CONTENTS
Thursday 7 March 1996
Ministry of Health
Hon Jim Wilson, minister
Margaret Mottershead, deputy minister
STANDING COMMITTEE ON ESTIMATES
Chair / Président: Curling, Alvin (Scarborough North / -Nord L)
Vice-Chair / Vice-Président: Cordiano, Joseph (Lawrence L)
*Barrett, Toby (Norfolk PC)
*Bisson, Gilles (Cochrane South / -Sud ND)
*Brown, Jim (Scarborough West / -Ouest PC)
Brown, Michael A. (Algoma-Manitoulin L)
*Cleary, John C. (Cornwall L)
Clement, Tony (Brampton South / -Sud PC)
*Cordiano, Joseph (Lawrence L)
*Curling, Alvin (Scarborough North / -Nord L)
*Kells, Morley (Etobicoke-Lakeshore PC)
Martin, Tony (Sault Ste Marie ND)
*Rollins, E.J. Douglas (Quinte PC)
*Ross, Lillian (Hamilton West / -Ouest PC)
*Sheehan, Frank (Lincoln PC)
Wettlaufer, Wayne (Kitchener PC)
*In attendance / présents
Substitutions present / Membres remplaçants présents:
Caplan, Elinor (Oriole L) for Mr Michael Brown
Cooke, David S. (Windsor-Riverside ND) for Mr Martin
Clerks pro tem / Greffiers par intérim: Douglas Arnott, Deborah Deller
Staff / Personnel: Steve Poelking, Lewis Yeager, research officers, Legislative Research Service
The committee met at 0911 in committee room 1.
MINISTRY OF HEALTH
The Acting Chair (Mr John C. Cleary): Good morning. We're short one of the parties, but I'm sure they'll be here later on. I know there are a lot of very important questions, very important issues, so I think we should get on with this. I think when we left off we were in 20-minute rotations. It's my understanding that the government party was last, so if everyone agrees we could move to the Liberal Party now for its 20-minute rotation.
Mrs Elinor Caplan (Oriole): I appreciate the opportunity to be here and I appreciate the fact that the minister is here. Having experienced Health estimates myself, I know what fun it can be and also how important it is, because it is an opportunity we have to ask some questions that I think concern many across the province.
Rather than starting with any kind of an opening statement, I'd like to go directly to questions.
I read your opening statement, Jim, and we could have quite some time debating some of the content. I only have one question that I think should be put on the record.
We just began, David, 30 seconds ago.
Mr David S. Cooke (Windsor-Riverside): I was lost.
Mrs Caplan: That's the point that you made in the first part of your comments, when you referred to the concern that everyone has, and that is the cost of debt servicing as a rationale for many of the actions that you're taking. Notwithstanding your election commitment to not touch a penny of the Health budget, you've admitted that your policy, in effect, is to see the cost to debt service reduced. I support that goal.
However, the economic indicators that we have, as produced in your own documents, suggest that your concern about the cost of debt service, the fact that -- and you use this term -- "We're spending a million dollars more than we're taking in," that's actually going to increase as a result of your policy, because you're going to be borrowing $20 billion to pay for your tax cut, so that the cost of public debt service is actually going to be increasing and you're going to be borrowing for that tax cut.
I put it to you as Minister of Health, you're taking $1.3 billion out of hospitals and you're doing it very quickly. People believe that's being done to pay for a tax cut. We know that if you're going to cut taxes and reduce the deficit as you're doing gradually -- you're gradually reducing the deficit, but you are rapidly making these cuts. How can you justify this to communities that are concerned about getting the health care that they need when they need it, having access to services in their hospitals, services they need?
What I'm hearing from people is that they would rather that you put the money that you will be spending on your tax cut into maintaining important and needed health services. So when they hear your argument that says, "We're spending more than we're taking in," they understand that, but they don't understand how you can justify borrowing an additional $5 billion that annualizes out over your term in office to $20 billion. They say: "Why are you making these cuts to our health services to provide us with a tax cut? We'd rather have the health services."
You raised it in your opening comments, which is why I think it's fair to raise it at the beginning. I then want to get into detailed questions of your policies and the impact on communities. But I think it's a fair question.
Hon Jim Wilson (Minister of Health): Do you want me to answer that?
Mrs Caplan: Yes, I would.
Hon Mr Wilson: It is a fair question. If I recall the commitments of the parties during the election campaign, I think we had the NDP saying they were not going to give a tax cut but balance the budget over three years, and the Liberal Party, as I recall, was going to give a tax cut of some $2 billion and balance the budget over four years --
Mrs Caplan: No, $350 million annually, $1.5 billion and a balance at the end of four years.
Hon Mr Wilson: I just read the red book last night and it was $2 billion over four years.
We simply said, and I think your party agreed, that the tax cut was needed in jurisdictions where taxes are high -- and our taxes are high -- to help stimulate the economy and to create jobs. It would be all for naught if we simply made spending reductions or cuts and didn't create any jobs along the way. It is our economic stimulus. We said we would cut approximately $4 billion in taxes in the first three full budgets and to make the spending cuts over five years. So the difference between the parties was $2 billion and reduce the deficit over four years; we said a tax cut of $4 billion. It will take an extra year, and I know we were criticized. I think the fifth edition of the Common Sense Revolution did move us from a four-year target to a five-year target. We were criticized for expanding the time frame to accommodate all that we wanted to do.
It's a frustration I have when I see the federal budget of last night, really nothing to stimulate the economy or return money to consumers so they can stimulate the economy. We know where tax cuts have been applied in the past -- for instance, the 1982 recession, where there was a major tax cut on retail sales tax to stimulate the economy -- that worked, and in our history it has happened about three times; not as large, mind you, as what we're doing, but it does work. You'll note Mr Klein today in the paper saying he doesn't necessarily agree with it, but Mr Klein doesn't have the high taxes that we have. Really, a tax cut to stimulate the economy only works in economies where your taxes are exceedingly high, and I think there isn't much argument that our taxes are high.
Mr Cooke: You don't stimulate the economy when you take $6 billion out of the system and then put a little bit back.
Hon Mr Wilson: With respect to maintaining health services, we are doing that. We have not cut health care. We are making cuts in other areas of government to maintain the health care envelope. I think people understand that and they also understand that we have not cut health services. We are reducing transfers to hospitals, as the Finance minister announced in November, over three years. As we achieve those savings, as we actually have those savings in hand, then we will make reinvestments over the life of the government and probably into the next government, because some of those savings won't be achieved -- even with the best efforts of restructuring, we may not see cash in hand during the life of this government for some of that money coming in hospitals.
0920
Mrs Caplan: I'm not going to refer to testimony at other committees, but the result of your policy, as stated in your own Common Sense Revolution document, says that your policies create a significant drag on the economy; that means, slow down the economy as a result of your policies. So clearly, when you say that you're stimulating the economy, that's not the result of what you said you're doing. But I did want to make the point on the tax cut, just so that we're clear and we understand, when you refer to what our policy was, we were talking about a $350-million annual, spread out over five years, targeted to stimulating business. Everyone has said that a 30% cut in the income tax rate will not achieve the objective. What communities are seeing is a $1.3-billion cut to transfers to hospitals. We committed to maintaining a flat line for the hospital transfers for five years. People thought you committed to that too when you said, "Not one penny from health care."
We can get into all kinds of debate and discussion and rhetoric; that's not my intention. My intention here today is to say what people are saying to you: We would rather know that we have the hospital services and the health services available to us. We see you cutting. Our hospitals just received notices of cuts that are going to affect services. Layoff notices are going out. I've spoken with many of these hospitals and they are saying these are service cuts. So these communities want to know, if you're cutting the services in the hospital, where is your plan to make sure that people will have access to these services? If it's not in the hospital, where's the plan to tell them where they're going to be able to get these services? All they see are the cuts.
Hon Mr Wilson: With respect to the economic drag that's created, that's fully explained in the charts in the Common Sense Revolution document. There's a marginal drag on the economy. The economic model, though, does indicate thousands of new jobs being created. We know that in economies that have cut taxes there's about a two-year drag from the withdrawal of government spending in the economy and transferring that into consumer spending in the economy. We expect to see jobs pick up as a result of the tax cut. It won't be immediate, though. Some people will save the money, some people will pay down debts, others will spend it on new shoes for the kids. The fact of the matter is, in economies that have gone down this road in the past it's been a net positive for those economies where taxes are high. Our commitment to health care is maintained at $17.4 billion, and you know the red book indicated $17 billion.
Mrs Caplan: That's not true, Jim.
Hon Mr Wilson: It says it on seven occasions in the book.
Mrs Caplan: Jim, let's be fair.
Hon Mr Wilson: You made us be very clear about our decimal point, about our number after the decimal point, and your number is very clearly zero.
Mr Cooke: You haven't fudged, Jim?
Mrs Caplan: That's right.
Hon Mr Wilson: Your number is very clearly zero after the decimal point of $17 billion.
Mrs Caplan: That is not true and that is not fair.
Hon Mr Wilson: It is true. Have you got a copy of the red book? That's the book you sent out to the people of Ontario and it says in many places $17 billion.
Mrs Caplan: Listen, you know that is not true.
Hon Mr Wilson: And you were going to balance the books over four years.
Mrs Caplan: That is true. That is absolutely correct and we were going to do it.
Hon Mr Wilson: So given that we're doing it over five years, given that our tax cut isn't the difference -- you also believed in tax cuts of $2 billion -- you would have had to make significant cuts outside of the health care envelope if you were to preserve that envelope, and that's what we're doing.
Mrs Caplan: The fact that your tax cut, which is going to cost you $20 billion over the five years when it's annualized, that you're going to have to borrow that $20 billion and the fact that 50% of that tax cut is going to the top 10% of the population -- based on the calculations of your own Common Sense Revolution of how you're going to it, an across-the-board 30% cut in the rate works out to a figure that says that the wealthiest 10% of the population are going to get 50% of the benefit of that cut -- to me that's not healthy public policy.
What I want to discuss with you is, how are people going to get the services that they need when their hospitals are downsizing? That's the issue for you. We can discuss what your policy or our policy was going go do. You won the election. We expect you to do what you said you were going to do. You said you weren't going to touch one penny. You said people were going to be able to have confidence that they'd be able to get the services they needed. They are being told by their hospitals, and I am getting phone calls from across this province, that services are being cut. People are asking, where are these services going to be provided? I'm asking you today, where's your plan?
Hon Mr Wilson: The plan is contained in each community, in their district health councils. The NDP quite correctly, when they sent district health councils and hospital restructuring committees to work on developing plans for the local communities, made very sure that reinvestments were outlined in those plans for beefing up community-based services.
You'll see an increase in our actual estimates this year, a slight increase. Contrary to some of the letters I get from the people of Ontario, there's been a net increase in community-based services. We've not cut one penny in community-based services. There will be more money, as we get money out of the waste in duplication in administration in our hospital structure, and reinvest that in communities. In Metro Toronto, you know the reinvestment's about $75 million. Windsor, which we hope to have some good news for in the very near future, also talks about a significant reinvestment in community-based services.
I think all three parties agree that in Ontario today and in the future we'll continue to have a mix of institutions, community care, home-based care and long-term-care facility care. As you know, because it was your party that started it, and I agree with it, we're shifting our investments into beefing up community services, and that's what we're doing.
With respect to the tax cut, 80% of the tax cut goes to those earning less than $50,000 a year. I'd also remind you, because in the same breath we talk about a tax cut, in fact page 2 of the Common Sense Revolution talks about the fair share health levy before you get to page 3, which talks about the tax cut, and that is the great leveller. That ensures that people earning over $50,000 a year don't get a proportionately larger tax break and that they will have to pay a fair share health levy. Otherwise you're right, we would be giving millionaires, of which there aren't that many left in Ontario, a significantly proportionately larger tax cut than anyone else. So we were very careful to emphasize the fairness of our program.
You talk about the people of Ontario, some saying not to move on the tax cut, others saying -- I think overriding all that is they want politicians to do what they said they were going to do, and we are bang on our plan to deliver exactly what we have a mandate to deliver to the people of Ontario.
Mrs Caplan: Well, I'll tell you, I don't think people think you're bang on your plan. I don't think they feel that you have a plan for making sure they have access to services in their community. I think they are reeling from the letters that were sent out to hospitals, and I think the research that we've done, which takes into account your health levy, shows that the tax break that is going to the wealthiest of Ontarians frankly is obscene and that it's not going to have the effect that you hope it will have.
The other issue you've raised -- and I have to say that everyone knows one of the greatest indicators of the health of society is people's ability to work. The one statement you make that I think people will hold you absolutely accountable for is the 725,000 jobs. There is no indication that that is achievable, and you'll be held accountable for that, because that's -- you know, someone said to me, "A 30% cut in income tax is great, but if I'm not earning any income, that's not doing me much good if I just lost my job" as a result of the massive cuts that you're making to pay for that 30% cut in the rate of income tax.
But I want to go back to the effect of the cuts in transfers to hospitals and deal a little bit with the formula that you used. I've been told and I'd like you to confirm that hospitals that were successful in having the support of their community in fund-raising efforts were penalized and actually had larger cuts because of the additional revenues that didn't come from the Ministry of Health, that when you made the cut you made it on revenue from all sources as opposed to just based on the revenue they receive from the ministry. Could you tell me if that's accurate?
Hon Mr Wilson: It isn't accurate and the formula doesn't have a fund-raising component in it. This is the first time that government hasn't cut across the board and we're trying to recognize those hospitals that have done significant restructuring and not penalize them for the work that they've done to date under governments of all three stripes.
The formula also I think showed tremendous faith and a true partnership with the Ontario Hospital Association. It was worked out, as you know, at the joint policy and planning committee, the JPPC, at arm's length from myself, and I have to commend the hospital association, which worked very, very hard. Mark Rochon was certainly one of the major authors of the formula. He is a hospital CEO himself, and I think it's as fair as we could humanly put together at the time. And most hospitals, I must say, have been very pleased with the approach. Those that know they've done restructuring received a lower reduction and those that have more work to do received a higher reduction.
I'll be the first to admit to you, Ms Caplan, that this is new ground and there may be some corrections that we'll have to make in year two to the formula to better recognize growth. This time we put forward a $25-million growth fund. They're still working out the details how high-growth areas and those hospitals will apply to that fund or what the criteria will be, but I would personally like to see growth factors better integrated into the formula for next year, that's for sure, because that's been difficult --
Mrs Caplan: What about the growth factors --
The Acting Chair: We're going to have to move on. The 20 minutes is up.
0930
Mr Cooke: I just have a few questions. I don't pretend to be as up to date on health care policy as I thought I was a few years ago, but when Mr Laughren is back full-time I'm sure he'll get after the minister in a more comprehensive, competent way than I'm going to try.
I do want to try to get some information from you, and I want to start by just asking if you or your staff could run through for me the announcements that you've made to date on reinvestment, because some of the public announcements have not had dollars amounts attached to them and I'd like to, for the purposes of the estimates and the record, run through those and find out how much money is being spent on those reinvestment announcements in fiscal year 1995-96 and which ones have any outlay of dollars in 1996-97.
Hon Mr Wilson: Yes. The dollar amount we'll provide in most of the media reports, because, as you know, Mr Cooke, that's usually the first question they ask you when you make an announcement. There are dollars attributed to most of the announcements.
Mr Cooke: There's a few that weren't.
Hon Mr Wilson: As you know, they've ranged from increasing cardiac surgery capacity to 20% over two years rather than the recommendation of --
Mr Cooke: Mr Minister, could we run through them one by one just with the dollar amounts attached to them? I just want to get a few factual things on the record.
Hon Mr Wilson: I can do some of them off the top of my head: dialysis, $25 million; paramedic training, $15 million.
Mr Cooke: Dialysis is --
Hon Mr Wilson: It's an expansion.
Mr Cooke: Oh, I understand that, but 1995-96, how much is being spent?
Hon Mr Wilson: We'll provide you with a breakdown of those reinvestments when our estimates are up before this committee. Our estimates aren't up. These are your estimates we're talking about today. So in fairness, we'll provide you with that information. There are 22 significant announcements from the Ministry of Health. Not all of those involve dollars. Some of them are policy announcements. But they're good news.
And I should remind you, we've not seen one penny of restructuring money. We've not seen one penny yet of hospital money. The $375 million to come out of hospitals this year isn't in the bank. It won't be until later in the year. All of that money's been found by the fact that my staff's half the size of the previous ministry. We've cancelled the advertising budget.
Mr Cooke: I didn't really want to --
Hon Mr Wilson: I've squeezed every line item to find the millions of dollars that we've reinvested in priority areas.
Mr Cooke: I don't really want to have an argument about whether it's the appropriate thing or not. I just want to get some facts. The dialysis announcement is a -- I've got a $20-million announcement, but you say $25 million.
Hon Mr Wilson: That's my recollection.
Mr Cooke: You've got staff with you. The deputy probably would know. How much of that $20 million or $25 million is being spent in the current fiscal year? Then it builds to an annual expenditure, I take it, of $20 million or $25 million. So how much is 1995-96? How much is going to be spent this year?
Ms Margaret Mottershead: I don't have that information right here, but we can get it for you, Mr Cooke.
Mr Cooke: Will you be up to the full annual expenditure of the -- is it $20 million or $25 million?
Ms Mottershead: It's $25 million.
Mr Cooke: And will you be up to the full annual expenditure in fiscal 1996-97?
Ms Mottershead: In 1997-98. What this involves, as you're aware, is establishment of the clinics themselves, having regard for the equipment, recruitment of staff. As you're aware, in setting up programs there is a lag, usually over a period of about two fiscal years, so the investment will definitely grow to around $20 million in 1996-97 and $25 million in the subsequent year.
Mr Cooke: The OHIP out-of-country expenditures: That was another $25 million?
Ms Mottershead: That's $30 million.
Mr Cooke: Oh, $30 million. All the ones that I've got written down here are short by $5 million.
Hon Mr Wilson: You're being conservative.
Mr Cooke: That's my reputation within my party.
Hon Mr Wilson: You're also known for your sense of humour, so I appreciate that.
Mr Cooke: Of course, you're not going to spend up to the $30 million in 1995-96, but that would be full expenditure in 1996-97.
Hon Mr Wilson: That's the best guesstimate. It would depend on how many people use out-of-country services, I suppose.
Mr Cooke: Emergency services: There was $15.5 million?
Hon Mr Wilson: It's $15.5 million for the pre-hospital advance life support program. Most of that's training for paramedics. In addition to that, symptom relief medications was $4.4 million annualized. Again, good news, and in fact you save money very often with that one, because in the pilot project that your government undertook in Ottawa, some people, after receiving their bee sting medication or asthma medication, didn't actually want to get in the ambulance and then go to the hospital so they signed a waiver and went home.
There's a $45-million reinvestment in expanding the Trillium drug program from the $500 deductible level to the $350 deductible level. The partial implementation of the Scott report with respect to the $70 emergency on-call sessional fee for physicians in small rural and northern hospitals -- 67 communities, I believe, have taken us up on that offer out of a total eligible number of about 71 or 72 communities -- was another $13 million investment that's in effect now and those dollars are flowing.
We'd be pleased to provide you with a list. There's another $12 million that we've announced to repatriate and beef up acquired brain injury services in this province.
Mr Cooke: Just on the emergency services, on training, are those repeated annual expenditures or are those one-time expenditures?
Hon Mr Wilson: Most of it is training, so it's upfront expenditures. I don't know if there's a recognition of merit in pay for the new services.
Ms Mottershead: It's a continuous cycle. The big investment is to train everybody at the same time, but they are required to have continuous upgrading and training as part of the working conditions in the collective agreement with ambulance workers.
Mr Cooke: But a sizeable chunk of the $15.5 million is training, so all I'm asking is, is that going to be repeated dollars expended in each year or is that a one-time expenditure?
Ms Mottershead: It's repeated dollars in each year.
Mr Cooke: Okay.
Hon Mr Wilson: Could I remind you too that the major reinvestments, this money again is money we found internally within the sealed envelope.
Mr Cooke: I understand that.
Hon Mr Wilson: The major reinvestments are like your community coming up in terms of kickstarting the hospital restructurings.
Mr Cooke: Well, I eventually do want to talk about my community --
Hon Mr Wilson: I thought you might.
Mr Cooke: -- but I don't want to be parochial off the top.
Cardiac surgery: Was that also coupled with the announcement on acquired brain injury?
Hon Mr Wilson: No, they were separate announcements.
Mr Cooke: Could you just maybe run through that for me, but could you also comment on the press reports of a week or two ago about some procedures, and in particular I'm thinking of the angioplasty that has been altered from the older approach --
Hon Mr Wilson: Stents.
Mr Cooke: Yes, and that doctors are predicting, or saying, that service is no longer accessible because of dollars. Could you maybe touch on both the reinvestment and the status of that procedure?
Hon Mr Wilson: The reinvestment in cardiac surgeries, as you know, came from a recommendation from the Provincial Adult Cardiac Care Network. They had recommended a reinvestment over three years. We felt, as a government, that we could do better than that and were able to find administrative savings in the ministry to apply about $16 million over two years, which is added to the base and expands cardiac surgeries by 19% or almost 20% or about 1,435 new cases over the next two years, which should significantly --
Mr Cooke: Those are repeated --
Hon Mr Wilson: Yes. That's added to the base and almost 20% more surgeries will be done year over year then or over the next two years and added to the base.
0940
The stents question I had an opportunity to discuss in fair detail recently. We opened a new catheterization lab at Sunnybrook hospital just two weeks ago. They are performing stents there. I think they were one of the hospitals mentioned in the media articles that we all read.
It is a significant new pressure. Up until recently the efficacy of stents was somewhat controversial in the medical community. The ministry's not received any formal proposals for new program funding and I certainly made it clear during the cath lab announcement that if we find the dollars and the medical community believes that significant lives can be saved or prolonged, the quality of life improved and the efficacy of stents is agreed upon in the community, then we will try and find dollars to make a reinvestment there. No promises at this time and, as I said, the medical community itself is still getting its act together as to how and when it'll approach the ministry, but hospitals are doing it in-house right now.
Mr Cooke: At this point, the concerns that were expressed in the press are legitimate concerns. That procedure is not funded and my understanding, and correct me if I'm wrong, is that it's used extensively in other jurisdictions like the States where the value of it has been demonstrated and that there's actually costs that are avoided rather than repeating angioplasty or moving on to more intrusive intervention like bypass surgery.
Hon Mr Wilson: To be perfectly frank with you, we've asked the Provincial Adult Cardiac Care Network, PACCN, to come up with a comprehensive plan. When we made the announcement on the expansion of cardiac surgeries, we knew we were just playing catch-up or patch-up with respect to them. We want, from the onset and detection of cardiac disease through to the rehabilitation of the patient, a complete program presented. I think we're expecting that soon, aren't we?
Ms Mottershead: In the next couple of months.
Hon Mr Wilson: In the next couple of months, which is the first time they've tried to put together a comprehensive program, and stents may or may not be part of their recommendations. They are very expensive. It's a wonder to me why they're so expensive. It's the R&D I guess involved because they're a very short piece of a wire mesh and it's $1,700 and hospitals are funding that in their global budgets right now. You're right; we haven't set up a separate program for it. If PACCN comes forward with this as a high priority for reinvestment, we certainly will look at it, and we'll know that this year.
We're doing the best we can, but it is a new technology and every day, as you know, in the health care business new technologies emerge and the governments of the day try and do their best to catch up and pay for what might be effective.
As you mentioned, quality of patient lives is what we'd want to look at and the cost-benefit analysis of that, which is unfortunate in health care but you have to do cost-benefit analysis.
Mr Cooke: I have a little bit of an interest in this since both my parents have had substantial intervention and heart surgery and it's been a major issue in my home community for a number of years, but my understanding is that this type of intervention can also be used with people who may not even medically qualify for intervention like bypass surgery, that there's a broader range of people that this can be used with.
Hon Mr Wilson: I'm not a medical expert, but I'll tell you just briefly my understanding of it. Angioplasty simply is the balloon. What they do is they put the wire mesh on the end of the balloon and when they expand the balloon, the wire mesh will stay to keep the arteries open and the plaque against the walls on a more permanent basis. The debate was with angioplasty continuing to be used extensively around the province and around North America and the world, they're only now, I think, or relatively recently discovering that the arteries have been filling in and perhaps --
Mr Cooke: I guess the only concern I ever have when I read about this stuff --
Hon Mr Wilson: But we'll take the lead from the medical community on that.
Mr Cooke: -- is that we've got to be able to have a health care system -- and I'm not advocating that we should use intervention unless it's been proven to be effective -- and I would never want to go the route of the States where we have single bypass surgeries being done down there or intervention that's very costly and not medically helpful.
On the other hand, I don't think we can have such an unresponsive health care system that when new technology becomes available we lag way behind, because then people do lose confidence in our system and see it as being overly bureaucratic and underfunded.
Hon Mr Wilson: I agree and it's one of the reasons that we're continuing what your government began, which is the reinvestment of dollars into an expansion of MRI services because it's unfortunate, for example, that Ontario only has 12 units right now. We're going to continue with what was planned, to expand to some 23 units in the province, to simply bring us up to world standards. That'll bring us in line with European countries, which recommendation is about one MRI for every 350,000 population. So I agree with you. Where we can, we're trying to come up to standards.
But let's not be too hard on ourselves. We're world leaders in many, many other areas including cancer care. In certainly the history, which I know well because my uncle Dr J.K. Wilson was one of the great cardiac specialists in the province, we were world leaders with respect to transplant and with respect to angioplasty and all of this, and we may, in future, be world leaders with respect to the availability of stents. That would be nice, if that's what the committee recommends.
Mr Cooke: What are the dollar amounts that we're investing on acquired brain injury services? That's basically reallocation of money that we will ultimately save by avoiding use of American facilities, correct?
Hon Mr Wilson: We're spending $21 million in the States now and we're repatriating that money. In fact, by doing that we'll save some dollars. The estimate is we may save upwards to $9 million so there'll be a net saving. But I just participated in the expansion of ABI services which the government made -- outside of the repatriation goings-on -- at Queensway just last week, an expansion of ABI services there. I guess if we added up all of that, special programs and expansions, the list would be far greater than anything we put on press releases. As you know, things happen in hospitals regularly --
Mr Cooke: That's what I wouldn't mind then getting from you, if it could be tabled with the committee or sent to critics.
Hon Mr Wilson: Certainly.
Mr Cooke: A list of all of the reinvestments: how much is spent in the current fiscal year, how much is spent in the next fiscal year, and what the outyears are going to be. Because there are a number of them that are one-time expenditures, and I think it's important that people understand that reinvestment is important but we want to see, over time, what the net impact is of your cuts versus your reinvestment. And at this point, we've got a long ways to go to see that all of the dollars that are saved are reinvested.
While I agree with some of the comments that Mrs Caplan has made, I think where you're going to be judged -- sure, on your job creation in other ministries, that's part of it -- but I think the one that people are watching more closely than any other is this one right here. They believed you, and they actually voted for you -- I would argue, aside from all the politics, that your party got elected instead of the Liberal Party because of your promise on health care. People actually believed that you were telling the truth.
Hon Mr Wilson: Well, we are. We've lived up to our commitment.
Mr Cooke: You know I don't agree with that and there's no use having the argument out here because not everybody reads Hansard.
Mrs Caplan: -- nobody believes that.
Hon Mr Wilson: The consensus is to move dollars --
Mr Cooke: Does this come out of Liberal time, Mr Chair?
Hon Mr Wilson: -- and live up to the speeches we've all been making for 10 years, and to reinvest the dollars out of administration in institutions into community based services. You gave a bunch of speeches like that yourself 10 years ago. We're actually acting.
Mrs Caplan: Look, I was on platforms with you and you never said, on those platforms, what you're doing now.
The Chair (Mr Alvin Curling): Is that okay with you, Mr Cooke?
Mr Cooke: No, it's not.
The Chair: Mrs Caplan.
Mr Cooke: We'll get it back around later.
Mrs Caplan: Nobody who listened to you make those speeches before the election or during the election would have ever believed that this would be your policy.
Hon Mr Wilson: We committed to stable and predictable funding and we're giving them a three-year time frame.
0950
Mrs Caplan: Come on, I was there, Jim.
The Chair: Order.
Mrs Caplan: Sorry about that.
The Chair: Mr Cooke, you've still got a couple of more minutes.
Mr Cooke: How much time do I have left?
The Chair: I'll give you three minutes more.
Mr Cooke: That's very generous.
I was looking through and I want to come back to -- well, maybe I'll leave that and I'll just get one thing on the record from back home at this point. Can you tell me two things dealing with my home-town health care situation. The dollars that had been reinvested or announced by our government on the regional cancer centre, are those dollars still committed? I haven't heard anything contrary to that so I'm assuming that those are still -- and that's outside of the restructuring announcements.
Then I would like to ask the minister: He knows right now there is huge concern in Windsor that you rejected the capital approvals that we had made on the hospital reconfiguration. While I disagree with you, that's your choice, and that's certainly within your powers to do that. But we've now been operating for several months not knowing what we're going to get from the government, and therefore all of the restructuring has been held up in Windsor. I'm getting calls daily from the health council, from hospitals, saying: "What the heck is going on? When are we going to know?" And the whole thing is going to fall apart.
I first of all want to know some time lines and I've been getting mixed messages from your political staff versus the ministry about what the role of the restructuring commission is going to be. My belief is that we don't need the commission's intervention in Windsor. We've had the studies done. The implementation is well on the way. During the Bill 26 hearings your PA said that the purpose of the commission was for implementation. We've got an implementation plan. The hospitals and health council have been doing all of that work. You said you need this commission in order to speed up restructuring. We're in the strange position in Windsor that you're holding up restructuring. You're slowing down the entire process. It's critical right now and the whole thing is at risk of falling apart if you don't act quickly.
I'd like to get some understanding of where you stand on the cancer reinvestment and the restructuring in my home town.
Hon Mr Wilson: With respect to the proposed cancer centre, we will be proceeding with the cancer centre. I've said that to the people of Windsor.
In a few more days we'll be done the capital review. I know your view is that I'm holding up hospital reconfiguration. The fact of the matter is, Mr Cooke, perhaps through no fault of the previous government, the dollars that have come back from a number of the studies in terms of the capital requirements to kickstart and get moving with the reconfigurations or restructurings weren't budgeted for, mainly because they weren't known. If you add up just what's in now with respect to Windsor, Sudbury, Hamilton and Toronto, we have capital pressures that would, in all honesty, spend the capital budget of the Ministry of Health five times or six times over.
Mr Cooke: I also remember --
Hon Mr Wilson: Having said that, I'm going to give you the good news: Windsor is a priority. We are very, very close to being in a position to make the final decision. I give you my personal word that it is a priority. I'd like to get it out the door. You've reminded me many times off the record in the House that there's tremendous pressure from the community, and we would like a win-win for everyone to show that this government is serious about restructuring, to build upon the work that you've done and your community has done, and it is ready to go, I understand that. We should have some good news very, very soon for your community.
Mr Cooke: "Very soon" meaning?
Hon Mr Wilson: Very soon. As a courtesy you will get some notice prior to the announcement.
Mrs Lillian Ross (Hamilton West): Good morning, Minister. I'd like to ask you a couple of questions about the hospital funding formula. In our community there was a difference between what the hospitals got, and I'd like to try to get an understanding of where that formula came from, how it was developed.
Hon Mr Wilson: The formula was developed in a joint working group with the Ontario Hospital Association, headed -- though I don't want to leave anyone out -- by Mr Mark Rochon, who's the CEO of Humber Memorial Hospital, and staff at the Ministry of Health. The previous government had set up a joint planning and policy committee -- it had been set up for a number of years, really -- and it's the formal linkage with the Ontario Hospital Association and the Ministry of Health. They developed the formula.
As I said, it's the first time the reductions weren't applied across the board but tried to recognize restructuring and administrative savings that had gone on before our government coming to office to not penalize those who had done good work to date and to give a bit of a heads-up to those hospitals that may have felt they had done some restructuring in the past but didn't actually achieve any significant overhead savings.
The other thing I'd say about the formula is that it really does compare oranges to oranges or apples to apples. It's the first time -- I think it's fair to say; at least I'm told by the people who developed it that it's the first time -- where outcomes are actually measured. It's a weighted case formula. They looked at a variety of treatments or procedures at hospitals that were common to all hospitals, with the exception of the specialty hospitals, because they were hard to measure, and followed the cases through, a patient through, and said: "Here's the benchmark. Other hospitals should be able to achieve that benchmark because some hospitals are doing it now and patient quality is high, outcome is good."
For those hospitals that received higher than 5%, the general rule would be that there's a bit more work they could do. We are not leaving them in the dark in terms of how to get more efficient. Manuals are to be sent out soon from the JPPC giving some very good suggestions to those hospitals on how they can catch up to the efficiencies already achieved by other hospitals in the system that would have received 5% or less.
It's pretty exciting, and I must admit that the feedback for the most part -- I'd say the vast majority -- has been very positive from hospital administrations. They realize that dollars have to be found in that system, that a true system has to be built. Ms Ross, you have Hamilton now reported. We're in the public input stage with respect to that hospital reconfiguration or hospital restructuring -- somewhat controversial, I certainly understand that, but again, a recognition from your community that savings can be achieved and reinvested in community-based services and other services.
Mrs Ross: Referring to the process that's going on in Hamilton right now, the health action task force has presented its report and is asking for any comments from the community. They've given them a two-week slot in which to do that, and from there it's going to go to the district health council. There's concern expressed that the time lines are too short. Is there a time line imposed on the district health council at which time it must have its report into the ministry?
Hon Mr Wilson: The district health council, I've been informed, will in all likelihood be receiving the final report of the restructuring study at the end of this month, and it's the district health council's intention to send a copy of that final report to the Ministry of Health and to the Health Services Restructuring Commission.
I'll just go back to what Mr Cooke talked about, because I didn't fully answer his question. The commission need not be involved in Windsor because Windsor's ready to implement. The commission's not there to interfere if everything's moving along smoothly. Therefore, because the commission isn't quite up and running -- and the public service strike has a little bit to do with that because the support staff would have come from the public service, most of them -- the fact of the matter is we hope to announce the rest of the commissioners. As you know, it's already been announced that Dr Duncan Sinclair will be the chair, and we're very, very pleased with that. We've received wonderful comment from across the province about the calibre of that appointment, and I have to thank him publicly for taking on the job. It's not going to be easy.
1000
Bill 26 made it clear, though, that this government wants to get moving on restructuring. The commission will have four years to do its work, and it's really there to assist local communities. I expect Hamilton will be one of the first restructuring studies, along with Metro, which is already in, and perhaps Sudbury, that is referred to the commission. They will work with your community to try and sort through what I know, reading the local papers there in the last few days, is going to be a very challenging task: to restructure the hospital system there.
Mrs Ross: Further to that, when the report goes to the district health council, one of the questions we asked -- they're proposing closing one of our hospitals -- was, "What do you expect to happen to that facility once it's closed?" The response was, "We weren't asked to look at what happens after the restructuring." Whose responsibility is it going to be to look after that facility and determine what use that facility will be put to? For example, they said -- just a suggestion -- you could use it for long-term care, you could use it for kidney dialysis and that sort of thing. I just wonder, where is that going to come into this process?
Hon Mr Wilson: It's a good question, because we're entering new territory. I don't think any other government has had to make those types of decisions. The commission, with advice from the district health council, will advise with respect to the disposition of property, if we get to that point in Hamilton, and we will take advice from the local community, keeping in mind that the Ministry of Health doesn't own the hospitals; they are separate, independent corporations, so we would want to take the advice of the community of what they felt was best for the community. We'd entertain reinvestment ideas for that site, for example, if that was deemed to be necessary for services in the community. But it would be a little premature to say, because the district health council would take the lead, as they do on health care issues locally, to advise the ministry and to advise the restructuring commission.
Mrs Ross: When the district health council reviews the task force report and hears input from the community -- and I believe they're going to hear quite a great deal of input from the community -- it will then be their responsibility, will it not, to alter that report to suit the needs of the community? Are they going to be able to make revisions? I guess that's my question.
Hon Mr Wilson: Yes, and Metro Toronto's report, which is the largest one, so I reference it often -- certainly from the time the restructuring committee in Metro released its so-called final report to the time the DHC dealt with it and passed on its recommendations to the ministry, which will go to the commission, changes were made, so there's already precedent to make changes. Even throughout the time of restructuring, changes may be made to some of the reconfiguration of programs, because the data in health care move so quickly. From the time Sudbury started -- and I think this is all quite public -- the benchmarks with respect to our ratio of patient days per thousand population have moved over the last two years since they completed their first study on restructuring in Sudbury. Things are moving very quickly with new technologies and with the application of better methods of providing care.
With respect to Hamilton, we would hope the DHC -- and certainly nothing contrary has come out from me or the ministry. The DHC's job is to be the eyes, ears and conscience of the local community, and if anything, I did express, and I believe it made it in one of the local media reports, that I felt two weeks was a bit short. I did express that to the restructuring study members. However, it's their report and they are sticking to that time frame. But the DHC does have the flexibility to and must, in my opinion, take into account the public's concerns, any new data or corrections to the data used in the original study and to give their very best advice on behalf of the people of Hamilton and district to the restructuring commission.
The whole idea is to get it right, to maintain a high level of access to services, and yes, to really downsize money that's being spent on bricks and mortar that may not be needed any more, on administration, waste and duplication, which everybody admits is in the system in varying degrees in different communities, and to really pull together a system for Hamilton-Wentworth in terms of program delivery. We don't want to see a deterioration of program delivery or access to services. That's not what restructuring's all about and that's not what three governments now have talked about when they talk about restructuring. It should be a net positive for the community in terms of the delivery of health care services.
Mrs Ross: One of the questions I did not ask but should have asked -- perhaps you can answer it. We have six hospitals in Hamilton. One is a Catholic institution. Is there a requirement that there be a Catholic institution in some communities? The reason I'm asking is because they've recommended that the Sisters of St Joseph run a different hospital, and I'm wondering if there's a requirement for that.
Hon Mr Wilson: There's no requirement, but I think we have to be mindful of the fact that religious denominations were in the health care business long before government was invented in this province, long before Confederation, and the policy of this government is to respect the role of religious institutions. For many years those sisters put two thirds of their salary back into the operation of those hospitals, for well over 100 years, and we have some very strong, not just Catholic, institutions in the province but many denominations; in fact most denominations run some sort of degree of health care. They were in it, as I said, long before government was invented or government set up health care systems. We don't want to lose that investment. We want to ensure that they're very much part of the system of the future, and we respect the role of denominations in the delivery of health care services.
Having said that, it's up to the local community in its reconfiguration or restructuring to accommodate the role of St Joe's, for example, in your community. I think the study's trying to doing that. Obviously, we're in the feedback period, and people have varying opinions on how that role will play out in the future.
Mrs Ross: I'd like to talk about Chedoke hospital and its program for brain injury. We've reinvested money into that area. I don't understand that either, so I need some clarification. From what I understand, people were getting treatment outside of Ontario for brain injuries. Do you have any idea what it costs for that service outside of the province?
Hon Mr Wilson: Currently we're spending about $21 million a year on treatment for about 76 patients in the United States. We expect that by repatriating those patients -- and we're doing it on a case-by-case basis. I want to make that clear. I thank you for bringing up the topic, because we're not holus-bolus in a cookie-cutter approach -- I think a previous Health minister used to use that line all the time -- repatriating the 76. We're working on a family-by-family basis and putting those dollars into Ontario-based facilities, of which Chedoke-McMaster is very much a part. There'll be a net savings, we estimate, of about $9 million once we repatriate all 76 patients. That money becomes part of the health care envelope; it's probably already been spent in the reinvestments we've made to date, to tell you the truth.
Mrs Ross: When the hospitals do their restructuring and there are savings found in that sector, will those savings stay in the community? Does the money come back into a general pool and then get redistributed from there?
Hon Mr Wilson: It's a good question, one that I was asked quite frequently in the House in our first session of Parliament with this government. Clearly, the policy of all governments has been that where a saving is found it's reinvested for the general good of the health care system, reinvested into priority areas identified by people in that system and working with government.
1010
It's important to understand that we all benefit from places like the Hospital for Sick Children or the research being done at Chedoke-McMaster or the Children's Hospital of Eastern Ontario, CHEO, or for the tremendous work and very cutting-edge scientific medical work done at Sunnybrook Health Sciences. All that is paid for from the general pot of money, and all Ontarians benefit from that work.
As we achieve savings, they will go back to priority areas, including, very importantly, the priorities identified through the district health council restructuring studies. The studies we have to date identify investment needs in community-based care in those communities. If you're going to be downsizing the hospital sector or reconfiguring it in some way, you don't want a gap in patient services, so you have to in many cases improve the community-based services, improve the nursing care available in the home and the therapy services and the providers available in the home. We want to see and we're challenging the studies to ensure that they very much include and integrate mental health services as part of that, because my personal belief is we could do a much better job of providing those services in the province. I think that pretty much answers your question.
Mrs Ross: I'd just like to touch on one other area in the --
The Chair: Please touch on it for about a minute. You have about a minute left.
Mrs Ross: Well, that's not enough time, so I guess I'll pass.
Mrs Caplan: I'd like to follow up and get some clarification on the rate-based funding formula. For the record, just as a reminder to those who may not know, the equity funding formula was initiated during my time at the ministry and for the very first time created an efficiency incentive for hospitals. I think it's fair to say that equity funding formula was cancelled by the ministry -- that was under the NDP -- and then reinstated because it was recognized that it was a very important incentive for the hospitals.
The reality was that the equity formula was in addition to the base budgets. Part of the concern was that there was no incentive for those who were so inefficient that they would never qualify for equity funding, and the result was -- this came later in the NDP term -- that there was what I called a negative equity formula developed. It was called the reallocation formula. That was never implemented by the previous government, and that, I think, was negative because it sent the wrong message out to the community. Also, over the years, the equity formula, the proposed reallocation formula, which the hospitals were getting used to, I think created an environment where you had a positive incentive for taking a look at what you did and seeing if you were doing it as cost-effectively as your neighbour.
The point you're making, Minister, is a very good one, about making sure you're comparing apples to apples and oranges to oranges and assuring communities that their hospitals are being treated fairly. I would like you to state clearly on the record, is there an appeal process for a hospital that feels it's been treated unfairly with your rate-based funding formula? -- which I think is a good idea. I think that is an appropriate way to fund hospitals. I think it has to be gradual. The concern I have is that because of the size of the cut you've made, the gradual approach to rate-based funding, which is what I think the hospitals were expecting, has had a severe negative impact on the system because it's happened too quickly. No one was prepared for the kind of cuts your transfer cut brought forward.
I'm supporting in principle the rate-based funding formula. I began the idea of incentive funding, and I spoke in support of the reallocation formula. But the principle in all of this is that it must be open and transparent, that there must be an appeal process built in, that the minister is ultimately accountable, even though the formula was done in conjunction with the Ontario Hospital Association. I felt that was a good process. The first question is, is there an appeal process in place, and is the information available to communities to assure them that you are comparing oranges to oranges, in your own words?
Hon Mr Wilson: I will ask the deputy to explain, because as you know she's a member of the JPPC, to elaborate on what I've said to date, that it's a weighted case formula; we're not quite at rate-based. Maybe we'll explain the difference in just a minute. But you're right, the general gist is the same in terms of where we're headed.
Mrs Caplan: You're getting to rate-based.
Hon Mr Wilson: There isn't really an appeal process, although I'm hearing very directly -- as you know, as minister, the phone rings -- from some hospitals that feel their transfer reduction is a little higher than they were anticipating. We're still working on the criteria for the $25-million fund available for growth areas, and those are mainly the ones we're hearing from. In terms of a formal appeal process, we will take into account all the concerns expressed. The JPPC, I think, will try to modify the program formula for year two. So far I'm not aware of significant problems, but we may hear more. Hospitals were given notice in November, in the economic statement, that it would be around 5%, so I think they have had some time to understand it.
To be perfectly frank, I've had CEOs and hospital presidents say it should have been higher on the front end, above the 5% average -- that was actually a recommendation that came forward to me at one time -- to really encourage and to really send the signal, because people are sceptical that the government is not serious about restructuring. I don't know how many CEOs in Toronto have said publicly -- I think some of them questioned it even during the Bill 26 hearings -- "Oh, you're not really serious; we don't see any evidence." Some of those hospitals were willing to take higher transfer reductions to really force themselves to find the efficiencies we've all been talking about. I will ask the deputy to talk about the weighted case formula and to enlighten us on the contents of that and the discussion around it.
Ms Mottershead: Mrs Caplan is absolutely correct in stating that the formula was developed under her leadership at the time she was Minister of Health. In fact, the formula was developed to recognize efficiency in clinical practice and clinical programs, and only clinical practice and programs; it didn't look at things like the efficiency of a records department, laundry service, linen, dietary and all of that, which is what we are attempting to do as part of the discussion on rate-based funding, which then takes the clinical component as well as the infrastructure component and attempts to assign weights to everything. That work is under way right now through the JPPC, but it has not been perfected or accepted at this point.
However, the equity formula that was used to distribute additional dollars at the time it was invented was felt to be sufficiently sophisticated to deal with the complex things that happen in hospitals and to be used to redistribute money as well as the practice of adding money. We have, in the ministry, continued the equity formula throughout the years. It's now into its seventh year. It's not obvious, because it didn't distribute the whole budget. It's only after the additional funds were reduced in equity that it was used for certain programs like hip and knee replacements and others, high-risk cardiac programs, for example. We did use the funding formula to deal with that.
1020
The current round of considerations included a number of factors and factor adjustments that were necessary because hospitals told us they didn't want to be compared to peer groups, for example. They wanted that to disappear. They wanted the teaching hospitals not to be compared among themselves. The community hospitals who have teaching programs told us it was unfair in terms of the way the formula was structured, that it weighted more on teaching when they do community teaching with GPs, for example, and so on. So we took away the peers, we took away the teachingness and we introduced new adjustment factors into the formula that would recognize that level of activity going on and whether it's a community hospital of 100 beds, 400 beds or a teaching hospital with over a thousand beds. So those adjustment factors were taken into consideration.
We understand through the JPPC as well, through the funding committee, that we need to develop more sophistication around growth and what kind of weight you give to growth, because growth is not just in a population; you could have growth within a certain community as the population ages, for example, putting additional pressure on some of the hospitals. This year, the decision was made based on the most up-to-date information and methodology available.
The committee is continuing to work on three other issues that will probably have application for the next allocation in 1997-98, that is: a formula to recognize growth and whatever weight is going to be assigned to that; a refinement to the formula to recognize the unique characteristics of small hospitals and their inability to reach efficiency because of their lack of critical mass and what kind of factor you use to deal with that; also, to look at the question of what relationship does other revenue -- which is a question you raised -- have in the context of total cases?
I just want to reiterate, because the question was asked earlier, that this equity formula does look at total cases in a hospital regardless of where the cases come from, whether it's an American patient at Sick Kids or whether it's Quebec residents from Quebec.
Mrs Caplan: What about parking lot revenue?
Ms Mottershead: It's being factored in as part of round two.
Mrs Caplan: That's not what I understood the minister to say.
Hon Mr Wilson: I said that right now my understanding is that it's not a significant part of the formula for year one, but it's something we want to look at in year two. It's only fair.
Mrs Caplan: I think there needs to be assurance, because if you're dealing with the hospitals fairly, two things have to be in place. First, you must have an appeal process for those that feel they were dealt with unfairly. That has to be addressed; they have to be able to make their case. I argued that during Bill 26. To eliminate appeal is unfair to communities who -- not that they're going to argue that the formula could be better, because I agree; the formulas are ongoing and they're refined, and on that one I'm very supportive. The original equity funding formula looked very different three years down the road, from the experience gained. On that, I don't think anyone should expect anything other than the formula, if applied fairly.
But I am arguing that the formula must be applied fairly, and those hospitals that have community support and raise revenues shouldn't be penalized. If what you're saying is that the formula was applied not only to the transfer from the Ministry of Health but to total revenue within the hospital, that's unfair. I believe your approach --
Hon Mr Wilson: Some hospitals have the ability to raise funding outside of MOH funding because of their geographic situation, because of their corporate base in the community. There is one taxpayer whether the money comes through fund-raising or otherwise. We're not setting out to be punitive. I think we're setting out to be fair.
Mrs Caplan: I don't think it's fair to say, for those hospitals who go to their community and get support through fund-raising, that that means they're going to have a bigger reduction than they would have had if people didn't give. Let me tell you what the result of that is. Corporate fund-raising is going to dry up if the result of that fund-raising is that they get a bigger cut from the Ministry of Health. Get serious. That's not fair. You're going to damage the ability of those hospitals to go to their community for fund-raising support.
Hon Mr Wilson: Keep in mind that fund-raising -- primarily -- I think the corporate fund-raising you're talking about is capital fund-raising. That's not what we're talking about in the formula, which is operating dollars.
Mrs Caplan: So I want your assurance --
Hon Mr Wilson: But you asked about parking fees.
Mrs Caplan: -- that if any hospital takes fund-raising and puts it into operating, that's not included in your funding formula.
Hon Mr Wilson: Correct me if I'm wrong, Mrs Caplan, but technically they're not supposed to do that with respect to their capital campaigns, and if you want to admit what all Health ministers are told, that every once in a while we have seen some dividends to capital going into operating, that is the beginning of a two-tiered system, because people might give to a hospital so they can get on a cardiac waiting list, and we don't want to see that. We're talking about operating dollars, and you mentioned parking fees. The deputy would like to make one comment.
Mrs Caplan: Before you stray from that, my view always was that the notion of a reserve fund was reasonable for hospitals. What I objected to when I was minister was that there was a suggestion that in years when hospitals ran surpluses, that went into their foundation and in years when they ran deficits, they asked the ministry to bail them out.
Hon Mr Wilson: Right.
Mrs Caplan: Nobody thought that was reasonable. Certainly I did not.
Hon Mr Wilson: I'm glad you said that, because if I said that, somebody would be hanging from the chandelier.
Mr Cooke: Seems fair to me.
Mrs Caplan: I think it's reasonable. What I said --
Hon Mr Wilson: I appreciate your honesty.
Mrs Caplan: What I said then, and I say now, is that if you put resources in your foundation, or you raise them through parking revenues, or through donations that are not designated for capital -- let me tell you I get appeals all the time from hospitals that do not say, "This is for a specific capital fund; it's strictly for care," and I can show you some of the fund-raising letters, they do not relate to capital -- those funds from the foundation or from the fund-raising campaigns that go into support operations shouldn't be targeted by the ministry for a result of a greater cut in the hospital. Just as it's not fair to say, "Minister, pick up the deficit," after we ran at a surplus the year before, my view was you bank your surplus, if you have a shortfall the next year, you put it back into operating to smooth things out. That was always my view and it remains. But what you're saying to them now is if they do take some dollars to smooth things out, they're going to get a bigger cut, according to your formula. That's not fair. There should be an appeal process, and I would ask that you put that in place.
The second point that I would make --
Hon Mr Wilson: Elinor, could the deputy just comment on that?
Mrs Caplan: Sure, okay.
Ms Mottershead: The reason why an appeal process was not built into this time is because the formula and the methodology and its applicability have been discussed with the hospital community for months and months. Some people on the funding committee have been on the road. They've had educational sessions sponsored by the OHA, so I don't think there would be any surprises to hospitals.
The question has come up, and we're dealing with this one like we're dealing with all of the other ones that have come up in terms of the methodology, and that is its perfection has maybe a few limitations. They're recognized, they've always been recognized, and we've got a committee that will work at that to deal with this for the subsequent application, but not in this round because, quite frankly, if you deal with that question of appeal, there are other imperfections in the formula, and you'd have to open up to the whole thing. People have accepted that.
As it is, they've signed off, there's OHA board consensus on this and resolutions passed to adopt this, and as the representative of hospitals, I think they have made a decision, and their recommendation to the ministry and to the minister is to stick with the current formula and its application and look at refinements later on.
Mrs Caplan: I'm not suggesting that you change your formula for this year, that's not what I'm saying. And if you're right, deputy, with due respect, and everyone has signed on, then there won't be any appeals, but I think any process that does not allow for the possibility of an error in application is a flawed process and you lose respect, and it is unfair not to allow for the appeal where there is the exceptional case. Let's hope it's an exception and that you wouldn't get any appeals, so I'd ask that you reconsider that, Minister, and allow for hospitals to appeal where they feel they've been treated unfairly.
I would like also a commitment from you that the ministry didn't tinker with the formula as it was developed by the JPPC, the joint committee with the OHA, that you accepted their formula and that you didn't tinker with it, so that in fact all communities were treated fairly. I've heard some rumours that there was some tinkering and people are concerned that a formula was developed that people felt comfortable with, so I'd like your assurance that you accepted that formula and that you did not make any changes to it arbitrarily or unilaterally.
Hon Mr Wilson: Keep in mind that the formula was jointly developed by the ministry and the OHA. I've read those media stories, too, so --
Mrs Caplan: Here's your chance to say, "No, we didn't do it; we did exactly what they recommended."
Hon Mr Wilson: In the end, we did exactly what they recommended.
Mrs Caplan: So if anyone now is dissatisfied, you took the recommendation of the JPPC, you didn't tinker with it, and at the last minute you didn't change the formula and --
Hon Mr Wilson: It was a very cooperative approach. I will admit that I had concerns about small rural hospitals, and I expressed those concerns as part of the process, and the final formula, I think, very much recognized those. We don't want to wipe the only hospital in town off the map because of the funding formula.
Mrs Caplan: The concern that I have is you began at the beginning by saying: "Look, this was an arm's-length process. The ministry was at the table with the OHA and they did it, and I didn't have anything to do with this." Now I hear you say, "Well, at the end, I looked at the formula and I expressed some concerns, and they went back to the drawing board." Which is right?
Hon Mr Wilson: The deputy expressed concerns about small hospitals, and that was part of the discussion, but the discussions were -- I wasn't in the room for the discussions if that's what you're --
Mrs Caplan: I think everyone, if they're going to --
Hon Mr Wilson: And a final formula was presented to me, and I took it to treasury and to cabinet, and they did not interfere with it.
Mrs Caplan: If people are going to accept equity funding formulas, rate-based funding formulas, then the one thing they want to know is that you are comparing oranges to oranges and apples to apples, and that if you set up a committee that is arm's length and they develop a formula, there has to be integrity in that process, and at the last minute when you take a look at what the impact is going to be on the Premier's riding, that the formula isn't changed. That was the rumour that was out there, and I just want your assurance that it did not happen.
Hon Mr Wilson: We did not interfere in a political sense in it. The ministry, through the deputy, expressed concerns that one of the things she was taking to one of the meetings was small hospitals and was trying to encourage them to develop a final formula that recognized small rural hospitals.
Mrs Caplan: One of the concerns I have, and I want to put it on the record because you can think about --
Hon Mr Wilson: I mean Margaret can speak for herself, but there was very much an ongoing process. It took several months.
Ms Mottershead: Can I just assure the member and everyone else present that there was no tinkering with the formula or the methodology, none. There was consideration by the ministry once the recommendations were received from the JPPC that we should look at narrowing the band of application, because the original recommendation, Mrs Caplan, was that some hospitals would receive as much as a 10% reduction, and we didn't feel it was appropriate to have a band that wide when we have hospitals, small, in rural areas, that would have been, as the minister indicated, just devastated if we had allowed the original recommendation to stand, but there's no tinkering with the formula or the methodology.
Mrs Caplan: Is that what the minister referred to when he said that some were recommending 10%?
Hon Mr Wilson: No. Some of the larger hospitals, Toronto-based hospitals, were recommending to me that --
Mrs Caplan: Because I never heard anybody that was recommending 10%. In fact, I think it's --
Hon Mr Wilson: You can imagine some of the larger hospitals that have a greater ability to --
Mr Cooke: The Liberal Chair is having difficulty getting in, because the Liberal Health critic does not allow the Liberal Chair to speak.
Mrs Caplan: Is my time up?
The Chair: I have no difficulty. I just want to say to you -- your time is just about up -- we'll take a 10-minute break now.
Mrs Caplan: "Just about" is different than "up."
The Chair: Just about. You have another couple of seconds, you see.
The committee recessed from 1034 to 1058.
The Chair: We can resume. I believe Mr Cooke has 20 minutes.
Mr Cooke: I thought maybe I would try to get some understanding from the minister about the hospital restructuring process, the time lines that you're looking at for the appointment of the balance of the commission, when they're going to get up and running. I'll leave it at that for the first question.
Hon Mr Wilson: As you know, a couple of weeks ago we announced the chair of the commission, Duncan Sinclair, and I hope to be able to announce the remainder in the very near future. It will be a very small commission. We're looking at certainly under 10 commissioners, which I think the parliamentary assistant, Helen Johns, indicated to the Bill 26 committee, and we realize we have to get going. Bill 26 limits the time frame of the commission to four years, and we already have a number of restructuring reports in or just about to come in that will be referred to the commission. At the time we announced the chair, we did put out the mandate of the commission, and it's consistent with what we've said, that it has the full authority of Bill 26. However, it's to work with local communities in implementing their reports, and it's my opinion, the vast majority of the time should be spent helping the local communities facilitate the implementation where there's a request from the local communities.
We've had to make it clear through our communications department recently when some hospitals have said hypothetically, "What if a hospital doesn't want to restructure and the other four or five in town do?" the commission clearly has the authority to be as persuasive as possible to try and make sure restructuring happens. That would be the worst-case scenario, I guess, but so far cooperation has been pretty good. Your area is way ahead of the government actually.
Mr Cooke: I'm sure this was properly explained during the Bill 26 hearings, but I'm still confused. The commission will be established. The health councils do their restructuring reports, so the restructuring report would come from a health council and would come to the minister, and at that point there would be some political decision. I'm not saying "political" in a negative way. When you say "implement the local plans," I'm always confused because I don't understand how they can implement the local plans unless somebody says that the local plan is acceptable.
Hon Mr Wilson: We'll be taking the advice of the commission on that, but I think Bill 26, the amended bill, makes it clear they're not to reinvent the wheel. They're to implement the consensus of the local communities. I can't say it any clearer than that, and that's what's come out in the media.
Mr Cooke: Yes, but there's major --
Hon Mr Wilson: Where disputes arise, we expect people to make their concerns known about a report to the commission. We were asked, Mr Cooke, quite seriously, by the Ontario Hospital Association to try and keep politics, whether in a good or bad connotation, out of it. The only other option that I could see, because we weren't exactly left with a blueprint on how to implement restructuring, would be to have to go periodically to cabinet to get decisions, and frankly I don't think the OHA trusted politicians to do this properly.
Mr Cooke: No. But you will agree that somebody at some point, if there's a report that comes forward -- you can talk about the Toronto one, you can talk about any one; when the report comes forward, there's recommendations on consolidations, closures, there's recommendations on reinvestment and capital allocations. Obviously you have to make a decision, as you're making a decision for my home community, about what the capital allocation is going to be.
Hon Mr Wilson: I can see with respect to dollars to implement it, we'll have to signal to the commission what's doable and what isn't, over what time frame, and yes, the ministry will have opinions to express to the commission also, but at the end of the day they have the full authority of Bill 26 to help local communities implement. Again, if I don't have all of the answers how it will play out, I'm being honest with you. No one has tried this before, and I think we're trying to do what we've been asked to do by the people whom we will very much rely upon to implement restructuring, and that's the hospitals themselves.
Mr Cooke: I understand that, except I think that while the concept of a restructuring commission is something we don't have a problem with, we have some concerns about the way it's being implemented. I don't know how you can expect communities to buy into it when we don't know exactly how it's going to work.
Clearly, the reports have to come from the community, and then are going to go to the ministry; in other words, the minister, because the minister is responsible. It's a neat process to try to set up a commission, and you say that it's at arm's length, and therefore all of the tough decisions can be blamed on the commission and the minister can take credit for all the good decisions. But you have to at least admit that when the reports come forward, you're going to be setting the parameters for implementation, because if you're deciding the dollars, then that's going to make a huge difference about implementation and what's going to be implemented.
You've made a decision that the capital dollars in my home community are going to be reduced from what we have announced. That has a huge impact on what the reconfiguration is going to look like, what's going to be implemented at the local level. So all I'm asking is, what are the steps? The report comes to you, you make a decision on dollars and then it goes over to the commission for implementation? Is that the process?
Hon Mr Wilson: Not exactly. As I see it, and as I indicated with respect to the Hamilton study, which I think will be one of the first, almost simultaneously, the report is released publicly at the same time it's released to the minister, so this isn't some big secret thing, as you know, going to the minister. The commission will also have a copy of it, and the Hamilton study already sets up a local implementation committee. If that committee needs assistance, data, whatever, it will request it through the commission.
Sometimes there will be bureaucrats in the Ministry of Health providing that data. We're planning on having about 10 people within our existing budget to be the support staff at the commission, civil servants who have been providing data to the studies to date, and I expect if I have concerns, I will relay those, probably in a very public way, to the commission, via a letter to the commission. At the end of the day, though, with respect to capital, we'll have to wait to see what the commission and local communities recommend to the government. We are asking communities, as we asked your community, to come in with the minimum required to get the job started. On the capital side, that's very difficult for us.
Mr Cooke: But in the end, obviously the political accountability, no matter how you set up the process, you're calling the tune; you're setting the parameters and therefore the number of hospitals that will be closed. One of the things that was provided for me, and I'm sure you have this, but I've got to read this out.
Hon Mr Wilson: Be fair. The fiscal realities set the parameters and I inherited those fiscal realities.
Mrs Caplan: The $1.3 billion, that's what's driving this. That's the fiscal reality that's driving this, a $1.3-billion cut.
Hon Mr Wilson: The $1.3 billion is very much tied and very doable if we get moving on restructuring.
Mrs Caplan: But that's what's driving it, Jim, and the speed of it.
Mr Cooke: I've got to read this into the record, because in reading some of the stuff that the researchers provided for me, I found this one to be the most interesting:
"I rise today in support of a Collingwood area petition campaign which is being driven by members of the community who are concerned about the rash of bed closures at the Collingwood General and Marine Hospital.
"I'm proud to say that I drafted this petition so that concerned citizens and labour groups could send a message to the NDP government that bed closures are killing jobs and they are threatening the provision of quality health care services in the Collingwood area.
"Earlier this month the General and Marine Hospital board announced that eight beds" -- eight beds is a lot of beds, but look at what we're going to see over the next four years -- "would be closed because of budget pressures and social contract obligations. As a result, 20 more hospital-based jobs could be affected and more jobs and beds could also be hacked if the government acts on its threat to rip an additional $214 million out of the budgets of Ontario hospitals. Just a few years ago we had 133 beds at Collingwood General and Marine Hospital. Today, and after last week's announcement, we have 74 beds left.
"At the same time the government is forcing the General and Marine Hospital to cut beds at a stunning pace, the NDP refused to release the funds to redevelop the Collingwood hospital. Area residents have watched helplessly while the previous Liberal government announced this redevelopment funding twice and the NDP has followed with two reannouncements of its own. Seven years, two governments and four separate announcements later, Collingwood still has a hospital wing that was built in the 1880s.
"If the NDP still cares about health care, it must give Collingwood a green light to rebuild its hospital and it must give all hospitals in this province some breathing space so that we can accurately assess the impact on the people of this province of these bed closures."
This, of course, is a statement that you made on March 22, 1994. Not that long ago, you were expressing incredible concerns about the impact of job losses as a result of cuts that are about one seventh the level of the cuts that you've announced and that things were happening too quickly. I guess, as you said when Mrs Caplan and I did a TV show several weeks ago and you wouldn't join us so they taped you in the afternoon, you were used to saying things when you were in opposition that you really didn't mean, that that's just the nature of politics and that you weren't particularly sincere in what you said when you in opposition, you were just saying it for political purposes.
I think this statement, whether you meant it or not, raises a number of questions that I think we're entitled to understand. I know that when the ministry is making recommendations to cabinet on transfer payment decisions there are impact statements that are prepared by the ministry on job losses, hospital closures and so forth. Of course, that would have been done much more extensively in preparation for Bill 26 and the restructuring commission. So I'd like to get an idea from you as to the number of hospitals that you expect to see taken out of the system over the next four years and the job loss that your ministry is projecting at this point and any numbers that you might have on -- I know, for example, in my community there's already been considerable layoffs announced in the hospital system -- the job losses to date and the projection of job losses in the hospital system over the next four years.
1110
Hon Mr Wilson: Well, Mr Cooke, I'll remind you that the bed closures you've seen to date, the 9,500, was your government and the previous Liberal government.
Mr Cooke: Which you totally disagreed with. Since you totally disagreed with it, I'm now saying, okay, you didn't agree with what we did. You were very critical about any bed closures, any cutbacks in transfer payments to hospitals.
Hon Mr Wilson: No, that's very untrue.
Mr Cooke: I'm just reading your statement, that parochial statement.
Hon Mr Wilson: Well, that was the bed closures in the Collingwood hospital, and subsequent to that --
Mr Cooke: And you criticized the $214-million cut in transfer payments.
Hon Mr Wilson: Subsequent to that statement your minister, Ruth Grier, who uses that hospital too because she spent just about every weekend in my riding in Glen Huron -- that's where her house is and I think they've pretty well moved up there now -- visited the hospital. She talked to the local community. She spoke with me and I came to a better understanding of what the government's plan was. So I don't think you'll find anything on the record past that.
Mr Cooke: Is there nothing on the record saying that you changed your mind, that you agreed with her?
Hon Mr Wilson: The local community knows where I stand on these and we're working with the hospital --
Mr Cooke: The point was not about your hospital in your area. The point is, I want some data on the numbers of jobs that you expect to lose over the next four years in the hospital system and the number of hospitals that you expect to see closed.
Hon Mr Wilson: I don't have those. We've said consistently that we don't have a list of hospitals to close. The district health council process is very public --
Mr Cooke: You did no impact statement on what the impact of this $1.3 billion would be?
Hon Mr Wilson: The local district health councils are preparing their restructuring plans and in those plans part of it is the effect and the need to develop human resource plans. We know from the closure of Shaughnessy Hospital in British Columbia that one of the first things that the communities have to do up front is develop those human resources plans. We have no central list. It's not our job; that's district health councils' job.
Mr Cooke: Well, Mr Minister, you're telling me then that the ministry -- and this would certainly be the first time in the last few years; I don't know what was done under the Liberal government but I assume the same thing was done, that there are always impact statements done -- did nothing in terms of projecting for you and for policy and priorities board of cabinet what the layoffs would be over the four years?
Hon Mr Wilson: The reductions in transfers to hospitals, particularly in years two and three, are to be tied as closely as possible to the restructuring plans. You know we have a report from Metro, for example, that talks about $1 billion over four or five years to come out of that system without affecting quality or programs or access to the system. Regardless of who was in my chair today, I would expect they would move forward with that type of restructuring when you can get that much waste and duplication out of the system.
The 9,500 beds are closed but, as you know, no hospitals closed. We're still paying on a proportional basis, quite a high proportion of costs, for redundancy in bricks and mortar. Bricks and mortar don't cure people. It would have been nice, as you closed the beds, if you had also downsized the wings of those hospitals and those institutions where the beds are vacant right now. You can literally walk through the second floor of one of my local hospitals. There's nothing there and yet we still have to heat it. We still clean it from time to time and there's still a great deal of overhead involved.
Mr Cooke: We know you don't agree with what we did --
Hon Mr Wilson: That's what restructuring is.
Mr Cooke: -- but now we're holding you accountable for what you're doing.
Hon Mr Wilson: What we're doing is trying to implement studies as they come in. You've spent millions of dollar on these studies and we're doing the best we can that's humanly possible to develop a blueprint to help local communities implement the studies.
Mr Cooke: Let me move on to some other questions then, because obviously the minister doesn't want to talk about the numbers of jobs that are going to be eliminated. They know what the job loss is going to be. They've done projections. They have to do those projections, and I understand the political reasons why he doesn't want to talk about the actual numbers. But I find it strange that in a conversation that was held earlier today between the minister and Ms Caplan and the lectures that were given about the tax cut and the jobs that are going to be created -- but just looking at it this morning, we're going to be cutting 13,000 to 27,000 out of the Ontario public service. We know that. That's been announced. We know in schools that we're talking 20,000-plus. Every day we now wake up and we're seeing school boards with 900 to 1,500 layoffs. So we're talking 20,000-plus there, and we're talking in the neighbourhood of 32,000 in the health system.
We're looking at, just in those areas -- and that's not looking at all the other impacts -- job losses of between 65,000 and 79,000. So you've got to be taking a look not just at how you restructure the health care system but also the economic impact on this province. These numbers point very clearly to a huge loss in jobs that will have a huge impact on the buying power, the purchasing power of people in this province. As many have said, we're on the edge of going back into a recession in this province because of the way you are depressing the economy.
I find it amazing. When I look through some of your statements, you clearly understood, when you were in opposition, the relationship between the public health system and the economy of the province. You lectured us several times about jobs in the health care system being directly and importantly connected to the economy of this province. Now there seems to be no discussion, no talk at all about the impact that you're going to have on economies -- the provincial economy as a whole, but also community economies -- with your closures. You know as well as I do that we're going to see more hospitals closed in the next four years than we've ever seen in the history of this province. I hope that you're not using Frank Miller as a consultant to learn how to do it.
I think it's important that we at least get your philosophy of how this is going to be handled. I'd just like to ask a few questions and put a few of them on the record and then perhaps you can answer them. We do want to get a better understanding of how you're going to reinvest the $1.3 billion. Is that all going into community services so that at the end of the next four years we'll see $1.3 billion more into community services?
What exactly is the plan? What is the plan in terms of human resource policy with the thousands of people who are going to be laid off? Are you taking some of the dollars and reinvesting them into retraining of workers who are going to lose their jobs? What responsibility do you see? I'd like to get a better idea of how much of this money is going to go into capital, because you can't properly restructure the system without reinvesting substantial amounts of money and capital. I'll leave it at those three for now and then I'll come back to some more questions later.
The Chair: Just as you said that, your time ran out.
Mr Cooke: Could I get the minister to answer and you can take the time off the next 20 minutes?
The Chair: Yes. You're manipulating the Chair now, but I think I'll bow to that.
Hon Mr Wilson: Mr Cooke, in response to the $1.3 billion, it's very much tied to the capital question. You should note that our soft estimate now of capital is about $1.2 billion, so you could say that almost every penny going in one part of the system, if we don't get the minimum requirements down -- because don't forget, your government, rightly or wrongly, and I argue wrongly, sent communities out and said, "Restructure but then reach for the stars in your capital requests," and that's what's happened. Our capital requests of what we know in restructuring now exceed what we're going to get out of the operating side, or is almost --
Mr Cooke: Operating or annual savings. Capital investment's a one-time cost.
Hon Mr Wilson: So that means without the reinvestments that your community is asking for in cancer care and asking for in mental health and asking for in community-based services. So the money coming out of the operating side over the next three years, as we achieve the savings -- because remember, past governments were very good at announcing the new spending programs but didn't do the restructuring to pay for the programs. Therefore, we borrowed more money. As that money is, we'll be putting it in priority areas, including capital, the capital requests that are piling up, including community-based care. That aside, human resource policy -- HSTAP is still in place, there's money still there. We'll be expecting the commission, in my opinion, to very much take a lead with local communities in developing --
Mr Cooke: Will there be more money going in?
Hon Mr Wilson: Again, when we have the money. Nobody's arguing that we should spend more on health care; $17.4 billion is flowed through the ministry of health for health care and another $9 billion is spent by the private sector in this province. That is a very large amount of money on a per capita basis; in fact, I'm not sure there's another jurisdiction in the world that spends more on health care than this province. So the argument has not been, over the years, that we should spend more. I haven't heard anybody say we should spend more. It's allocating it within the envelope, and that's what we're doing.
1120
Mr Toby Barrett (Norfolk): Mr Minister, I wish to discuss again the issue of hospital funding and its impact on health care in rural areas of Ontario, areas represented by my riding, for example. I've been meeting with local health care providers and there is no shortage of ideas on how to meet some of the health care needs and to find efficiencies. People recognize that savings must be made; for example, you mentioned earlier that your ministry has reduced staff to a level of one half of the previous Ministry of Health.
I also appreciate your comments earlier about your concerns for small rural hospitals. On February 23 of this year you announced a new funding approach for hospitals. Adjacent to my riding, West Haldimand General Hospital, which services many residents of my riding, has had its 1996-97 funding allocation reduced by 2.5%. The allocation of Tillsonburg District Memorial Hospital, at the other end of my riding, will be 4% lower. But what is disconcerting for me and many people in the area is a situation with Norfolk General Hospital in the town of Simcoe, which will be faced with a 6.66% reduction in its 1996-97 funding allocation.
Notwithstanding the high quality of work and dedication to serving people from the other two area hospitals, West Haldimand and Tillsonburg hospitals, Norfolk General's reduction has me very concerned. In a letter to hospital executives, assistant deputy minister Andrew Szende stated that under the new funding criteria "small rural acute hospitals will receive a reduction of between 2.5% and 4%." Again, both West Haldimand and Tillsonburg hospitals fall into both ends of that spectrum, respectively. However, for residents who rely on Norfolk General a 6.66% reduction seems onerous. Indeed, cuts of that magnitude to any what I consider rural small-town hospitals to my mind have a much more significant impact than cuts to hospitals in multihospital communities or perhaps what may be considered overbedded communities.
I've had an opportunity to look into the funding reductions to hospitals as they affect my riding and your office staff have been very helpful in this regard. I'll continue to seek concrete answers to why what I consider a rural small-town hospital is being hit so heavily. In fact, with funding reductions that are approaching that 7% level for many hospitals, I've learned that Norfolk General Hospital in Simcoe is one of the hardest hit in the province. Only five of the 20 acute care hospitals in Metro Toronto have percentage reductions that are higher than Norfolk General in the town of Simcoe. As my first question, I'm still not clear, Minister, on how this is justified. Secondly, I'm not clear on how Norfolk General Hospital -- it's about a 100-bed hospital -- fell over the line to be classified with, as I say, many of the other hospitals in the Toronto area rather than being classified as a small rural acute hospital.
Hon Mr Wilson: The Chair was just informing me that the toughest questions do come from my colleagues. This would be true. But, Mr Barrett, to reiterate the formula, I guess your comments are exactly what we didn't want to happen: people running out and comparing building to building and the transfer reductions that those hospital corporations receive. Again, the formula targets what's going on inside the buildings and it compares services that patients get, the treatments they get, with other hospitals. No one wants to be told that they're inefficient, but the fact of the matter is, including hospitals in my own area of the province, they can do better. What we will be doing is not simply leaving them in the lurch to try to figure our how to do better and become more efficient.
It's the hospitals themselves leading the efficiency benchmarks. The hospital association and the joint planning and policy committee, the JPPC, don't simply pull these benchmarks or efficiency measurements out of the air. The formula recognizes that certain hospitals seem to be able to get their patients through various services for X number of dollars and we're simply saying that we'll be giving the information to your hospital; Norfolk General, for example. In the next days and weeks they'll be receiving a manual indicating how they can become as efficient in certain service areas as other hospitals already operating in the province.
It's an exciting thing and I'm sure you've received feedback too. People aren't complaining. They're accepting the challenge. Again, if the government had simply pulled a benchmark out of the air and said, "Everybody go for it, this is where we want you," then I could understand. The fact of the matter is that these are, for the lack of a better term, benchmarks or measurements that are already existing in hospitals. I think people need the information provided to the administration, to the medical staff, to the nursing staff on how to be more effective.
With respect to the nursing staff, I should say we've just launched a province-wide nursing project and put some money into that, where a manual will be prepared and distributed around the province, hopefully by this time next year -- oh, I'm sorry, that's a three-year program, so in about three years -- one of the first times nurses are getting together on how they can improve their techniques. One of the examples used is how dressings are applied now. The frequency and the type of dressing that's applied for various ailments have changed over the years and we want to make sure all the nurses are up to that efficiency measurement; not only that, but the quality of care.
It's a tough one, I agree, but the fact of the matter is that it's good news in the sense that this government, unlike any other government, didn't cut across the board. We're recognizing efficiency and we're challenging others to become more efficient, and in the name of the taxpayers. That's what they elected us on. I heard nothing else in the campaign. They want our own government to do it and we've taken the hits first. We're reducing government operations by a third and we've asked no other transfer partners, including education, to do what we are doing as a government.
Mr Barrett: I understand that the administration at Norfolk General is actively pursuing options to make the savings and has done over the years. We know across Ontario, under the previous government, something in the order of close to 7,000 hospital beds were closed. At Norfolk General during that time 42 acute care beds were closed. The hospital currently is operating 94 acute care beds and 54 chronic beds.
Another issue around expenditures relates to, for example, under the previous government and the social contract, which wraps up March 31 of this year. The hospital will be returning to the bargaining table with its unions and there's concern around the Hospital Labour Disputes Arbitration Act, whether the hospital will be armed with the tools that it needs. There's concern that the ability to pay on behalf of the hospital, that this criterion is not strong enough for them to discuss wage issues.
This particular hospital was hit fairly hard under the Pay Equity Act. In fact the biggest single increase in cost at Norfolk General Hospital over the last few years has been a direct result of the pay equity program where nurses' salaries were adjusted, as I recall, to be in line with police officers' salaries in the Haldimand-Norfolk region. It cost the hospital a fair bit of money, and at the time only about one third of the actual cost of this program was funded by the government of the day.
1130
I wonder if these are perhaps some unique situations that the hospital has had to deal with. Over the last few years this hospital has been successful in reducing hospital patient days by 30% and, again, hence this reduction of acute care beds from 136 down to a level of 94. I know that 6.66% reduction is not only based on the fact that it is not classified as a small rural hospital, but this decision is also based on a track record of finding savings. Again, I'm just wondering what advice I could give this particular hospital in the coming time to deal with what is a bit of a crisis situation.
Hon Mr Wilson: You raise some very good concerns, which have been raised by the hospital association with me and the ministry and also raised by individual hospitals with respect to bargaining in 1996. I think we all understand that most of the broader public sector collective agreements are to be bargained during this year. So it's going to be a very interesting year across the province and the entire broader public sector including hospitals, and I think we're seeing some evidence of that out front today and the last couple of weeks with the OPS.
But Bill 26 did for the first time -- we lived up to our commitment of the campaign and the Common Sense Revolution to put a clause in there that arbitrators, for the first time, have to take into consideration the employer's ability to pay. That in itself was controversial. The hospital sector did ask us to go further than what was contained in Bill 26. However, it's the opinion of the government that we should monitor collective bargaining this year.
If the sectors are able to reach agreements that are in the interests of both parties, there'll be no need whatsoever for the government to step in. Certainly it would've been premature to put anything, I think, stronger in Bill 26 than the employer's ability to pay, given that that's all we talked about during the campaign. We never talked about anything else, and the Common Sense Revolution does commit us, after the expiry of the social contract, to restore full collective bargaining, which is what we're doing.
However, my ministry and I will be monitoring how those discussions are proceeding throughout the year in the hospital sector. We will take advice from the hospital administrators and from both sides to help facilitate as smooth a year as possible and to try and get new collective agreements in place.
Pay equity is a constant pressure. As you know, this government put more money into pay equity than the previous government, but we capped it. So we gave some new upfront dollars, but then we capped it. Pay equity was about a 99-year process under the NDP, and in the health sector there are many parts of that sector that didn't actually get into the first few rounds of pay equity. So we've added more money to it, and the NDP were planning on spending this year and next on an ongoing basis, because they said they had a very open-ended program.
We've invited all the different players that weren't part of pay equity to come into that pool. Of course, the more that come in over the next few months, the smaller the amount of money there'll be for everybody in it, but we're trying to get ourselves out of an open-ended mess, and really an immoral mess, in my opinion, that the previous government put us in. There's no rhyme or reason to the pay equity rules, as you know, that this government inherited, so we, in the interests of the taxpayers, tried to cap it. We don't believe in open-ended programs. Those days are long gone, and we'll have to see how it goes divvying up the pool that has been provided. I remind people, at the end of the day, it's more money than the NDP were going to spend, at least that they had put on the books they were going to spend this year and next in terms of adding it to the bases.
As I said, I hope that you will continue to let me know, let the ministry know, how the bargaining's going in your area with your hospital. Keep in mind there are two sides at each table and we want to hear what both sides are saying. That's the approach we want to take, being reasonable and living up to our commitments we made during the campaign.
Mr Barrett: Again, it has been discussed in this committee, the money saved from budgets would be reinvested in other places within the health care budget. Many of these reinvestments have already been announced. Locally, in speaking with people connected with these hospitals, they're concerned that the savings they are being asked to make may not be reinvested locally, again concerned that reinvestments would be perhaps used to contribute to major restructuring of hospitals in Windsor or Toronto or Brantford or other areas.
Next week I'm meeting again with administration and hospital board members, both Norfolk General and West Haldimand, and I expect some very pointed questions on this issue, and I know it has been discussed in this committee. There's an expectation that the money would be reinvested locally in Oxford county and in the Haldimand-Norfolk region, again to enhance other aspects of patient care, home care, kind of post-hospital care. Again, I would ask specifically, how are savings found in rural hospitals to be reinvested? Are they targeted specifically or does it go into the general tax pool?
Hon Mr Wilson: The answer is consistent across the board in Ontario, and that is, money that is found through savings in hospitals will be reinvested in health care across the province. What I would suggest you do, as a community leader, is if we were to seal every little geographical area of the province and say, "There's your dollars; you provide the full continuum of services for patients," they couldn't do it. So simply ask them, on the basis of logic that every dollar saved should be reinvested directly back into that community, dollar for dollar, then ask them how we pay for the air ambulance for your constituents to go to Sick Children's or how we pay for the heart operations for your constituents that are done at Toronto Hospital and that money comes out of the general fund.
I think if you're that stark with them and say, "Okay, on that logic, I guess I have to ask the minister to cancel the air ambulance that goes all over the province and our centralized services," like our specialty hospitals, like Children's Hospital, our research that's done down in southwestern Ontario, for example, in London with the five major research centres we have down there.
Much of that money, at least the ministry funding, comes out of general health revenue, so it's a non-starter argument, and don't let them go down that road. Please, as I know you will Mr Barrett, show leadership in that area, because it's simply a non-starter with any government, and don't let anyone tell you otherwise.
1140
Mrs Caplan: I'm going to start talking about services to people, but since Mr Barrett raised it, if I could just make a statement, I think the one thing that people are shocked about, frankly, is the determination of the Harris government to centralize control.
In your document, which I have a copy of here, you were very clear in sending a message that communities had every right to interpret that they would be able to share in the savings that they found locally and that there would be local control and opportunity to reinvest, is your word. That was in your health backgrounder dated May 3, 1995. It says: "Local health care communities will share in any savings identified locally for reinvestment in community priority." The position you have taken --
Hon Mr Wilson: Is exactly that.
Mrs Caplan: -- in not telling them what the percentage is going to be, how you're going to allocate it to allow them to do that, you just said, "It all comes back centrally and we will allocate it and there may or may not be a process," but there's no incentive for the community to know or to understand that if they identify savings that they're going to have an opportunity to share -- and I think "share" means 50-50. I don't think anybody suggested 100% is a reasonable number. But to not let them know in advance what they're going to be able to identify for community priority breaks the commitment that you made.
That's not the point I want to spend a lot of time on. I want a commitment from you. You've talked about 9,000 beds closing, and that's true, and during that period of time services increased to people. I was the first Minister of Health who made the point repeatedly that beds are not the benchmark of services delivered and that we have seen a dramatic shift in this province from services being provided on an inpatient basis to a short-stay and outpatient service delivery. As beds were closed in fact services were improved and there were more services provided.
You're cutting Sick Children's Hospital by I think it's 5%, you're cutting cancer services, the hospitals that provide cancer services, particularly the Princess Margaret Hospital. Those are two hospitals that are brand-new. The needs were identified when those budgets were set, and I want a commitment from you that there will be no service cuts as a result of your reductions in the hospital budgets.
When I closed beds, I was able to say there are no service cuts. I want you to tell people that programs and services will not be cut as a result of your $1.3-billion reduction in transfers, and that when you close hospitals -- even though Harris said very clearly, "I have no plan to close hospitals," we know that you now intend to allow hospitals across this province to close their doors. The transfer payments that you've given to them are going to result in service cuts.
Tell us today, are the waiting lists at Princess Margaret Hospital for cancer patients going to grow longer, notwithstanding the fact that you have said, for many who need care, your plan would mean an end to rationing and waiting lists? The fact that cancer patients can be trapped on a waiting list for a month is a crime. Is a 5% cut to Princess Margaret Hospital going to eliminate their waiting list? Are people no longer going to be trapped on a waiting list for cancer care because you've cut the budget by 5%? Are paediatric services in Metropolitan Toronto in a process hospital going to be protected?
I've heard there's going to be a tremendous shortage of paediatric services because there's no comprehensive plan as people implement your transfer payment cut to ensure that those services are protected. Hospitals are capping service in the area of labour and delivery. I'm being told that very shortly you may see women having difficulty finding a hospital in their community that will be able to guarantee them access to their labour and delivery suites.
I think it's reasonable, as Minister of Health, that you give your assurance during these estimates that services will be maintained for the people in this province and that services will not be cut, and when I do a survey of the hospitals across this province, that they will assure me they have not cut services as they lay off staff, that it's all administration, that it's all duplication and waste and that you're not cutting services for people who need care in this province. Just give us that assurance. Tell us right now, "We will not be cutting services."
Hon Mr Wilson: Ms Caplan, you know that you're wrong on a number of fronts. The first comprehensive plan, the largest of it's kind in North America, is in place, by the district health council, to restructure. Restructuring is not meant in any way to cut services; it's meant to improve access, to get rid of administrative inefficiencies. There are food services in every one of our 44 hospitals in Metro, there are laundries in most of those, and only in recent years have they decided to get together and share services.
You mentioned Princess Margaret, the oncology agreement, unprecedented in terms of cooperation -- now they're having a little dispute over governance, which I'm staying out of and I think you're staying out of -- but the fact of the matter is that the idea is that there will be one administrator for the oncology program between Toronto and Princess Margaret and Mount Sinai. Hopefully, if it all works out, the idea is to save that salary that would have otherwise been there and to drive those dollars down to front-line services. In a sealed envelope, the health care system, the money's not going to leak out, it's going to stay in, but we have to see the savings first before we make the priority reinvestment. So to scare people otherwise, I think is not a good idea --
Mrs Caplan: No, I want you to give them assurance that you're not going to cut service.
Hon Mr Wilson: The ministry will continue --
Mrs Caplan: Put that on the record today.
Hon Mr Wilson: -- we give that assurance and nobody is under the impression that otherwise will happen except when you go out and tell people that otherwise is going to happen, they get all worried.
Mrs Caplan: I'm hearing from hospitals that are cutting programs and services.
Hon Mr Wilson: I get letters every day, people saying, "Stop cutting health care," and I say: "I've not cut one penny from health care. Where did you get this idea?" "Well, the Liberal party told me you've cut health care."
When I did the Toronto Star editorial board recently I basically said to them: "If Elinor Caplan told you pink elephants could fly, you'd probably print that but you never bother asking me whether we've cut health care or not."
Mr Joseph Cordiano (Lawrence): If we had so much power why didn't we win the last election campaign? Give me a break.
Hon Mr Wilson: Well, the fact of the matter is there are facts that exceed your opinion or my opinion on this. The facts are the facts.
Mrs Caplan: All I want is an assurance that services will not be cut as a result of the $1.3-billion transfer cut. They have all had notice from you --
Hon Mr Wilson: Certainly we are doing everything possible to ensure that services are not cut, that access is actually improved, that duplication is taken out of the system. That is the thrust of this government and it was the thrust, I hope, of previous governments as you made tough decisions. As I said, we have comprehensive plans developing in the local communities, unlike we've had before, and I think we're going to see an improvement. At the end of the day, the Ministry of Health will continue to review operating budgets.
As you know, the NDP, I think it was last year, had to send some operating budgets back because hospitals wanted to cut psychiatric beds and, quite correctly, the previous government said, that's not on. The deputy minister, Margaret Mottershead, sent a letter out on January 23 to hospitals, saying there are protected areas. Mental health beds are protected areas and we are doing, as these things come to our attention, everything we can to make sure that services are maintained and enhanced. Otherwise, politically or otherwise, we would not be going through this exercise. The exercise is to improve services, to improve access. That is our motive, and our only motive, for continuing with the restructuring that was started under the previous governments.
Mr Cordiano: Let me ask you perhaps a very basic question. How will you reassure us that that will be the case? How will you know that that will be the case? What mechanisms have you put forward to reassure, not only us in the opposition and the Legislature, but the public, that these services will be maintained?
Hon Mr Wilson: Well, one of the mechanisms, and it's a pretty powerful tool, is the review of the operating plans of the hospitals, which is a yearly review now and we intend to continue that. We might streamline the process a little bit because it's pretty cumbersome for hospitals. That's one measurement.
Our new hospital funding formula with respect to the reductions is another way of measuring things that haven't been measured before and we're moving the whole system towards outcomes. As Ms Caplan correctly said, we don't count beds any more, and that's taken a long time. She did a lot of work to change the mentality of the people of Ontario.
Mr Cordiano: You're cutting service providers.
Hon Mr Wilson: We don't count beds, I should say, but we've not moved significantly towards outcome measurements, and that's the challenge of restructuring, is to put the benchmarks in place. We're starting with our formula and reductions, the transfer reductions --
Mr Cordiano: What about --
Hon Mr Wilson: -- and people like Dr David Naylor and others are trying to do it on the medical side and the service side to ensure that we can actually measure because it's often anecdotal that services are cut and that --
Mr Cordiano: But services to people are being cut --
Hon Mr Wilson: We're moving towards trying to measure each and every treatment that patients get.
Mr Cordiano: You are cutting service providers. You're cutting staff. You're cutting nurses that provide those services --
Hon Mr Wilson: You can do better with less. We're running a ministry with less. There will be less public servants and we expect to deliver better services --
Mr Cordiano: We want to make sure that you're going to do this --
Hon Mr Wilson: Sure. So do we.
Mr Cordiano: -- and to date, I have not heard that you will be doing things like value-for-money audits to follow up on these things. Bring forward a model that would indicate an accountability framework which would indicate very clearly what those value-for-money audits will reveal. If you're not going to do that, then I don't think you can come back to this committee in a year's time or go through public accounts committee, which I think we should have the opportunity to do, and then for you to very clearly state to us how you're providing those services in a value-for-money way and still maintaining the integrity of those services.
1150
Hon Mr Wilson: Well, I tell you, Mr Cordiano, we are working with our partners there to develop exactly those models. That's exactly the way we want to go. Ontario's very much a leader in some areas with respect to --
Mr Cordiano: Would you be prepared to share those things with us? Those models and --
Hon Mr Wilson: They're all public. They're not internal ministry things. Most of this stuff is developed outside of the ministry, and as my ministry downsizes, I can assure you almost all of it will be developed outside of the ministry.
Mr Cordiano: So will you allow the auditor to have access to those value-for-money audits?
Hon Mr Wilson: Sure. The auditor has access to everything we do in the Ministry of Health.
Mr Cordiano: Well, not in the ministry, in each of the hospitals.
Hon Mr Wilson: They're all public institutions.
Mr Cordiano: He does not have access now. You know that. The Audit Act does not permit him to do that sort of auditing.
Hon Mr Wilson: The deputy informs me, I didn't know, but apparently another committee is debating that very point.
Mr Cordiano: Okay, but I want your reassurance that you're not opposed to that type of value-for-money audit.
Hon Mr Wilson: Well, I'll see what the recommendation is from public accounts. We don't own hospitals, Mr Cordiano. They are private institutions incorporated --
Mr Cordiano: We could bring in legislation to change that act and --
Hon Mr Wilson: They're private public institutions like a university is.
Mr Cordiano: -- make it possible for the auditor to then do the value-for-money audits that I am referring to.
Hon Mr Wilson: Well, we'll see what public accounts recommends.
Mr Cordiano: So you're not opposed to that.
Hon Mr Wilson: I don't know the intricacies of the argument. I suspect there's more to it than the debate we're having right now, because I recall having this debate last time and I recall the Liberals having this debate 10 years ago.
Mrs Caplan: I think that what people and communities need is assurance that when they need health services they're going to be able to get them. You referred to the fact of Ontario's leadership and I'll tell you something: I am not suggesting that pink elephants can fly but the reality is that Ontario is a laughingstock compared to every other province. The centralization and the centralization of control within the ministry is totally contrary to what every other province in this country is doing when they are looking at methods to get communities involved in dealing with health issues on a local basis.
Everyone else is moving to regional or local involvement and Ontario is moving to centralization of control and all power to the minister. That runs totally contrary to what's happening across the country. So your suggestion that Ontario is taking a leadership role -- the only thing that you're doing in the area which is different than the other provinces, frankly, is cutting $1.3 billion out of your hospitals, doing it within three years and the impact of that, if you take an average of $40,000 a job, the impact of that potentially is 32,500 jobs across this province and those people, Minister, deliver services to sick people who are in the hospital.
I want some assurance from you that when hospitals have to deal with the budget cuts -- these are real and significant budget cuts -- recognizing that the hospitals in this province over the last five years have dealt with restraint, severe restraint, and many of them are efficient and many of them are lean and when you impose a cut it is going to be a service cut. Nothing you have said today tells me that those communities can have any assurance that people in the communities are going to have any assurance that when they need care, they're going to get it. As Minister of Health, you will be held accountable.
While everyone recognizes there may be a better way of doing things and you might be able to do better for less, what I'm hearing is service cuts, program cuts and people being told that the service is not available for them. You will be responsible for that because you promised that you would not cut one penny from health care. People thought that meant that you would protect services. Just as beds are not a benchmark, and I agree they're not, services are. Service levels have become the benchmark and unless you can make the commitment, you are going to be held accountable, whether it's the Provincial Auditor or the community who identifies service loss. You'd better be prepared to respond quickly because I'll tell you something: I agree with you that there's enough money in the system. I have not been an advocate for more money but I'll tell you, I am very concerned that you are dismantling medicare and threatening it if you cut services and allow them to be cut, because what will happen is that people will say there's not enough money.
So that's the message and I'd ask you to give us an assurance that you will not allow services to be cut.
Hon Mr Wilson: I've given you the direction the district health councils are taking and the ministry is taking and that is to maintain and improve services in this province. That is what re-engineering and restructuring is about. I will be interested to know, Ms Caplan, where you want to move the money out of when we go through the votes of the estimates. What pocket do you want me to take money out of to stave off the $1.3 billion in transfer cuts to the hospitals? That will be an interesting debate, and I'd be happy to have that on a line-by-line vote.
The second thing, though, is you started by saying we're centralizing. District health councils are being relied upon more so now and, I would argue, probably more than any other jurisdiction in Canada, because nobody in North America is doing the massive restructuring that we're undertaking. We are relying on the local communities and district health councils. We are decentralizing that decision-making as much as humanly possible, given that the funding still comes from the taxpayers through the Ministry of Health.
Regional structures: The debate will be ongoing, whether we should be adding more layers of bureaucracy. You remember the Orser report, which would add another super-DHC on top of the district health councils that are already there.
I would argue that the Health Services Restructuring Commission is a tangible sign like no other jurisdiction, that the government is handing over massive powers to restructure our hospital system, to assist in that restructuring, decentralizing that authority like no other. So I guess we would agree to disagree that we are relying on our local partners and relying on people outside of government to help with the re-engineering and restructuring.
Finally, I would say: Let's say you achieve the restructuring over the next four or five years of Metropolitan Toronto, where its report indicates there's upwards of $1 billion or a little over $1 billion in savings, without affecting patient care or quality or access or services, but that that money is to come out through restructuring, getting rid of duplication, waste and administrative overlap.
Would you just leave the $1 billion to sit in limbo or would you take that money, as you achieve it, and reinvest it, as is the plan of this government? I dare to say you would want to move on that report, I would think, and you would want to achieve as much savings as possible, keeping an eye on the quality and access to services, which is the whole idea, and I agree with you. All of us will be held accountable on how this works out; that's what we do when we go into election campaigns -- you've been in more of them than I have and probably knocked on a lot more doors than I ever have -- that's what we do. We stand on people's doorstep and we're directly held accountable. We're accountable for things we've no control over. As I said, we have to use funding levers to get hospital corporations to try and restructure and get rid of administration and drive dollars down to front-line services.
Moral suasion is used in many other parts of the sector and when you have a ministry where over 95% of the dollars simply are dealt out to transfer partners, we're doing everything we can to put faith in our partners and to assist them where we can and encourage them where we can to restructure and drive dollars down to front-line services. So I think we have decentralized like no one else has, and I think that we're making the commitment to do everything humanly possible to keep on an eye on the service levels and to make sure that at the end of the day we have a better health care system.
The Chair: Thank you, Mr Minister. Let's just take a break until 1:30.
The committee recessed from 1159 to 1344.
The Chair: Can we get Mr Bisson? It's a 20-minute rotation, Mr Bisson.
Mr Gilles Bisson (Cochrane South): My apologies to the committee and to the minister. As the minister well remembers from being the third party, sometimes a lack of members means you have to stretch your resources and it's little bit of havoc on your schedule.
I had a series of questions I'd like to ask you, partly tied to yesterday's budget in regard to Mr Martin's announcement in regard to the block funding arrangement they're putting in place that was announced in the last budget and how it relates to Ontario. The government federally, as you know, announced a couple of years ago that it was going to move to block funding to the provinces when it comes to paying for health care, social services and education, and would put that in one block so that the provinces then supposedly would have more flexibility in being able to decide what their priorities are.
My fear is that by doing that the government is really removing any ability it has to police the Canada Health Act because the biggest deterrent for getting a province to stay in line with making changes to the health care system that are contrary to the Canada Health Act is by withholding transfer payments, and by moving to block funding there would be some dangers.
The first question I have is that by moving to block funding, and with that envelope getting smaller and smaller, do you see it as a problem in regard to the federal government not having the ability to be able to keep some of the provinces in line when it comes to the Canada Health Act?
The Chair: Mr Bisson, before the minister answers, he has to leave here by 2 o'clock for a very short time.
Hon Mr Wilson: Thank you, Mr Chairman. Yes, they called a policy and priorities meeting for 2. I don't think it will be very long, though.
It's a very good question. As I watched the budget last night, I noted that Mr Martin's going to keep a floor or a minimum of about $11 billion.
Mr Bisson: I think it was $11.2 billion.
Hon Mr Wilson: An $11.2-billion floor. We don't have the details of that yet. Our hit, though, over the next couple of years is about $2.2 billion in the Canada health transfer, in the block. But I've only been to two federal-provincial meetings, and for the most part I'd say the provinces, even without having a hammer over their heads, even with the dispute in Alberta, want to see portability, want to see comprehensiveness, want to see a health care system and services across Canada. Without even the federal minister -- I think sometimes the provinces get along better without the federal minister in the room -- there is pretty good cooperation. In fact, I'd say the provinces lead in keeping this country together on health care services rather than the federal government.
I was not impressed with the previous Health minister, Ms Marleau, and her understanding of the health care system. I'm a former assistant to a federal Health minister, and the federal government doesn't deliver any services, except on native reserves and to the armed forces, and much of that's contracted out. I don't think they understand at all what it's like to have to actually deliver the services and live within the budgets. So I think even without the tremendous hammer, because it's not going to be much of a hammer, even at $11 billion -- I don't know how much of that is cash and tax points --
Mr Bisson: It's a mixture.
Hon Mr Wilson: That's the cash. What would be left as Ontario's share? Do we know that, John? Because right now we get about $9 billion something total. I think that's Ontario's share.
Mr Bisson: The $9 billion, that's with the reduction that you've already got.
Hon Mr Wilson: Anyway, it's a worry, but I'll say that Ontario moved to restore the out-of-country payments as the primary insurance people of Ontario, without being prodded by the federal government. So we're trying to live within the Canada Health Act, and I think the other provinces are too.
Mr Bisson: I don't want to put words in your mouth, but I take it what you're saying is that to a certain extent you share my concerns. First of all, I agree with you, I think the provinces have led in the sector of health care for years. It was a provincial initiative that was eventually put across all of Ontario, but it first of all came from a province, Saskatchewan, went on from there. We all know the history of the health care system, so I think evidence and history show that the provinces are the leaders when it comes to this issue.
What I really want to get to here is this whole notion that you as the Minister of Health or myself as the Minister of Health, let's say, if we were to win the next government, may have the best of intentions. We may believe that health care is something that is sacrosanct and something that we need to make sure stays in the public sector and publicly funded. We may have all the best intentions, but in the event that a government decides not to, decides to move away from some of the principles of the Canada Health Act, do you think it'll become more difficult for the federal government to enforce adherence to the Canada Health Act by going to this system of block transfer funding?
1350
Hon Mr Wilson: It could. I think common sense dictates that it could, depending on the pressures. Ontario's a little different, I think, than some of the other provinces that might be a little leaner in their spending on health care. My personal view is that we have our hands full in the next four years, the term of this government, to simply find the efficiencies and prioritize the money within the $17.4-billion budget. That's going to keep us busy enough.
That's what I say to physicians, and I think you'd agree and I think all parties would agree, because when presented by some of the resolutions that have come out of the Ontario Medical Association in the last few months, a lot of it is to ask for two-tier medicine or more fees and that sort of thing. I've said to them, as I said earlier today, when you're spending $17.4 billion through the Ministry of Health and another $9 billion through private insurance and other private dollars into the health care system now, that's a lot of money on a per capita basis, so how do we go back to the taxpayers and say, "By the way, every time you receive a service, you should also pay another few dollars," when it's hard to justify the huge amounts of money we're spending on health care expenditures in this province right now?
The first challenge I always put to physicians at every physician meeting I'm at and all through Bill 26 and in the last nine months was, "You want more money in the system, you say that's the cure, but I challenge you to explain to the people of Ontario why we need more money when we already spend so much on a per capita basis." You'd probably agree with that.
Mr Bisson: I'll come back to that because I think that's another issue. But I just want to get --
Hon Mr Wilson: It's not another issue because that's the major debate. About the only thing the federal government seems to ever clamp down on from time to time, with the exception of a couple of provinces that it turns the other cheek to, is extra fees or extra-billing. It doesn't seem to clamp down on a lot of other things that perhaps are in violation of the act.
Mr Bisson: One of the basic tenets of the health care system, as you well know, is that it's a universally accessible program that is not paid through user fees or direct fees; it's paid through our tax. For a province to do otherwise obviously is going in the opposite direction of the intent of the Canada Health Act. That's why I'm asking you, if I can get you just specifically on that, will the block transfer funding, in your view, severely limit the ability of the federal government to keep provincial governments in line with the Canada Health Act?
Hon Mr Wilson: No, I don't see it. If they hadn't put the floor in, I would say it would be very difficult. But I'm not going to criticize Mr Martin at this point. At least we've seen a number for the floor; we heard about it. Ms Marleau was telling us at meetings for the last nine months that there was going to be some cash held back. We'll have to see. Ontario's not planning on violating the Canada Health Act in any way.
Mr Bisson: I don't say that you are. That's not the point.
Hon Mr Wilson: We have our work cut out for us in finding efficiencies within the system and the dollars we spend now. I don't want to go on the record as saying one way or the other. Just speaking for Ontario is all I can speak for. We've moved the opposite. We, without prodding, are in full compliance with the Canada Health Act, and that is the policy of this government. It doesn't mean we won't try and participate in federal-provincial discussions on the future of health care in Canada.
Mr Bisson: In regard to your comments that it's hard to justify the amount of money that we presently spend on health care, I don't think at all that that is a realistic argument. I think that we spend a fair amount of money in the health care system, there's no question about that, $19 billion of provincial expenditures, but they're going to something that I think 99.9% of Ontarians support, which is a publicly funded, universally accessible health care system that is responding to the needs of individuals. If the price tag is $19 billion or the price tag is $20 billion, people are prepared to pay those taxes in order to support that system, provided they know there's accountability. That's really the issue.
Let me get to the second question because I know you have to leave. You made an announcement two or three weeks ago with regard to hospital funding across the province of Ontario. I understand, being in government before, as all members in opposition have been there before, there are realities when it comes to containing a budget. It is difficult to do any kind of expenditure control without looking at health care, because there are always better ways of being able to run the system.
But in your announcement you're saying basically that you're cutting hospital budgets back differently in the north than you are in different parts of Ontario. I think the number you used was about 4% as what you would be doing in the north, on average, compared to a higher percentage in Metro and the rest of southern Ontario.
You would well know the discussion I had with you in the House with regard to the Porcupine Continuing Care Centre and the Timmins and District Hospital. I just have to advocate on behalf of my community in regard to the recent announcements that you made in regard to hospital budget cuts for the TDH. Timmins and District Hospital -- and Eleanor Caplan, the member for Oriole, would well understand the history of this issue -- has not had a budget increase in at least six to seven years. That's about right; I think it's about six to seven years. I take it you're getting some information here.
They haven't had an increase in six to seven years. They've had to move into a new hospital. They've had to deal with a whole bunch of issues that arise out of moving into that new hospital. They've undergone a severe amount of restructuring -- I wouldn't say "severe," but a lot of restructuring within that hospital, not without difficulty. They did that through our time in government; they did that through the time of the Liberal administration; they're now doing it again under your particular government.
We're at the point now where we've closed down the continuing care centre. It's shortly going to be closed down. All of the patients there will be moved into the Timmins and District Hospital. Efficiencies at that hospital -- if you were to look at any hospital of comparable size, I think you'd have a hard time trying to prove there's any hospital that is doing it better than the Timmins and District Hospital is doing.
My fear is, though, that the announcement you've just made in regard to the 4% cut realizes to Timmins and District a reduction of $1.4 million to that hospital budget. I guess the question I have to ask you is, as minister, do you believe that the Timmins and District Hospital can sustain a $1.4-million cut and not adversely affect or not affect in any way the services that the Timmins and District Hospital provides?
Hon Mr Wilson: I was just at the Timmins hospital, as you know.
Mr Bisson: I'll come to that later.
Hon Mr Wilson: We announced some very good news there in terms of a new psychiatric program, a joint program with Queen's -- that was dollars to that program, new dollars to that program -- an MRI, Timmins and Cochrane. It's only the second MRI -- it's amazing. All my announcements so far as minister have been, it seems, the significant ones, in NDP ridings.
Mr Bisson: You know why? We work very hard in our communities to make sure those particular projects go ahead.
Hon Mr Wilson: No, it's because I prioritized. You didn't fund these things. You had a lot of things in the pot, and --
Mr Bisson: Minister, you well know -- we'll come to the MRI later. My question right now is --
Hon Mr Wilson: I'm saying, I think your hospital was -- was it 2.5%? It was the 4%, which is also a recognition of this government, and the JPPC, more importantly, of the importance of the northern and smaller rural hospitals. We went through this this morning.
Mr Bisson: But my question to you is, with the reduction of the $1.4 million, do you believe that they can achieve reductions without affecting services? Because they've done a whole bunch up to now, my friend.
Hon Mr Wilson: They told me they could. They told me they had the first meeting of all the hospitals in Cochrane just a little while ago.
Mr Bisson: Oh, that's been going on for a while. I was part of those meetings.
Hon Mr Wilson: No, I sat in the board room in a private meeting --
Mr Bisson: I've been part of those meetings as much as a year ago.
Hon Mr Wilson: -- with the chief executive officer, and he told me, "We're just finally getting together," and that they truly do want to make a hospital system. I asked him if they had a study, and they've been working on that.
Mr Bisson: Yes, the district health council's been --
Hon Mr Wilson: They were confident, I felt, anyway, that they could achieve the savings and develop an integrated system for Cochrane district.
Mr Bisson: The problem I have is that Timmins and District and the Cochrane District Health Council have been working I think quite hard and quite effectively with other hospitals in the region and internally within the Timmins and District Hospital to take up their responsibilities as an organization.
I was part of a lot of what happened in the Timmins and District Hospital, you know as well as I do, in regard to where we are at right now with hospital restructuring, where we are at with regard to the district-wide review in regard to hospital funding, where we are at with regard to the MRI. The one thing they've told me from the beginning when we started this process is that the Ministry of Health has to recognize that if they're going to do all of this stuff voluntarily -- because they did this voluntarily; it wasn't the government that pushed them into it at the very beginning, we're the ones that encouraged them -- you have to recognize in their funding that they are different.
My fear is that by taking away the $1.4 million that you're doing now -- I'm talking to hospital people at the hospital on administration and on the board and they're saying, "Gilles, this means to say we've got to start cutting services." That's what they're telling me.
Hon Mr Wilson: In fairness to both of us, Mr Bisson, I heard that same message from Timmins hospital, but I also heard they actually asked that the ministry get tougher and order all the hospitals to do true restructuring in that area and I said: "No, that's contrary to government policy. We expect you to do it, as every other area" --
Mr Bisson: That's including the hospital budget --
Hon Mr Wilson: -- "and I'm not going to strong-arm this. It's not my role. I'm not the local MPP."
Mr Bisson: I don't work that way.
Hon Mr Wilson: "If you want to do that -- I know you don't, because you're looking for consensus too."
Certainly, with the expenditure reductions, those hospitals -- and let's not be specific to your areas, but across the province -- that may not have achieved restructuring certainly have the impetus now, I think, to get together with the other hospitals in the district and find savings.
Timmins hospital very clearly told me a list of things that could be combined that were being duplicated. In fact, I think their preference was that I strong-arm it and do it and I said, "No, you've got to do it from the grass roots up." I left there with a very good feeling that they were going to continue to work together.
Mr Bisson: Listen, they're very accomplished, very responsible --
Hon Mr Wilson: But we're not seeing true restructuring up there. You've got a nice new hospital, lots of capacity. I congratulate you; it's a beautiful hospital.
Mr Bisson: There has been major restructuring at Timmins and District, let me tell you, big time.
Hon Mr Wilson: There's been some, but they told me they could do more.
Mr Bisson: One of the things as well is that in the Cochrane district, Anson General, Bingham Memorial and other hospitals in the area have been working together to share a whole bunch of administrative services and different services throughout. That stuff that we started way back when we were in government is stuff that's carrying on. But what I'm trying to tell you is that that particular district, I think, has been in the vanguard of trying to follow through and making some of that stuff happen.
There has to be a carrot and stick approach is what I'm saying. If these people are doing it on their own and they're taking their responsibilities locally, such as the government wants them to do, I don't think you can go to them and just say, "Here's a $1.4-million cut." That's my argument, and I'm saying --
Hon Mr Wilson: But the problem we inherited was these reach-for-the-stars carrots that nobody budgeted for. It wasn't right to tell Windsor, for example: "Reach for the stars. Do your restructuring. Go from four hospitals to two."
Mr Bisson: There's no reach for the stars in Timmins and District Hospital, Jim.
Hon Mr Wilson: No, but I'm a little more realistic with respect to the carrots. We're trying to do what we can in terms of the MRI in your area -- I congratulate you for that -- and secondly, bring psychiatrists into the area. The joint program with Queen's is an absolutely innovative program.
Mr Bisson: Yes, we working on that.
Hon Mr Wilson: I gave my Ontario pin to --
Mr Bisson: Jean-Paul.
Hon Mr Wilson: Yes, to the psychiatrist up there, who deserves an absolute medal at Timmins for carrying the load on his shoulders for the whole area.
Mr Bisson: Yes, he has been on his own --
The Chair: That's positive news.
Hon Mr Wilson: By the way, they were very, very nice to me. I enjoyed my tour.
Mr Bisson: Oh, yes, they're good people. We'll come back to this later, because I --
Hon Mr Wilson: Sure. I'm just going to pop out, Mr Chair, for a minute.
The Chair: Thank you, Mr Minister. What I'm going to do is I'm going to ask for an adjournment. It's my understanding that the Tories were going to give up their time, and we'll take a 20-minute break, but it will be counted, as the clock would roll anyhow continuously. In other words, they will give up their 20 minutes while he takes --
Mrs Caplan: Can I assume the minister can be back in 20 minutes?
The Chair: Yes.
Hon Mr Wilson: No, I don't know.
The Chair: If not, we'll just direct more questions to the deputy. So shall we take a 20-minute break?
Mr Bisson: I think we take a break.
The committee recessed from 1402 to 1426.
Mrs Caplan: The minister is not back yet. If it would be all right, I'd like to ask the deputy a couple of questions. Recently, we've seen a resurgence of tuberculosis in the province, and I'm wondering what, if anything, the ministry is doing to combat this outbreak. If the minister were here, I would express my concerns that the policies of the government, which have, I think, created a crisis in homelessness and certainly exacerbated poverty, are not doing anything to help. I hope he'll hear that message, because I think it's more than just the issue of tuberculosis, it's the climate in which tuberculosis thrives, I think is the word I would use.
What I want to know is, are these reports accurate? Are we seeing the numbers of cases that have been proposed here in this newspaper article when it says conditions are ripe for an epidemic? I'd like to know the response from the Ministry of Health.
Ms Mottershead: I would like to first of all assure everyone that we don't have an epidemic per se, as you've indicated, but there has been a gradual increase in reported cases of tuberculosis, particularly in urban centres. We are working with the public health departments. We're redeploying a lot more nurses to deal with the issue directly, because one of the important features of trying to deal with the therapies and treatment is to make sure that people are taking their medication, which is really important that they do, and that they don't break the cycle, which has a minimum of three months to it.
What we're also doing is developing some guidelines that are being issued to the public health departments which attempt to highlight the latest modalities. We have provided additional funding, for example, to West Park Hospital in Toronto, which is the only hospital that has got the isolation unit for tuberculosis, so that if we come across cases that require isolation and intravenous therapy, that funding is available.
We're also working with the federal immigration department and making sure that they, as much as possible, do screening and testing. You are aware that the immigrant population is one of the populations that is highly affected by this increase. Currently, there are physicians in Ontario who have been assigned to deal with the refugee claimants in particular, and they're being directly reimbursed by the federal government. So we are working in concert with them, and hopefully it'll decline, rather than continue to increase.
Mrs Caplan: I read this article, which was in the Globe and Mail, and I would like to put excerpts on the record. I'm not going to read the whole article. I don't believe everything I read, but I would like to know if this is accurate.
The first one is that the conditions are ripe for an epidemic. That doesn't mean we have an epidemic, but it means if you don't do something, it could get out of hand. It says here, "Some" -- of those who would be at high risk for tuberculosis -- "are very threatened about coming into a hospital," and "Many don't have health cards." I was wondering whether or not you were dealing with that issue because that is a real and serious issue. Many homeless people do not have health cards, and if they are at risk I want to know what you're doing to be able to respond to that. They don't have phones. You can't find them. That's also in the article. I'll give you the copy of the article after I've made the excerpts, if that helps you.
Dr Edelson, who is expert in this field, is quoted as attributing the high rate of infection to the overcrowding in shelters and the depressed immune system of people who use those shelters. He says: "`They are living in very close, crowded conditions. It only takes one in close quarters to infect a lot of people.' The weakened immune systems are due to pneumonia, exposure, sleeplessness, hunger, alcohol abuse, or all of these.... `It's expected that TB will be higher in people who are malnourished and living in overcrowded conditions.'"
You go to the bottom line, and this says: "The pilot project's recommendations are still being finalized, but there will be three pages of them, sources say. They will call for the hiring of several public health nurses to conduct regular TB testing among homeless and poor communities; the reversal of social assistance cuts that are pushing more and more people out of stable housing; and improved access to health care for people with no fixed address or personal documentation."
I suspect those are exactly the recommendations that are going to come forward, and this is to the Toronto board of health, I realize that. However, I know that the Ministry of Health certainly would have an interest in this from a province-wide perspective. You mentioned that you are working with the Toronto board, but the reality is that the government's policies are creating these conditions, and while, Deputy, you're not accountable for the political decisions, you are accountable for cleaning up the mess that results from the policy decisions of the government.
I'm interested to know rather than working with, whether or not there are considerations, particularly within the responsibility of the Ministry of Health, dealing with the issue of improving access to health care for people with no fixed address or people who would be high risk who may not have a health card. While there are those who might say it's fraudulent for someone without a health card to receive care and treatment from the ministry, I would argue that we will be at a health risk unless we look after those people who may be carriers and infected with tuberculosis. If we do not reach out to them, then we place our society and population at risk because they will be carriers of a disease that can be treated. It's not like the old days of tuberculosis where you couldn't treat it.
With that in mind -- and I'm the first one who says fraud is bad and we don't want people using our health services that are not entitled to them -- this is one of those situations where you want to make sure that if someone has tuberculosis, could be a carrier of tuberculosis and could infect the population at large with TB, they are being encouraged to come in even if they don't have a health card. I'm wondering if the ministry is doing anything.
Ms Mottershead: Let me say that you're right, I'm not here to defend the government's policies, but I just make an observation that tuberculosis does take many years to actually mature and be fully blown, so I don't think it's an overnight phenomenon that we're seeing. It's something that has been building up gradually over a period of time.
Having said that, what our people are doing right now in our public health branch and with our chief medical officer of health, is encouraging and asking, quite frankly, all of the public health units in urban centres to work directly with the patients, with the people in shelters, with the homeless, to do a one on one nursing review to make sure that they are taking their medication. They're actually redeploying nursing staff that would normally be engaged in prenatal care, for example, or postnatal care, and redirecting them to deal with this issue where it is an issue in the urban centres. The guidelines that will be coming out will, I'm sure, incorporate some of the recommendations that are contained in the report. I haven't seen the report myself directly.
Mrs Caplan: I appreciate --
Ms Mottershead: Just in addition to that in terms of the cards, the health cards themselves are not an issue with the redeployment strategy that we're working on right now and also the fact that we have community health centres up and ready.
Mrs Caplan: What do you mean, it's not an issue?
Ms Mottershead: We have the public health nurses doing, hopefully, as much as possible one-on-one, going out to see people so they don't have to show the health card to receive, to be seen, to be counselled about their medication, to determine whether they do have their three antibiotics that they need to be taking all at the same time. It's that kind of thing. We're also paying for the drugs directly ourselves and distributing them to the public health units.
Mrs Caplan: That was the follow-up question because the people who are infected are homeless --
Ms Mottershead: Homeless, without money.
Mrs Caplan: -- and without money. If they don't have a health card they would be classified, I think, as the most vulnerable you would find in our society.
What I would like to ask is, in the annual report of the ministry, if you could give us a history of tuberculosis and the trend for Ontario. I think you're right that these things evolve and develop over time. The concern that I have is that the conditions -- and I'm just going to repeat again -- the point in the article is that the conditions are ripe for an epidemic. And if we have a situation which we're having difficulty controlling or addressing now, I think we have the conditions where it could get out of hand and perhaps having the accountability or commitment -- I hope the minister will agree -- to report in the annual report the trend lines and how well you're doing to eradicate a disease that we were rid of in the 1940s and we do not want to see a resurgence of in the 1990s.
Given the policies of reduction in social safety net support for the most vulnerable, the increase in the numbers of homeless and the issues around crowding, hunger and poverty, I think that if we could see that as just one indicator it would be helpful to us -- and perhaps it's also a way of keeping the ministry on its toes and taking a look at that as an indicator to make sure that it doesn't get out of hand. So I'd make that request. I'm going to give you the article --
Ms Mottershead: Can I respond, Mrs Caplan, by saying that I will make the recommendation to the minister in terms of the next annual report. The 1994-95, I believe, has been written and printed already. But I also will convey a serious request to the chief medical officer of health who also produces an annual report that perhaps that be considered as well.
Mrs Caplan: That would be a very appropriate place. I'd forgotten that they do that. I think it's a public health issue.
Ms Mottershead: Yes.
Mrs Caplan: I think it's one that we should be concerned about and stories like this give us an opportunity to take a second look at what we're doing and make sure that we are taking appropriate action. So I'll give you the article --
Ms Mottershead: Thank you.
Mrs Caplan: -- and just ask that you convey that concern to the medical officer of health.
The next question I have for you is in a new area. I had a call from the chairman of one of the psychiatric hospitals and I'd like you to confirm what I've been told, that psychogeriatric patients in the psych hospitals, as a result of withdrawal of service, are having to stay in their beds, not being taken out of bed. Are you aware of that?
Ms Mottershead: I am aware that as a result of our essential services agreement with our union, in terms of patients being allowed up and about with the same frequency as they had before the strike, it's not the same. Yes, there are more patients being kept in bed longer and that's consistent with the essential services agreements that we have. That's what it means when you're providing essential services, you're limiting the kind of work and care that is being provided as a result of the situation that we find ourselves in.
1440
Mrs Caplan: I guess the concern I have is that the patients here, if they were in the general hospital, where there is not the ability of the hospital to strike, would never be in this situation.
I'm wondering if you've considered transferring those patients into general hospitals for some period. I happen to be very sympathetic to the concerns that OPSEU has and to the strikers. I believe an essential service agreement that was negotiated may not have been adequate to address these needs, but here you have helpless psychogeriatric patients who, if they were in a psych unit in a general hospital, wouldn't be subject to the conditions that they are, and these people are suffering.
I'm just wondering whether the ministry has a contingency plan or has considered -- not all the patients. I'm not talking about all of the patients, I'm talking about those that are being kept in bed because they require assistance to be able to get out of bed, and that assistance isn't available to them and isn't being provided under the essential service agreement. I think there was another option, and the transfer to a general hospital, I think, is reasonable in some of those cases, and I suspect that it's not a huge number.
Ms Mottershead: We are monitoring the issue on a daily basis, and if I wasn't here today, I would be monitoring that situation very, very closely. In considering a transfer to a hospital somewhere else, what in effect would happen is that you would be removing work that is determined to be the work of the union, and you would be violating the collective agreement, and the essential services agreement. Given that we do have those issues to address, we are working very hard to see what other options might be available and, like I say, we're monitoring on a daily basis, but no decisions have been made to violate the agreement at this point in time.
Mrs Caplan: I understand. I'm concerned about those elderly psychogeriatric patients that are suffering and I fear at risk. I certainly wouldn't want to see an agreement that had been reached in any way breached. I think it might be amended to respond to that. However, the concern I have is I understand that none of the chairs of the psych hospitals were at the table when the essential services agreement was developed, that only management was there. I'm wondering if that's true --
Ms Mottershead: That would be true.
Mrs Caplan: -- and if so, why were the chairs not --
Ms Mottershead: The chairs of hospitals or the chairs of community organizations are usually not the ones that negotiate agreements, it's usually the direct employer and the employee representatives that bargain an agreement. That's a protocol that's quite normal and regular throughout industry as well as government.
Mrs Caplan: However, in a general hospital, the boards would have to ratify that, so they're more than consulted if it was a general hospital. You have a psych hospital, where the provincial psych hospitals have advisory boards and they have chairs who represent the community and the community interest, and it just seems to me that it is a special case, and that they should have at least had an opportunity, before the agreement was ratified, to have their say about whether they thought it was adequate or not.
What I've heard is that they immediately said, when they saw the agreement after it had been agreed to, that it was not adequate, and I'm concerned that the ministry, as the employer, wouldn't have respected the role of the boards, particularly the board chairmen, to involve them in something as important as patient care during a strike situation.
The Chair: Maybe Mr Bisson could continue that line of questioning, if you so wish.
Mr Bisson: I'd like to hear the answer, actually. If she can respond on my time, I'd be delighted.
Ms Mottershead: The government is really the board of management for psychiatric hospitals. The community boards that you're referring to are advisory boards to government. They don't have the obligations that accrue to a board of governance that has certain obligations, and they were not brought into the process because the negotiations were handled centrally by the employer and that's the way it went. They actually have been, over the last several days in particular, very vocal and concerned about some of the things that could be happening as a result of perhaps not having the level of services in the agreements that they feel should have been there, and we'll certainly be following up their concerns at some tables that have been organized already.
Mrs Caplan: If I can just make one comment before I hand it to my colleague, and I promise to be brief, you did acknowledge that they are advisory boards, that they are advisory to the minister. I may say it again when he's here, but please bring it to his attention: What the hell good is it to have an advisory board if you don't consult them and get their advice when you do something as important, and particularly given the fact that it was negotiated centrally? I'm very critical of the fact that they were excluded and I think some of the problems that have resulted could have been avoided if they had been brought into the process. My frustration is not directed towards you, Deputy. I wish the minister were here, but given the fact that he's not here, I believe that it was a gross error in judgement on his part not to bring his advisors into the process.
Ms Mottershead: Can I just confirm --
Mr Bisson: Now we're on my time.
The Chair: Your time --
Mr Bisson: That's fine. Respond. The minister's not here anyway.
Ms Mottershead: Essential services agreements were negotiated in 1994.
Mr Bisson: That's right, it was under us.
Ms Mottershead: That's correct. I just wanted to state that for the record.
Mr Bisson: I was going to clarify that. I take a bit of a different view. I understand what the member from the Liberal Party is saying but I guess the problem I have is that if we, as the employer, being the province of Ontario, were to take the views of the chairs of the board, that's fine, but I think we'd have to give the union the same opportunity and go back to the local unions and say to the president or the chairperson of that particular unit, "What do you think about this?" It gets to be a very large, cumbersome process.
I think you well know, through negotiations, that there is a move on the part of the government to central bargaining when it comes to teachers. I don't want to get into that whole issue, but it's a much easier process to negotiate when you've got it done the way that it is. I would just want to put on the record that if the minister was to take her advice and go back to the chairs of the boards, I would just ask that the unit people, whoever the heads of the different units are, also be consulted. I think they have a say in this as well as the chairs do.
I have a bit of difficulty because the minister isn't here. I understand you have a job to do but I don't want to get into any kind of questioning that would put you in a difficult spot, because a lot of these questions are political in nature, quite frankly. But I do have a couple of questions in regard to information that you may or may not have, and if you don't, if you can supply the committee with the answers, that would be appreciated.
One of them is the whole question of the agreement -- I shouldn't say "agreement" -- the announcement on the part of the government in regard to emergency services, the program that was put in place in order to pay doctors a remuneration for covering off emergencies. Can you tell me how many hospitals presently are utilizing those agreements, what your experience has been up to now, how it costs us, that kind of stuff, just to get a bit of a sense? Just go through it and explain it to me, if you could.
Ms Mottershead: We're actually subsidizing the physicians at $70 an hour to provide emergency room coverage, and there has to be an agreement signed by the physicians and the hospital, which is the host hospital for the provision of services, to make sure that there is a roster of physicians, that it's known when they're actually going to be covering, and therefore we receive confirmation that they have covered and will actually pay.
Mr Bisson: Do you have any stats in regard to how many hospitals and how many physicians?
Ms Mottershead: There are about 58 hospitals that I'm aware of, the last time I looked at this, that have applied to be part of this program.
Mr Bisson: How many are in now, do you know? Are there any where you're actually paying doctors? Of the 58 hospitals that have applied, how many have actually gone ahead and everything's in place? Are there any?
Ms Mottershead: I don't have the number on that one right now but I will get it for you. We do have some that have signed up and which are receiving funding right now.
Mr Bisson: Do you have any estimates in regard to how much you figure this is going to cost? Just in fairness to you, as you well know, as we were looking at this particular issue there was some concern on the part of our government, and I think it was shared within the ministry, that although that is a very attractive, very good news item for northern communities or rural communities that are without hospital emergency services, it's an expensive alternative. I'm just wondering if you have any kind of numbers as far as what you think it might cost.
1450
Ms Mottershead: Again, it's difficult to estimate because this is the kind of scenario that you may have: You may have an arrangement where there's one in three positions that takes up that kind of coverage; you may have one in five in a hospital; you may have all of them rotating and you only get that supplement once every 20 days. The way the cycle works is $70 per 12-hour shift, and that translates to $840 per day, or night, when that service is provided.
Mr Bisson: Excuse me, at $70 per hour, it's more than $140 a day.
Ms Mottershead: No. It's $840, I'm sorry, for the 12-hour shift.
Mr Bisson: Oh, I understood $140, sorry. Do you have an estimate?
Ms Mottershead: The estimate that we had early on was between $16 million and $20 million.
Mr Bisson: How would you make that up? I take it you would go find that money internally, within the ministry. That's not new dollars; the Minister of Health hasn't got a cheque from Ernie Eves for an okay of $16 million to $20 million. I take it that is from within the ministry itself, right?
Ms Mottershead: That's correct. It's a reallocation from inside the ministry's allocation.
Mr Bisson: What I'd be looking for specifically is, how many hospitals as of today have basically signed on and have agreements with their doctors; or I should say you have those agreements. How many doctors are we really talking about here? Obviously, it's different for different communities. How much does that cost? What's the cost? I'm just writing this down here.
Ms Mottershead: In terms of this fiscal year, it will be a minimal impact. In terms of 1996-97, it is part of our budgetary process, which involves both the consideration of where we can reduce spending and what the priorities for reallocation are. That process is going on right now and will be subject to next year's estimates.
Mr Bisson: For whatever it's worth, and I think Mrs Caplan would probably agree with me to a certain extent here, I think we're supportive in principle of what they're trying to do here. I think we have to congratulate the government for trying to do something positive here. But I really think that it's an expensive option and that there are other issues, as you well know, that we've dealt with and that I'm sure Mrs Caplan tried to deal with in her term in government, in regard to really trying to deal with the issue of not only attraction of doctors -- it's one thing to get them into rural and northern communities -- the real issue is keeping them there. There's everything from burnout rates in small communities to isolation to being able to offer doctors the ability to upgrade their skills by getting them tied in with other medical staff in other institutions; there are all those other issues.
For example, in the community of Iroquois Falls, one of the things they did was to make a house available to the doctors who wanted to come in. If a doctor was to accept, he would get a house, and it was greatly subsidized by the municipality. It was a great way to get them there but it doesn't do a heck of a lot to keep them there.
What I'm saying is that I don't think throwing money at this one is really the answer over the longer term. I think we'll still have this problem six years from now, and the government will be stuck with a fairly large bill. Who knows where governments will be six years from now? They may have to revisit this whole issue and say, "We can't afford the $20 million that we're paying to doctors for these kinds of agreements." Then you're going to be really stuck. How do you get out of this one? Doctors will say: "You're not taking that money away, because we've had it through all these years. Take it away, and I'm moving out of northern Ontario or rural Ontario." I think it really could become quite a mess.
I would encourage the ministry and the government and government members to really look at this issue from the perspective of retention, because it's an issue for rural Ontario as it is for the north. I think many of you understand this issue as well as I do. It's one that we wrestled with as a government. The real problem is that it really means to say we have to challenge each other as government and doctors and hospitals and there's lots of politics involved in that, as we well know. We're politicians but there is also politics within the OMA and within the OHA and we've got to deal with all of that. But none the less, I think this is going to be a problem later on and I just wanted to put that on record.
The other thing is, we used to receive information from the ministry in regard to the northern travel grant, how many applications were made, how many at the time existed within the system. It gave us a fairly good idea, as far as members in our ridings, to be able to track that a bit closer so that we could identify there were problems and we could pick up the phone and say: "What's going on with those travel grants? Get them going." You remember those conversations well.
Ms Mottershead: Is that why the phone has been quiet? The information is not there?
Mr Bisson: No, we're still having the problem. This is the point I'm getting at. In fairness to the staff within the Ministry of Health who deal with the travel grants, we've had very good cooperation with them. I would say in some ways we're having better cooperation, in the sense of them wanting to work with us as opposition members and the fear of having the front page show some tragedy, so I think it's an interesting thing being in opposition; some things work a little bit easier. In fairness, the staff has done a good job, but we are still getting problems, and I would just be curious: Is there a possibility of members' offices receiving on a monthly or a three-month basis that report that we used to get?
Ms Mottershead: It's a possibility. I'll look into it. I think it's probably more relevant for northern members. It's not something that I'm sure others would be all that interested in.
Mr Bisson: Yes, especially in underserviced communities. To me, it's a fairly large issue. It might not be for somebody in Sudbury, but I can tell you in Timmins or Kapuskasing it's a big issue. So what I'd be looking for specifically is the kind of information that Minister Grier used to provide us with in regard to what the numbers were. It was actually -- I forget her name, out of Sudbury.
Ms Mottershead: Eileen Mahood.
Mr Bisson: It was Eileen Mahood's office that used to pass that on to us, so if we can get that information.
Ms Mottershead: I'll see whether it's a possibility in terms of developing some fact sheets that we could do quarterly and send out to all members.
Mr Bisson: We found it very useful because it allowed us to stay ahead of the problem before it got really too big. There are times where you get a number of patients trying to travel to Sudbury or Toronto on the northern travel grant and all of a sudden you get this huge problem when they end up in your constituency office and the ministry ends up with this huge backlog in trying to deal with it. So if you can identify problems ahead of time, you're able to minimize them. I think that would be good not only for myself as an opposition member; I think it would be good for the government.
Most of the other questions I have would be better directed to the minister. But maybe for the record, if you can just give us a bit of a perspective -- you might have already provided this or the minister might have already provided these answers and you can tell me otherwise -- in regard to the cardiac care unit in Sudbury, the whole hospital restructuring issue that's happening out there.
There is, as you well know, a concern throughout northeastern Ontario that, with both the restructuring efforts on the part of the local community in regard to the three hospitals there and also the direction the government is taking in regard to its reductions in health care spending, that unit in regard to the Sudbury Memorial Hospital is in jeopardy. I wonder, for the record, if you just can tell us or try to assure us and assure northerners that yes, they will still have access to the cardiac care unit, wherever it might be, that they won't have to travel to Toronto if they need a heart bypass or angioplasty or whatever it might be. Maybe just to respond to that.
Ms Mottershead: I don't recall the minister being on the record on this but I certainly recall discussions, when the Sudbury recommendations came in, that services have to be absolutely protected. Cardiac services are a provincially managed program with standards and criteria developed by the Provincial Adult Cardiac Care Network. Whether the Laurentian and the Memorial combine, merge or whatever is decided there, that program will be protected, so it's a question of potentially what site it would be delivered from, but the program is definitely protected.
Mr Bisson: Do we know -- you must have that information within the ministry -- in regard to Sudbury Memorial and its cardiac care unit, has the utilization actually increased over the last year or so or is it pretty well where it is? Do you have that kind of information?
Ms Mottershead: The report itself from the restructuring committee would have that kind of information. I don't have it here now, but if one was to refer to that -- I think it's a public document that's been out there in terms of the restructuring committee -- there are that many data that deal with utilization in every single department in every single program, and that would be available in that report. It is there and it's available.
Mr Bisson: I would just look for a little bit further assurance that if utilization is at current level or higher, it's not the intention of the ministry to reduce that level or frequency or quantity of services that is offered by the hospital in Sudbury, Sudbury Memorial, that it's not the intention to cut back.
Ms Mottershead: No, it isn't.
Mr Bisson: I know that's an issue we've had to deal with as a government, to try to assure northeastern Ontarians, and also I'd like to do that through you.
1500
The other thing is the question of dialysis. You would know, and I hope most government members would know, that there was a huge investment on the part of our government that's been carried on by your government in regard to dialysis services, not only in northeastern Ontario but across the province for all kinds of reasons. The whole question of the need for dialysis treatment has been quite a problem in regard to accessing the dialysis units in a lot of communities in northern Ontario and I would imagine in rural Ontario as well.
We had the fortune four or five years ago of putting in place, I think it's four or six dialysis units -- I forget the exact number -- at the South Porcupine Continuing Care Centre, in Timmins; that is now moving over to the Timmins and District Hospital. Are you at a point now -- I know it's not a pilot program, but I think it's through Laurentian --
Ms Mottershead: Laurentian.
Mr Bisson: -- that it's being monitored. Is there any indication at this point that any kind of review of those services or just reviews, period, are being contemplated by the government in regard to dialysis treatment at the Timmins and District Hospital through that program?
Ms Mottershead: I'm not sure I quite understand the question. In terms of protection of dialysis services, the answer is yes, and restructuring activities will not impact on that.
Mr Bisson: Let me be direct. I'm trying not to be confrontational here, because you are the deputy.
There is a fear, because of the closure of the South Porcupine Continuing Care Centre in South Porcupine, where the dialysis units are, that once they're moved into the Timmins and District Hospital, within a period of time -- not immediately -- people believe there's some kind of a plan to undermine that dialysis program at TDH. Is it the government's intention to maintain at least at its current level the level of service we're getting for dialysis treatment at the Timmins and District Hospital?
Ms Mottershead: Yes. As a matter of fact, the dialysis program in the Timmins hospital is operated as a satellite of Laurentian Hospital in Sudbury and we've had no recommendation to date through the restructuring process or otherwise that there should be a change in that arrangement, either in terms of service volumes or funding or management, so there has been no change and as far as we're concerned the program will continue and it will be a protected program.
Mr Barrett: I want to raise the issue of fraud and misuse and overuse of our health care system and the resultant misallocation of scarce health care resources. I raise this for the purpose of determining to what extent the proposed smart card can alleviate some of these problems. I understand that health care fraud has been estimated at, I have a figure of $691 million a year. The 1987 auditor's report found that there were 24.7 million OHIP subscribers in the province, which at that time was triple the province's population of nine million people, and at that time as well the computer system was outmoded and not able to track these health card carriers.
Many of us recall the story of someone who had a health card for their dog. Minister Wilson mentioned earlier in this committee the recent case of a physician who, I think to highlight some of these problems, made a claim for about $2,000 for a heart-lung transplant which he claimed to have pulled off in his living room.
The concern for misuse, duplication of laboratory tests, doctor-shopping, concern for physicians who may be dispensing prescriptions for patients who have come in over and over again, or the concern for a pharmacist who may not really have access to records to know whether this individual has received certain drugs from other pharmacists and is misusing these drugs, and again the dangerous side-effects and the need to access a patient's history if they are suffering an overdose or an adverse side-effect to a particular drug -- I don't think anyone argues that we need a better system, a better computer system to track the way patients are using the system and overusing the system, or misusing our insurance system.
Not to dwell on doctor-shopping, but an incidence of someone visiting four or five different physicians for perhaps the same illness -- I've talked to a number of people. When they are moving from physician to physician, verbally they describe their symptoms over and over again, and there doesn't seem to be any backup system for the physician to really know what the history is for this person.
The concern is that we have something like 223 hospitals in Ontario and 24,000 doctors and 82,000 nurses, and many other health care providers and other providers under WCB and Comsoc who are providing health care, and as I understand it, we don't seem to have a system that links everyone together. My concern is to what extent can an improved health card system, the smart card system, alleviate doctor-shopping and alleviate misuse and overuse and alleviate fraud in the system.
Ms Mottershead: Let me start by saying that if the minister were here he could tell you himself that he is really quite committed to making sure that fraud can be substantially reduced in the system, from all sides. He's very keen, and we are working on some elements of a smart health information system versus smart card. It's important that we do have systems that link with each other so that in fact you can see what the provider data tell you with the client data, so that we can do some matching to determine what kind of encounters people have had with the health care system. Not only would that deal with issues of fraud, it deals with the issue of quality, which I think, Mr Barrett, you have already mentioned.
One of the issues we are looking at right now is the issue of primary care. For example, the Ontario Medical Association has recently released a report for discussion purposes of a new primary care system potentially to be implemented in the province.
One of the features of that particular report is that physicians' offices need to be automated to accomplish a couple of things. One is to make sure that the health record of the patient is well documented and that it is also portable, so that when a patient is referred to a specialist the patient record moves to the specialist so that the specialist doesn't have to do more tests that have already been done, knows already the test results and can deal with that right off the bat.
That very clearly addresses the issue of overuse of the system, but it is also a quality issue because it means that the specialist can act very quickly, doesn't have to wait a couple of more days for test results and the like. In addition, that record would move to a hospital should that specialist have to put a particular patient in a hospital. The hospital record can then flow and be maintained and so on. So that is an excellent feature in that system.
What the primary care information system will also do is help physicians in terms of how they relate to government and payment and claims, and facilitates all that and integrates information.
1510
Another feature of this proposal has a suggestion in it that patients in a particular community be rostered to a physician or a group practice, so there would have to be some kind of commitment by patients to have a relationship with a particular doctor or group of doctors. In doing that, the system will tell you who the patients are, what doctors they're relating to, and if there is shopping around, that will be very evident and there could be some consequences. We're looking at that as one of many proposals that have come forward on the primary care front to deal with better system management, quality assurance and elimination of misuse or abuse of the system.
The other thing members here would be aware of is that Bill 26 actually has within it an expedited process for adjudication of physician claims, and that was part of that whole exercise, so that gives us new tools through the CPSO to deal with the question of overbilling, as an example.
You should be aware that in looking at a smart information system, we're very mindful that we need to protect personal privacy and that only people who need to see information actually have access to that information. If a patient record moves from physician A to a specialist, it's only the specialist who sees their record; it is not the Ministry of Health employees and it's not the general public. I have held discussions as late as last week with the freedom of information commissioner and have invited him to work with us on the development of a policy framework for the protection of individual privacy with particular emphasis on health records and health management and what implications that would have for development of technology. So that's where we are on that front.
Mr Frank Sheehan (Lincoln): District health councils: We spend a lot of money on those, $21 million I guess it is. Can you tell me how you manage or control them or just generally assess their effectiveness? Do they file business plans with you? How do you measure or track what they do on their business plan, both on policy-setting and on financial concerns? In the Niagara district they're spending $500,000. How do you assess the qualification of the members? I'm particularly concerned, with the charge that's been given to them under the restructuring, what qualifications the various members of these councils have to make these major decisions.
Ms Mottershead: We currently have a memorandum of understanding with the district health councils that spells out their accountability to the ministry. They are required to have annual work plans, and we do see them and we do monitor so that we know how many committees need to be set up. As you know, the councils are primarily made up of volunteers, thousands of them, and they are organized into subgroups that deal with specific issues the ministry asks them to look at: things like planning for mental health; planning for long-term care; reviewing the annual plans of hospitals, the operating plans; making sure that there are no cracks in services as a result of, potentially, hospitals getting out of one business, the only business in town. That's their role. On an annual basis they're looking at their restructuring plans and dealing with that
There is an ongoing relationship that we have in addition to knowing exactly what they're going to be tackling in any one year. We have staff who actually participate and attend meetings of the district health councils to make sure they are working along the lines that had previously been agreed to.
With respect to the qualification of members, in our memorandum of understanding, we've made it very clear that there has to be a balanced representation as between provider groups and community groups, for example. It's the community members who actually provide the validation, if I can put it that way, as to whether or not the district health councils are reflecting the views of the communities or are they being swayed on the provider side, whether that's hospitals or doctors or all of that.
There's a nominations process. The ads are put into the local papers in terms of advertising for membership and availability of a seat on the councils. They have a nominations committee and they review all the applications. They determine, if they need a provider, whether that provider's got experience in the health care system, whether they're good business people who represent the community, whether they need some legal knowledge, for example, because of some of the tricky issues that they're getting into with recommendations around restructuring. So they actually vet out the applications. Those applications are sent in to the minister and the decision is made by the minister, because they are ministerial appointments. That's the current process.
Mr Sheehan: How do you monitor? I've looked at some of those processes and I evaluate the CVs on the basis of some business experience I would have. You've given them a rather substantial charge. It's a big operation and an onerous responsibility. In the CVs that I observe, I have a problem understanding the qualifications.
Also, another thing you could address, if you would: If you've got a $500,000 budget, for example, in the peninsula and you've got mostly volunteer labour, where is the 500 grand going?
Ms Mottershead: I think Mrs Caplan wants to answer this one for me.
Mrs Caplan: Actually, I wouldn't mind making a statement, if I could, if you don't mind.
Ms Mottershead: I don't mind.
Mrs Caplan: I was involved in having to answer the questions that you've just asked about the district health councils, and it was my belief -- and it remains my belief -- and I think it was the original intention when the DHCs were established that they not be filled with professionals, people who had expertise, but that in fact they came as members of the community with an interest and a dedication, and that part of what they would receive, since they are volunteers, is the education, as well as the opportunity of influencing the delivery of services and access to services in their community.
I always felt it was a mistake to only accept people on the district health council who came with CVs. In fact, when I was Minister of Health, I said that the ads that went in the paper should specifically say "No experience required," because of the fact that you wanted to have community people who were interested. The composition of the board, as the deputy said, requires a certain amount of expertise for those who come as professionals. There are also spots for municipal people. But if you wanted a balance of a lay interest, "lay" being general public, then it was really important to encourage average people who were interested to come out and participate. I think the province has gotten very good value from the district health councils.
Further, my concern is that at the very beginning of his time, the minister was talking about a change of mandate for the DHCs. So maybe in answer to your question, the deputy could give us some assurance of the minister's support for the DHC program and not changing the mandate.
Mr Sheehan: I'd like to ask my own question on the current policy to persist in that practice, because I obviously disagree with Ms Caplan. I asked the local health council if they reviewed the plans. "Oh, yes, we do that." I said, "What are your qualifications for reviewing a $50-million or $60-million budget?" "Well, we don't actually review the budget." I said, "Then how are you evaluating the cost benefit to be derived from spending all this money if you lack the expertise to make the financial judgements?" So I think it's nice to have well-intentioned amateurs, but we're talking about the health system of this province, we're talking about spending an awful lot of money, and I'd like to see better than well-intentioned amateurs. I'm not going to spend 40 bucks a seat to go down and watch a bunch of third-rate hockey players, what have you, and I don't think we should have that kind of good intentions -- you know, the road to hell is paved with them. So maybe you can assure -- or tell me; I hate the word "assure" -- just advise me whether or not it's your intention to adhere to this appointment policy. If it isn't, what steps are you going to take to get yourselves out of it, because you've given these health councils an enormous responsibility.
1520
The Chair: Sounds like a question that the minister should answer.
Ms Mottershead: If there are 30 seconds, I would like to add another bit of information on this.
In addition to the volunteers, the amount of money that you mentioned earlier is being spent also to support some staff. We do have really quite good staff who are health planners, epidemiologists, accountants, you name it -- well-rounded -- who actually do the analysis, summarize the information, and then that information is shared with council. Council itself doesn't pore over reports that are this thick and contain, in many cases, very technical data. So there are people with the technical abilities that help the volunteer members do their job.
Mr Sheehan: The question stands. I'd like an answer, please.
The Chair: Mrs Ross, you have about a minute and a half.
Mrs Ross: A minute and half.
Mr Sheehan: You're not going to do it quickly.
Mrs Ross: I'll let Frank finish up, then.
Mr Sheehan: I guess I will. Do you have it in mind or is it contemplated by the ministry to implement an accreditation process for long-term-care places like nursing homes, rather than the current --
Ms Mottershead: Do we have a what?
Mrs Caplan: Accreditation.
Mr Sheehan: Accreditation, similar to what they have in the hospitals, do you intend to switch that to the old folks -- is it your intention to do that?
Ms Mottershead: The national accreditation body, which is currently responsible for hospital accreditation, has over the last couple of years been looking very seriously at community programs, community agencies, long-term care, nursing homes, and they are moving very directly into an accreditation program for nursing homes. The guidelines have been established, the criteria have been developed, and they're moving in. They've done some pilot programs already to test their accreditation criteria against what's actually happening in places like nursing homes. We're looking at province-wide -- actually, country-wide -- implementation of accreditation in the very near future.
The Chair: It looks like, Deputy, we may have to get you to run soon as one of -- Ms Caplan.
Mrs Caplan: Just to follow up on that, and I would support an accreditation program, provided that you didn't end the compliance program to ensure that nursing homes maintain the standards and work with them to achieve those standards, because accreditation happens, if you're good, every three or four years, and it has tended to be voluntary. So could you assure us that there's no intention to end the compliance program within the Ministry of Health?
Ms Mottershead: There's no intention to end compliance reviews.
Mrs Caplan: Thanks. I think that's an important message.
To follow up on the question that was asked about overuse or inappropriate use: I wouldn't call this fraud but I would call it inappropriate use. At the same time as we're all concerned about appropriate use, I think that there are some messages being sent out which are causing overuse and inappropriate use. I have before me a memorandum to "all airport customer service employees," and this is from Air Canada. It says as follows:
"All absences due to sickness for three days or more require that you" -- in bold, large caps -- "must" -- underlined -- "provide a medical certificate which indicates the reasons for your absence and that you're fit to return to work, with or without restrictions."
Since we all know that if you have a cold or the flu it isn't necessary to go to the doctor, would you consider this requirement of Air Canada to be appropriate use of the health services in Ontario?
Ms Mottershead: What you're referring to there is service that is not medically necessary, and that in fact, in our discussions with physicians and contained in Bill 50 was the provision that third-party billing would occur for things like a visit to the doctor just to get a medical note for absence from work. In fact, Air Canada, I believe you mentioned, is probably going to be the party that will be paying the bills for those visits.
Mrs Caplan: That was my next question. But they haven't informed their employees that they should identify that to the doctor, nor have they mentioned that they're going to pay the bill. I'm going to give you this and ask if you would let Air Canada know, because I think what's likely to happen is people will go to their doctor and ask for a certificate, and inadvertently OHIP may be charged. I think this is one place where Air Canada wants something that is not medically necessary, they should pay for it, and employees should know that that's the case and they don't have to pay for it themselves.
Ms Mottershead: I will follow up on this, but you may be aware that physicians already know that when these cases present themselves, they're not to charge the health insurance plan. It wouldn't be in their interest to charge the health insurance plan, given the competition for that limited pool of money. But we will follow up; thank you, Mrs Caplan.
Mrs Caplan: Thank you. I do have another question that I was asked by the Metropolitan Agencies Representatives' Council, MARC, and that is that there is an interministerial initiative on dual diagnoses for the developmentally delayed and mental health needs. That's coming to an end on March 31. The original intention of this interministerial initiative was to bridge the gap between the mental health and developmental service sectors. While some progress has been made in terms of sharing the responsibilities at the service level, the question is, what is the Ministry of Health's commitment to maintain and continue the activities of this initiative jointly with the Ministry of Community and Social Services in terms of planning, policy development and funding? Is the initiative going to continue beyond March 31?
The Chair: Again, Mrs Caplan, that sounds almost like a question to put to the minister.
Mrs Caplan: No, I think it's a program question. If the deputy's happy to answer, I'm happy to have her answer.
Ms Mottershead: In terms of the exercise that we're going through right now, and that is planning for 1996-97, it has not been brought to my attention from the program area that there should be any kind of program elimination. On the contrary, I think, if anything, the government is committed to expansion of community-based services for mental health.
Mrs Caplan: I think it would give the agencies some comfort if they had some notice before the end of the month that the interministerial initiative on dual diagnoses was going to be continued, and MARC just asked me to get that on the record. They'll be very happy to hear that.
Ms Mottershead: I'll try and get an answer for you tomorrow.
Mrs Caplan: That would be great; thank you.
The next question has to do with the issue of falling through the cracks. We know that health services for youth as they relate to Comsoc -- this is again dealing with this dual diagnoses thing -- that there's an age where from 16 and over they're eligible for Health mental health services and before that, it's children's mental health under Comsoc. The concern is the difficulty that youth in that gap have in accessing mental health services that are funded by Health. The question is, what is the Ministry of Health doing with regard to establishing shared accountability with other ministries -- for example, the Ministry of Community and Social Services, the Ministry of Education, corrections -- for the group that's called the transitional-aged youth, to make sure that there is a continuum and not an interruption in their ability to get service?
Ms Mottershead: We are in discussions with the Ministry of Community and Social Services; we've also had discussions with the Ministry of Education and Training. We want to try and approach this area in a continuum, as you've indicated. There are regular meetings of the program people to review the odd case that does fall through the cracks, and to see how they can better improve service coordination so that doesn't get repeated too often. So we are talking to them and we're trying very hard.
1530
Mrs Caplan: The next question that I have really is a concern as it relates to other disease areas, but certainly in the area of HIV and AIDS we're seeing the rapid development of drugs, which is good. I think everyone is pleased that there's hope for people living with HIV and AIDS.
We know that you have the Trillium drug program for those people who are able to work. Notwithstanding that, listing of drugs becomes an issue, particularly for the Ontario drug benefit program, so it's a simple question, but I know that it's a complex question. What is the government's plan and what will be the cost for funding the many new and expensive AIDS drugs which are now becoming available? In other words, how are you going to make sure that, as the drugs are available and are listed, you will be able to pay for them? Is that part of the reinvestment? Can we be looking for that? Are you going to be shifting from one envelope to another? What's your intention of making sure that people have access to the new drugs that come on the market?
Ms Mottershead: I think that you're absolutely right, it is a complex question. We do rely on the DQTC to give us its best advice. These are the experts who tell us whether or not these drugs and their efficacy are as indicated and what circumstances they should be prescribed in. The ministers -- in my recollection, all parties -- have had that DQTC and have respected many of its recommendations.
Mrs Caplan: With fairness, if I could interrupt you just for a minute, one of the concerns that I have is that the criteria for the DQTC have been changed. In my time, while cost-effectiveness was always a concern and an issue, drugs were not left off the formulary because of cost alone. It's my understanding that with Bill 26 the minister can choose to not list a drug if the cost is prohibitive.
Ms Mottershead: That's a complicated question as well, because cost-effectiveness doesn't just look at the cost of the drug. It also looks and compares that to the kind of outcome that particular drug and therapy will have, and it relates the outcome to other drugs and other therapies and makes that comparison. So it's not just, it's a costly drug and therefore it's not on the formulary. It looks at the actual outcome in comparison to other drugs, similar drugs or other therapies.
Mrs Caplan: That's why I raised the issue particularly in the area of HIV and AIDS. I think there are other illnesses where there may be drugs and other therapies that can be compared. Given the unfortunate reality of the newness of HIV and AIDS -- I mean, it's a decade that we've been dealing with this disease and virus -- the concern is that those living with HIV and AIDS have access to new drugs as they become available. They want some assurance that they're not going to be denied simply because of the cost.
Ms Mottershead: Our recommendation to government is that where the drugs have been shown to have a high level of benefit and where people need the drug to treat their particular problem, those drugs be made available. I believe that if the minister were here, he'd say that the changes that were made to the Ontario drug benefit program in terms of introducing some copayment in the system were to ensure affordability and sustainability in light of the fact that we do have many, many more drugs coming on stream that are very, very, expensive. And in a lot of cases the drugs are to be taken in combination with other drugs. It's not as if they are replacement drugs in and of themselves; they do have to be taken, in many instances, in combination. For that reason, we need to have the ability to pay for those new drugs that are coming on.
You've mentioned HIV and AIDS. Our analysis, for example on the cancer front is just as remarkable in terms of the kind of breakthroughs that are coming forward and the cost of individual drugs over a period of a year for any particular patient. Combining all that together, the copayment introduction I think will help deal with the question of sustainability.
Mrs Caplan: I was going to deal with cancer drugs next, actually, but I guess before I leave that, it's my understanding that the $225 million in savings is going to the deficit. There's no suggestion of reinvestment in the drug benefit program. I saw that on the bottom line. Is there a reserve fund at the ministry?
Ms Mottershead: We have a reallocation process. I know that members have been asking the minister for reinvestment numbers and so on. In the ministry we look at the budget as a total budget, and we have savings and reinvestment opportunities, and to the extent that we can move from one to the other side of the pot, we do that. It may not naturally flow that portions of savings from the $225 million will go back to drugs. They could be recycled in the same --
Mrs Caplan: No, Margaret. That $225 million flowed to the consolidated revenue fund of the Ministry of Finance; it didn't stay with the Ministry of Health. Let's be accurate. The $225 million out of the ODB went to the consolidated revenue fund at Finance. Show me where it is in the estimates of the Ministry of Health and if that's in a reinvestment fund.
Ms Mottershead: That's next year's issue. We know that $225 million has not been reduced yet. The program will not come into effect until June of this coming fiscal year and that reduction will be reflected at that point in time.
I think what your question was, will there be additions to the drug programs, whether it's Trillium or ODB, that will deal with the question of making sure that there would be availability of drugs that are needed for certain things, HIV and AIDS? The answer is yes, the intention is that.
Mrs Caplan: My next question has to do with cancer. Most of those drugs are not provided through the ODB and Trillium, but rather through the OCTRF and Princess Margaret Hospital. I wondered what the impact of a 5% cut is going to be on their ability to provide not only services but those new expensive drugs which you've just alluded to.
Ms Mottershead: Right now, we are in a stage with the OCTRF of doing a couple of things. One is the development of clinical guidelines, particularly with emphasis on systemic -- chemotherapy, for example -- so that the system itself can become a lot more efficient and physicians who are required to prescribe drugs actually know which drug and how effective it is. It's the first time that it's ever been done in North America in cancer. The guidelines are being prepared -- this is what OCTRF tells me -- in its clinical trials group.
Mrs Caplan: British Columbia.
Ms Mottershead: In oncology?
Mrs Caplan: British Columbia has what I had hoped Ontario would have, and I don't know what ever happened to the cancer agency where you would actually have one large cancer network. But right now, I think OCTRF does have guidelines and so does PMH, but they don't have systemic guidelines. But I think they do in British Columbia.
Ms Mottershead: My information is from the OCTRF clinical working group, and as of last night, when I met with some of them, the information that was given to me, and it's been written in one of the US articles, so we can bring that forward because they had it there, is that this was the first time in the USA, to the extent that they're applying the guidelines and dealing with the detailed information that is required. There may be guidelines specific to a drug, but these are comprehensive guidelines that deal with the effects of one drug on an issue linking to something else to something else. So it's comprehensive.
1540
Mrs Caplan: So this is specifically drugs?
Ms Mottershead: It's primarily chemotherapy and other drugs. The point there, again, is to deal with the question of quality care, best care, appropriateness -- which you've mentioned before -- and also to try and become a little bit more efficient, because we know that there is perhaps some misuse going on out there as a result of not everybody being up to speed with the latest in the clinical guidelines and so on. So that deals with that aspect of it.
Because there are certain pressures in the system, the previous government -- and certainly this one has continued with the policy, and that is to fund drugs like Taxol. That is continuing and that is over and above what's already available to those hospitals and cancer centres in their drug program.
Just one more bit of information that I think might be useful is that in looking at the systemic therapy area, what OCTRF is doing, and we're trying it out with the Taxol issue, is linking in all of those community hospitals and teaching hospitals that are using chemotherapy --
Mrs Caplan: That's my next question.
Ms Mottershead: Sorry. Do you want to ask a question? Then I can answer it.
Mrs Caplan: No, you anticipated my next question. Go ahead.
Ms Mottershead: Linking everyone and looking at the profile of patients and who's using them and how long their use has been in place. There's an evaluation of that program and that system of linking and reporting through OCTRF that we will be doing in the next couple of months, because that program of Taxol and integration with hospitals in the distribution of guidelines and information is fairly new; it hasn't been quite six months yet.
Mrs Caplan: I'm planning to continue the questioning in the area of cancer. Given the incidence increase that is contemplated, I think the minister is very shortsighted in cutting the funds. I want to talk a little bit about the impact of those cuts, given the fact that you have a rising incidence of cancer, and also want to know whether or not there are any plans for the development of a cancer agency, and what is going to be the impact of the merger of PMH and the Toronto Hospital within the cancer system, given the fact that PMH and OCTRF for years have been coming together and then establishing the kind of cancer agency that would ensure a coordinated access to cancer treatment.
The Chair: Mr Bisson.
Mrs Caplan: Are you saying we're out of time? You can take that as notice; we can start with that for the next round.
Mr Bisson: I'd just like to ask, when do expect the minister to be returning?
Ms Mottershead: Brett's just gone out to check, to see.
The Chair: I was told me he would be away from the committee 10 minutes, and that was after 2 o'clock. I know the committee has been extremely patient.
Mr Bisson: I would rather pass my questions to the government and wait for the minister, to be honest. No disrespect to the deputy minister, but there are --
The Chair: Would you like to take some time now, a break?
Mr Bisson: If the government members -- it's up to them.
Mrs Caplan: I have a number of questions that I've been asked to place on the record by groups that I'm quite happy to have the deputy answer. I would prefer if it were the minister, but I don't think we're going to have enough time with the minister, so I'd like to get these on the record, if that's okay.
Mr Bisson: Do you know when we're expecting him back?
Ms Mottershead: The minister's assistant just left to go and check.
The Chair: Let's work out this time then. Let's work out this time itself.
Mr Bisson: Oh, no. If Mrs Caplan wants to utilize some of her time to ask questions, that's fine by me. I just would rather utilize my time with the minister at this point.
The Chair: Would you want to put your time on now, Mrs Caplan?
Mrs Caplan: No. Rather than adjourning, the thing is I don't want it to count --
Mrs Ross: I wouldn't mind asking some questions.
The Chair: Okay. Let's proceed then.
Mr Bisson: I just want to make clear that I'm not giving up our time.
The Chair: No, no.
Mr Bisson: Once the minister returns, it will come back to me.
The Chair: Right on.
Mrs Ross: I'd just like to ask a couple of questions in the long-term-care area, if you don't mind. With the community care access centres starting up, I'd like to know, with respect to a nursing home that provides those services through its own facility, how will those services be delivered now? Will they have to go through a community care access centre or will they still be able to provide those services themselves through their own nursing home?
Ms Mottershead: The nursing homes' programs will not be affected by the community care access centres at all. There's no change on the facility or residential side of long-term care. The community care access centres are primarily responsible for access and coordination of community home care, not inside nursing homes. However, there's one element. Because we're trying to integrate placement coordination services, the referrals to nursing homes, for example, would happen from the community care access centres. Right now, they are being referred by an independent agency called a "placement agency," and we're taking the placement agencies and home care programs, combining them, reducing the numbers, and in that way becoming more efficient. Nothing programmatic changes in the nursing homes as a result of that initiative.
Mrs Ross: I'm sorry, but I'm a little bit confused in this area. The reason is that in this particular nursing home I'm speaking about, I understood they looked after the placement as well through their own facility. Is that possible to happen?
Ms Mottershead: They did, I would say, several years ago. Over the past few years, though, placement coordination services have been offered to people inquiring, "Where can I go? Is there a home for Mom?" or whatever, and that service is being provided by the placement coordination services that exist now.
There are some situations where the direct placement does happen as a result of -- depending on how small your community is, you pretty well know the administrator of the particular facility, and arrangements, if there's space, can be made fairly soon and fairly directly. Where there are issues like waiting lists, the placement coordination group actually is responsible for making sure that the next person in the queue is placed rather than queue-jumping and that kind of thing. It's a service that's intended to deal with the question of fairness.
Mr E.J. Douglas Rollins (Quinte): Some information about something that's a little confusing to me. My colleague across the way here said the $70 an hour had some bearing in terms of how long it was going to stay in place and what the outcome was and whether it could be taken away at some time or something of that nature. Bancroft I think was one of the first hospitals that signed on for the $70-an-hour system, and it has worked out extremely satisfactorily. They were in the position where basically the doctors felt very overstressed, very underpaid and were prepared to withdraw their services; once this came about they became very happy and are now satisfied and seem to be working along quite well under these conditions.
Just as a rookie here, there's another thing I'd ask about Ms Caplan's statement that "beds are not a measure of service," that you don't believe that, yet you turn around and try to say that hospitals are a measure of service. Maybe I'm a little thick, but if one is and one isn't, is one a live bullet and the other a dead one, or are they both bullets?
Mrs Caplan: No, you don't require a bed to provide a service. In fact, about 70% of services are now provided in an ambulatory outpatient environment, and the best example of that is cataract surgery. It wasn't so many years ago that you stayed in a bed for five days. Now they do it in half an hour in an outpatient facility. You can close the bed, shift the resources to your outpatient department and do five times as many services. That's what I meant.
Mr Rollins: Maybe we can remove one hospital and do the same thing.
1550
Mrs Caplan: What I have always said is that you should be focusing on services, not on the bricks and mortar. I haven't seen any plan that said how you're going to protect those services, particularly in light of the transfer cuts. You've said to hospitals, "Cut 5% this year, you're going to have 6% next year and 7% the year after." Where's the plan to protect services? That's the question. It's not out there.
We've heard that there are DHCs moving around bricks and mortar and discussing how services may be provided, but your own document in the election said the services should be in place before you reduce services in hospitals, and I agree with that. You should not be cutting services until you can tell people where they're going to be able to get that service, and that's not happening, sir.
Mr Rollins: But if one hospital can provide it for two places, why bother having two hospitals? One will do it.
Mrs Caplan: Tell us how that service is going to be provided. I haven't seen that.
Mr Rollins: I can tell you, in our Quinte area, where we used to have four hospitals doing obstetrics, now we have one -- no big deal; we're doing it at one.
Mrs Caplan: That used to be called rationalization. By any other name -- you can coordinate, you can amalgamate, you can merge, but your community has no less service by moving it all into one place. I would support that. I'm not against reallocating --
Mr Rollins: So you will support closing hospitals in some places?
Mrs Caplan: In fact, I was the minister who set up the Guelph study and the Windsor study. I've never said you don't need to restructure. What I've said is that you have to guarantee the community they're going to get service. Your plan doesn't do that. That's the worry.
Mr Rollins: I think it kind of guarantees that there.
Mrs Caplan: No, it doesn't.
Mr Rollins: I disagree with you there.
Mrs Caplan: We're going to be watching. Wait till the hospitals announce their layoffs and tell you which programs they're cutting. The minister today said you have protected programs. Ask the deputy what those protected programs are. Anything that isn't on that list is gone or cut severely. You wait. Don't assume that you've protected all programs and services. You haven't.
Mrs Ross: I want to address that very issue. When our health action task force came to us and gave us a report, we really didn't have opportunity for too many questions, but one of the questions that was asked by Mr Christopherson was, what's the impact on loss of jobs with respect to this restructuring they're talking about? The answer that came back was that there may be some loss of jobs in some areas, but what they could see was an increase in jobs because they're focusing more on long-term care and providing more opportunities in the long-term-care area. They thought it would provide more opportunities for more jobs, and that was the response we were given by the health action task force in our area.
Mrs Caplan: Like St Peter's?
Mrs Ross: No, I'm talking about the health action task force report that came back that suggested that if they recommended --
Mrs Caplan: I thought you were referring to the 200 layoffs at St Peter's.
Mrs Ross: Could I just finish what I'm saying? They recommended that we increase the long-term-care beds, and I think the amount was -- it's quite a lengthy report and I don't remember which tab it's at, but it was about 800-some beds. Increasing by that number of beds in fact would create jobs in that area. It may lose jobs in other areas, but it would create substantially more jobs in those areas. I just wanted to make that comment.
I'm also reading from that report, and I'd ask if you could clarify for me exactly what this means, because I'm not an expert in health care and I don't understand it particularly well. "The restricted hospital-by-hospital approach to credentialling also affects the system's ability to develop a common medical staff who would be able to practise anywhere in the city and be able to provide an efficient on-call system." Can you please explain to me, when they say "hospital-by-hospital approach," exactly what that means? Does that mean that when a doctor is assigned to a hospital he can only practise out of that one hospital and he's limited to where he can go? Is that correct?
Ms Mottershead: The "hospital-by-hospital approach" relates to the privileges given to the physicians to work in that hospital. I believe what they're suggesting -- and I have not read that report -- is that we shouldn't do a single approach, because what happens in some hospitals is that the kind of services they end up providing has a direct relationship to the kind of specialist they bring in, and it may not be exactly what the health of the population in the next 10 years really needs. I think what they're trying to say is that if that approach were changed to a system approach, if there was pooling of resources to match what the population will need and allow the physicians to move around more freely, that would be somehow more beneficial. That's the only interpretation I can put to that, and it's a bit of speculation on my part in terms of whether that's what they meant.
Mrs Ross: I also want to ask a question -- I'm sorry, but I've got tabs everywhere -- with respect to restructuring and the formula for funding in the hospital area. The minister's come back, so he can probably answer this. In our area, one hospital received a 7% change in funding where another hospital received 2.5%, another 3%, that sort of thing. My response was, when I first heard it, "Well, the person who got the 7% obviously hasn't done their job in restructuring."
Earlier we talked about the formula under which funding was provided to the hospitals. If a hospital had a funding formula assigned to it -- I know it's very complicated and involves the type of care they deliver, the cost of that care and all that kind of stuff, but it also takes into effect the restructuring they've already done. Am I correct in saying that? For example, if they've eliminated one CEO from a hospital, that doesn't really mean they've restructured. Would I be right in saying that?
Ms Mottershead: I'll continue with that one, if that's okay, and then let the minister pick up fresh from a full question.
In Hamilton, for example, the way the allocation was done, St Peter's would have had a 2.5% reduction because it happens to be a chronic care hospital. Chedoke-McMaster got a reduction of about 3%. Part of that really does reflect the fact that over the last four years, Dr Jennifer Jackman has been doing a tremendous job in terms of re-engineering, reducing costs on a case basis; that particular allocation is reflective of the fact that real restructuring and re-engineering has been going on in that hospital. That's why the variance. At 7%, you don't have that kind of effort, and it just shows that there is room for additional improvement and efficiency.
Mrs Ross: I just wanted to clarify that, because that was my understanding. I will pass on any further questions if you want to give up our time so we can proceed with the minister.
The Chair: We'll go back to Mr Bisson.
Mr Bisson: Thank you very much, Mr Chair, for accommodating my waiting for the minister.
Let me come back to what we were talking about earlier this morning. We didn't get a very good chance to get into it. As the minister, the representative of your government for the ministry and the person in charge, you've announced a series of reductions in budgets to hospitals across Ontario in a multi-year plan, in the neighbourhood of 4% this year for a hospital in Timmins and somewhere around 5%, 6%, 7% for the next two years after that.
I want to ask you something you always used to ask us when we were in government. Have you put together any kind of estimates, first of all, of what you think this will mean in regard to effect on services? Have you looked at what it means at all in the impact on services to those communities and those hospitals?
Hon Mr Wilson: The advice this government received from the Ontario Hospital Association -- and it's the line of thinking we're taking -- is that we shouldn't see an effect or reduction in services with respect to the transfer reductions, and we'll be monitoring that through the operating plans of the hospitals.
1600
Mr Bisson: So there's no plan as such. What you're telling me is that the Ontario Hospital Association has told you that if you cut the amounts you're cutting over the next three years, there will be no reduction in services to communities, quite apart from the bricks and mortar side.
Hon Mr Wilson: That's certainly the line we're trying to make hospitals adhere to. As I said, your government caught hospitals last year reducing psychiatric beds, and, through the same process we will use, you didn't approve their operating plans; you sent them back and said, "No, those are protected areas." My deputy has already, on January 23, had to send a note out to hospitals that were trying to do the same thing over again -- not cut their administration, not cut the fat from the system.
We know there's 4% worth of fat in the system. In your area, your own administrators told me that, and they know this will spur them to get on with the other hospitals in Cochrane district to do some restructuring. The bottom line is that we'll be monitoring to make sure there continues to be high-quality health care and good access to services and not a net reduction in services. We're not looking at that. We may see a merging of programs, as you've already done up there. We may see more of that in the future.
Mr Bisson: Let me come back to it again. What you're telling me is that there have been no impact studies done on what it means to individual hospitals or hospitals in general across the province when it comes to these reductions.
Hon Mr Wilson: That would be correct, but we're taking the hospital association's word. Whether you agree or not, the hospitals themselves agree that money can come out of their system -- we have DHC reports that say that -- and the money should be reinvested in community-based services and other health care priority services, so you're harping on a dead horse.
Mr Bisson: What's that?
Hon Mr Wilson: You're harping on a dead horse.
Mr Bisson: I think not. First of all, that is a huge shift from the position the Ontario Hospital Association took both with the Liberal government and our own when it came to reduction in budgets. At no time did I ever meet with the Ontario Hospital Association during the time we were in government, and I would imagine it would be the same for Mrs Caplan, where the Ontario Hospital Association said, "You can take a total of 15% or 20% out of our budgets and it's not going to affect services." Either the Ontario Hospital Association has really revised the position it's had over the past while or --
Mrs Caplan: Did you say yes, they have?
Hon Mr Wilson: David Martin's been very clear, certainly in discussions I've had with them, that they feel this is doable or they would have been fighting us and screaming. They put out press releases agreeing with the way we went about the transfer reductions, they put out a press release agreeing with our Health Services Restructuring Commission, and I take their press releases and letters at face value.
Mr Bisson: Gee, you never took anybody else's press releases at value when we were in government. Why should you start now?
Hon Mr Wilson: I don't think that's fair or true. There are hundreds of things I never commented upon.
Mr Bisson: Anyway, the point is that the Ontario Hospital Association never took that view with our government, had not taken that view with the previous Liberal administration of Mr Peterson, and I have a really hard time believing that the members of the Ontario Hospital Association, those board members, would actually support your comment. I've actually had a conversation with some of the members of the association who are telling me quite the opposite. But I ain't going to sit in this committee and argue with you.
Hon Mr Wilson: Could I just make a clarification?
Mr Bisson: You'd better.
Hon Mr Wilson: No, I'm not backing down on what I said. What's different is that they presented us with about a 20-point plan -- more than that, actually -- and we agreed with about 95% of everything on the page, and Bill 26 was part of that. So we didn't leave them out on a lurch.
What we did differently from other governments is that in the pre-budget, mini-budget or whatever we call it, the economic statement -- in Ernie Eves's office they presented us with a very lengthy list, including things like crown foundations and that, and we moved on almost everything on that list. There were a couple of things with respect to arbitration. They wanted us to go farther than Bill 26, so we met them halfway.
That's what's different. They were very reasonable in coming forward. "We need tools X, Y, Z," up to 20 or 21 points -- more than that on the page, actually, just going by recollection -- and we met them and gave them the tools to do the restructuring. Therefore, in that climate, they've been very, very cooperative. You can do nothing but praise them, I think.
Mr Bisson: Let me take two of the things you said and we'll just get into those a bit more. I have never had somebody from the Ontario Hospital Association, a board member of the OHA or a member, come to me and suggest, "There's a whole bunch of fat in the system." I've never had them say that, and if you're saying that as a minister, they're certainly changing their position awfully quickly.
Hon Mr Wilson: Read the releases.
Mr Bisson: Well, listen. Where we're having a disagreement here is that generally I don't think a party or a member in the House disagrees with the direction the government needs to go in terms of containing expenditures within the health care field. Medicine is always advancing, always changing, and consequently the system must keep pace with that change in technology. Nobody argues that, and we also don't argue that hospitals are strictly bricks and mortar. It's a health care continuum. That ain't the issue.
Where I have a problem with your comment about the tools, where the Ontario Hospital Association came to the Minister of Finance and said, "Give us all these tools" and you just opened up the tool chest and let all the tools they needed fly out, is that you are also the protector of certain principles within your health care sector. Governments previously had refused to give them those tools, both in the time of Mrs Caplan and the time of Mrs Grier and others, for a very good reason.
I won't get into debate at this point on this committee with regard to Bill 26, because it's not the time and place, but I would say you certainly gave them tools and I think we're going to see the effect of some of those tools on the machine of health care over the long run. Quite frankly, I think you threw a spanner into a couple of issues -- but debate for another day.
Coming back to the question of the cuts over the next three years, you haven't done an impact study about what it means for services. The hospital association is telling you they can deal with it, that there's 4% fat. Is the 4% figure you used a little while ago the number the Timmins and District Hospital gave you, or is that the number the Ontario Hospital Association gave you when it came to fat?
Hon Mr Wilson: Timmins, while I was there, made a similar argument to the OHA; that is, they believed they could handle the reductions provided there was some encouragement to do further restructuring in the Cochrane district. I have no more to add to that. You can phone the chair and he will vouch for the fact that that was the conversation. In fact, the conversation was, "Could you encourage us a little more to get together in the Cochrane district?" As you know, they want to be the hub of health care for that whole area. I said: "That's up to your local area. You know the transfer reductions that were announced in November, there's no surprises here" --
Mr Bisson: You're getting into a different part of the question here.
Hon Mr Wilson: -- "and you do whatever you have to do to restructure."
Mr Bisson: Let me slow you down because we're going to come to that in a minute. The question I asked was that you made a comment a little while ago --
Hon Mr Wilson: That's the answer to the question you asked me.
Mr Bisson: No, no.
Hon Mr Wilson: It is.
Mr Bisson: No, no. I asked the question a little while ago, and I'm not sure who you were referring to, that "There's fat in the system."
Hon Mr Wilson: The 4% was Timmins.
Mr Bisson: Timmins told you that?
Hon Mr Wilson: You had said the sentence before: "My hospital got 4%, Timmins hospital." I said that 4%, we know, can be handled, provided the hospitals get together --
Mr Bisson: So you're telling me the Timmins and District Hospital board has told you they can absorb a 4% cut because that's the amount of fat in the system?
Hon Mr Wilson: They put it in the context of a system that needs to be better developed in the Cochrane district. They said it would be difficult for their hospital; that was their point. They said --
Mr Bisson: I think you'd better clarify your point.
Hon Mr Wilson: I'm doing the best I can. They said it would be difficult for their hospital. That was very clear. As they took me on the tour, every room we went into, they said, "This is going to be very difficult." I said: "You've known since November. What have you done?" In the private meeting, they said, "If we can get together better with the other hospitals in Cochrane district, we think we can handle this." If you're telling me otherwise, I guess you're telling me otherwise.
Mr Bisson: No, no. There are two issues here. The first issue is, how much fat is in the system? You're telling me the Timmins and District Hospital is telling you they can absorb a 4% cut within their hospital and not affect services, because presumably that 4% represents fat, the $1.4 million.
Hon Mr Wilson: Well, the play on words. The fact of the matter is that I'm telling you what they told me, that they could handle that in the context of restructuring --
Mr Bisson: Without affecting services?
Hon Mr Wilson: -- in the Cochrane district.
Mr Bisson: That's two different issues, though.
Hon Mr Wilson: There's no net loss of services. But that's not what they said. They said they can handle this in the context of --
Mr Bisson: Minister, with all due respect, you're mixing two issues together. If you're saying to me today that you're prepared as minister to work with the Cochrane district in regard to a system-wide hospital review that will result in a reduction of $1.4 million in those hospital budgets, the nine of them together, I am prepared to run back home and make the press release with you.
Hon Mr Wilson: Do you want me to take you back to the original announcement in November? You're distorting the entire announcement.
Mr Bisson: No, no. I'm not distorting any --
Hon Mr Wilson: The announcement was that each hospital would take its cut based on a new formula. Your own people said, "We'd like some help getting everybody to the table," and I said my preference would be -- in fact, I think I used your name, saying you'd be screaming at me if I went up there and restructured from Toronto, as Mr Laughren, when I was up there, by the way, kept slamming at me. I had to remind him that I don't live in Toronto.
Mr Bisson: Sure I would. If I did it in your community, you'd scream too, wouldn't you?
Hon Mr Wilson: Exactly, so I don't know what your point is.
1610
Mr Bisson: That's not the issue. The point I'm getting at --
Hon Mr Wilson: I'll just withdraw from this conversation, since you seem to be having it with yourself.
Mr Bisson: No, no. I'm asking you a question and you as minister are going to try to respond as best you can.
You already answered my first question with regard to the 4%. I say to you that the $1.4 million that you're withdrawing from the Timmins and District Hospital budget on its own is going to be a big difficulty for that institution to deal with. If you're saying you're prepared as the minister to look at that $1.4 million and how we can reallocate services and budgets within the entire Cochrane district that's a different kettle of fish, and I would work with you on that.
I want to say this in a framework of trying not to take this into partisan politics. I, with you, want to work with our system of health care to make it better; nobody argues with you on that. The conversation I had with you in the House way back when, last fall, on the chronic care unit was the issue that the Timmins and District Hospital was making a decision to close its chronic care unit. It wasn't you making them do this by order. They were doing it because of the restrictions in budgets. They knew they weren't going to get new money to make up the $1-million deficit they would have at the end of this budget year coming, so for them to take on the responsibilities and not be over budget, they were making that decision on their own. As I told you then, they don't like making it. I'm sure you don't like having them make that decision, and neither does the community, but people are responsible on that hospital board and they were going to do what was necessary.
The case I tried to make back then was that the Timmins and District Hospital is in a very different situation from a lot of hospitals across Ontario. They have not had an increase in their budget in over six years. We gave them one-time funding shots, I think in 1992 and 1993, so they had time to deal with certain issues, but they have not had an increase in their budget and they've had to move into a new institution. All that, in addition to many more people utilizing the district hospital in Timmins with regard to referral services from the outlying areas, has put extreme pressures on that hospital. That hospital board has gone through hoops to try to work within the community in a positive context to live within its means and do things responsibly.
What I argued with you then was that I as the local member am not going to fight you as the Minister of Health. It would have been easy for me as the opposition member in Cochrane South to stand up and make all kinds of noises about the closure of chronic care and blame it on you, but I wasn't going to play politics with the health care system in my community. I said, "I will work with you because I too want to see the hospital work in a responsible way with the Ministry of Health."
But what I asked you at the time was that you look at the Timmins and District Hospital a little differently when it comes to reductions in the future because it doesn't have a lot of room for taking money out of its budget. I'm not saying they can't do things to make themselves even yet more efficient, but when you take out $1.4 million at this point, it means they're getting into the bone. It's not just fat. What I'm saying is, I think you've got to view them a little differently.
You've got a couple of options. One option is that if you want to work with them and with us and with the district in a system-wide hospital review, there's some opportunity there to make the system more efficient, to make the system better respond to the needs of people in northeastern Ontario and -- guess what? -- at the same time meet your fiscal objectives of being able to reduce the overall amount of money you're spending in the hospital system. People aren't going to like it, but I think it's doable. But if you treat each hospital individually, as you're doing now, there's a big danger. What I'm asking you is, are you prepared to allow that process to happen, and not only to allow it but for your ministry to be directly involved, to do that little push that needs to be done for the outlying hospitals to get involved in the process?
Hon Mr Wilson: The short answer, Mr Bisson, is yes, we're prepared to do that around the province. If my ministry staff there encourage a restructuring study more than what we've seen to date, please don't get up in the question period and say we've interfered in the local study. The policy of the government is to allow local communities to get together. If they need some moral suasion, we're using the tool we have now, which is funding, to move forward on restructuring studies throughout the province. Yes, we would welcome movement by your hospitals to enter into the study. So I don't know --
Mr Bisson: Minister, in all fairness, I think if you talk to people within the ministry I dealt with over the last five years on the hospital issues in Timmins and northeastern Ontario, and you talk to the board, my view has always been we have to do this together because if somebody stands on the outside and starts yelling in and yelling out, it makes the process that much more difficult, but there has to be certain tenets to how that's done.
What I'm saying is, you have also a responsibility as the Minister of Health. But the problem I'm having right now is that you're saying in isolation to the Timmins and District Hospital, "You must reduce your budget by $1.4 million next year in order to meet your target."
What I'm telling you is, that $1.4 million at TDH is a huge problem. I've talked to the board and I've talked to the administrator and they're saying: "Gilles, we don't know how we're going to do this. We don't want to fight the minister. We don't want to make a big spill over this because we've developed an attitude in the community of doing things positively. We're trying to figure out how best to do it, but it will affect services."
I have a concern about that, as you do. I'm asking you, rather than take that route, why don't we look at it from a district-wide perspective? In other words, it would mean to say, you would look at how much money you want to save overall in the district and do it through a district-wide review.
Hon Mr Wilson: I would certainly entertain an invitation from your area for my ministry to become more active in a system-wide study, but it has to be an invite from the local community because I think you said, you don't want us to go in and do it.
Mr Bisson: Oh, it has to be done by the community. It can't be done by you.
Hon Mr Wilson: But I can tell you that I couldn't agree more. It was pointed out by the people at the Timmins and District Hospital that there's certainly a need up there and my response at the time was, "Well, you certainly don't want us to come in and do it." I think you're making that clear now.
Mr Bisson: Okay.
Hon Mr Wilson: Could I ask your indulgence? The deputy does want to add one thing in terms of --
Mr Bisson: How much time do we have, because I notice the Chair is getting twitchy here?
The Chair: Exactly. Your time is up.
Hon Mr Wilson: Which you might find useful?
The Chair: I'll just have the deputy come in then --
Mr Bisson: Yes, because I've given time to others. Perhaps I can ask the Liberals to give me a few minutes just to get the response.
Ms Mottershead: I just wanted to let you know that even though there haven't been any increases to the hospital's budget, it is one of the few and rare hospitals in the province that is not funding laboratory services from its global budget. They're being done by the Ministry of Health lab. That has got a monetary value. That's all I wanted to put on the record.
Mr Bisson: Apparently they want to privatize that as well. That's not your decision. That's the hospital.
Mrs Caplan: They couldn't get a better deal than having the ministry pay for it, no matter who does it.
Interjection: That's right.
Mrs Caplan: Tell them. Show him the Hansards.
The Chair: Ms Caplan, if you've got something, we will deal with it now.
Mrs Caplan: I have some very serious questions for the minister about mental health services. Can you give us the number of the reduction in mental health program spending over the NDP administration, the actual reduction in mental health spending in the province? Do you know the number?
Hon Mr Wilson: Given that it was the NDP's time, I'd have to defer to the deputy.
Mrs Caplan: These are their estimates. I just thought you might have the number handy.
Hon Mr Wilson: I know we've not made any cuts to the mental health envelope and we've preserved the $20-million community investment fund. But you're right, I think the previous government took some away, it was my understanding, and then created the fund.
Mrs Caplan: I was curious what the reduction was and I wanted to know if you would make a commitment that there would not be any further reductions to either community mental health or psych hospitals, that if there are any changes in the psych hospitals, that dollar for dollar there would be investment in community mental health services. I have no problem with the shift, Jim.
Hon Mr Wilson: Ms Caplan, your questions are always a little too narrow. You never leave me any opportunity but to --
Mr Bisson: Oh, come on.
Hon Mr Wilson: Well, dollar for dollar is the catchword. I've been in this game 13 years.
Mr Bisson: Come on. Just look at the Hansards when you were in opposition.
Hon Mr Wilson: I didn't --
Mr Bisson: Come on, Jim.
Hon Mr Wilson: Okay, fine. I'm not going to answer your questions.
Mr Bisson: Geez, you used to go so apoplectic in the House.
The Chair: Let the minister comment.
Hon Mr Wilson: I recall your minister not even showing up to estimates. I'm sorry I had to leave for two hours, but I recall Lankin not even being here for a whole day.
1620
Mrs Caplan: Seriously, this is a very serious question.
Hon Mr Wilson: I know it's a serious question. But you have a tendency to try and mask things as serious and earnest --
Mrs Caplan: It is.
Hon Mr Wilson: -- and then come back with little things like dollar for dollar.
Mr Bisson: You used to go apoplectic in the House. Come on, Jim.
Hon Mr Wilson: I never said "dollar for dollar" in committee; that was one speech Ruth gave, for God's sake, through this whole bloody restructuring -- totally irresponsible because of the words she used.
The Chair: Order. Estimates are quite trying things, so let's proceed.
Mrs Caplan: To repeat the question, do you know what the reduction in spending was over the NDP's term?
Hon Mr Wilson: We're just trying to figure that out.
Mrs Caplan: Okay, we can wait for the answer.
The second question is, are you committing to ensuring that there are no further cuts in any mental health programs in the province?
Hon Mr Wilson: On the community mental health side, yes, we are looking at, through the community investment fund -- which, by the way, we had to find that money; nice announcement -- that's a net increase to community mental health. Those projects are being reviewed now, and I expect there will be some announcements in the communities in the near future.
Mrs Caplan: Given the fact that you went ballistic when I said "dollar for dollar," I will not phrase the question that way.
Hon Mr Wilson: Because you tied it to the psych hospitals.
Mrs Caplan: The question that I have is, what amount of money are you going to be transferring to community mental health programs from the closure of psychiatric beds in the public hospitals or in the provincial psych hospitals? It's easy for you to say that whatever it is, it's going to be dollar for dollar; if it's not, what's it going to be?
Hon Mr Wilson: The measurement is not the money; the measurement is, will there be gaps in services? We've committed to not close any more psych beds in this province until we ensure community-based services. Community-based services are essentially cheaper than institutional services, right? So dollar for dollar doesn't make sense. Dollar for dollar doesn't make sense in hospital restructuring necessarily, and in psych hospitals it's the same.
Mrs Caplan: What I've suggested on hospital restructuring, my personal view, is that communities should share, like 50-50, where they see needs in the community.
Hon Mr Wilson: But you would admit, Mrs Caplan, that's an arbitrary figure.
Mrs Caplan: I agree, but that it is share, and it is an incentive to communities, I think, to then do it themselves and do it appropriately, and they have the incentive because they know what the needs are. In mental health, while I'll agree with you, and I do agree that you can provide community mental health services more cost-effectively, there is a need for expansion. I believe that dollar for dollar would not be unreasonable. But if that's too rich for your blood --
Hon Mr Wilson: Well, in fact, right now we're ahead of it. We've not done anything on the psych side, and we have $20 million. So we're ahead dollar for dollar. We're, like, zero for $20 million.
Mrs Caplan: Not exactly.
Hon Mr Wilson: No, we are. From my administration, we are. I found that money, because it wasn't totally accounted for, in my opinion, so I'm ahead of the game. I'm ahead of dollar for dollar; I'm zero for $20 million. I'm trying to make sure, because both you and I were very vocal and I think quite correct that we were starting to see gaps in services and worried about it, and it was one of the first things I did coming to office. I think we all have these sort of problems in our own families and that. I'm very much aware first hand of the need for mental health services. So we put a sort of moratorium on bed closures and said we'll get the community investment fund and those community services up and running before we do anything more on the bed side. That's the commitment of the government.
Mrs Caplan: I'm pleased that's on the record. That's the reason I asked for that. I am concerned, because we have seen gaps. I think the communities need to know that mental health reform is going forward and that there will be significant dollars available for the community services and that they will be in place before there's any reduction in either provincial psych hospitals or community hospitals.
I am concerned, because I have a letter dated January 23, 1996, from your deputy to the administrators of the schedule 1 facilities, the chiefs of psychiatry, which suggests that there could be reductions. This is the paragraph; it says, "If the hospital's programs and services need to be reduced because of financial pressures, the resulting reduction to psychiatry is not to be of a greater proportion than that experienced by other services in the hospital."
After listening to your assurances that your intention is not to reduce services, this letter seems to contemplate reduction in all kinds of services and what it's saying is, if you're going to make reductions, the psychiatric services should be in the same proportion as other reductions. Frankly, Minister, that's not protection of service, in my definition.
Hon Mr Wilson: But, Mrs Caplan, in all fairness, it's in the overall context of health care services to people in that community and you've asked that there be no net reduction of health care services in the community, and restructuring is designed to improve services, not take them away.
You may see services move out of the hospital, which is what the deputy's referring to -- Bill 26 allows us to set up independent health facilities where a hospital may disappear, but the services still need to be provided -- some services need to be provided. The programs may go down the street to the hospital down the street, other programs may stay onsite -- the Metro Toronto report's a good example of how that might occur -- and so, while we don't want to see a net reduction, we don't want hospitals with this first round of expenditure reductions to do what they tried to do under the NDP government and that's get rid of those high-cost beds or the hard-to-serve beds, which are the site beds.
The deputy has tried through that memo, which I've cited at least four times today, to say, "Look, you're not going to get away with shedding your site beds, as part of your meeting the reduction, and if, as part of overall community services, you are reducing some services in the hospital, you're not to, once again, treat site services differently." They're always the poor cousin; at least, that's what it appears, that they're treated as the poor cousin. The memo is designed to ensure that doesn't happen, as it has happened in the past. I know the deputy wrote the memo, she may want to add to it.
Ms Mottershead: Can I just make a comment on that, because we had a number of discussions with administrators, and what they were cautioning us is that, even in the area of mental health, there are improvements and efficiencies that could be made, for example, moving from having people in the bed to more day programs and that kind of thing. The language in that was intended to accommodate that you could shift some if you had to deal with a different way of delivering service.
Your point's well taken, because some folks, lots of them, have come back to us to say, "The language isn't strong enough," and I intend to do a follow-up memo that will make it much stronger, to convey the government's commitment to full protection.
Hon Mr Wilson: In fairness, I thought protected services in that memo, when I read the memo, but you're both right in terms that people are interpreting it. They're trying to drive a truck through it, and that's not the intention of the memo.
Mrs Caplan: Good, because this is the opportunity to clarify it, put it on the record and then, I think it's very important that you be very clear. What I'd like to know is what are your protected programs and which are the programs, if any, that you do not consider protected programs? What's going to happen to those non-protected programs?
I'll give you one example: I had a call from someone who said: "We've been told that the hospital is considering closing or cutting an eating disorders program. What do we do about that? Is it possible" -- they wanted to know, because that program could be provided, it doesn't require the hospital base. Sometimes it needs an inpatient component to it, but very often, as long as there was an affiliation, that's a program that could be provided in an independent health facility. But there's no process in place for people who are experiencing that to have a place where they can go to say: "This service is going to be cut. It's an important service in the community. What do we do?" These decisions are being made arbitrarily and there's nowhere that this is considered a protected program.
Hon Mr Wilson: I would disagree in terms of -- this all has to go through the local DHC. The DHC is to set priorities and tell us what the protected programs are for their area. It varies from place to place in the province, as you know.
I don't have any mental health up in my area, but we rely on Newmarket to keep some of their schedule 1 site beds to serve the people of Simcoe county. But in my part of Simcoe county per se, we don't have any beds to protect. Alliston and Collingwood don't have site beds. But we would consider it a protected program as per that memo in Newmarket, because that's where the natural flow is of psychiatric patients or emergency admissions usually. It depends on the area and we rely very much on the DHCs to tell us what the priorities are of their areas.
Mrs Caplan: What advice do you give to those who see services being cut before the DHCs decide what is a protected program? The reason they're being cut is because you've sent them out a budget that's 5% less than it was last year or 6% -- I don't want to identify any particular hospital, but they're cutting programs, Minister. They are cutting services, they are cutting needed services and the DHC has no say in this.
Hon Mr Wilson: No, the DHC does have some say in it. As you know, it's a to and fro from the hospitals, sometimes the hospitals don't like that, but it's a to and fro.
Mrs Caplan: As I understand it, the hospital does not require DHC approval.
Hon Mr Wilson: And we will ask, as we're doing in government and as we're doing in all areas of health care, we'll expect the DHCs to set the priorities for their local areas. We can't be all things to all people in every area, and you know that, and we're not today.
Mrs Caplan: Now, if a program is being cut, and there's been no process -- they're just doing it because they've got to meet their budget targets -- is there an appeal process? Should they call the DHC? Should they call the ministry? Should they call me? What should they do?
Hon Mr Wilson: Well, preferably through the DHC and in fact, if it was brought to your attention and then brought to my attention, or directly brought to my attention, we would refer the matter back to the DHC and ask for their advice.
Mrs Caplan: Have you designated someone in your office they could call?
1630
Hon Mr Wilson: Sure, the MPP liaison. We have all kinds of case workers who deal with this sort of thing. We hear about it.
Mrs Caplan: Because I think that service cuts and program cuts are going to be a reality. They're going to happen, they're going to happen quickly, and you need to know about them so that you can intervene.
Hon Mr Wilson: Again, though, we expect communities to give us the best advice on setting the priorities for health care in their communities, and I can't say it in any stronger way. I think if we do it from the top down, to go back to your first question today, we'd be accused of centralized, authoritative dictatorship, and that is not the direction we're moving in. I'm doing everything I can to rely very much on our partners in the local community.
Mrs Caplan: The point I'm making, and I agree we do not want to see the Ministry of Health trying to micromanage, is the concern I have is that you have the power to do that, but on the effect of the --
Hon Mr Wilson: Sure, in an area.
Mrs Caplan: -- significant cuts to the hospitals, you have a responsibility to protect essential programs, and if the hospitals are not following appropriate procedure, you need to know about that so you can send out a strongly worded letter or have your deputy give them a phone call.
Hon Mr Wilson: Sure, and I think the psych one is a good one. We have a responsibility to look at it province-wide, clearly. We felt on this one it was important to warn hospitals not to cut those beds as an easy way out to meeting your reduction targets.
Mrs Caplan: Are there any other programs you've identified?
Hon Mr Wilson: Certainly, in some areas we've just beefed up cardiac services. We wouldn't expect them to be going behind our --
Mrs Caplan: But that isn't a provincial program.
Hon Mr Wilson: Well, it is now. I had to fund it on a provincial program basis.
Mrs Caplan: Right. It is a provincial program.
Hon Mr Wilson: Dialysis, anything we've just started up, I wouldn't expect them to go behind our back and take that new money and apply it towards reductions.
Mrs Caplan: Have you told them that?
Hon Mr Wilson: Yes, we have. As you know from having been minister for three years, the to and fro from district health councils is pretty good, and we hear from a number of them on a weekly basis, as they ask for advice from the ministry on how to handle some of these questions also.
Mrs Caplan: Are you monitoring the service in communities? What's the mechanism within the ministry for doing that?
Hon Mr Wilson: It's the district health councils. Sometimes it's the MPPs flagging something to us. As you know, we still have the process in place to review the operating plans of hospitals to make sure they're not pulling the wool over our eyes, but I don't have any cases.
I remember reading, when the NDP -- about them sending back some operating plans with respect to psych beds, and I think the deputy headed it off this time, I hope, and as you've pointed out, maybe not strongly enough, so we'll take another round to make sure it doesn't happen. I'm not aware of any real problems yet, but we'll monitor it and I'm sure you'll bring it to our attention and MPPs will bring it to our attention, and district health councils will be asked to set those priorities.
Mr John C. Cleary (Cornwall): Changing a little bit, I've been asked by the customs and immigration officers why Americans coming into Ontario -- it used to be the policy that they were able to pick up their illegal OHIP cards and mail them back to OHIP. I want to know why this policy was stopped.
Hon Mr Wilson: If anyone has an illegal OHIP card, we'd appreciate having it mailed back. The law is clear that if you know of fraud one is to report it, and that would be a form of fraud, an illegal OHIP card. Perhaps you could clarify it for me, Mr Cleary.
Mr Cleary: They've told me that policy was stopped almost a year ago now.
Hon Mr Wilson: Well, I don't know. If people know of fraud, the 1-800 lines are still up, our fraud lines. They can call that. They should approach their MPP. If you get a card, the law is clear, from an NDP amendment to the law, that anyone knowing of fraud must report it. Fraud is a criminal matter under the Criminal Code, so they could hand the cards in to the local police station also. As customs and immigration officers, they should understand that they are peace officers under the law of Canada and that they have an obligation to send those cards back to the general manager of OHIP. The law is very clear.
If they can't handle that, tell them to send them to the local OPP. Fraud is fraud. If they're wondering whether somebody has a card who shouldn't have a card, if they collect as much information as possible, the general manager of OHIP, I think, and the OPP might be quite interested in that also. If there's something out there that is wrong, we want to know about it. There has been no change of policy. In fact, the previous government made some measures to try and crack down on fraud after Elinor, I and Barbara got after them a few times.
Mrs Caplan: Did you order the new computer yet?
Hon Mr Wilson: I'm working on it. Could we do that tomorrow?
Mr Cleary: Under the drug plan, the delisted drugs, not a lot but some of my constituents and some people in Ontario tell me they cannot get the drugs they need and have been into our office a number of times. I was asked just recently that if the doctor gives them a letter that there's no substitute available, will they cover the former drug they were taking?
Hon Mr Wilson: If it's a drug on the Ontario drug benefit plan --
Mr Cleary: No, they're ones that were taken off.
Hon Mr Wilson: Okay. If it's not covered, it's not covered. We hope to be able to cover more drugs in the future as a result of the copayments we've introduced.
Mrs Caplan: Oh, come on. That's going to the deficit. Show me where that -- I had this debate with your deputy. Where is the $225 million savings in the Health estimates?
Hon Mr Wilson: It will be next year. It's exactly budgeted for in terms of that's the saving; $45 million of that's already committed to be reinvested in the 140-person expansion of the Trillium drug plan, and it will be part of the 17 --
Mrs Caplan: In the economic statement from Ernie Eves that went right to the bottom line on the deficit.
Hon Mr Wilson: Not really.
Mrs Caplan: Really.
Hon Mr Wilson: It's part of the money we'll spend on drugs in the future. I'm sorry. Yes, I see. It's not like 17.4 plus 225. That's your point.
Mrs Caplan: Right. That's my question.
Hon Mr Wilson: Okay. Our commitment was to keep it at 17.4. You tell me --
Mrs Caplan: So where is this new revenue for drugs going to result in that? That is still misleading, Jim.
Hon Mr Wilson: But the almost $1-billion hit I'm getting in a few weeks from Mr Martin, where does that show up? You know where it shows up?
Mrs Caplan: In your Common Sense Revolution you said you had taken that into consideration.
Hon Mr Wilson: It shows up in all of the cuts we've had to make in order to preserve the health care budget.
Mrs Caplan: You said you took that into consideration. That's baloney.
Hon Mr Wilson: So if Mr Martin wants to take some of the credit for the cuts --
The Chair: Let's have some order.
Mrs Caplan: You said that was in your estimates.
Hon Mr Wilson: -- that have had to go to Education, that have had to go to Agriculture, that have had to go to other ministries --
Mrs Caplan: Baloney.
The Chair: Order.
Hon Mr Wilson: That's it.
Mrs Caplan: In the Common Sense Revolution you said --
Hon Mr Wilson: You can't have it both ways, Elinor.
Mrs Caplan: You said, "We took all of that into consideration." That's the post-Martin budget document.
The Chair: I think Mr Cleary had --
Mrs Caplan: Don't give us that crap.
The Chair: Order.
Hon Mr Wilson: The fact of the matter is when it happens and you have to preserve budgets, we also take into consideration the cuts outside of health care, and that's what we're doing and you're complaining about those.
The Chair: Mr Bisson, you're on.
Hon Mr Wilson: You can't have it both ways.
The Chair: Order.
Mrs Caplan: You can't say that the dollars are going when you're holding it at 17.4. That's misleading.
The Chair: Order.
Hon Mr Wilson: The fact of the matter is --
The Chair: May I get some order, please?
Mrs Caplan: Come on.
Hon Mr Wilson: The fact of the matter is it's part and parcel --
The Chair: It's late in the day --
Hon Mr Wilson: -- of the package to keep that program affordable and sustainable.
The Chair: Minister, may I just get some order, please. Mr Bisson.
Mr Cleary: In other words, you're cutting me off.
The Chair: Yes.
1640
Mr Bisson: Before we proceed, Mr Chair, I believe we have an all-party agreement that we were to go on till 6 o'clock tonight and from 9 to 12 tomorrow, in order to complete the Health estimates. That is what I think the government caucus has agreed to. They would give up basically an hour of their time and we would finish just after this rotation and come back tomorrow 9 to 12, so basically we're out of here by 5, if everybody is agreeable, or just shortly after 5.
The Chair: Let me see if I get the understanding. You're saying that there is an agreement --
Mr Bisson: Once I'm finished my rotation.
The Chair: Let me just see if I get this. There is an agreement to end at 5 and --
Mr Bisson: After my rotation, whenever that happens.
The Chair: It's the agreement to end off with this 20 minutes which is the NDP time.
Mr Bisson: That's correct.
The Chair: You have given up your time, the Liberals have given up their time --
Mr Bisson: No, they take --
The Chair: We're going to end at 5.
Mr Bisson: That's right. Okay.
The Chair: Let me just complete. If you end after your 20 minutes, it will be one rotation here with the Conservatives and one rotation with the Liberals. Is it my understanding that both parties are giving up their time to end after your 20 minutes, start tomorrow at 9 and end at 12, but ending at 12 tomorrow, and you're talking about the Health estimates?
Mr Bisson: We would deem to have them completed, because we're scheduled to finish --
The Chair: It's all right. I don't want to confuse it any more.
Mr Bisson: Well, you're doing it.
The Chair: Is that the understanding we have? Okay. We'll do that. Mr Bisson, you've got 20 minutes and then we just finish at that time, and tomorrow 9 to 12, and we'll deem the time for estimates has been completed at 12 o'clock tomorrow.
Mr Bisson: Just in fairness, I think the minister wants to add something here.
The Chair: In regard to the estimates?
Mr Bisson: It's on my time.
Hon Mr Wilson: I think Mr Cleary has a point here about drugs. I didn't answer the "no substitution" because "no substitution" really refers to something that is on the formulary. If you have something, a specific drug or something we should be looking at, I'd be happy to do that, in fairness, because I know -- 250 drugs were delisted, so if you go into a seniors' hall now and you say, "Do you want to do copayment or do you want us to do 100% delisting?" believe me, the hands go up, or if you go into a seniors' hall now and say, "Are you paying 100% for a drug this year that you weren't paying for last year?" you'll get quite a few hands, and that's probably what your question is.
You may disagree with our copayment scheme, but the fact of the matter is it is used to keep that program affordable and sustainable. Having set Mr Bisson up for that, I'm going to pay for it, I know.
Mr Bisson: I'll try to be nice because I'm always a cooperative type when it comes to health care.
Interjection.
Mr Bisson: Well, no. I've got to say I don't combat here when we come in on health care estimates. I think health care is an issue that goes beyond political boundaries. I think we all have a stake, as we're both citizens and we're legislators and we're trying to do the right thing here, so let's -- I'm trying to be civil here. If you were Al Leach and you were here for Housing, that would be a different question.
Just a point of clarification: The estimates committee in regard to Health was supposed to finish at 12 tomorrow, right?
The Chair: Yes.
Mr Bisson: Okay. I just wanted to make sure I was clear there.
I'm not going to get into the ODB thing at this point. I hate to go back to this again, but I need to, because I want to make sure that you clearly understand what it is I'm saying, and I'm trying to do this in a positive way.
As you know, the Timmins and District Hospital has gone through an enormous amount of change over the last six years, both in the restructuring of their hospital from three different sites to one, to the startup of the new Timmins and District Hospital, which has different operating structures in regard to building maintenance, in regard to heat and hydro and a whole bunch of other issues. There is the whole issue of more people utilizing the hospital from throughout the district, because we now have services in that hospital, thanks in part to work we did as a government and you did as a government in regard to more specialists and more equipment to be able to utilize the hospital more fully, and all of that has added to the pressures on the budget of the Timmins and District Hospital. So that sets up the first part.
In the last six years, under Elinor Caplan's government, the Liberal government, under our government and under yours, there has not been an increase to the base budget of the Timmins and District Hospital. What I'm saying to you is that in working from the government side of the House on the issue of the Timmins and District Hospital, I want to carry on the work I did there and do it in opposition and try to take a positive role rather than fighting with the ministry or fighting with the hospital. I don't think that gets us anywhere.
Realizing that the Timmins and District Hospital, its board and its administration and staff have done an extreme amount of work to make that facility much more efficient than it was six years ago, I can sit here and list for the next 20 minutes what it is they have done, but you're aware of it as minister, because I'm sure you get briefing notes on it, everything from how we run the hospital to the amount of beds in the hospital to the closing of the chronic care facility, moving it into the Timmins and District Hospital, the dialysis unit being moved into Timmins and District. There's all kinds of work that has been done.
They, in their work, have always told me as a board and as an administration, that the problem they have is there is not a lot of fat left on the bone. In fact, I think some would argue, not all, that there isn't any fat left on the bone. When they made the decision to fold the chronic care unit from South Porcupine into Timmins, the message they asked me to take to you and that they passed on to your subordinates within the Ministry of Health was: "We're doing this in order to keep to our commitment to be a responsible board and administration and staff. We are going to fold this in so that we can keep ourselves on budget. But when you make your decisions about future budget cuts, we ask you to take all that into consideration so that we are not severely affected, because if we take another hit" -- at the time they were telling me if they get another hit of $1 million they are going to have some problems trying to find those savings within the existing structure without losing services.
To be positive here, not to try to get into a fight with you, what I am asking is, would you as the Minister of Health be prepared to entertain the suggestion that, rather than the Timmins and District Hospital being affected like all other hospitals in the province over the next three years and losing $1.4 million this upcoming year, another probably $1 million-plus in the next two years after, rather than doing that, through our Cochrane District Health Council and with the hospitals we look at finding a way of doing a system-wide review of how we're able to achieve savings and look at the services and how we offer them throughout our district so that we don't severely limit the ability of the Timmins and District Hospital to function? That's the question.
Hon Mr Wilson: I appreciate that. In the dialysis and chronic services that were located at South Porcupine, the 4% is towards acute care services, so let's call that the main Timmins hospital. I will undertake tonight to review this as soon as we go back to the office because it has been brought to my attention by you in the past and I guess we haven't given you a good enough answer. I might be wrong, but I'm not aware of us taking away the dollars at the chronic --
Mr Bisson: No, you didn't.
Hon Mr Wilson: So they should have saved money, theoretically.
Mr Bisson: They did.
Hon Mr Wilson: Right. So it was a benefit to move South Porcupine.
Mr Bisson: It was a benefit --
Hon Mr Wilson: By the way, I went to South Porcupine also so I'd know where it was.
Mr Bisson: Just to back up so you'll clearly understand what happened, they were facing for next year another --
Hon Mr Wilson: They should have been ahead, though.
Mr Bisson: They had a balanced budget last year, okay? With the social contract coming off this year, in April 1995, and other pressures that they have in regard to increased costs through inflation and everything else, they were facing a budget of around $1 million for next year. So what they did in order to not be in a deficit --
Hon Mr Wilson: Sorry, a deficit at that time?
Mr Bisson: They were facing a deficit for this upcoming year because of the situation, the items that I told you. So they made a number of decisions within the hospital that were not popular decisions in my community, but it was none the less communicated I think fairly effectively as to what the options were: to transfer the chronic care unit and dialysis unit over to the Timmins and District Hospital. That resulted in about a $700,000 saving. So that's not money that you took away from them; that's just them trying to make up the difference they would have next year to keep on target; plus the remainder, that would be the deficit.
They found other things that they can do, which means to say quite frankly they had to affect some services. There's a whole discussion about what's going to happen to laboratory services, some staffing issues in regard to maintenance, some staffing issues in regard to the wards in the hospital. Some of those decisions had to be made in regard to finding the rest of the money they needed. What the hospital told me at the time and what they're still telling me today is that if they were not to have another hit, they'd have a balanced budget for next year because of everything they did and everything they've done over the last five years. But to do another $1.4 million now really is going to severely limit their ability to function as a district hospital, because we are the referral centre, as Sudbury is in northeastern Ontario, for our area.
I understand the politics of system-wide review. We can come to that later because that's a very difficult issue to deal with, and I very well understand maybe your reluctance to get into that because politically it's a bit of a hot potato. But the problem we now have is that we're looking at, over the next three years, reductions in budget at the TDH, and by doing that, both the board and the administrator are telling me that is going to have an effect on their services, and the problem we've got, if we limit their ability to provide services to the district, is that people in the district will be referred outwards towards Sudbury and Toronto, which will again impact on their overall situation.
1650
What I'm asking you to do is to recognize, because I think you understand this -- I'm not doing this maliciously; I want to work with you on this because I think we all have a stake in it -- could we, rather than saying we're going to do this $1.4 million and let the chips fall where they may, take a different approach, where we get our district health council involved with the other hospitals? There are good examples of what's already happening in the district of Iroquois Falls, Cochrane and Matheson with Danny O'Mara and others. Could we look at how we can do a system-wide review that looks at the overall budget within that area, what services are being provided and how we can best deliver the services to our communities through a sort of district-wide model? I realize we'd be a bit ahead of the pack on this, but I think our district can do it.
I think we've got very competent boards, very competent administrators and a member who's willing to do it with you, who isn't going to fight with you. I think the communities would be prepared, not without some difficulty, to take a look at that.
Hon Mr Wilson: In fairness, though, the problems, the difficulties and the concerns you express are very common to many hospitals in the province. What the 4% is directed towards is acute care services, a particular range of services that was measured at all hospitals. What we're doing hopefully in a couple of weeks, the JPPC is sending a manual saying, "You can do better for less in that service, in this field of services, and by the way, if you don't know how, very politely, here's how." That's what they're doing with all hospitals.
Maybe we can look at it in a positive way, as the OHA has, from what I've heard: bringing everybody up to an efficiency standard. We're not leaving them in the lurch. We're telling them how to do better with less, and that's this year. Next year, I think you'll agree, is very much tied to restructuring. Your hospitals will have to get together whether my ministry or the government gets involved, whether you continue to lead it there or whatever, and they realize that. When I talked to them in Timmins they said, "There's no way in year two we'll ever survive this." I said, "You'll have to do a system-wide approach."
We will be sensitive because your distances there are tremendous between institutions, and sharing facilities is not like downtown Toronto, where you're literally within spitting distance, sometimes, of the hospital next door. So we'll be sensitive to that and again, your district health council, which I was very impressed with, by the way, will take the lead. I guess if it's all impossible they'll tell us it's impossible, but we also reserve the right, through the JPPC, to say: "Don't tell us it's impossible right up front. Here's a way that is possible. Here's what other hospitals are doing. Maybe you should try these techniques and treatment approaches."
Mr Bisson: So what you're saying is that for this cut that's coming this year, the $1.4 million one for the Timmins and District Hospital, you're going to make some suggestions through the manuals that you'll provide about how they can be more efficient. That's the plan.
Hon Mr Wilson: That is the approach we're taking. You'll be the first to tell me that it's working or not working.
Mr Bisson: I recognize that. There's some validity to that. Then you're saying your feeling is that in the following years the overall cuts to all the different hospitals in the district will precipitate the discussion between hospitals to share services, to find better ways of doing things etc, and if the district health council was to come back to those hospitals and say, "Here, we have a different way of doing things," you would be amenable to working with them in order to achieve those ends.
Hon Mr Wilson: Yes.
Mr Bisson: Okay. I congratulate you. That's positive. Now let's say, and this is just a for instance, in year one they get that manual from you and they're to target $1.4 million, they find they can come up with $800,000 and they've got a $600,000 shortfall and say, "Listen, if we've got to go after this, it really means at this point there is this, that or other services that would be in jeopardy." Are you prepared to do what we did as a government and say, "All right, we recognize there's some ongoing restructuring here; we will give you one-time funding for this year to make up your shortfall"? We did that I believe at least twice in the past in order to deal with it as they went through restructuring.
I recognize you have pressures as a minister and I know that you have to play ball with the rest of your cabinet colleagues when it comes to overall budget constraints, but are you prepared, if they've done what they could do and the rest of it is reliant on the district and the health council and the hospital working together, to buy them the time they need to get there before we lose the service?
Hon Mr Wilson: We'll be as reasonable as we can. It's cast in stone, the 4% this year, though. As you said, we need that money. Every one of your other colleagues, Windsor, for example, which Mr Cooke was at me this morning on -- we need the money to reinvest in kickstarting these restructurings so we can get the mass of dollars out to build up the community services. Now, we've all given speeches about this over the years. It's just that when you actually move, it's difficult stuff.
But the 4%, I don't want to mislead you, is cast in stone. We will work, I hope we're working now with your area, through the district health council, to address that, obviously, and I'm assured that we're sending out through the JPPC some recommendations of how to meet that. Then we have 12 months to move forward and address the next round which I think we're agreeing should be a system-wide approach in the Cochrane district.
Mr Bisson: But if I came to you, let's say six months from now, with a recommendation from both the hospital board and the district health council that said, "TDH, if they have to get this other $600,000 -- which is to say whatever service is going to be affected -- are you prepared to give them the one-time funding in order to give them the opportunity to carry on with the rest of that process?" We've done that before. It's not impossible.
Hon Mr Wilson: You know the 4% doesn't come out April 1 -- "Write us a cheque for 4%" -- it's out over the monthly payments.
Mr Bisson: I recognize that. It's overall.
Hon Mr Wilson: There is time there to work. I guess if you come back and say it's impossible, we'd have to have a discussion, but we might be pointing to some other areas that have achieved it under equally difficult circumstances and say it wasn't impossible in other areas. But my door is open to you and if it's impossible, it's impossible. That's not what I heard out there. I heard it's going to be difficult; a system-wide approach would be preferred.
Mr Bisson: It is difficult. Yes, I agree. It is, there's no question, and I won't be a popular opposition member in advocating a system-wide review. I recognize that, but I also recognize that I have a responsibility to my community.
Hon Mr Wilson: You're probably in for life, Gilles. I don't recall us winning too many seats in the last 10 years.
Mr Bisson: I came back at 60% this time.
Just a last point; I want to add one thing.
Hon Mr Wilson: It's because of all the special deals you made with your hospital, for God's sake. It's thrown the rest of the system out of kilter.
The Chair: You seem to be doing well with the minister now, but you've only got about a minute.
Mr Bisson: I'm going to use that minute just to say this: I want you to recognize that the problem we have with the Timmins and District Hospital, like other hospitals in the north, is that if we shut down a particular service because we don't the money to fund it, for example some services of internal medicine or whatever it might be, it is very difficult, if you don't have the money and you lose that specialist, to get him back.
In some cases it's very difficult to keep the confidence that you need to have northerners use their hospitals. I'm sure you don't want to have a health care system that says you are forced, as a person living in northern Ontario, to only use the TDH. We have to have people use the hospital system and the services in a way that shows confidence in their system. That's a problem I've got, that once you lose services, it is very difficult to get people to use them again and to get the specialists back.
The Chair: It now being almost 6 of the clock, we stand adjourned until 9 o'clock tomorrow.
The committee adjourned at 1759.