevant criteria for the exercise of provincial discretion. We have simply attempted to demonstrate the need for the enumeration of principles and a subsequent public debate as to their sufficiency, but our recommendation is as follows: that Bill 26 define the criteria for the exercise of powers given to the minister, the Health Services Restructuring Commission and the supervisor, and further provide that the exercise of those powers be subject to the consideration of those criteria.
With respect to the provisions of the bill related to the increase of powers to the supervisor, we reiterate our comments with respect to the need for a sunset provision. We also endorse the limitation on the right of the supervisor to exercise his or her powers for the reasons set out in clauses 9.1(c) and (d) only for the period of four years. In this regard, we support the position of the Ontario Hospital Association.
On behalf of St Joseph's Hospital in Chatham, I want to take this opportunity to thank the government for the time it is taking to study Bill 26. Part of the success of our health care system in Ontario has been the traditional empowerment of local communities to have input into the planning and a measure of control over the delivery of its own care.
We recognize the complexity of the task you are undertaking and your desire to have the tools necessary for your task. These factors point to the need for careful deliberation and reflection upon the implementation of these policies.
Thank you for giving me that opportunity.
Mrs Ecker: Thank you very much for taking the time today to put forward some suggestions and concerns you have about Bill 26. I think you put very well the importance of local community hospitals, the role they play in the system, and I think also you have reinforced well the role of local planning and the need for that. That is exactly why the minister did not remove district health councils from the legislation and is continuing to allow them in their capacity to advise, to recommend to the minister, to do local planning.
We have heard suggestions from many that we need to make that more explicit in reference to the hospital commission, and I think that is an excellent suggestion that the committee members here have certainly been prepared to recommend.
You talked a little bit about the investigators and that you thought the powers of the investigators should be sunsetted. Should they be sunsetted, or if there was a due process for their use in terms of situations where you would foresee they might well be used, what would you advise?
Mr Fuerth: I didn't say anything about the investigators; I talked about the supervisor. In any event, they're in the same section of schedule F, so I'll respond to the question. I abhor any process that doesn't have due process as part of it, and I have real concern about the powers I see in schedule F to the bill. Accordingly, I would suggest to you that at a very minimum, there needs to be due process as part of the consideration in the exercise of powers. You've provided in this bill extraordinary powers of investigation and management of local community hospitals. Quite frankly, it had better be an extraordinary situation before the government steps in and exercises these powers. Let's face it, the government has to be accountable for this, so there should be either a minister who's responsible to make these decisions and accountable to the public, or a fair hearing and a fair process in order that accountability be ensured. There has to be one or the other.
I could accept as a fallback position that there be a sunset clause, but we need to know that at some point these extraordinary powers are at an end. If the government is going to embark on this bill and on these provisions, we should all recognize that these are extraordinary powers in very difficult times, that four years perhaps is an appropriate period and then we start with a clean slate again. For that very limited purpose, I endorse a sunset clause.
Mrs Ecker: You've recommended that we define the criteria for the exercise of the powers given to the minister, the commission and the supervisor. Any specific suggestions on what some of those criteria might be, from the experience you've had?
Mr Fuerth: We've outlined a couple of areas, but this is an area of provincial concern. This is your bill, your attempt to have the province intercede in the local community and make decisions and exercise management and control with respect to local providers. What I'm suggesting to you is that it's your onus, your responsibility, to set out clearly what the provincial policy is, what the criteria are that you think important in making these judgements, not what I think is important. You're the one with the power, so you tell me what you think is important in the exercise of your criteria.
1720
Mr Crozier: Thank you, ladies and gentlemen, for your presentation. I want to say at the outset, as I said earlier today to the presentation by the Hôtel-Dieu Grace Hospital, that I happen to believe -- and I've been in the Legislature a short time -- that all legislation should have a sunset clause. Every piece of legislation should be reviewed at some point to see if it's doing the job it's supposed to do.
Having said that, and noting that you have made comments about limiting the powers of the supervisor to only four years, let me put it as the Ontario Hospital Association has. And you mentioned due process, that if we had due process, you perhaps wouldn't be concerned as much that we have a sunset clause. The Ontario Hospital Association says it should be limited to March 31, 1999. "The statute will assist hospitals and the government in restructuring the hospital system, yet at the same time preserve for the future the fundamental principle of voluntary governance."
As I said, I asked this question once before today: Why, if we believe in the fundamental principle of voluntary governance, would we say, "But we'll give it up for four years"?
Mr Fuerth: The government has indicated in a clear statement what its intentions are. I think the agreement, at least in the extraordinary circumstances, to a four-year provision is intended to be a compromise: "If we have to have it, we'll accept it under these terms and we'll live with it." The only additional item we've attached to the exercise of those powers is that it be exercised only under due process. We've taken that position and we support OHA because it appears that the government is intent on having and exercising these powers, and the suggestion is that they do it within their mandate.
Mr Crozier: I'm having a hard time understanding why you would do that, because there are some things in this bill -- in fact, if the bill had been passed in December the way it was originally going to be, it would have made the Legislature relatively irrelevant, and when we get to regulations, we have no idea, essentially, what the regulations are going to be for this bill, and that may be where we have another interesting time.
But I don't think I'd want to give up, just because they have a majority, for four years. Do you see what I'm getting at? I would like you to come here and say: "Look, we don't like this. Please put a process in." That would be the kind of thing I'd like you to come to the committee with. I understand. You're saying there's a compromise, and there are various reasons you might come to that compromise.
Mr Fuerth: We have an ongoing responsibility in our community to provide health care. We recognize that we have to build partnerships and that we have to work with the government of the day and with the district health council and with community agencies and with our physicians and with our workforce and with the community we serve.
We know we're in a very significant time of change, of restructuring. We've just completed in our area the work of local restructuring. We know that the next three or four years are going to be very difficult. The only thing we've attempted to say today, in addition to the OHA, is that if you're going to exercise extraordinary provincial powers at the local community level, give us a fair hearing, give us an opportunity to make our case.
Ms Lankin: I appreciate your submission very much, and I also understand from my time working with hospitals and the hospital association the tone the association has taken and the attempt you are making to find a space for dialogue with the government, given what the government is attempting to do. I understand that completely.
I'm still having trouble understanding the government with respect to this provision, however. A couple of examples: the appointment of supervisors, the stripping of the due process of the inspector's report having to be in first and having due regard, and the greater powers the supervisor has.
If it is in a circumstance where you are implementing a restructuring report of a local community and attempting to close a hospital and you're having resistance from the board of that hospital, and then you want to put a supervisor in, that's a very specific circumstance. Why, for any other reason -- concern about quality etc etc -- wouldn't you follow the due process rules already set out in the old act? Why wouldn't you separate it out? If this extraordinary power that's required is about closing a hospital that you think is going to buck the system, then spell it out, if that's what it is.
I asked the minister, "How many times has the government used the supervisory powers in the existing act?" Once or twice; hardly ever. It's extraordinary. So I asked him: "Why do you need something even more extraordinary? Why is 30 days too long in terms of due process?" I don't understand what is actually being requested and what is really required here, and this is very genuine.
The other thing -- I guess it's a little rhetorical and I'll apologize for that -- is that every hospital that's come forward has said it's absolutely committed to restructuring and downsizing, that they know the writing's been on the wall and they've been participating and they're prepared to proceed. With a little bit of grief from the minister in terms of persuasion and working through with communities, you don't have to impose solutions. We've been finding most communities coming to their own consensus.
I am not supportive of the extraordinary powers as they are set out. I agree with you that if worse comes to worse you get them sunsetted, but I'd like to see them done away with. Failing that, I'd like to see set out why and when the extraordinary powers are going to be used, and only in the circumstance of forced closure of a hospital. Everything else should revert to due process.
Mr Fuerth: One of the curious things when I read schedule F was, why is the provision of supervisory powers here at all? If the purpose of the bill is to assist in the fiscal responsibility of the government of the day and to assist the implementation of local restructuring for the purpose of achieving fiscal responsibility, why isn't the Health Services Restructuring Commission sufficient? Why do we need this additional heavy-handed, unilateral person or office to carry out the process? But assuming that the government needs it -- and it was part of our submission -- then clearly set out the criteria when it needs that power to act.
Quite frankly, as I struggled with the criteria set out in the section dealing with the supervisor and tried to relate it to hospital restructuring, I couldn't come up with a connection. I had difficulty. I understand "the public interest," and my imagination can run wild about what that might mean and that the government of the day can use it in that way too. But it seems to me that we would be better served, in understanding the rationale of the government in asking for these kinds of powers, if it would set out the criteria clearly enunciated. And as I said earlier, it's not my job to set out the criteria; it's the government's job to do that.
The Chair: Thank you very much, folks, for your presentation this afternoon. We appreciate your interest in our process. Have a good day. And thank you very much to the people of Windsor; we appreciate it.
The committee is adjourned until 9 o'clock tomorrow morning in the fine city of London.
The committee adjourned at 1739.