Assemblée législative de l'Ontario

MINISTRY OF HEALTH

CONTENTS

Wednesday 9 October 1996

Ministry of Health

Honourable Jim Wilson

Ms Margaret Mottershead

STANDING COMMITTEE ON ESTIMATES

Chair / Président: Curling, Alvin (Scarborough North / -Nord L)

Vice-Chair / Vice-Président: Cordiano, Joseph (Lawrence L)

*Mr TobyBarrett (Norfolk PC)

*Mr GillesBisson (Cochrane South / -Sud ND)

*Mr JimBrown (Scarborough West / -Ouest PC)

Mr Michael A. Brown (Algoma-Manitoulin L)

*Mr John C. Cleary (Cornwall L)

*Mr TonyClement (Brampton South / -Sud PC)

Mr JosephCordiano (Lawrence L)

*Mr AlvinCurling (Scarborough North / -Nord L)

*Mr MorleyKells (Etobicoke-Lakeshore PC)

Mr PeterKormos (Welland-Thorold ND)

*Mr E.J. DouglasRollins (Quinte PC)

Mrs LillianRoss (Hamilton West / -Ouest PC)

*Mr FrankSheehan (Lincoln PC)

*Mr WayneWettlaufer (Kitchener PC)

*In attendance /présents

Substitutions present /Membres remplaçants présents:

Mrs ElinorCaplan (Oriole L) for Mr Cordiano

Mr BillVankoughnet (Frontenac-Addington Ind) for Mrs Ross

Also taking part /Autres participants et participantes:

Mr David S. Cooke (Windsor-Riverside ND)

Mrs LynMcLeod (Fort William L)

Mrs SandraPupatello (Windsor-Sandwich L)

Clerk / Greffier: Mr Todd Decker

Staff / Personnel: Mr Steve Poelking, research officer, Legislative Research Service

The committee met at 1547 in committee room 2.

MINISTRY OF HEALTH

The Chair (Alvin Curling): We will resume the estimates of the Ministry of Health. We have three hours and 34 minutes to go, somewhere around there. Mr Kells has raised a point.

Mr Morley Kells (Etobicoke-Lakeshore): At the end of yesterday's proceedings, I had raised a situation in my riding where a woman had trouble, in her estimation, getting properly identified on the Ontario drug plan. I tried to document the story and I tried to explain that as much as I appreciated the work done by the civil service in trying to reach a solution, I was somewhat surprised about a follow-up call from the minister's office. All I was really trying to do was suggest that maybe the minister's office and possibly the minister himself could be somewhat more flexible about the rulings in this case.

The minister took it upon himself to suggest that I was somewhat derelict in my duty in not understanding how to question people when they come through the door and answer their questions straight out, which I thought evaded what I was trying to get at.

As a matter of fact, I went back to the file. I'd like to have this read into Hansard, because I found it a bit disturbing. The lady did send me a letter ahead of time, and in the letter she said, basically:

"This is my situation: My husband and I share separate quarters at the above address. I have a small bedroom on the main floor and a living room and separate sink/toilet in the basement.

"On my income tax return I put that I am single (I also receive GST). My net income was $9,822 for 1995. I have no idea what my husband's net income is, only that it is far more than mine, and he shows himself as married on his IT return."

I could go on and restate her problems, but basically, I just wanted to read it into the record. My staff and I are not necessarily derelict in our duty. We do try to find out exactly what the situation is, and I think it's rather unfair to have the lecture that I received yesterday from the minister.

Hon Jim Wilson (Minister of Health): I never said that.

The Chair: It's not a point of order, Mr Kells.

Mr Kells: Well, I wanted to get it into the record.

Hon Mr Wilson: Review Hansard. It'll show that's not what happened. You're the one who said at the end, "Oh, I guess you're a better MPP than I am." I never suggested that, Morley. I read the Hansard.

Mr Kells: I'm glad you read it. The point is, I didn't need a lecture from you. I was trying to --

Hon Mr Wilson: I was trying to make a constructive suggestion. I'm sorry you took it that way.

The Chair: When we completed our rotation yesterday, we were about to come to the Liberals. Ms Pupatello, we're doing 20-minute rotations.

Mrs Sandra Pupatello (Windsor-Sandwich): I have some specific questions for the minister regarding information you released to the press following question period yesterday where you indicated you were opening up a clinic in Windsor.

Specifically, you told the press, and it did appear in the CP wire story, that you have contracted obstetricians, midwives etc. Your assistant James also said that the clinic could be ready within 30 to 60 days. The story that appeared in the Globe also indicated that you have contracted a team of midwives, nurse-practitioners; that they've all been contracted to staff a clinic in at least one Windsor hospital.

I'm looking at a release that the hospital was forced to put out today in which they indicate that the plan is in its initial stages and no staff have been contracted at this date. They also indicate that they are looking to you, and that in your discussions yesterday they included an integrated maternal health program, which is a far cry from an immediate crisis-resolving type of clinic where you would drop in an obstetrician, as you suggested to the press yesterday.

With these discrepancies, could you please tell me what exactly you have done? Have you contracted staff or have you not contracted staff? Will it be open in 30 days or won't it?

Hon Mr Wilson: I'd remind you that in the press release that your own community put out today, they remind the public that it's their suggestion to the Ministry of Health that they brought forward. We had been working with your community for a long time trying to find a long-term solution. I did not say to the media yesterday that we had contracted. I said they were discussing. That was the object of the meeting. I think the scrum was at about 3 o'clock, just as the meeting was occurring. I didn't even notify the media that there was your hospitals here. They knew that. I simply conveyed that these were discussions.

Now my understanding is that your hospitals, the three involved, are going back and talking to the community, and the doctors themselves are actually having a meeting this Saturday to discuss providing services to your constituents.

Mrs Pupatello: Will we have that clinic in 30 days? As your assistant James has said that the clinic could be ready to take patients within 30 to 60 days, will that be the case?

Hon Mr Wilson: The proposal, as I understand it, from the hospitals is that they could be ready in 30 to 60 days. That's what they told us.

Mrs Pupatello: What level of salary are you prepared to offer to the obstetrician that you're prepared to find to bring to our community?

Hon Mr Wilson: Again, we've asked your hospitals to come back with a detailed funding plan.

Mrs Pupatello: Have you authorized the envelope of funds, and what is the level of that funding for this project?

Hon Mr Wilson: No. We've only approved your local community's idea in principle at this point.

Mrs Pupatello: How quickly are you prepared to come back with an answer in terms of how much money you're prepared to spend, and where is the money coming from? Is it out of the $3.8 billion in terms of the cap for doctors' fees, or is it a new fund that you're prepared to spend for this clinic?

Hon Mr Wilson: There will be new funds. I'm prepared to give approval to it as soon as they come back and we agree on the financing.

Mrs Pupatello: As per your discussions yesterday, you confirmed with our people in Windsor that it is new money you are bringing into our community for obstetricians, outside of the doctors' fees that you've confirmed to leave at $3.8 billion. It won't be coming from anyone else's fees or any other group of doctors' fees. This is specifically new funding for this particular model?

Hon Mr Wilson: As with all alternative payment plans, the physician, if it's an Ontario physician, and the family obstetrician and the family doctors who would be recruited by your local hospitals to work in the clinic or clinics, there would be a conversion from fee for service to an alternative payment plan. Usually, in any conversions done by the previous government, for example -- 10% of Ontario's doctors are already on alternative payment plans. That's what attracted new physicians to your area, and that's the 21 communities in the north where we've announced alternative payment plans. The previous government signed alternative payment plans with Queen's University and I've signed with psychiatrists at Children's Hospital of Eastern Ontario. All the Sick Kids' doctors are on alternative payment plans. It brings income stability and predictability to their lives.

So we'd see some conversion, probably, of those fee-for-service dollars and perhaps other enhancements as part of the alternative payment plan contract. Certainly the hospitals themselves are indicating that they're willing to put some money forward in terms of having some of their obstetrical nurses perhaps do shifts in the clinic.

Mrs Pupatello: Can you tell me what you are currently paying obstetricians who are on alternative plans in underserviced areas that are being designated as such?

Hon Mr Wilson: I'd have to find out. There are very few obstetricians on alternative payment plans, and although there are 72 health service organizations in the province where the doctors are all on salaries, some of them are --

Mrs Pupatello: Can you arrange to get us that information?

Hon Mr Wilson: Yes. If there's an obstetrician on APP, within the confines of confidentiality guidelines, we'll --

Mrs Pupatello: "`We have a person who's an obstetrician who's willing to work in this clinic,' Wilson said." Could you tell me where that person might be coming from? Is it from outside of province?

Hon Mr Wilson: The hospitals didn't indicate a problem there. They said they would do the recruiting. There's a meeting this afternoon, I understand, with the hospitals and the medical society in Windsor-Essex to discuss this matter.

Mrs Pupatello: So you have not found this person, then.

Hon Mr Wilson: No. I didn't indicate that we had, or I certainly didn't mean to indicate we had. The whole meeting was -- we were hearing the proposal for the first time.

Mrs Lyn McLeod (Fort William): I understand that you have undertaken to get back to the committee with information as to the current salary levels being paid to physicians in underserviced areas.

Hon Mr Wilson: Yes, those would all be within ranges.

By the way, I'd remind the member for Windsor-Sandwich that you've had a chronic problem with obstetrical services even before any threat of strike action. Second, the age of your obstetricians is between 55 and 65, and normally obstetricians stop doing deliveries near that point in their career, so whatever happens, we have to come up with a long-term solution.

Mrs McLeod: I asked for clarification from the minister that we will get that information because the whole question of the way in which alternative payment plans are being provided in underserviced areas is causing some other issues to arise.

I have a number of other questions in other areas; some may be requests for information, if you don't have it available today. One is in relationship to the acute care operating budget, which I think is vote/item 1502, if you're going by that. I'm not going to make specific reference to numbers in the estimate book, Minister, so you don't need to worry about looking; rather, in terms of your planned expenditures in acute care, how you're basing the actual operating funding given to hospitals.

You've indicated that in the restructuring process, there is a target for reduction of beds that would take hospitals down to essentially -- I think the figure is about 585 patient-days per thousand that's been applicable in Thunder Bay, or close to that. You made reference yesterday in the House that there was a target that you believed 25% of hospitals in the province had already achieved. What I would appreciate receiving, and I think it should be public, is a complete list of all hospitals that are in fact achieving that target rate of bed utilization, and the nature of their referral patterns, to the extent that that's available. I don't expect you to have it today, but I would appreciate it.

The second area I want to ask a question on is the long-term care area, specifically the basis for long-term care funding and the way in which it's being allocated. It's a bit of a complicated question. I want to start with the fact that the long-term care branch of the ministry last spring put out information that put out very clearly that the basis for funding for long-term-care beds was going to be the RUG 3 data. It's been made equally clear to me by the commission members, both verbally and in writing, that there is not confidence in the RUG 3 data and that they are not going to use that, necessarily, as a guide to their decision-making.

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They also acknowledge that they do not have an alternative methodology to determine what the long-term-care funding will be, and of course in terms of restructuring, a direct relationship to the chronic care bed requirements.

Minister, given the obvious contradiction between your long-term care branch and their methodology and what they say funding is based on and your commission's restructuring and their indication that they have no methodology, exactly how are long-term-care beds going to be funded in the coming budget year?

Hon Mr Wilson: I'll take the question on notice and get back to you. I didn't know there was a discrepancy in the commission's funding. Are we talking about the true long-term-care beds in nursing homes and homes for the aged? The commission has no option in that. The provincial funding is set. Or is it the new transitional beds?

Mrs McLeod: No, specifically in terms of the restructuring, it's decisions the commission is making about chronic care beds. If I may, Minister, it's been made quite clear by your commissioners that as they reduce chronic care beds, in some cases by as much as 50%, they expect the long-term-care facilities to pick up the current chronic care patients. This, they say, is part of an integrated system of management.

It breaks down because they have no basis for a methodology for determining either the number of chronic care beds that a community is likely to need or the number of long-term-care beds. In turn, I would suggest there's no basis for funding either X numbers of chronic care beds or X numbers of long-term-care beds.

My question really is, how are you going to make those decisions? How are you going to make the decisions about numbers of beds that are needed and therefore dollar allocations to communities? This is where I find it a complicated question. We know that you have flat-lined the funding for institutional long-term care. At least it was our understanding from your announcement, when you indicated there was some $170 million going into community-based care, that it would not be done at the expense of institutional long-term care, but because you had to act on the equity issue and fund nursing homes on the same formula as you would fund homes for the aged, we could expect to see a reduction in funding for homes for the aged.

What is difficult to understand is why we're seeing most nursing homes, as well as homes for the aged, receive reductions in their funding. I'm looking for some explanation of the way the specific bed funding is being carried out. It appears that there has been a significant reduction in the base funding, as a starting point. I know that the intention is to increase that in two different stages. My question is, how many nursing homes and homes for the aged will even get back to the base they started from when you flat-lined the funding?

Hon Mr Wilson: Approximately 500 homes; 390 homes will receive more funding under the levels-of-care funding scheme, and as we apply the new equity formula over the next three years, about 110 homes. We have the exact figures, including every home in the province, if you'd like us to table that. It was tabled at the time of my announcement so that people could compare.

We have 110 homes that will lose some funding. As you know, Mrs McLeod, the funding is done with the levels-of-care funding system, which I think generally is a pretty good system. Nurses from one home go in and assess the other home, so you don't do your own assessment, and it's done on an annual basis or on a needs basis when new clients come in. For the first time we are going to see people funded based on -- I think it's a principle that all parties agreed with when we voted for Bill 101. We all voted for levels-of-care funding. Mrs Caplan and I and Barbara Sullivan sat through those hearings on behalf of our parties.

Mrs McLeod: Wasn't it part of the methodology, providing for that?

Hon Mr Wilson: Yes.

Mrs McLeod: So there would be some concern that calculations for funding of beds are not being based on averages.

Hon Mr Wilson: Bed calculations -- as I said to the committee yesterday, we are doing a survey of 56,000 beds now. Do we need more? It's not a hard question to answer in terms of our needing a better distribution of beds in the province. There are some overbedded areas and some severely underbedded areas. But we want to find out before the end of this year whether we need a net increase in beds in the province. I'll have to ask the deputy, I think, to talk about chronic care. I agree with you that it's in a bit of a transition right now and there are several schools of thought about funding of chronic cares beds.

Mrs McLeod: There's just a final question, if I may. What I understand is that as chronic care beds are reduced and as you examine whether there is a need for more long-term-care beds or potentially the same number and fewer long-term-care beds, if your flat-lining of the budget for long-term institutional care -- if that continues to be allocated -- is based on funding existing numbers of beds, as you reduce the numbers of chronic care beds, will we see a corresponding decrease in the total long-term-care budget? Are you integrating those budgets? Are you flat-lining the entire budget for institutional long-term care, whether it's chronic or in the long-term-care institution? As for chronic care patients, will they have to suffer just to have their funding flow into the long-term-care institutional setting?

Hon Mr Wilson: On the long-term-care beds, when we've completed the survey and we find we need more beds we'll have to put more funding in that envelope, and that's part of the restructuring. Right now, you're right, we've flat-lined or we've kept constant the envelope while we do the equity funding, which all parties agreed to in principle; it's just that the previous government got bogged down with some union issues and didn't actually apply levels-of-care funding and bring fairness across the system.

On chronic care and the transition from chronic care beds to long-term-care beds, I'd appreciate it if you'd give the deputy an opportunity to comment on that.

Ms Margaret Mottershead: I just want to confirm that the budget, in terms of the transfer from chronic to long-term care, will mean an increase in long-term care, both in bed capacity and the corresponding budget. In some of the conversions we're undergoing right now we've given those organizations, like St Marys in St Marys, Ontario, the Perley and other places, an opportunity to convert from high chronic care costs, including per diems and levels of care, to a stepping down. We've agreed to about a five-year transitional plan where you have existing chronic care being converted to long-term care, so the patients move, the budgets move and we'll be increasing the capacity in long-term care. That is part of the plan.

Mrs McLeod: So we'll be able to see a flat-lining, because right now we don't see chronic care and long-term care separated. It's going to be difficult to track the flat-lining of the two budgets.

Ms Mottershead: What you'll see in the hospital vote, with the conversion to long-term care, is that because chronic hospitals are in the hospital vote, that vote will start to come down and the vote for long-term-care facilities will start to come up as the budget transfers with the patient movement.

Mrs Elinor Caplan (Oriole): I've had a request from a constituent who has an outstanding case before the Health Services Appeal Board. It's not the case itself that I'm questioning, it's the time line. The case has been before the board for a year, and we made representation on the basis of how long it takes.

The information we've received is that in the last year you've had over a 1000% increase in the numbers of cases before the Health Services Appeal Board, there have been no additional resources put to solving consumer complaints, to people who are making those cases, and a year is average that people have to wait before a complaint to the Health Services Appeal Board is resolved. I wonder if that's acceptable to you and what you're going to do about it. It's not acceptable to me.

Hon Mr Wilson: We're certainly aware of comments to that effect from some members of the Health Services Appeal Board, but I think it would be best if I asked the deputy to comment on that.

Ms Mottershead: Yes, there was a tremendous increase in the caseload of the appeal board as a result of changes that were made to eligibility for health insurance, as one example, dealing with the question of students and the three-month waiting period for new entrants and so on. So their workload in fact did go up. There has been a tremendous effort by staff to --

Mrs Caplan: I think that's important, but you're saying that you're denying somebody access to insurance and it's taking a year before you can resolve their appeal?

Ms Mottershead: That's not the case. I think what's happened over the last three or four months is that we've had a tremendous effort and drive to address that. As a matter of fact, I actually directed that an audit be done of exactly how the work was being handled at the appeal board in terms of case management because we were concerned about the case management abilities and staff and the board in dealing with that kind of backlog. I have the findings of that report, and we're acting on it right now. We will definitely be in a position to implement the changes right away.

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Mr David S. Cooke (Windsor-Riverside): I just have a few questions. I want to follow up on the issue that the member for Windsor-Sandwich was raising.

First, from what I understand at this point of the idea of a prenatal clinic, it is a great idea. I think there's been considerable confusion because the way it was talked about yesterday linked it to the problem you're having with doctors and what I'll call the strike, the work withdrawal. As I understand it, the meeting with doctors that you're describing that's occurring back in Windsor this afternoon is not a planned meeting. There are a lot of folks scrambling right now, back home, to get this thing back on track because of the way it's been reported. Everybody is scrambling. We all got calls today so that we understood what the confusion was and how it had been reported. Doctors are quite upset, thinking that this is part of a strategy to undermine their negotiations and all the rest of it.

What I would like to do is give you an opportunity, between yourself and the deputy, to first of all answer a question for me. This has nothing, as I understand it, to do with the dispute between doctors and the government at this point. This is a proposal that has come forward from the community, from the hospitals, that is a long-term solution to some of the access problems and some of the resourcing for pregnant women and prenatal services.

Hon Mr Wilson: Mr Cooke, you're correct in terms of your being the member for the area and you would know better than I. But I think the timing of yesterday's meeting did get the backs up of some of the doctors, and I understand that, because there are negotiations going on. Certainly we got it from both sides. We got the OMA calling us, saying, "Jeez, what are you doing talking to the Windsor doctors without going through us?" and the Windsor doctors saying, "What are you doing, bringing in scabs or something?" and we said, "No, no."

The integrated delivery system that your district health council has presented to our ministry, which we haven't responded to yet -- we've got nine of these coming in from nine different district health councils, and I understand from reading the local media that meetings are still going on in selling that whole concept to your community -- part of it is this clinic. The age of your obstetricians requires that we come up with a long-term solution, so a long time ago the doors of my ministry were flung open and we were asking for solutions. They came forward, and the timing perhaps is a bit unfortunate, given the doctors' wanting to make sure we understand their frustrations down there over in Windsor-Essex.

That's the best I can tell you. At the end of the day, though, we're trying to work with your community, all of us together, to try and make sure that patients have services.

Mr Cooke: The budget question, obviously, will be determined by what specific proposal comes forward, but the question was raised earlier about staffing. Where you will get midwives and obstetricians, whether it's for a clinic or whether it's services that are provided in the traditional way of fee for service, it still doesn't necessarily answer the question of who, because we're not having a lot of individuals go through medical school and then go through specialization to become obstetricians. We still have a problem in that we don't have any midwives in Windsor-Essex, so I guess the advantage of the clinic is that there can be a multidisciplinary approach to providing the service.

When you were asked the question about a doctor there was some confusion again. There's no resourcing that the ministry has arranged at this point, I take it. This is a concept and all the details, including whether there are going to be any midwives or OBs, is all up in the air because none of that has been answered.

Hon Mr Wilson: In my understanding of the meeting, what your community asked for was approval in principle, which they received, and they will go out and they're confident they will find the required physicians and other --

Mr Cooke: Why would they be confident?

Hon Mr Wilson: I don't know why they're confident other than -- I asked that question. I think the attraction is, why are 17 communities now willing to be in primary care, which is salaried APP physicians? Because they're just tired of the clawback or recovery, they're tired of the unpredictability that's gone on over at least two governments, about three governments now, and 52% or so of our graduates now are women coming out of medical school and they want pregnancy leave, they want the pension, they want the family benefits they can't get as an independent fee-for-service physician. So more and more --

Mr Cooke: But we're not producing OBs in medical schools.

Hon Mr Wilson: It's a resource problem that, in that particular specialty, is not unique to Ontario. But also, and I've said this to the OBs, they're to do difficult births; some of them are doing volumes beyond difficult births. If we can get them in a more comfortable setting with their salary, if that's what they choose -- and again there's no gun to anyone's head, but there may be an obstetrician in this province who would like to go Windsor, work on an alternative payment plan, with all the benefits, and really do what he or she is specialized to do, and that's the difficult births. They can get out of the 2 o'clock in the morning normal delivery business, which midwives, if we can attract them to your area -- and we are graduating more midwives as per your government's program that you got up and running -- and other health care providers like family practitioners in the clinic could help out with and share the load.

The attractiveness, in my opinion, might not only be the predictability of income and stability of life, but also to do what they're trained to do and not do all the normal births and that which they do now.

Mr Cooke: Now that we're clear that the clinic idea is the long-term solution, that still brings me back to the fear that families, and in particular pregnant women, have in our community right now about the dispute that's taking place between the government and the doctors and the refusal to take new patients by the existing OBs in our community. It really is getting to the point where some of the folks I talked to this morning were saying that we've got people who are genuinely frightened about what might happen because they're not hooked up to a doctor. If anything happened, or even if there should be some work done to diagnose whether there is a problem, they don't have an OB.

I remember your saying very clearly in the spring when these questions were raised, I think by my colleague from Oriole and by my colleague from Nickel Belt, who was our critic at the time, you saying time and time again, "I have a contingency plan." Well, here we are in October and I'd like to be able to go back to my community this weekend and say, "Here is the contingency plan." The only thing I've heard so far from you is, "If a problem develops and it's a crisis, you can go to Detroit." That's not a solution when a woman is pregnant and needs to be hooked up with an OB.

Hon Mr Wilson: When it was indicated to us that all of the obstetricians in your area were not taking on new patients, we asked the College of Physicians and Surgeons to investigate that, and they did that the very day we asked, just a couple of weeks ago. They found that some of the obstetricians are still taking patients, regardless of what they might be telling the public.

Second, keep in mind that this thing tends to get blown out of proportion province-wide -- and I don't blame anyone. OHA surveys their hospitals regularly -- weekly for sure, if not more -- and only 40 of the 219 are expecting any service disruptions in a worst-case scenario. So we very much believe that we will never use our contingency plans, that we have very serious negotiations going on with the doctors. I think we'll make good progress there.

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Mr Cooke: I don't know what the College of Physicians and Surgeons said to you about doctors in Windsor-Essex, OBs, taking new patients, but I can tell you what people I've talked to in the system as late as this morning said. One of the executive directors of one of the two hospital administrations we have said this is a problem, that they are dealing with women who are frightened because they can't find an OB who will take them.

If you're saying that 50% of them in our community are still taking patients, then at the very least there should be something put in place where there is a referral mechanism at the local level, because it's not working and we can't wait for the negotiations to settle. It might or might not happen. We've been waiting since the spring.

Hon Mr Wilson: I agree. The bottom line is that this government will do everything it can to ensure that patients receive the services they need, and that stands --

Mr Cooke: I'm sorry. I think you have a further obligation to say -- it's not good enough to say you're going to do everything you can.

Hon Mr Wilson: We are right now.

Mr Cooke: If you're telling me that the college is saying in our community 50% of the obstetricians are taking patients -- I thought you said that. Did I hear the number wrong? I'm sorry. What did you say then?

Mrs Pupatello: He said "most."

Hon Mr Wilson: I said "some."

Mr Cooke: Whether it's 10%, 20%, 50%, whatever the number is, I think you have an obligation as the ministry. It's not to try your best. We have a principle in this country and in this province that people have access to health care. This is a universal system. This is not a "We'll try our best" system; this is a universal system. You've got to move in there and you've got to at least have some mechanism for putting together patients who are in need -- I don't like using the word "patients" -- pregnant women who are in need with doctors, OBs, who are taking referrals. You can't wait. You've got to do that now.

Hon Mr Wilson: We are doing that. We're finding OBs for most of the patients and we have about three or four patients probably --

Mr Cooke: How is that happening? Because this is not what the CEO of the local hospital told me this morning.

Hon Mr Wilson: As you know, all CEOs of the base hospitals in our contingency plan have been notified as of several Fridays ago. They can ask for prior approvals to go to other provinces or to the United States.

Mr Cooke: That's great. On a Friday afternoon a woman's supposed to fly to Manitoba --

Hon Mr Wilson: We've only had one of those so far. If there are 68 patients who are in absolute crisis, then why isn't your CEO phoning me and asking me for 68 prior approvals?

Mr Cooke: I'm not talking about a crisis. I don't pretend at all to be an expert in this particular field, but we're not talking about a crisis. We're talking about pregnant women who need to have diagnosis and ongoing monitoring to make sure that there's not going to be a crisis and to be hooked up with an OB.

Now you told me just a few minutes ago there are OBs who are taking referrals. I want to know what the process is, how you are facilitating the matching of women who are in need with the OBs who are taking referrals, and would you at least --

Hon Mr Wilson: But you don't like my answer. The college is still matching people up.

Mr Cooke: But how? How is that happening?

Hon Mr Wilson: They're keeping a list of those who are still providing services. I mean, half of the obstetricians and gynaecologists in the province are still providing services. Baby deliveries are exempt, as you know, from the threshold, so that doesn't affect their incomes.

Mr Cooke: Since the ministry asked the college to take a look at the situation in Essex county, could you supply to us as local members or to the media the list of doctors, OBs, who are taking new patients? Because we get the calls and I don't have a list. In fact this is the first -- everybody I've talked to back home is saying it's a crisis, including CEOs of hospitals. Now I've been informed by somebody that's 240 miles away that it's not. Then let us have the list of doctors so that we can tell women who are needing services, "Here's a list of doctors you can go to in our community."

Hon Mr Wilson: I didn't say it wasn't very serious. You're debating whether to use the word "crisis." I'd say when we have worried people, it is a crisis. They've got other things to worry about during their pregnancy than availability of medical services. So I'm treating it as a crisis -- and your doctors don't like it when I say that, by the way; they feel I'm inflaming things. But I treat it very seriously. If patients have been referred and gone through the CPSO and at the end of the day there's still no match with an obstetrician, we're asking them to tell us that and we'll give prior approval to get services elsewhere if that's what we have to do until we get through these negotiations.

Mr Cooke: Wouldn't it make sense, since Windsor-Essex is one of the communities that has been in this situation for a longer period of time and is probably experiencing the tightening of this sanction greater than most areas of the community --

Hon Mr Wilson: What sanction?

Mr Cooke: The sanction by the doctors. Wouldn't it make sense that the ministry send somebody down to the community or arrange with one of the offices that exist there and say, "Here's the phone number to call, and we'll match up OBs with patients"? Doesn't that make sense, instead of calling the College of Physicians and Surgeons 240 miles away?

Hon Mr Wilson: The deputy will tell you all the people she's been sending down to do exactly that.

Ms Mottershead: Let me just go back to the CPSO investigation which, to give them credit, they responded within two hours of my letter to them to go and investigate the Windsor situation. The individual was down there within 24 hours.

Mr Cooke: This was after you had asked the federal government to get involved. Sorry.

Hon Mr Wilson: No, that's my side of the business.

Ms Mottershead: The report -- and I don't have it and the ministry doesn't have it yet -- which they do have, they interviewed every single obstetrician. They asked the question, "Have you refused to provide care to those in need?" as in a situation presenting itself where they had to use their specialist qualifications. This is not your obstetrician providing primary care. I think we have to make the distinction, which they clearly did in their review of the situation, that if it was for primary care purposes, regular prenatal care, you do not need an obstetrician. But when you get to a stage where the services of a specialist are required, their survey of all of the obstetricians indicated that they had not refused care. That was the situation they found, and we haven't finished having that discussion with them.

At the same time, or even before that, probably two weeks before the CPSO review, we did send down a couple of people to have a discussion about immediately implementing an alternative payment plan which would actually provide some predictability, stability, to the situation. There were meetings with the hospitals, there was a meeting with the medical society, and those discussions continue. They do want us to participate in an alternative payment plan. The difficulty at the moment is that they want to try and find a solution with us, but we're caught up with the emotion and then the negotiations.

Mr Cooke: Deputy, we've got a provincial office building in Windsor. Why does the Ministry of Health not indicate publicly that there's a telephone and there's a Ministry of Health representative for women who are having difficulty being matched up with an OB during this particularly difficult time? Why do we always have to get on the phone and call some organization in Toronto when the crisis is in Windsor? It's not in Toronto. That doesn't seem so difficult. I know your FTEs have been cut back; they were by our government too. But there's probably somebody who can do it for a few weeks, and they can check out the casino at night. Why not try to get a solution and show that you're proactive instead of this other arrangement?

Ms Mottershead: We do have some regional medical consultants placed around the province. We don't think we need a medical consultant to do that kind of referral in every single location. There is one in London for southwestern Ontario. The medical consultant will actually determine whether or not we're at a stage with a particular patient, their inability to access care, to make the determination as to where they go next and to try and find them that immediate care and make the matchup. It's not Windsor, but we do have London.

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Mr Cooke: Who knows about it?

Hon Mr Wilson: There was a notice --

Mr Cooke: Why not take that person from London and ask them to go 120 miles up the 401 where the problem is right now and see if they can provide service in our community?

Mr Toby Barrett (Norfolk): Minister Wilson, rural communities in Ontario such as the communities that I represent know only too well the struggle to maintain accessible health care with limited physicians in certain parts of Ontario. However, I want to mention that Port Rowan, a community that you designated underserviced, has now found a doctor to serve the community and, as we speak, the Port Rowan medical centre is hosting an open house this afternoon to welcome Dr Long to the community. Your support was greatly appreciated in that effort. I think the task at hand now is to continue to try and ensure that there are no more Port Rowans across the province.

The second point I want to make with respect to rural health care, and this relates to my question, is it's my understanding that it's not feasible for some doctors in rural communities to cover emergency rooms on a simple fee-for-service basis. Locally there's been a problem with respect to the hospital in Tillsonburg. I know in the past West Haldimand hospital in Hagersville has had an issue with this and was able to solve it by other means. Also in the past there have been problems associated with keeping rural and northern emergency rooms open during certain times of the year. My question is, what have you done to alleviate this problem and what are you doing to ensure that emergency rooms can be kept open in rural areas?

Hon Mr Wilson: Mr Barrett, I very much appreciate your comments and would also extend my welcome to Dr Long, and please do that on behalf of the government and the ministry. It's nice to hear some positive news once in a while.

Mr Cooke: Where's Morley?

Hon Mr Wilson: Good question, when I find him.

As you know, when we came to office about 67 or so small, rural and northern emergency rooms were -- some of them had closed, or certainly reduced their hours, and many others were threatening to close. So we introduced, based on Graham Scott's report, which had come in just about the time we came to office -- and he talked about a $70-an-hour emergency on-call fee. I'm happy to say today about 70 communities of the 76 that qualified for that -- again it's small, rural and northern hospitals. Generally you could say the criterion is if you're the only show in the area. If you're close to another emergency room, you may or may not qualify, but if you're a small rural hospital and there's nothing within a certain radius, then you certainly qualified for this program.

Interestingly enough, while about 70 communities took us up on it -- my own in Alliston, for example, Stevenson Memorial Hospital, qualified. They were quick, though -- within a day -- to come back and say they added up all their fee-for-service billings at their emergency room day and night and it averaged out to more than $70 an hour per doctor, so they turned it down.

Mr Barrett: I might interject that also with Tillsonburg general hospital physicians seemed to present the same concern and for that reason did not pick up on the offer. I'm still not clear why this would occur.

Hon Mr Wilson: We should find out why, I guess, in terms of -- some of them, when the $70 was decided on, and that really came out of Graham Scott's report under the previous government. He had gone around and really did a lot of interviews with rural and northern doctors and came up with a very good report. We were able to implement one of the recommendations last year. It's brought some stability to those emergency rooms. They're open today.

Now, in other parts of the province, it's been very much ad hoc in the past and it's something we're certainly talking to the Ontario Medical Association and the Ontario Hospital Association about. Local hospitals have also done top-ups or various arrangements to the fee for service just to have doctors cover the emergency room.

We have our program, which has had excellent takeup, and hospitals have their various programs. What we've said at the end of the day is, if we get into a real crisis, part of our contingency plan is to fund some more money through hospitals so they can directly contract with their local doctors and then there'd be reciprocal responsibilities. You don't just get the money and then may or may not cover emergency. You get the money and it's tied to a contract that you've signed. Hospitals have been doing that with their top-up money in terms of making sure that doctors and hospitals and boards understand what privileges mean and understand that with privileges of hospital admitting and other things, there's a responsibility to do your share in emergency and other services.

Mr Tony Clement (Brampton South): Thank you, Minister, for being here today. I wanted to illustrate my query with a particular situation that involves my city, the city of Brampton. As you know, Minister, the city of Brampton has a population of 274,000, which will be close to 300,000, I believe, next year. We have one hospital for that city of 300,000. As we know, because of growth factors and what have you, certainly some of the services have reached what could be considered the upper threshold of what is feasible in terms of delivery of services to patients in Brampton.

Having said that, I agree with you that new bricks and mortar are not necessarily the solution, that we as a community as well as a province have to find new solutions that are much more community-based. That's why I was intrigued by your comments to this committee on October 2, which painted at least the broad brush strokes of something which seemed to make sense to me. You called it integrated health care. It is similar to the phraseology, as I think you mentioned, of the Ontario Nurses' Association. I think we're all sort of coming at the same conclusions perhaps at the same time.

My city of Brampton is seeking to meet that challenge of integrated health care through the establishment of what is called the Chinguacousy Health Centre, which is based upon lands that had been purchased a long time ago. Most recently, the region of Peel has contributed $3.5 million to the establishment of the Chinguacousy Health Centre.

What is exciting about this, as a preface to my question, is that the Chinguacousy Health Centre overview or concept would be for an integrated health centre where we would be integrating primary care access with what is called priority care. I believe that the priority care aspect of the Chinguacousy Health Centre would be to alleviate some of the pressures on the emergency department at Peel Memorial Hospital. So you've got this wonderful combination of the primary care, meeting the goals of primary care, but also meeting the goals of priority care in the city of Brampton. They're going ahead. They've reached agreement with the Peel Memorial Hospital in terms of making sure that there is an independent board and yet there is not overarching bureaucracy that would duplicate the administration of Peel Memorial Hospital. There are going to be a number of different ancillary services -- labs and X-rays and so on -- and they are now formalizing the proposal to the district health council, which would be financing either through a global budget or alternatively through the regular fee for service. But they're quite keen at looking at different ways of financing it through systems of rostering or what have you. So they are grappling with some of the challenges that are ahead for us and I would commend their bold experiments to you as they move forward.

The one issue that came up that I wanted to draw your attention and your reaction to, when I spoke with the movers and shakers on the Chinguacousy Health Centre, was that they have had no problem selling this idea of integrated health care to your ministry. In fact, they have been I think very gratified by the responses of the administration in your ministry to this idea. Every Ministry of Health branch that they've touched upon with these goals in mind has loved the idea, but the problem is no department takes ownership of actually making the decision as to whether they move forward or whether there has to be further review. So I've come to the conclusion that although we are pushing for integrated health care out there in the community, perhaps within our own ministry we have not got an integrated approach to the integrated health care. I guess my question to you is, what can we do to get this going so that when communities such as Brampton come to you with some very forward-thinking proposals that meet your goals they can actually get to the stage of promulgating those goals?

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Hon Mr Wilson: It's a very good question and one that I ask myself as minister from time to time. We have nine that I'm aware of that are already through or very close to getting through their district health council process in terms of integrated delivery systems or integrated health care systems -- about nine different proposals from around the province where the communities are clearly way ahead of the ministry. They're where our business plan says we should be, so congratulations to them, because the whole business plan is the first business plan the Ministry of Health has ever had in history. So I think we got that right in terms of saying we're moving towards integrated systems, and then we looked around and a lot of communities are already -- in fact, this morning I spoke at the St Lawrence Town Hall to the Canadian Association of Health Care Executives, an absolutely massive meeting where their whole day today up until five o'clock is to be spent on integrated health systems. A lot of the management at the Ministry of Health has been going to seminars about what an integrated health system is. There are a lot of different models out there.

Our first attempt, as I said yesterday, just to begin integration is to start with primary care reform and try and get a couple of models out before Christmas and work with primary care and then hopefully expand it into a more integrated system, as you talked about: labs and hospitals and all kinds of things.

You're right. The deputy and I really aren't at much liberty today to talk about it because we're just having discussions with senior management at the ministry, but we are going to restructure our ministry fairly dramatically. The senior management team was told that today, so it's no surprise to them any more. We have far too many silos and people do have to approach us in different phone numbers and different offices and different departments. We fully admit that we don't always talk to each other, that really because of the pyramid structure of the parliamentary system itself and of government, in my opinion there are really only about two people out of 11,000 or so who actually see the whole picture, and that's the deputy and the minister, because everybody reports up. We need to change that; we need to get into modern management, whether it's flat-line management or whatever. There are a number of different models being suggested that we're reviewing right now, and this government's committed to making those changes.

I think you'll see a dramatically different Ministry of Health a year from now -- I know you will -- and really focus on customer service so that people don't have to flip through the phone book to try to give us their good ideas, that they can go in and talk to -- my preference would be, for example, to be able to go in and talk to one senior manager who has a good grasp of what's going on in the entire spectrum of health care. It's a lot to ask people to do, but we know it's possible. There are some good people over there who, with some retraining -- I think there are some real possibilities. We'll also, of course, be looking for other people too.

You used to say, when you worked in government, especially when I was an assistant -- because the public doesn't know whether you're an assistant on a political staff or whether you're a bureaucrat. I used to go to cocktail parties, and I never told anyone what I did. "I work for the government." We want people in five years' time to say, "I work for the government," and people to say, "Well, you must be the best; that's why you're still there," or "That's why you were recruited." I think that's Rita Burak's goal; we want people to be proud of working for this government and working in public service, as was the British tradition for many, many years.

So we'll be better able to respond, and I do apologize to your community who, frankly, are ahead of us with respect to integrated systems. It sounds like it, anyway.

Mr Clement: Just as a quick follow-up to that, I don't want to jump the gun in terms of what your thoughts are on this, but could one of the methods we could employ within government to deal with these sorts of situations where there's a lot of experimentation out there, good, positive experimentation that we have, through our words and deeds, promoted -- is there a possibility of having some sort of internal Ministry of Health task force that is multidisciplinary that would be able to foster and encourage the experiments that are going on out there that are going to get us to the new health care system that is patient-oriented and integrated? Would some sort of intra-ministerial cross-disciplinary task force help the situation?

Hon Mr Wilson: If you don't mind, Mr Clement, I'll ask the deputy minister because I know she's given a lot of personal thought, not only to the restructuring, but to how we can better respond to these innovative proposals that are coming forward. Your idea of a task force or something is something we've been bantering around ourselves.

Ms Mottershead: I believe credit has to be given to a number of people and politicians going back a few years in contemplating what was then called a comprehensive health organization. We have a team of individuals in the ministry that is looking at those things and we have a pilot -- it was a called a comprehensive health organization but we're now calling it an integrated health delivery system -- in north Algoma, for example, where the hospital, the long-term-care facility and public health have already come together to deal with the population they have in an integrated way. By April 1997 we will have the physician, the primary care piece -- because we are in discussions with them on how on we want them into the comprehensive system. Probably a few months after that we will be looking at how to connect that particular system to the rest of the province, because clearly specialists' services aren't all going to be available in north Algoma, and therefore you need the ability to refer some of the population out and make sure that they have a connection and that someone's going to pick up their specialized care or their tertiary care.

We are working through a number of models already and there is a team in place. Where we're going as a ministry is to try and have more than just one team but actually change the culture of the organization and the work ethic so that all of our people in the ministry have that kind of thinking, foster that, and create accountability mechanisms that flow from one thing to another and standards that are set that are transferrable. We now have standards around hospital care, a different set of standards around long-term care and different rules around primary care. We want to make sure that we get into a system of accountability, financing, capitation and so on that is consistent and fluid, where the patient comes first and that, where that patient needs it and where they're moving in the system, the money moves with them, the accountabilities move with them, and the whole thing. That's our hope and that's our design.

What we have, fortunately, is a community, both of providers and the public, which has actually come to grips with understanding that they need treatment teams, they need a multidisciplinary approach to care because it's becoming so complex. They're out there now, having a full understanding, promoting it. I think it's quite a good marriage in terms of time, because the community now has become mature, both providers and the public, and the ministry is now in a position, over the next couple of months, to respond in a very positive way to make it happen.

Mrs McLeod: In addressing one area, the capital budgets for institutional health, the figure shown in the estimates is $167-million-plus. I want to know, first of all, how that figure was derived. On what basis did you determine that you would need $167,277,800? They're pre-determinations of the capital allocations that are going to be made prior to the restructuring commission's recommendations being made to the minister. That's the first question.

The second question is, in any decisions you've made about allocations that would have given you the $167 million as your base figure for next year, was that based on the assumption of 50% funding or was it based on some assumption of 75% funding? When was the decision made and why was the decision made to go from 75% to 50% funding of capital?

The last part of the question would be, assuming that you have some basis for having decided to increase the budget by that amount, and only by that amount, can we get some indication of how far you see the $167 million stretching as the restructuring commission proceeds?

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Hon Mr Wilson: The deputy minister's been in discussions with other deputy ministers, like Finance and Management Board, about this very issue because, as I said yesterday, capital is a very difficult part of the restructuring. There's no doubt about it. The commission is, I think quite correctly, making some pretty large demands on the capital side of the ledger, but we do have a plan and we are trying to find the dollars through some good planning, which I'll ask the deputy, if you don't mind, to explain.

Mrs McLeod: Before the deputy begins, obviously you recognize that I have some concerns related to my own riding in posing the question. One of my concerns is recognizing that the capital dollars that have actually been allocated for the restructuring -- you may debate this and I'd love to have an opportunity to give you the details of it -- are not adequate to carry out more than a renovation of one quarter of the floor space of the building that is to be used as the single acute care facility in Thunder Bay, and that's a statement in writing from the commission. One wonders why the advice to you in terms of providing capital dollars would not have been adequate to deal with the total needs. That's the first question.

The second question then is, why is the community now expected to raise $45 million to shut down its hospital and be left with a clearly inadequate physical facility?

I put those questions in terms of a local riding on the table, but it leads naturally to the question of, if there is a plan and the plan resulted in a very specific figure of $167 million -- your commission is out there and will continue to be out there making recommendations for restructuring that have significant capital costs. They can only advise you on the capital costs. I don't know how you can ever plan for capital or even be able to make an estimate of capital before you know what your commission is going to advise you. Maybe you'd respond to that.

The final part of it would be, are you looking at something beyond in-year funding for capital costs to address recommendations from the commission?

Hon Mr Wilson: I'll take the second-last question, and then ask Margaret Mottershead to comment more fully on our capital plans.

I fully admit that we have a very good idea but not down to the penny in terms of what the capital requirements might be if the commission follows the DHC report. We have all the DHC reports, which the commission also has, and a cursory view of those gives you a ballpark figure of what sort of capital planning we've had to do, and it's quite a few dollars. You're right, I can't predict what the commission is going to do in each community and exactly what it's going to recommend, but for planning purposes we can add up quite a few dollars that may be required. I would ask the deputy to comment on the specifics of how we're approaching this issue.

Ms Mottershead: The $167 million in the capital allocation is simply a cash requirement for this year that has been booked by projects that have already been approved, that have been well under way and are in construction and actually drawing down their cash flow in terms of meeting their construction and tendering obligations. That's the basis for the bulk of it.

In any one year there is an element that is maintained, this part of budgeting, for unforeseeable events. In the Ministry of Health and in hospitals and other facilities you have things that happen -- boilers blow up and things -- where you need some quick response and also an ability to commit to new situations. But that is a very small element, because what the government wants to do is to pay the bills, and our new accounting system now is such that on the accrual basis we only book cash against what's owed and what's expected in terms of payment.

With respect to restructuring, we are going through a process right now that is trying to anticipate what those requirements might be. We have Thunder Bay. We have Sudbury, an indication there. We're trying to estimate, as best we can, what the requirements will be for the future. An approval to Thunder Bay around its capital requirements doesn't trigger an immediate payment today or perhaps tomorrow, because there's a whole process of capital planning that starts to get engaged right away. That requires architectural drawings; that is, what is the functional program going to be in the hospital? We match up the services that are going to be delivered in that particular hospital with the space requirements. One has to go through that whole process.

We have enough money to deal with the planning that will be required, at least from now until the end of the fiscal year, until we get into another budget cycle. I'm pretty confident that the government is going to come through with the capital requirement because it is so critical for restructuring.

Mrs McLeod: Given that level of confidence, and I hope it's well founded, could you explain to me why with the first advice tendered to you by the commission, which was funding at a 75% level, two days later the ministry made a decision to reduce the capital funding to 50%?

Ms Mottershead: I think that's an unfair assessment of the situation.

Mrs McLeod: It's factual, though.

Ms Mottershead: I wrote to hospital administrators and I mentioned to the OHA, the JPPC and anyone else I ran into the fact that for this fiscal year we were certainly looking at changes in the coming formula to give government, and indeed the taxpayers who are footing the bill for capital expenditures, an opportunity to spread that resource to as many places and as many projects as possible. That change did happen before the Thunder Bay announcements were made. I know that I've communicated that.

Mrs McLeod: So the change to 50% was based on your understanding that your capital allocations would be limited. You were not considering at this point allocating any of the operating savings anticipated from restructuring to the capital needs that would be required to carry out that restructuring. So to allow taxpayers' dollars to be spread more thinly, you're prepared to tax local communities that have been forced by your law into restructuring.

Ms Mottershead: Quite clearly, the Ministry of Health was a little bit out of sync with what's happening in the capital and cost sharing formulas in many other services and programs, and one of the reasons was to bring that into line with most of the other programs across government. We were clearly out of sync, and that has been a long tradition. That was one factor.

The other thing I think the member certainly understands is that when a government makes its allocation decisions it isn't one tradeoff against another. Money that is saved is pooled. Once you pool you actually think about the priorities and look at your reinvestments and create those opportunities. It isn't a one-for-one tradeoff.

Mrs McLeod: I'll leave this at this point in deference to my colleagues, but I have to tell you that to suggest that you're out of sync with other ministries doesn't hold up against the fact that this is the only ministry and the only situation in which by law you are forcing restructuring on communities and then saying to communities, "Regardless of your wealth, regardless of your assessment, regardless of anything else, you are to raise 50% of the cost of a restructuring that by law we are forcing on you." Any thought that there might be any equity in that, I'd suggest to you, is completely false.

Mrs Pupatello: If I could carry on the discussion with the minister regarding our contingency plan that you've been speaking of for months, could you tell me then what is the contingency plan, given that we've all agreed on what has been happening in consultation with hospitals as of last week when you called them and asked them for a proposal to help? We understand that this is a longer-term solution. We understand that this integrated development plan for maternal health is something that has been in the works for some time, it's a great idea whose time has come etc. We know, though, that this is a long-term solution. We still don't have anything for the immediate crisis we're facing. Could you tell me what contingency plan you have for our immediate needs?

Hon Mr Wilson: So you now think the clinic's a good idea, even though you put out a press release today totally crapping on it?

Mrs Pupatello: Absolutely not. In fact, that plan has been on paper since the 1980s.

Hon Mr Wilson: I'll just read you your press release.

Mrs Pupatello: The whole concept of CHOs has been around since the 1900s. The whole concept of integrated delivery systems is appropriate. What I'm suggesting is that what was out of sync was your announcement to the reporters yesterday, which was very premature, because what was taken from your comments was that we were going to have something in 30 days, which was quoted by your staff, and so the people on our list believe that in 30 days they're going to have somewhere to go in our community. That's what they were led to believe based on comments from the press. That's the difficulty here.

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I would never say that an integrated model's not a good idea, because that's where you have to be in the future. Our concern has always been from the beginning that we have an immediate crisis in our community that you have to help us with. What is your contingency plan for our immediate crisis? You suggested going over to the United States. How we're going to go through the process of getting them there -- we need to have pre-approvals, for example. If that's your contingency plan, just so I know there isn't anything else available to them, we'll keep trying to work with this pre-approval plan, which at this point I'm having some trouble with.

When you suggested you only have one that so far has come through, it's because all of the referrals that are required to get the application forms. The process requires referrals by family doctors, for example; in some cases they didn't have that. We were able to find an OB for one woman in London who wasn't prepared to sign the forms that OHIP required to do the approvals for the American hospital. If that's your contingency plan, and it is solely that, then I'd like to get into some specifics about guaranteeing the approvals for these women so that we can get over the hurdles.

We've developed in our constituency office a three-page plan for all of the calls. We have all of the contacts for your OHIP office out of Kingston. We've been working very closely with that office and it is trying to be helpful, but we're coming over obstacles. The timing is critical and we can't get them resolved in the time frame for the cases we have. One woman has cardiomyopathy. Her OB will not allow her to do the drive to London, so the London OB wasn't an option. Another woman is due in February; she's in her third trimester. We've got to get her to an OB now. Another woman is bleeding and we've got to get her to a hospital. The OB who saw her there once told her he wouldn't see her again -- that's in Windsor -- and now she's filling out these forms which --

Hon Mr Wilson: Be careful. You can't refuse patients.

Mrs Pupatello: Listen, this is coming from the women, and these women are frightened. I'm telling you that if you've got reports that OBs are taking them, then clearly we need to get these women to them, or directly to a hospital. I have another woman who's growing tumours. She had to cancel her appointment at Henry Ford in the States because we couldn't get her through the approvals system in time for that appointment, so we've rescheduled for when she will have the approvals.

Understand that when you made your comments yesterday it was taken by the press that you were resolving this instantly, or at least within 30 to 60 days. If that was the case, somebody would be having a party in my town.

Hon Mr Wilson: I'm not going to sit around and wait for some timetable; I'm going to resolve this as soon as your community comes back. There are going to be no hold-ups on our side.

Mrs Pupatello: Actually, James, who's your staff, said --

Hon Mr Wilson: Yes, it may be 30 days, it may be 15 days. Maybe we could do it tomorrow. The plan has been around long enough.

Mrs Pupatello: Therefore, the details you've just gone through with the hospitals are a longer-term solution than this immediate crisis with these women whom we can't get through the system that you're allowing us. Could you please tell me what I do with these women? I need something very specific that I can do with these particular cases, all of whom have contacted the ministry, all of whom have contacted the college of surgeons, all of whom have gone through the list of OBs that was given to them by the college, which was directed by the ministry. I really need to have some answers. They're very specific.

Ms Mottershead: Have you referred the names to us?

Mrs Pupatello: All of them have called you directly.

Hon Mr Wilson: After you accused me of misleading the House yesterday, I checked with our general manager during that exchange, who was watching it on television. We don't have 68 names of women from Windsor. The general manager of OHIP is the one in prior approvals. Given that everybody's on crisis alert over there, she would have those names. Mary Catherine Lindberg is a highly respected 30-year bureaucrat who doesn't lie. I want the names of women who aren't able -- I don't want them, but the ministry needs them; the minister doesn't need to know the names of patients unless the patients want me to know. Mary Catherine Lindberg is the assistant deputy minister. She's also the general manager of OHIP. We want to be helpful, is the way I'll put it.

I've explained the contingency plans the best I can. Perhaps the deputy could explain the base hospital system we have. Your press release says, "Minister Throws Gasoline on Fire Already Out of Control." To keep talking about contingency plans across the province and that sort of thing, we have to be careful, because only 40 of our 219 hospitals are expecting problems. I admit your area is a problem area; and I respect your going to bat for them; you're doing a good job there. But let's not blow this out of proportion, because every time we say something the doctors get angry.

Mrs Pupatello: That's exactly right.

Hon Mr Wilson: But I didn't say anything yesterday to the media or anything that I didn't think your community already knew, given it was your community's proposal. I was stuck in the middle of trying to explain. You were accusing me of no action and I said: "Hold on. They're here right now having a meeting with the ministry on a local solution."

Mrs Pupatello: That's what you said in the House. What you said to the reporters and the press that appeared on the CP wire from you and your staff was a different story.

Hon Mr Wilson: Right. I told them what I knew at the time.

Mrs Pupatello: Today you've clarified for the record that you didn't intend for them to get the impression that this was an immediate resolution to the issue. You did earlier in discussions today tell me that now you realize this is not going to help me immediately. That's why I'm leading you to the question that I need some immediate redress.

It's been difficult for the women to say yes and let me use their names publicly, so we did have them call specifically. If the ministry staff responding on the phone are simply referring them, then they're not taking the names. We have been taking their names. I'll tell you all of the 68 on my list are not at high risk. I simply selected the five who are top priority today, who are, in my view, critical. I think all of them are critical; these in particular are at risk. I've got the greatest concern for them. Several of them have histories where these pregnancies simply are not going to carry to term and all of us are interested in getting that done immediately.

I believe the deputy mentioned earlier that the regional consultants were not needed to do referrals. If I could show you that in some cases we do need them for referrals, could you make them available to us for these cases, for those referrals?

Ms Mottershead: The referral has to come from the physician. Obviously I would hope the majority of them would have a GP who has actually assessed their condition and their requirement, at which point they say, "You need a referral to an obstetrician." If an obstetrician is not available to take that high-risk patient, we want to have two things happen. One is that we need to have the obstetricians reported. The women who have been turned down by their obstetrician or anyone they've approached should be calling CPSO and reporting that particular individual, because now you have a situation where you've got medical necessity and high risk combined and we have a case. We need to make sure that CPSO has the capacity to deal with individual-specific cases, because obviously it can't deal with the generality.

Mrs Pupatello: You've probably been told the same very carefully worded phrase that they are available on a consultative basis for the family physician.

Hon Mr Wilson: That's correct.

Mrs Pupatello: Patients who are calling and saying, "Will you please take me?" will not see the difference between, "No, I'm not going to deliver your baby," and, "I'm available on a consultative basis for your family physician."

Ms Mottershead: But surely the first step, if we really are concerned about women getting care, is to do that first step and to go through the consultation so that the specialist can actually do an assessment at that point in time. That's a very critical point.

Mrs Pupatello: Yes, and several have gone past that point.

Ms Mottershead: Some have gone past that point and what we need for them to do is that our medical consultant, through the physicians doing the referral, will actually assess the situation. You may know that we've already had to do one referral.

Mrs Pupatello: So that regional consultant then would be available? So we can give those names to our family physicians to call the regional consultant, who will do the referral?

Ms Mottershead: The medical consultant will be available to answer the questions and to take down the information from the general practitioner to determine whether or not a consult with the obstetricians has taken place, what the situation is in terms of high risk and medical condition and so on. Then, once the physician and our medical consultants have gotten together, a determination will be made as to where the care for that individual will be provided.

Hon Mr Wilson: Can I just clarify that all your hospitals and your chiefs of staff and everyone was given -- the phone numbers and the pager numbers and the cell phone numbers for our medical consultants were given out at the beginning of this whole thing, probably about three or four Fridays ago. The deputy wrote all the hospitals. Part of the contingency plan is that certain hospitals have taken on the responsibility to be disseminators of information, to be the referral centres. You have a base hospital in Windsor and it has all this information.

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Mrs Pupatello: Just for clarification, the gasoline on the fire is that as the information comes out and is misinterpreted in my community from what you exactly said, and I wasn't there to hear it, they interpreted that as back-door negotiation, not bargaining in good faith etc, in a very inflammatory environment.

The Chair: You have to end there now.

Mrs Pupatello: Can I ask you a really quick question? When the restructuring commission is being discussed, why do they keep adding Windsor to the list? You're not going to come to Windsor, are you?

Hon Mr Wilson: It's at arm's length.

Mr Gilles Bisson (Cochrane South): Minister, always fun to have you back at our committee so we get an opportunity to ask you questions as they relate to, not only health care generally across the province, but more specifically to the ridings we represent. Those are the questions I'd like to ask you.

Just to set this up, the cuts that were made to the hospitals that were announced last year, if I remember correctly, were over a three-year basis. Generally, those cuts were somewhere in the neighbourhood around 6% for the first year for large hospitals -- I forget; 5%? Can you explain how that was supposed to work and explain the formula? I am aware that there is a formula that treats hospitals differently. Maybe you can explain that a bit before we get started.

Hon Mr Wilson: Yes. For the first time in Ontario's history, savings targets weren't assigned just across the board. The old way of doing it was that if your target was 5% across the province everybody took 5% whether or not they'd been efficient in the past or whether or not they had already taken moves to improve their operations. So the government -- not the politicians though; it was the joint planning and policy committee, which is the ongoing committee between the Ministry of Health, and the deputy sits on that committee, and the Ontario Hospital Association -- came up with an equity funding formula. The parameters of the formula were 5% as the first-year savings target average across the province. A minimum was set of 2.5%, so the most efficient hospitals would not receive a savings target any greater than 2.5%, and a maximum was set at 8%.

Mr Bisson: That was in year 1? It was 6% in year 1, if I remember.

Hon Mr Wilson: I don't remember all the details. It's a long time. Six per cent? Those were basically the parameters, the average. Then within those parameters they actually looked for the first time at procedures and outcomes, compared hospitals and said, "We're not going to ask anyone to do anything that someone else isn't already doing." The formula recommended that.

Mr Bisson: I understand that part. In year 1 it was a maximum of 6%; year 2 was a minimum of 2.5%.

Hon Mr Wilson: It's not 6%. I think 7% or 8% was the maximum.

Mr Bisson: Can you have somebody check that out? I'd like to know what it was.

Ms Mottershead: Seven per cent.

Hon Mr Wilson: Seven per cent was the ceiling.

Mr Bisson: Seven per cent for year 1. Year 2 was?

Hon Mr Wilson: Year 2 isn't announced yet.

Ms Mottershead: Oh, can I clarify that just for a moment? We're getting the funding equity formula mixed up with the actual announcement. The reduction to the global budgets of all hospitals, to the hospital vote, was 5% in the first year, 6% in the second year and 7% in the third year.

Mr Bisson: But that was for the voted estimates for the three years.

Ms Mottershead: That's for the total operating account of all hospitals in the province.

Mrs Caplan: Total it up, add inflation and it's 25% over three years.

Mr Bisson: But it was greater depending on the hospital.

Hon Mr Wilson: Yes.

Mr Bisson: I'm also aware that the government allowed smaller hospitals and northern and rural hospitals somewhat of a break in that regard. I know Anson General, for example, in Iroquois Falls, and Bingham and Matheson received a 2.5% cut in recognition by the ministry that those particular hospitals had fixed costs, that no matter what they tried to do, if they tried to get any higher savings than that, they were really getting into services. We don't like cuts in the first place, but if you're going to get cut, the least amount is always better. That was fairly well received.

The concern is what's going to happen year 2 and year 3, because in year 2 it appears, from discussions I've had with hospital administrators in my area and other people I know in the health care field, it's fairly unsure at this point if you're going to apply that special provision for small and northern hospitals who have high fixed costs who may be in trouble if they've got to go to the full 6%. I'm wondering if you can share with us where you're planning to go this year with those cuts.

Hon Mr Wilson: The instruction I've given is that we do the equity formula again. My preference would be, rather than have a separate pool of $25 million for growth, that we incorporate that in the formula. Again, this will only be coming up to the second fiscal year beginning April 1, 1997.

Mr Bisson: You said $25-billion pool --

Hon Mr Wilson: Million. There was a growth fund.

Mr Bisson: I was going to say we don't spend that much in the entire health care field.

Hon Mr Wilson: Here's the hospital category and the range of savings: all rehab hospitals, 2.5%; chronic hospitals, 2.5% to 5%; specialty paediatric hospitals, 5%; small, rural acute hospitals and all acute hospitals in northern Ontario, 2.5% to 4%, so they were capped at 4%; all other hospitals, 2.5% to 7%. The average was 5%. That's from treasury.

Mr Bisson: I understand that. I think there was a recognition, like I said a little while ago, on the part of northern hospitals like Anson General, Bingham and others, that if they were going to get a cut, at least they weren't being severely affected in the sense of having to take the full cut. But I say again, there's a real concern that that's not going to happen next year. The direct question is, can those hospitals expect to get the full 6% cut this upcoming year? Will there be special consideration, as there was last year? That's the question.

Hon Mr Wilson: I'll let the deputy, who sits on the JPPC, because we tried honestly, the politicians -- we were asked directly last year whether I interfered in this, and I didn't. The hospital association and the ministry staff have been trying to refine the formula for year 2, so perhaps the deputy could comment on that.

Ms Mottershead: The work of JPPC is continuing to refine the funding methodology. There is every indication at this point that we will definitely have a variation in terms of how the target is assigned, not unlike the current year's allocation. We've had a recent request from over 20 northern small hospitals to actually make a presentation to the JPPC -- you probably saw the letter -- and we're going to receive their representations, I think, because that will just strengthen the argument to continue to have a differential treatment.

Mr Bisson: So is the answer yes?

Ms Mottershead: The answer is that we're looking at the same approach for next year as we took this year. What I can't verify or confirm at this point, because it's too early, is whether or not the 2.5% is going to continue to be 2.5%, or whether that gets increased a little bit.

Mr Bisson: That's the fear.

Ms Mottershead: We haven't finalized those discussions.

Mr Bisson: The problem with hospitals like that is that last year, if you had gone to the maximum -- I think in their case 4% would have been the maximum they would have been cut.

Ms Mottershead: Yes, it was.

Mr Bisson: This upcoming year it's 6%, and if there's not a floor, for lack of a better term, of trying to keep it down around the 2.5%, what I'm told by the hospitals is that really now they're going to have to start digging into services. In communities like Matheson and Iroquois Falls it's a big problem because there's not a lot of places you can go if you need hospital care in a heck of a hurry.

Do you think you're going to be relatively close to where you were last year, around the floor of 2.5%? Do you see that going higher, or what can I report back to them?

Hon Mr Wilson: It is too early. Members have been asking me this in and outside of the Legislature too, and frankly, the JPPC hasn't nailed down the formula. We're aware that it gets tougher and tougher every year for some hospitals. You've got to remember the Ontario Hospital Association fully endorsed the formula. They know there's fat in the system and they weren't defending their members in saying status quo.

Mr Bisson: Well --

Hon Mr Wilson: No, they weren't. I'll table David Martin's Empire Club speech.

Mr Bisson: I've seen it; I've read it.

Hon Mr Wilson: As the deputy says, that's why they agreed to 7% for some of their members in the first year, when the average was only 5% because they knew some of these people have not restructured. Some of them have huge overheads.

Mr Bisson: So you're telling me that hospital administrators across the province have accepted that there's too much fat in their budgets?

Hon Mr Wilson: Yes, very much so.

Mr Bisson: So if I were to go to the directors of hospitals, executive directors in places like the Timmins and District Hospital, and if I were to go to Anson General and I were to go to Bingham, which is the same person, he would agree with that comment?

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Hon Mr Wilson: I think you'll find many CEOs -- let's take Metro Toronto where I've had those discussions -- who agree that for years there was no requirement to cooperate with the hospital across the road. There was no requirement to share services. You did your own fund-raising, you hired your own presidents, you had your own board and you jealously guarded everything you had and you lobbied government to get more. Now there is a requirement to share services where they can.

Mr Bisson: It's a simple question. You're saying that hospital administrators feel that there's too much fat in the system and that they can afford to take some money out of their budgets and they won't be affected negatively when it comes to service?

Hon Mr Wilson: For instance, in the restructuring area of Thunder Bay -- the average administration is about 27.5% in the province and we saw administration as high as 49% in that system. There's fat in the system. They admit it. I've not seen any newspaper articles saying there wasn't fat in the system that should come out.

Mr Bisson: In working with the hospitals that I've worked at, they certainly worked hard to make themselves more efficient. I think hospitals recognized, even before your government got in, that something needed to be done in order to make sure as many dollars as possible go into front-line services. But I think your comments are a wee bit strong and there would be some argument with that. But I don't want to --

Hon Mr Wilson: Sorry. I didn't criticize your hospitals. I don't know the specifics of your hospitals. They may be most efficient. I know 25% of our hospitals are reaching 586 patient-days per 1,000 population and they are very efficient. So I know 25% of our hospitals are leading North America in efficiency. We're trying to get other hospitals near that standard, where we make them more efficient.

Mr Bisson: But that's the point I'm getting at.

Hon Mr Wilson: We're not asking anybody to do what other hospitals aren't already doing. We're telling CEOs, "Your peer over here seems to run a more efficient shop and still maintain quality and access."

Mr Bisson: Here is where I agree with you. I agree with your first comment, that you have to look at hospital reductions from the perspective of what the hospitals are doing and how they're run. I guess what's difficult for some hospitals, for example like the ones in Iroquois Falls and Matheson, is they've already started the process of merging. They are now merging their administrations to the point where they're saving the dollars that the ministry would like to get saved so that they can make sure the dollars stay in the front-line services where they're needed. I guess when they're faced at looking at possibly a 6% reduction in budget next year if there wasn't a base, they're really going to be hurt because they don't have a lot of slack in the system.

I think we've exhausted this line of questioning. Just to finish, should they brace themselves for the 6% reduction this year or could they look forward to some sort of base such as they had last year on the floor? You've indicated there will be some sort of a formula. At this point you're telling me you don't know what that formula is going to be. When it comes to the final result, will it be 2.5%, 2%, 3%? You don't know, is what you're saying, right? It's too premature.

Hon Mr Wilson: It's too early to know the formula exactly, yes.

Mr Bisson: The last part of this question is, when could they expect to find out the answer to that question?

Hon Mr Wilson: I'll ask the deputy to make a comment.

Ms Mottershead: In answer to that question, certainly not before Christmas. As part of the JPPC responsibility, we're doing runs on hospitals in terms of verifying a lot of the data. What that means -- and I just want to stress this because it is really, really important -- is that in those hospitals that have gained efficiencies, those efficiencies will show up when we do the run and that is going to tell us how much more efficient they've become and how much less of a reduction they will take. There is a direct correlation between efficiency levels and the amount of reduction. So we are gathering that information, we're running it through, and that will form the basis of the recommendations to the government.

Mr Bisson: I don't want to stay on this any longer because we've already taken 10 minutes, but I just want to make the case for those hospitals. Anson and Sensenbrenner and all of those that you know have been working on this for a number of years. They've gone a long way, and if they've got to see that full 6%, it's going to be services out the door. That's just where they're at.

Just quickly, what I basically did is I called various people in the health care field who work in my riding yesterday and today to have a bit of a chat with them and said, listen, if you had to say something to the minister, what would you have to say? Some of it I can't repeat here because it would be unparliamentary, so I'll try to keep the nicer of the comments.

Hon Mr Wilson: I'm probably about as popular as your health ministers were.

Mr Bisson: Actually, our health minister was pretty popular.

Mr Clement: Where? That's your line, and you're sticking to it.

Hon Mr Wilson: I'll admit we probably have equal popularity.

Mr Bisson: We had a discussion yesterday about what's happening in the long-term-care field. The reason I asked you the question yesterday around the nurses' issues and ratios and all that -- and you answered that yesterday -- was that one of the administrators for one of the long-term-care facilities had indicated to me that he was a bit worried that over the longer run, as patient loads increase -- because as you know, with changes that we instituted and you've carried on where long-term-care facilities are taking in much sicker patients than they did in the past, who need a lot more care, the workload for those nurses is getting quite high.

In talking to the nurses in some of the long-term-care facilities in my area, the message they bring to you is that at this point they're managing -- that's what they want me to tell you -- but they're starting to find it extremely difficult. The patients who are coming through the door now are not coming in under their own power; they're coming in because they need long-term-care services in a big way, many times to the point where you have to utilize lifts to get them into the bed because they're not able to do anything on their own.

The nurses are finding it very difficult, although they're managing at this point, to keep up with the level of care that they want to give the patients. The message they asked me to bring to you is that we need to take a look at that over a little bit of the longer term, because as the level of care increases, we need to get some sort of adjustment on the nursing ratios within those particular floors. They're saying if something doesn't happen over the shorter term of the next year or so, we will be in some of those places, quite frankly, in a bit of a crisis situation.

They're noticing now that the maintenance within those facilities is not as good as it used to be. Again, it's not catastrophic at this point, but they're noticing that the housecleaning and other services are being affected. They want to bring the message to you that they're doing the best they can to meet your targets, but they're starting to find it somewhat difficult to meet the needs of the residents and are asking me to ask you what you plan on doing in order to be able to alleviate some of the stress they're starting to see at this point.

Hon Mr Wilson: The long-term care has not been cut. In fact, community-based service is beefed up and there's been a redistribution -- as I said, about 390 homes have gained under this program and about 110 haven't. So we have brought in equity based on the actual levels of care in the homes. The annual reviews that are done by the teams of nurses actually try to match the dollars up to the care of the residents, and that's a dramatically different way of doing business. Your government passed the legislation but didn't fully implement levels-of-care funding. You should see an improvement; certainly 390 homes out of almost 500 are seeing an improvement. There's more money available in those homes today.

Mr Bisson: What's happening in homes that we red-circled as a government is that they're having to manage within the existing budgets, and in fact their funding has gone down. They went from a per diem of $124 -- which was high, I understand that -- at the South Centennial Manor and I think they're down to somewhere at $110 or $111. They're starting to find that a difficulty and they're wondering what you're going to offer to take some of that pressure off eventually.

Hon Mr Wilson: Our offer is to be resourceful and act as resources. Our long-term-care offices, in particular our team here at Queen's Park, are available to those administrators to help them explore ways to bring costs down, to share information with other homes that are living with $95-a-day per diems, frankly, and providing top-quality care. My homes in my riding are at about $95 a day, and I tell you there are waiting lists still for social admissions because people want to live there.

Mr Bisson: We have the same.

Hon Mr Wilson: Yes. They're still providing very good care. I do take the concerns of your nurses seriously; we can't continue to flat-line forever the long-term care. Right now we're doing the redistribution, and as we make reinvestments over the next few years, our long-term-care facility funding will be looked at.

Mr Bisson: So the relief isn't in the short term; it's more in the longer term, is what you're saying.

Hon Mr Wilson: Right now I think honestly the best approach with homes that are experiencing an adjustment downward is to work with them and see if there are some efficiencies.

There's also a lot of red tape. Mr Sheehan here has a red tape commission, and Frank could do his whole 20 minutes on what he's found in terms of red tape, things that cost an awful lot of money for those homes in filling out government forms that we hope to get rid of and free up dollars there. We're talking about a business where every penny counts. They adjust their little envelopes by five cents and it makes a world of difference to the level of care they're able to provide in that home. So if we can also cut the red tape and free up dollars that way, that will be good for the system.

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Mr Bisson: Can I just raise one concern with that? I understand the government's desire to reduce the administrative load. A lot of nurses and a lot of administrators would probably agree with you up to a certain point, but let's not forget why some of those forms were put in there in the first place: to make sure we have accountability in the system.

I get a little nervous when I hear some of the members of the government talk about red tape as if all reporting and all forms are bad. They're not. They're there for a reason, to make sure there is accountability in the system so that if something goes wrong, we're able to catch it before it does become a problem and (2) if it does go wrong, we have some system of accountability to go back to where the problem came from. We need to keep that in mind.

Mr Wayne Wettlaufer (Kitchener): I want to start by questioning what was in Gilles Bisson's lunch today that he thought their health minister was more popular than you, Jim.

Interjections.

Mr Wettlaufer: I was really pleased with your response to Tony Clement's question in regard to staffing cutbacks, management cutbacks, senior level. That's very important.

I was sorry to leave here early yesterday, but I had to go back to an emergency meeting held in the region last night by the regional council and the district health council and the administrators of the hospitals. There was a very lengthy session. Two of the questions raised by the district health council and the administrations of the hospitals were: What will the hospital of the future look like, and what kind of funding can be expected by hospitals in the future? They suggested they haven't received any guidelines from the ministry. I'm not sure that the ministry should give guidelines, but perhaps you have some. If so, could you comment on that?

Hon Mr Wilson: I think it's a fair question if we're dealing with old questions. The new question is, what do patients need? We want them to design their system from the ground up, not that we hand them an envelope. Traditionally, hospitals have been funded for the last 50 years on, "You get 2% more a year based on your historic funding," or 5%. At one time the government in the 1980s was doing 10% more. No one ever asked exactly all the accountability questions that should have been asked in those buildings, frankly.

Rather than to prejudice your process there, we want them to be creative. We want the district health council to properly survey, with the help of the ministry, if they need it, the needs of the people in your area, and not just on a per capita basis, but who's actually using the health care services: Do a lot of your people commute to Toronto and use the services there, as mine do? We're talking about per capita funding.

To simply set a block of money based on some historic funding would perpetuate the status quo and they would just build their plans towards that block of money. We wouldn't be any further ahead in terms of creativity, patient-based budget and so on. We have resources available. The DHCs, frankly, have the resources and they usually tell us, but we also have resources available and some guidelines to help people with this planning. We don't want to prejudice it. I think they are, from what I see. You have tremendous community interest and I commend the community for that.

I know it's not easy, because there are a lot of emotions involved and a lot of mythology out there, but the fact is that your DHC is local people and not us politicians. They're free to hire within the budgets they have and they can ask for more money if they need it. They're free to do the proper studies that need to be done to find out what the patients in your area need and build the system up from there and form those alliances as they go, not just this whole debate I read in your papers focused on hospitals.

The poor home care people must feel like second-rate cousins right now, and they're not. They're providing top-quality home care to people in your area in a massive way that hasn't been done before. They're not getting the credit.

We need your DHC to do it in an integrated way, and I think they're up to the task. They got off to a bit of slow start out there compared to other DHCs in the province, but I think they're moving ahead now. Certainly they're doing the right thing in having the public meetings and asking the public what they expect from their health care system.

It's hard to give you a hard-core number, because all we'd do is we'd fill that number and we still wouldn't know whether we're serving patients and we'd probably still have gaps in services, like we have in many areas now.

Mr Wettlaufer: You would agree that they have not been given a number to aim at, though, in the way of funding cutbacks?

Hon Mr Wilson: The DHC would know what health care spending generally is in your catchment area, so that would be the number. Now, they may want to recommend that there be a shift in dollars to community-based care; they may want to do what other communities are doing. But the ministry isn't going to set a target and say, "Here's your money," until we see the community plans and then we'll fund accordingly.

Again, at the end of the day it's that the patients need the services. It doesn't make sense to give an institution a fixed budget, forget about mental health, which always seems to lose, and then give money to home care. We always seem to have gaps when we fund on a silo. If we can get them, as many communities are doing -- in my opinion, what I see the commission doing as its modus operandi is the patient. They're following, almost in an schematic way, a patient through a system in Thunder Bay, for example, and that's why they're getting good editorial comments on that. For the first time we can answer -- almost; we're getting there -- pre-cradle-to-grave services in a community. We can actually tell Mrs Jones where her daughter will get services, by whom, and that the money will follow the patient and not the providers and not the administrators and not the bricks and mortar.

Hospitals in a home is something I've learned through this estimates process, when the deputy was talking about how a lot of hospitals right now, to deal with the savings they have to find, are actually sending teams of nurses out to the homes. They're starting to break down their own walls and move out. Those hospitals that are thinking creatively like that have got rid of the old mentality of just thinking within their own piece of real estate. That's fantastic to see, and I understand it's happening more and more across the province.

Mr Wettlaufer: The input last night was exceptional. The district health council's report to the public was excellent. It was commented on more than once that they are making a move away from the bricks and mortar and towards better resourcing, ie, more integrated delivery systems in the areas where we have been underserviced. You would have enjoyed being there, I'm sure.

I know you want to go someplace and I know Mr Clement has another question, so I'm finished.

Mr Clement: Just a quick question, I hope, to the minister or to the deputy. Under Mr Bisson's line of questioning, there was a question with relation to the proposals for the JPPC formula. You made a comment, Madam Deputy, that you were looking at the efficiency of the hospitals as one of the criteria with respect to amendments to the JPPC formula, and I congratulate you and support you on that.

My question relates to a particular circumstance in some of the 905 hospitals. One of the arguments I get frequently from the 905 GTA hospitals is that they don't mind the test of efficiency, but the question in their mind is whether it is based on historical efficiencies or whether it's based on efficiency gains. A lot of these hospitals make the argument that they have made tremendous efficiency gains over the years -- in fact, they never had the flab in the first place because of growth factors and other things. So if the sole criterion is efficiency gains, they were already closer to the bone, let's say, than a number of other hospitals that might have 40% flab they can rid of and then claim they've become much more efficient. Would you at least consider the possibility of looking at historical efficiencies as well as efficiency gains in amending the JPPC formula?

Hon Mr Wilson: Maybe efficiency gains in the way we're thinking of it right now is not the right way to look at it. They looked at outcomes and more like performance measurements. The deputy can explain this a lot better, but I'll give you my layman's version of it as it was described to me.

They actually took a patient with a particular illness and followed that same patient through different hospitals, the end result being that the patient is cured or the treatment is done. Some would deal with it quickly and efficiently and there weren't long pauses between service and you weren't sent around the country to get service and all that sort of stuff, while others just weren't as efficient. So they did compare oranges to oranges.

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When we think of efficiency, I think we tend to think it's that we looked at all the administrators, and did they get their two boards together and all that sort of thing. That's all very good, but the coffee and doughnuts for boards doesn't cost us much money. The fact is that they followed patients through the system in each hospital, without prejudice from the ministry.

The more technical explanation would come from the deputy, who actually sat on the committee. I don't know any other way to describe it.

Hospitals were also given this data so they could improve; they were given what others do for the same type of service required so they could improve. Actually, CEOs did phone each other. Every time David Naylor puts out his atlas every two years, they phone each other and say, "How in the world are you doing Caesareans that quickly?" or "without high infection rates?" and all that. They do compare notes, and it's peer pressure as much as anything.

Mr Bisson: Mr Chair, I think we have an agreement among the parties that we can wrap up early tonight and count the full time --

Hon Mr Wilson: Can we do this, though? We might want to table some of these criteria so everyone can understand the formula.

Mr Bisson: Okay. I understood the minister was the one who wanted to get out of here. How often is the opposition going to offer you time on your estimates?

Hon Mr Wilson: Well, Mr Clement deserves a better answer than what I gave him, though, so perhaps the deputy could have a minute.

Ms Mottershead: Even less than that. What happens in our formula is that we give a weight and a rating to a procedure. I'll take appendectomy as an example. A simple appendectomy will get a weight of 1. If there's an appendectomy with complications, it'll get a weight of 2. Every single procedure is documented to see how much resource it uses, both nursing time, recovery time, in terms of the cost of the case. We run that through all the procedures on the acute side and we actually look at hospital to hospital, those that are at the highest level of performance, which means they've used the least resources with the best outcome.

When you have those kinds of examples -- we use that information for peer analysis so we can actually share that information hospital to hospital. "How come you could do that and it cost you that much less and you had a better outcome than some of the other hospitals?" Each procedure is weighted and severity is weighted and then it's costed, and that's what we use.

We also, for your information, do the historical analysis as well as the current, because we want to see exactly what the performance improvement has been over a period of time and not just in the last six months of the last data run. That's done on a consistent basis.

Mr Bisson: Just so we have it on the record, I have just one question, and once we're done, we'll count the rest of the time towards the estimates.

Minister, I've had a bit of an opportunity to chat to some of your staff here on the issue of the community physician contracts that were let by your government a while back. I understand the criterion to get a community physician contract is that a municipality must be 10,000 people or less and have two physicians within that community.

The community of Matheson has about 3,000 to 3,100 people. They have two doctors, but they're actually in danger of losing one again. These two doctors, if we can get them designated under this contract, would stay and we would be able to resolve the problem they have over there. I'm wondering, Minister, if you can indicate to us whether there's a possibility of amending the rules there in order to allow Matheson to be designated under that particular physician contract arrangement.

Ms Mottershead: We don't do designations for the community contracts. How we're starting in the development of the contracts, which is an alternative payment plan, is to look at communities of highest and greatest need, the most isolation and least opportunities to attract physicians, and go in there and do that.

Two-physician communities have been a target. We are moving to three to four to five to seven. There are discussions going on with Matheson in terms of developing a contract, and we have people doing that right now.

Mr Bisson: We're going to be getting together next Tuesday again. Can you come back and give me some indication if it's possible to go that way?

The Chair: I'd just make a comment. I'm glad the whip is here; the Liberals are not here. After today, there will be an hour and a half left. The health services restructuring commissioner we have requested to come, if he's available. As I understand it, he travels a lot, so it's if he's available. I wonder if we can get some understanding that we have an hour, and after his presentation we divide up the time in equal parts. If he's not coming --

Hon Mr Wilson: That's great. Do you want to have another guest to fill in the rest of that hour? I see all the staff smiling.

Mr Bisson: It's a little bit difficult without the Liberal caucus here, but I'm sure, as they're the ones who asked --

The Chair: The other thing I'm trying to do is that at that time -- it depends on when he finishes. Economic development, trade and tourism follows. I have to give instructions by tomorrow about whether they would be appearing on Tuesday.

Mr Bisson: What you've just told me is that there's an hour and some left in the estimates for health, and you want to split that equally between the Liberals and the New Democrats? Sounds good.

The Chair: I'm suggesting that we take an hour for the commissioner --

Mr Bisson: If there's an hour and a half, we may as well take it all.

Mr E.J. Douglas Rollins (Quinte): If that gentleman comes from the restructuring commission, I think we deserve an hour and a half with him, if it's at all possible, if he's here.

The Chair: The danger, though, when I make these suggestions as the Chair -- it's the whips who should get together and do that. It seems to me, then, that I have to give instructions that the other ministry comes on Wednesday. There would not be enough time.

Mr Bisson: Can I just ask the deputy to get that response to me? I gave the number that your staff can get hold of me to let me know about the Matheson situation.

Ms Mottershead: Yes.

Mr Bisson: Thank you very much.

The Chair: The instructions here, and I will get in touch with the Liberals, is that economics will start on Wednesday. We stand adjourned until Tuesday.

The committee adjourned at 1747.