Assemblée législative de l'Ontario

MINISTRY OF HEALTH

CONTENTS

Tuesday 17 June 1997

Ministry of Health

Hon Jim Wilson

Ms Margaret Mottershead

Mr Bill Hawkins

STANDING COMMITTEE ON ESTIMATES

Chair / Président: Kennedy, Gerard (York South / -Sud L)

Vice-Chair / Vice-Président: Bartolucci, Rick (Sudbury L)

Mr RickBartolucci (Sudbury L)

Mr MarcelBeaubien (Lambton PC)

Mr GillesBisson (Cochrane South / -Sud ND)

Mr Michael A. Brown (Algoma-Manitoulin L)

Mr John C. Cleary (Cornwall L)

Mr EdDoyle (Wentworth East / -Est PC)

Mr BillGrimmett (Muskoka-Georgian Bay

/ Muskoka-Baie-Georgienne PC)

Mr MorleyKells (Etobicoke-Lakeshore PC)

Mr GerardKennedy (York South / -Sud L)

Ms FrancesLankin (Beaches-Woodbine ND)

Mr TrevorPettit (Hamilton Mountain PC)

Mr FrankSheehan (Lincoln PC)

Mr BillVankoughnet (Frontenac-Addington PC)

Mr WayneWettlaufer (Kitchener PC)

Substitutions present /Membres remplaçants présents:

Mrs MarionBoyd (London Centre / -Centre ND)

Mr GerryMartiniuk (Cambridge PC)

Clerk / Greffière: Ms Rosemarie Singh

Staff / Personnel: Ms Alison Drummond, research officer, Legislative Research Service

The committee met at 1536 in committee room 2.

MINISTRY OF HEALTH

The Vice-Chair (Mr Rick Bartolucci): Can we bring this meeting to order. The rotation will continue in order. We left off with the NDP last day. They had used their time. We will move to the government side for their 20 minutes.

Mr Trevor Pettit (Hamilton Mountain): Good afternoon, everyone. I'd like to ask you, Minister, a little bit about cancer, if I might. Cancer is a disease that affects the lives of all of us in this room. We always hear and have concern and are reminded about the fight ultimately to find a cure for cancer. You recently announced the creation of Cancer Care Ontario. I wonder if you could elaborate to the committee a little bit about what Cancer Care Ontario is and how you expect it will change the way cancer services are delivered and anything else the ministry is planning to do to help in the fight against cancer.

Hon Jim Wilson (Minister of Health): Thank you, Mr Pettit, Mr Chair and colleagues. I'm pleased to answer that because the Premier made an important announcement on April 29 of this year, adding a $16.5-million reinvestment first of all overall to try to launch Cancer Care Ontario. It is a good attempt to coordinate cancer services, to make sure that when someone is afflicted with cancer they and their loved ones, their doctors in particular, and their health care providers will soon experience a seamless system for care. Right now one of the major complaints you get from patients, people who are diagnosed with cancer, is that it's very difficult to make your way through the labyrinth of services that are available. We have very good services in the province but they're not coordinated as well as they could be.

Cancer Care Ontario is an umbrella organization to try and bring together the Ontario Cancer Treatment and Research Foundation, working with the Princess Margaret Hospital, with the other components in the system. I'm thinking particularly of the Ontario breast screening program, which is one of the programs that's offered. Ideally we would like to see almost a buddy system, where our regional cancer centres in the province are the referral centre or the centre for information for people and that people aren't left to make their own doctors' appointments when diagnosed. Ideally we're working towards having the computer technology in place so that your record is kept and shared by the appropriate people throughout the system. You get your radiation in a different place, often, from your chemo and depending on where you live in the province, you first go to your general practitioner.

We're also working to improve the guidelines in the early detection of cancer through doctors and trained nurses in our Ontario breast screening program, for example. Essentially Cancer Care Ontario is a way to bring everyone together under one roof and make sure we're all pulling on the oars in the same direction. But because it is a very significant initiative, and our deputy minister has had a lot to do with it, I'll ask Margaret Mottershead to comment further on it.

Ms Margaret Mottershead: Cancer Care Ontario is a provincial agency. Its mandate is going to involve education, prevention, research, teaching and treatment. Currently you have the Ontario Cancer Treatment and Research Foundation, which actually runs the eight regional cancer centres, and the eight regional cancer centres provide for radiation primarily. They are linked to host hospitals in their area and they try and connect, once a diagnosis is made, with other clinical programs that are available in the hospitals like cancer surgery, and once there's surgery, they may go on to radiation treatment.

However, the effort of Cancer Care Ontario will be to go well beyond what their mandate is currently, and that is radiation treatment and systemic treatment like chemotherapy, to develop guidelines that will actually link all the players the minister spoke about, particularly doctors. Doctors who diagnose cancer are not always aware of what to do exactly with a particular type of cancer. They need backup. They need to be linked to oncologists -- these are the specialists in the area of cancer -- and start a whole teaching program for community primary care physicians in dealing with these kind of things. They will be developing guidelines; they will be developing networks. The regional cancer centres will have a much broader mandate and they will try and develop agreements with a whole number of players, including hospitals, community physicians, community care initiatives like palliative care, and bring everybody in a network to create a seamless system of cancer care services for each part and region of the province.

Mr Pettit: Can I make a comment? There was a story roughly a month ago in the Sun, I believe it was, about comparing the $24 million or $25 million for breast screening. There was concern from the male side that very little was being put into prostate cancer. I wonder if you can tell us if there are any plans imminent or down the line to increase funding for that.

Hon Mr Wilson: It's an excellent question and one that was raised in my seniors seminar last Friday in my own riding. Usually the question centred around the PSA and why people continue at this point to pay $10 to $20 out of pocket for that PSA test.

The answer is that right now we will fund the test if it's recommended through the process by the medical experts to be a cost-effective test that should be added to the regime of testing we have. Right now the medical community is somewhat split on the issue of whether it's an effective test or not.

In the budget, and I'm just trying to think of the budget figure, there was a great deal of money set aside to address the PSA test specifically -- the finance minister spoke about it in his remarks -- and to do further research on it, because there's a divided medical community on whether it's an effective test. Maybe the deputy wants to comment further on that.

Ms Mottershead: I think people are aware of the issues with the PSA test itself. It produces too many false positive results, and people who are making decisions around the kind of treatment the patient should have are relying on a test that hasn't been scientifically accepted by the medical profession at this point. We had an expert panel from around the world that had a look at that PSA specifically, and their recommendation to us was that we should fund it for established cancers for the purposes of monitoring and following up on treatment. In our health insurance budget it is a treatment that is eligible for OHIP payment for established cancers and the monitoring of that.

The minister referred to a review that is going to continue to be conducted by ICES to determine if there are further things we could do on the whole question of prostate cancer, and together with the new Cancer Care Ontario I'm sure we will be seeing a number of initiatives come forward in the next few months.

Mr Pettit: Let's discuss, and you're undoubtedly aware, the physician shortage in certain parts of the province. It's my understanding that in some areas it's quite significant. Even within half an hour, an hour or so of Toronto, people are having difficulty accessing physician care. What are you or the ministry doing to address or combat this problem?

Hon Mr Wilson: Again a question that's top of mind for a lot of the communities. I don't think there's anywhere you would go outside of our major urban areas where it isn't raised as a concern.

One thing I think that doesn't get enough recognition, and we're very hopeful it will have the impact we need to have to address this problem, is the physicians' agreement that was recently signed between the government and the Ontario Medical Association where there is 25% discounting in the first year and a gradual discounting over three years.

If graduating physicians, residents and interns decide to go and practise in an area where they're frankly not needed, in what we call an overserviced area, I think that will have an effect. People don't want to take a 25% discount, especially when they're in their heavily indebted years after so many years of medical school training. They have a lot of student loans to pay back and other things. Even though they may have been residents and interns for a few years, they usually still have quite a burden, and I don't think they would want to face the financial penalty of going to an area where they're simply not needed.

We've done a lot of things on this front. When we came into office there were initially about 65 -- it ended up about 69 -- small emergency rooms in northern rural hospitals. Based on Graham Scott's report, which was launched by the previous government and came in under our government, he recommended a $70-an-hour sessional fee for physicians to be on call in these small emergency rooms for working nights, weekends and holidays and providing emergency coverage. That not only helped provide the coverage but I think it also helped to retain a number of physicians who were feeling that the extra hours and the extra effort they had to put in to serve the people of those areas wasn't being properly compensated or recognized by any government up to that point.

We now have quite a menu of alternative payment plans for physicians to try and retain them in the areas where we have them, outside of the large urban areas, and to try and attract new physicians, and we're quite flexible on the benefits that are offered.

Recently in an underserviced area -- it was Stratford -- we announced some underserviced areas like Aylmer and St Thomas, but we also announced new globally funded group practice contracts which are part of the menu now of alternative payment-type contracts, away from fee-for-service. They, for example, could contain financial incentives. They certainly do contain as a base opening bargaining position up to 37 days' vacation per year, which is very, very important. A lot of physicians, obviously in our small towns and that, if there are only one or two in town, never get a break. The burnout rate is pretty high and the stress on their lives is very high.

The Graham Scott report talked about a medical corps, and I think we can safely say today we've almost got the 20 physicians, don't we, for the medical corps?

Ms Mottershead: We've got a good core of them.

Hon Mr Wilson: We've got a good core of them. We're working to get up to about 20 and we've had good response that these would be sort of the flying wedge, I call them, who work directly on contract with us. They're available to go out to communities to do locums and to replace doctors during that 37-day period, for example, where they may want to go on vacation or do continuing medical education.

We have a whole myriad of programs, community-sponsored contracts; we work with the clerks of municipalities to see if the municipalities wanted to chip in also towards a benefit package or an enhancement package to physicians in communities.

I think it would be interesting to table for the committee our success to date because there is some very good news. There are a lot of communities that two years ago simply were on the verge of shutting their emergency rooms because of no coverage. We've covered that off and we certainly can provide that list for the committee -- I think we provided it last year at this committee -- or they were certainly at risk of not having adequate physician coverage, and we've been able to do some things on that front by being creative and being flexible. It's very much one-on-one, group practice by group practice negotiations with the ministry.

In the north the previous government had an economic development officer for part of northern Ontario. Which one? The east or the west?

Ms Mottershead: We have one east and west.

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Hon Mr Wilson: Now we have one east and west, anyway, and we're recruiting for another community development officer. That's worked fairly well because they tie the communities better into -- what do we call our trade fair every year? Residents and interns, what's the tour they do?

Ms Mottershead: It's a recruitment tour.

Hon Mr Wilson: A recruitment tour. Sorry, my mind is elsewhere today.

The Vice-Chair: Final question.

Mr Pettit: All right. I wasn't aware I was going to have the full 20 here, Chair. I'll shift over to something else that's close to me. I have two young daughters in elementary school and I know you had the cross-province immunization for students. What can you tell us about plans or programs you have for school kids along the lines of immunization? Is that going to continue or are there are any other things you've got up your sleeve? Where are we headed in that direction? Anything on that?

Hon Mr Wilson: On the hepatitis B program, which is one we're very proud of, it's the first extensive inoculation of school children for hepatitis B ever in this province. In fact, it should wipe out that disease over the next couple of years, I think is the projection, so it's a wonderful investment in public health. We've heard from a lot of public health nurses who were quite appreciative of the program. They actually got out to the schools. Some of them hadn't had the opportunity over the past years to get out to schools as often as they would have liked. We've also moved with some other immunization programs, particularly for our seniors. But in particular for children and youth the immunization program was the big one. I'll let the deputy comment on any future plans we might have.

Ms Mottershead: Our chief medical officer of health produces an annual report on areas where he thinks prevention and health promotion are going to be critical. We expect his report probably around November of this year.

Clearly the focus on children, in addition to the immunization, is best exemplified through some current initiatives we're working on, like the healthy babies program, and actually having public health units identify children and families at risk and then developing whatever program is necessary for intervention or prevention of those risks. They include speech and language, they could include issues around nutrition, they could include medical services as necessary and a whole host of other social programs as well. So together with public health units, that's a major initiative around interventions for children.

The Vice-Chair: Thank you very much, deputy. We move over to the official opposition. Mr Cleary, will you start?

Mr John C. Cleary (Cornwall): Minister, I'd like to talk about dialysis. When you were in opposition you thought there were a lot of areas in the province that were neglected, yours being one and ours being one.

Over a year ago in April you announced that you would be correcting that situation, that you had selected a provider for dialysis treatment in the area. However, within a few days you retracted your announcement, and it was because we're not sure whether the ministry may have erred in picking their provider.

At this point, you promised to bring them dialysis and there has been much delay. We'd just like to know what your plans are and when you think you can finally make good on your promise.

I know the Kidney Foundation has written you many letters. They think it's very unfair that people in eastern Ontario have to drive to Ottawa and Kingston several times a week so that they can carry on their lifestyle. I would hope that you wouldn't answer me back and say you can't comment because it's in the court system. I understand there's a court date of August 25, and that's about a year and a half after you made the announcement. I'd just like you to bring us up to date.

Hon Mr Wilson: I'd ask the deputy minister to comment on that.

Ms Mottershead: I think the only response that can be given at this point in time is to state what you have just said, and that is the court case is scheduled for August 25. You may be aware that in the preliminary court decisions they were very explicit in what they directed us to do, and there was no way that the minister or the Ministry of Health could not abide by a court order, which precluded us from going on with the expansions. We'll have to wait for that 60 days before we can do anything.

Mr Cleary: Sixty days?

Ms Mottershead: Being to August 25, roughly, from now. It's another 60 days, roughly.

Mr Cleary: The other thing I'd like to talk about is OHIP coverage. I have been contacted many times in the past two months regarding the difficulties that constituents are having with the ministry in obtaining OHIP coverage.

To refresh you with some of the details, an elderly woman, along with her now deceased husband, signed a homesteader card in Florida. They did not realize that such action disqualified them from Ontario health insurance program coverage. As quickly as they realized the repercussions of their signing, steps were taken to regain OHIP coverage. That was back in December 1996, over six months ago. The elderly woman has been living in Ontario full-time. She already lost her husband and is fearful of her health, particularly without hospital coverage. We have called the ministry many times, and this is the third time verbally, and I would appreciate an update.

Hon Mr Wilson: I can't comment on individual eligibility cases at the best of times, other than to commit to get back to you with the case. It shouldn't take six months to adjudicate whether she qualifies or not. The rules are extremely clear. It usually takes about six minutes to figure it out, so there must be something to it.

Mr Cleary: It was December 1996.

Hon Mr Wilson: I'll certainly look into it.

Mr Cleary: The other thing I want to talk a little bit about is that many of the people in our area have to travel to Ottawa to the heart institute. The policy used to be that you would go in there, you would get your tests and you would stay in the hospital. There is a waiting list in our area.

Last month a gentleman by the name of Mr Stanley Pitt, who has an 80% to 90% blockage, finally received word of a cancellation. On May 19, he travelled to Ottawa for blood tests and X-rays. On May 21, he travelled again for an angiogram. That evening he insisted on staying in the hospital. The doctor said that he had to stay close to Ottawa but they refused to keep him in the hospital. That meant he had to go to a hotel. We sent a letter on May 14 asking, was that the policy of the provincial government, that people had to go to a hotel when they were waiting to go into a hospital and taking their tests on account of complications.

Hon Mr Wilson: Certainly that's not a new policy. That's been practised for many years. My constituents coming down to St Mike's for years have been given a pamphlet saying: "Here's the Bond Place Hotel. It's $65 a night. It's a discount rate for people who are patients of St Michael's Hospital."

That's the way it's done. When people have financial hardship with that, certainly we've looked after that through service clubs and so on in the past. So that's not a new policy.

The Minister of Health doesn't admit or discharge any patients; that's a medical decision. If they're of the opinion that the patient needs to be in a hospital bed, that's where they will be; otherwise, other arrangements are suggested.

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Mr Cleary: You say that policy has been in place for quite a while?

Hon Mr Wilson: I've been aware of it for many years. It's been the practice of many hospitals to do that in an effort, I think, to make the most prudent use of resources. I know my constituents get a map showing that if you live outside a certain radius from the hospital, they recommend you be near the hospital and you pay for your hotel charges. They always have. I'm not aware of any other system.

Mr Cleary: I happen to have had experience at that hospital, because I went there for an angiogram and they kept me overnight.

Hon Mr Wilson: It's not a political decision whether you're in a hospital or out of a hospital; it's strictly a medical decision. I don't think anyone would appreciate our meddling in that affair.

Mr Cleary: I want to talk to you a little bit about paranoid schizophrenia. I don't know whether I'm saying that right or not, but I know that an individual in our area has a son who is suffering from that disease but refuses to admit that he is ill. Under the provisions of the current Mental Health Act he is able to refuse treatment. Neither the mother nor the psychiatrist whom she has consulted can intervene. The mother says changes must be made because, as arm's length, not only mentally ill persons but their families who are trying to assist them -- I know we have Bill 111 to amend the Mental Health Act and I would just like to get an update from either the deputy or the minister.

Ms Mottershead: Under the current Mental Health Act, you can involuntarily commit an individual if it's the opinion of the experts that the individual poses a risk to himself or herself and to others. That's there, so that determination has to be made.

Bill 101 that you referred to I believe is a private member's bill.

Mr Cleary: Is it Bill 111?

Ms Mottershead: Bill 111? Is it a private member's bill?

Mr Cleary: Legislation to amend the Mental Health Act.

Ms Mottershead: It's not a government piece of legislation. That's the point I wanted to make.

Hon Mr Wilson: I don't know what the status is. What's the status?

Mr Bill Hawkins: It's going before the justice committee.

Hon Mr Wilson: It's before the justice committee?

Mr Hawkins: It's going to be.

The Vice-Chair: It isn't before the justice committee yet.

Mr Cleary: I just wanted to ask the minister and the deputy what their opinions on that were.

Hon Mr Wilson: Certainly I'm personally familiar with the disease of schizophrenia -- it runs in my family -- and deal with it probably every week in my life, so it's not a topic I like to deal with. But there is a balance in the current Mental Health Act that tries to balance the rights of patients, the rights of families and the rights of practitioners. It is true that the triggering point for an involuntary committal to a hospital is that the person has to be in imminent danger to themselves or others, and that very much is a judgement call on behalf of the medical authorities, often working with the police and the social workers and often a complete mental health crisis team. There is no easy solution to it.

I'm just not up to speed on Bill 111 right now. I'd be happy to take a look at it. It is before the justice committee. The justice committee will deal with it and make recommendations to the government.

Mr Cleary: Do I have more time?

The Vice-Chair: Yes.

Mr Cleary: I just wanted to mention to you about some of the things on the overloading of emergency room staff: an 87-year-old bedridden lady on an understaffed maternity floor, patient using adult diapers soaked with urine up to her neck, ER staff had no time to change her. The OB staff sought the help of the sick lady's daughter to change the diapers and to provide basic comfort. That was a big issue. It goes on to say...."as long as we get our 30% tax break, ha ha." That's a letter that came to me. That went on in the same room that newborns were in, and I mentioned that I would bring it to your attention.

Hon Mr Wilson: Please inform your constituents that the tax break has ensured that revenues are up in the province so there's more money to spend on health care and that's why we're spending more money on health care. We've closed about 10 or 11 ministries around here and every penny and more is going into health care so that we have a record budget and we spend far more than anybody else in Canada on health care. It is the number one priority of the government and we fully lived up and surpassed our commitments.

With respect to hospital complaints and the quality of care, the first line of complaint is to bring that to the board, which has a fiduciary responsibility to your constituents to make sure that quality care is maintained by the standards that we've set. If they don't live up to that responsibility, then it becomes a matter for the Ministry of Health and there are powers under the Public Hospitals Act to make sure the care that is required is delivered.

I certainly encourage people to contact their local boards. Don't just jump up to the Minister of Health. There are local community people who are, I think, of sincere mind and sincere heart to try to make sure that care is delivered. If conditions as deplorable as those sound are occurring in a hospital, it shouldn't occur in Ontario with the amount of money we give to hospitals. It sounds like a quality matter that the local board should deal with in terms of their maintenance in care standards on that particular ward.

Mr Cleary: I was bringing it here as the way the letter came to me.

Hon Mr Wilson: Yes, I appreciate that, but we would refer that back to the local hospital and ask them what happened in that particular incident.

The Vice-Chair: Mr Kennedy.

Mr Gerard Kennedy (York South): Minister, I'd like to talk to you a little bit about the arrangements you've arrived at with the province's doctors. Just for people's general knowledge, there was kind of an attack phase when a number of measures were brought down on doctors and when a new clawback was brought in, 6.5% in March last year. Then by November 1 it was removed retroactively as part of the interim agreement. The thresholds were first lowered and then in the interim agreement they were increased.

You didn't want to recognize the OMA as a bargaining agent. Now you've done that again. Then you wanted to withdraw coverage of the CMPA, but after the Dubin report said there were no grounds to do that, that was all restored.

It caused, as we've said here before, a lot of consternation on the part of people in this province, a whole year of war going on with the doctors, the doctors feeling under attack. Now we've come to where a deal has been signed that has significant implications for the future of doctors -- and we've heard you expound on some of those -- but also in terms of the rest of health care. Here is an opportunity for you to be able to give us some assurances.

For example, can you table here today how much it will cost for the interim and the final deals with the OMA on behalf of the province's doctors? What will that cost, compared to the arrangements before those deals were struck? How much money will it cost the provincial treasury? We won't get into the semantics about doctors getting fee increases or whatever, but how much will that cost in, let's begin with fiscal 1997-98?

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Hon Mr Wilson: First of all, I don't agree at all with your capsule summary of two years of my life negotiating with Ontario's doctors. On the one hand, you say it's an absolute giveaway to doctors and we didn't take any tough stances as part of our negotiating positions over the last two years and that I shouldn't have questioned CMPA; on the other hand, I shouldn't be giving them $45 million in the deal for some of these initiatives. You don't appreciate one day and then the next day -- just complete inconsistency from your party and from others.

I don't regret any of it, and I never have said a punitive thing against a doctor in my life. I was raised as a Tory to respect professionals and to try to be a professional myself and that's been my modus operandi. I didn't say doctors were ripping off the system. That was Dr Philip Berger. Unfortunately, one of our newspapers quoted me, wrongly, for that. You will not find anything -- and I had 11 weeks to review all of the tapes and every media interview is taped -- of me saying anything punitive.

The odd case came forward that got blown out of proportion where doctors were threatening to withdraw services. I have a fiduciary responsibility and an oath I took, two oaths, to do this job, to protect patient care. That is all I ever did and that's where my heart was and my mind was in every incident. I can't help it if you and your colleagues blew these things up into "Wilson fighting doctors," because that is not the case. Many doctors, including three in my immediate family, are very good friends of mine and continued to be so throughout the process. I don't regret any of it.

Secondly, this deal, as I've explained ad nauseam to you during this process and every other time you asked me -- and I'd be happy to do so again -- is 1.5% on a current pool of $4.1 billion. My calculation shows that to be $60 million. Then you do 1.5% on the new pool each year and you're into about $100 million a year; you round it all up, include the CMPA and the $45 million for physician initiatives to get them out to areas where they are needed to practise.

There's no more mathematics than that to be done. I challenge others who seem to come up with different figures to show me those calculations, because I've been putting up with this for weeks and I just don't know where these things come from.

Mr Kennedy: Minister, I've got my figures here with me today and I'll pass you a copy. But I would ask again, would you table the figures here, because what you've omitted so far is the clawback elimination. The clawback being gone, most of it for 1997-98, all of it for the following year, is an annual implication in the order of $370 million, which you have not included in your assessment of the estimate.

The cost then rises from $438 million this year to $539 million next year, to $547 million. I would concede, Minister, there are some conditional things in there. Does the CMPA go up or doesn't it? Are you able to implement the underserviced areas?

But that is a vast difference, Minister, and I think you need to address for the public of Ontario the cost, because that's a $1.5-billion cost. That's what people are talking about. This is not mumbo jumbo. First you imposed the clawback and then you took it off. There is a fiscal implication to that and you haven't included that in the cost of the deal. It's part of the interim deal, it's part of the final deal and it's certainly part of the new threshold that you've set.

My question would be, and I would really appreciate your assistance with it, will you table the detailed figures? Secondly, will you permit a briefing with your ministry staff, which we have asked for now 17 times and not been given the courtesy of a return phone call? I think it's the secrecy that hurts your ministry. We just would like to be able to get the details. This has not been provided. We have their figures. I'll table these figures and I'll distribute them widely and I'd welcome your comment on them. But I would like you to address your own figures. Will we have them and will we have access to be able to address these questions?

The Vice-Chair: Thank you, Mr Kennedy. We're going to have to move to the third party now. Mrs Boyd.

Mrs Marion Boyd (London Centre): I'm interested in going back a little bit to the doctors' settlement because I think it has certainly raised a lot of concerns in terms of the rest of the system and I think we have to recognize that.

In the discussion that has been held over the last few days around the so-called released information on MDs with big billings -- you know the "$5 million for the top 10" kind of headline -- one of the things that distressed me greatly was that the explanation that was given from the ministry official was that this may not be fee-for-service for patient care, but in fact may be because a physician owns a laboratory or a physiotherapy clinic or some other form of medical clinic.

I would like to ask you, Minister, whether you and the ministry have any guidelines around conflict of interest for physicians who are involved financially in other medical agencies to which they refer patients. I think one of the concerns we all have around utilization rates, and we talked about utilization rates quite a bit last week, one of the challenges when you have a fee-for-service system is dealing with overutilization of the system because of the obvious interest that someone might have if they were engaged in medical practice largely to make money to overuse the system.

That becomes even greater if a physician not only has a patient care role but is a financial backer and a financial gainer from other medical services such as physiotherapy services or laboratory services. I understand this is fairly widespread, that in fact financial advisers often advise the medical profession that this is an obvious good area for them to invest their dollars in. I'm just wondering if the ministry has any controls on that sort of thing, what concerns you have about what I think could be a potentially huge conflict of interest and one which is costing the Ontario taxpayer a good deal of money.

Hon Mr Wilson: It's a very good question and I'll have the deputy deal with the processes that are in place mainly through the regulatory colleges to deal with conflict of interest, as you know, because your government was instrumental in setting up those processes.

I would not like to leave the impression that the one article that appeared on this -- and, by the way, it's an interesting story in terms of you'll know that during my 11-week absence the privacy commissioner concluded that no such document had ever been generated, and here the Toronto Star asked us to generate a document that frankly we didn't want to generate because we have never asked, and your government never did and the Liberals never did, who the top billers were. It's irrelevant to the proper management of the health care system, because it's also irrelevant, false information and a terrible story to put on the front page of a newspaper. I think its intent is awful.

Right now we're asking our cardiac surgeons to work overtime and to do as high a volume as they can stay awake to do. We're asking our dialysis nephrologists to do as high a volume as they can possibly do across the province to keep up with the demands in dialysis. We have literally dozens of billing codes that are exempt from the thresholds -- and, by the way, the thresholds are significantly lower under this deal than they were under the previous government's deal with the OMA -- so that a doctor could bill for all kinds of reasons, depending on their specialty, well above the $380,000 cap for specialists, for example -- completely legitimate billings and thank God they're doing it.

We have no idea from the story that was generated what the overhead costs are or whether they've delegated some of those acts to nurses in their offices and the nurse is putting the code through that billing number. It's a completely fallacious way to look at anything and it's probably why no government of any stripe has ever produced that type of record, because it's absolutely meaningless and an absolutely misleading thing to put on the front page of a newspaper. It's just disgraceful, in my opinion.

Having said that, you make a very good point about conflict of interest because you don't want people owning labs and referring patients to themselves. I'm going to ask the deputy to explain what safeguards have been set up for that.

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Ms Mottershead: Thank you, Minister. I just want to clarify another point in the story. It was an OMA official who made those remarks; it wasn't ministry.

The second thing I'd like to mention is the fact that the fee schedule itself is broken up into two components. There are fee codes that start with a P, professional fees, that involve the act of providing medicine or the procedure, and there are the T codes, which are technical codes that deal with things like radiology and laboratory testing. Basically, the section on radiology of the OMA does that kind of reading. So it's not necessarily an implicit conflict of interest. It is work they are required to do, either in independent health facilities or in hospitals, that is very technically oriented; they're not medical procedures as well. They're reading a film or that kind of work. They are legitimate and paid out of the OHIP pool and are in the fee schedule.

Having provided that clarification, I just want to let you know that we have been working with the Ontario Association of Medical Laboratories, the section on radiology, the OMA and the CPSO on the development of specific conflict-of-interest guidelines. The colleges themselves and the RHPA, for example, and CPSO do have a specific provision on conflict of interest. However, we felt that it didn't go far enough in deterring some of the things that might be happening in the system and we in fact had worked on a regulation last fall. I'm trying to think of the timing exactly and where it is in the process to actually be more explicit on that point. I'll just check back later tonight to see exactly what happened to the regulation.

Mrs Boyd: I would appreciate that, because I know certainly that this is not a new problem. This has been an ongoing problem and there has been real resistance around the kind of declaration of interest in those kinds of activities that, for example, we as MPPs routinely make. If we have an interest in anything we make a declaration. I think there would be great interest for a lot of people to be sure that kind of safeguard was somehow built into the system, because the possibility of magnification, while I'm quite convinced it would be by a very small number of people, in terms of the cost to the taxpayer could be quite high and, frankly, the cost to the patient as well because the patients are constantly undergoing testing that is not necessary. That causes a lot of difficulty as well.

I wonder if, in the kinds of discussions you'll be having in the committee that has been set up under the OMA agreement, you have any way of introducing some kind of a requirement around some declaration of interest in these other operations.

Hon Mr Wilson: I think the deputy should handle that particular question. I'd like to comment on where I think you'd agree one of the great cure-alls could very well be information technology, where we would automatically catch the repeat tests and we'd know who's doing them and have a much better handle. Slowly but surely it is occurring. You can point to some integrated systems at the local level beginning to form and some almost formed throughout the province, and certainly you can point to some pretty good computer systems that are doing some pretty good patient tracking right now.

I'd also remind you that we do continue the practice, for many years now, where the general manager of OHIP does send out about 3,900 statements a month. Some of them are randomly generated and some of them are -- if she who is in charge of OHIP suspects there's any reason to suspect a claim from a physician the patient is asked to verify that the following tests occurred, and they're actually given a statement of their OHIP account for that period of time. So there are many checks on the system now.

Every claim by a doctor is verified before it's paid. If there's any question, we don't pay. Recently governments -- I'd give credit for your government as much as anything -- started to get tough and say, "We're going to withhold payment for a while until we straighten out," if there's any dispute at all about a bill. So they may get half their cheque one month and there may be a bit held back while there is some dispute. Specifically, to your question, I'll ask the deputy to answer that.

Ms Mottershead: In the current agreement with the Ontario Medical Association there is a specific reference made to the question of accountability, both sides of the coin: the patient and the physician. I take your suggestion. It's a good place to have the conversation about what more can be done in the area of conflict of interest and how do we make sure that is eliminated to the extent it can be by any single act.

Mrs Boyd: Particularly when we're talking about integrated systems, we know there are different definitions of integrated systems and we know there are many physicians who are joining together in groups to lessen their office costs and that sort of thing. But if there develops a referral pattern within those groups of doctors that begins to show there is just a routine of sending somebody to your colleague who's a specialist, whether there's a particular indication of that or not, I would hope there would be some way of catching that, because when physicians talk about integrated health systems they generally seem to be talking more about physician control and physician clustering that gives them ease of referral.

I guess one of the real issues around the need for primary care reform and the need to look at how that all works is, are we having far more referrals than we really need, particularly in the large urban centres, and is it possible that the whole move towards integration in the way that many doctors appear to be doing it to save overhead costs these days could give rise to a very unhealthy referral system in some areas?

Again I would stress that I'm talking, I'm sure, about the minority of cases, because I'm not questioning the reality that most physicians are primarily concerned about patient care. But when we are talking about overuse of the system, I suspect if we are taking the kinds of steps that we're taking in terms of fraud in the welfare system -- and we're assuming that it's 3% to 5% in the welfare system -- we would have no reason to assume it was any less among physicians than it would be among welfare recipients, and that's a lot of money when you have a $17.9-billion system. I'm just quite concerned that we have some real assurance that we're not being naïve about the possibility of overreferral, overtesting for patients and the result being a huge cost to the taxpayer.

Ms Mottershead: What we're trying to do in terms of establishing integrated systems, starting with the primary care reform, is to introduce the technology, and having the patient record as the central key information move from one provider to another, it won't be too hard to look at what kind of referral patterns are forming. Usually in communities you do have a pretty well-balanced system of referrals that are being made to all kinds of specialists. I think that with technology and also with the fact that in those communities the specialists who are losing a lot of the business would certainly know and feel it, we'd have those two sources to rely on in tracking that pattern.

Mrs Boyd: I wanted to talk a little bit about some of the issues that were raised last week when I was here. We were talking about quality of care and, Minister, you were saying that we are doing more procedures, more surgeries, more dialysis, more heart surgeries, that sort of thing, and that both the number of procedures and the number of patients served is higher. You were indicating that there was no change in the quality of care.

I really need to ask you about some of your other statements. For example, in one place in the record you say that patients aren't being released from hospital earlier. In fact the restructuring commission has based many of its recommendations on the assumption the patients are being released from hospital much earlier.

The justification for having the CCACs was very much because patients are being released earlier and therefore we need to have a way of ensuring that they have care when they're released earlier. Then when we add to that the reduction in staffing in hospitals -- let's not fight about numbers, but we know that hospital after hospital has had to announce layoffs of nursing and other health care workers. I'm just curious about whether it makes any sense at all for us to assume that increased load, higher level of need and fewer staff doesn't result in some lessening in quality of care.

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Hon Mr Wilson: I would say you always have to be diligent about quality and I don't think there's any institution in a community that's scrutinized more than the local hospital. There are nurses there every day, there are other front-line providers, doctors, visitors who are constantly looking at the quality. At least in the towns I represent, when you've been in the hospital it's a pretty big event these days and everybody in town knows about it. There's no better measure of quality than customer satisfaction and there's no greater set of eyes of any institution I can think of than those present in the hospital. Nothing essentially happens in our hospitals undetected in terms of quality.

Again it's a fallacious argument to put all those together and say it equals less quality. What are we supposed to do, keep someone in for 10 days for a gall bladder operation that only takes a few minutes now -- sorry, an hour, an hour and a half -- and they're ready to be discharged in 24 or 48 hours if there are no complications? You're not implying that, I know, but you've got to remember that technology has changed. We are paying for all of the leading-edge drugs that are coming on the market which help patients to recover faster. Community supports are in place -- we have no waiting lists in the province for home nursing, at this point at least. We monitor it all the time and I'm not aware of waiting lists at this point because of reinvestments that have been made there -- and the tremendous growth over the past few years in the community-based long-term-care services.

We're trying to move the whole system towards outcomes because it's a fallacious argument to talk about money any more. More money doesn't equal more care or better care. We know that; that's why we're doing restructuring. To always have an argument about money is meaningless when it comes to health care, as you know. It's outcomes: Are the patients better? Are they healthier? That's the goal. The goal isn't to spend $1 million per patient; the goal is to be cost-effective, prudent along the way, maintain and enhance quality and make sure people get better, and ideally make sure people don't get sick in the first place in a properly tuned health care system.

Mrs Boyd: I don't disagree with you but I guess I'm worried when you say that communities watch and we would find out very quickly if there was a drop in quality of care, that you consistently dismiss out of hand any of the concerns that are brought forward in individual cases around the quality of care that's offered and around the problems that real people and real patients are facing in their communities.

I think one of the real issues for us ought to be that if what people experience is the measure of quality care, once they're informed -- I agree with you, 10 days in the hospital probably was more harmful rather than less so in terms of the mobilization of people in getting better in cases of some surgery. I'm not disagreeing with you on that, but I would like to know why when we bring forward situations where the report about quality of care is from the very people that you rely on -- the community, family, friends, the patients themselves -- you immediately dismiss that out of hand and start talking about having higher quality than we've ever had before. Can you help me with that?

Hon Mr Wilson: I can help you by saying you're dead wrong. I have never dismissed a case. I usually get you an answer during question period. Every case ever brought to my attention in my two years as Minister of Health is immediately looked at, if I can get the proper information from the minister's office, and you know that. Behind the Speaker's chair there are people running all the time when we get these questions. We have always found that there's a different reason than the one given on the floor of the House. In my opening remarks to this committee I gave some of those examples of how I was told children were denied heart surgery and yet had never been to that hospital, no record of them at all in case after case.

The fact of the matter is that there are quality councils in every one of our hospitals. As I said, every hospital has a community board. They're the ears, eyes and conscience of the local community to measure quality. We take it extremely seriously, as I did in the years I was a constituency assistant. The big question is, are there more complaints because there are more people or are there more complaints because it is the issue for politicians in Canada today, the top-of-mind issue?

All I can say is we intend, and whoever sits in this chair has to be diligent every day, to take seriously every complaint, as we do, and keep ensuring we have quality. We're moving towards setting up Ontario's first quality council to ensure it isn't just our people doing the investigations, but some arm's-length people also measuring quality in the system.

Mr Wayne Wettlaufer (Kitchener): Minister, we've heard a lot of rhetoric and hyperbole here from the opposition parties and much of it, particularly from the Liberal health critic, centres around dollars. They keep talking about reductions in health care spending by our government, yet when I went through the estimates figures I saw a definite increase, as near as I can see about $400 million in increased program spending and about $1 billion, give or take, in total overall spending.

Aside from that, what our government has been trying to do is save on administration costs and put that, through reinvestments, into restructured health care. You were in Kitchener two or three weeks ago to announce a reinvestment of some $5 million in community-based services, long-term care, Meals on Wheels. I wonder if you have any idea of the numbers of people who are being served through these community-based services?

Hon Mr Wilson: The experts' estimate, with the $170 million, of which that announcement in Kitchener was part -- we're rolling that out and we'll soon have just about all of that spent and committed and out there. We're still reviewing some proposals that have come in. It should serve between 80,000 and 100,000 more seniors, and is in many communities now. We're hearing back from the groups that provide the services. It is building in some extra capacity. In many communities we're proud to say that we're staying ahead of the demand, before the actual significant hospital restructuring occurs in the province. That's a lot of seniors and it will create, they estimate, over 4,000 jobs for front-line providers, including nurses.

The interesting statistic, though -- I don't know why it finally hit me on the weekend; I'm sorry, it was Friday, at the seniors' seminar in my riding that reminded we have 1.4 million seniors today in the province, and by the year 2015, and I think this is probably a pretty solid statistic, that will triple.

Can you imagine that? Think of it. We're about a $20-billion health care budget, to all intents and purposes, what we'll spend this year or over the next little while in terms of capital and operating, and the provincial budget is, what, $50 billion or $54 billion. We're spending on seniors' drugs this year about $1.3 billion; those areas, $1.1 billion, $1.3 billion. Long-term care, another $1.1 billion, $1.3 billion. Government is going to have to have a very serious chat in the next few years about how we continue to carry on business the way we've been carrying on.

That's why we're doing restructuring. We're trying to catch up to other provinces that have got their health care systems on a firmer footing, trying to get every dollar squeezed out and put back in; squeezed out of what we don't need like waste and duplication in administration, and back into front-line services. That's why our government has never said it's about saving money. Where that comes from is unfortunate; we've even had some unfortunate comments from the commission about saving money. The next sentence always has to be: Every penny and more is going back in, just to keep up with the growing and aging population.

We're certainly on the right track. The long-term care and community investments you refer to in Kitchener are on the right track. We're not just covering in-home nursing in that. We're also covering through other investments, the community investment fund, which is $23 million and change; trying to expand the mental health system. I know we've done a great deal in your area also to ensure that people can be served as close to home as possible and in their communities.

Tremendous challenges ahead. I think restructuring, although it's the buzz word of the 1990s, will be with us forever. Every day people are going to have to get up and no longer say, "My budget next year is going to be 3% more because that's what it was this year and let's just add to it." Every day people are going to have to examine what they're doing. Total continuous quality improvement or TQI and all these things have to be practised every day in our institutions, more so than in the past.

To the credit of many of our managers, they've had that training and they are doing that. They're living that in your hospitals in your area and trying to make sure that, every day, they manage and not do things as we did so often in the old days when we didn't have the growth and aging pressures and there seemed to be unlimited amounts of public dollars to spend on health care.

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Mr Wettlaufer: According to some figures I've seen, or maybe it was what I heard last week at the seniors' seminar I had in my riding -- on the weekend actually -- there are about 1,200 hip replacements in the province going on right now. I say hip replacements, but I think it's hip and knee replacements. What is the cost of these hip and knee replacements? I know some of them are being done with this high-tech plastic that's very expensive.

Maybe I should give a little background. My wife is a sufferer of rapidly advancing, crippling rheumatoid arthritis, and at some point in her life, she's going to have to have hip or knee replacement. When you're younger I can see the investment by the province, by our health care system in these expensive joints. However, as people get much older -- this was addressed by some of the seniors -- as you're older and you may only have a couple of years of quality life left, is it in our interest to have these very expensive joints put in, or would it be feasible to have something less expensive replaced?

Hon Mr Wilson: I think the toughest questions come from my own side.

Mr Wettlaufer: I didn't mean it to be tough. I'm looking for information.

Hon Mr Wilson: Let's give you an example, if anyone can do quick mathematics. Since 1995, we've put $8 million into joint replacement surgeries, hip and knees. That's new dollars and --

Mr Ed Doyle (Wentworth East): I beg your pardon, how much was that?

Hon Mr Wilson: It's $8 million. Here's a note: $4.8 million for replacement of joints in 1995-96. In 1996-97, an additional $3 million, which we announced in March of this year, for more than 1,200 replacement joints. So somebody divide $3 million by 1,200 and that will give you a rough idea what the cost is.

Having been down to Hamilton in March when we made the announcement in the operating room -- I do apologize, I can't remember the doctor but he's one of the world leaders in hip and knee replacements. He was showing me and the media exactly how the apparatus works and the rather large hammers they use to get these things into the bone. He mentioned there are at least a couple of different types in terms of cost. It's a medical decision as to what's most appropriate. There is a plastic hip and knee -- it's pretty space-age plastic, mind you -- that's more appropriate for people who will only use it for maybe 10 years or something, and then there's a titanium hip and knee, which generally is more appropriate for people who may get several decades of use out of it.

It's a medical decision and the guidelines are not even written by the Ministry of Health. They are written by the specialists themselves. They know. To make sure they get every dollar out of their budgets, they do the best they can to prescribe the appropriate apparatus for the age of the person they are dealing with or the fitness level of the person they're dealing with.

I should dispel the myth I heard in the Legislature a couple of weeks ago that there's somehow an age limit. There's some doctor running around the province saying there's an age limit. If he's putting an age limit, he's totally against the law in this province. There's no age limit on when you can receive surgeries of any type. There is the odd guideline that doctors have made up to suggest the appropriateness of various procedures, and that would only make sense as one changes anatomically in life. There are different guidelines for different stages of life.

Certainly, I think we all would have in our ridings -- I was at a 50th wedding anniversary on Saturday in my riding in Beeton and the lady was showing me the scars on both her knees; she has new knees and she's quite elderly and a very good friend of my family. Thank God that we live in a province, in a country that does afford those surgeries, does provide them under a publicly funded system, because although she's quite elderly she's quite spry, she and her husband, and she'll have many more pain-free years.

They were describing it to me when I was at the hospital in Hamilton in March to make the announcement. They had some patients there to describe the excruciating pain they go through. I know it's very personal to you and your wife, but to hear those accounts first hand and then to hear how a hip or a knee replacement will relieve that pain and will give them, hopefully, many years of pain-free life, it's well worth the investment. I hope I always live in a province and a country that has that as a priority.

Mr Doyle: This is along the lines of Mr Wettlaufer's questions. When it comes to hip replacement, and you had mentioned the aging population and so on, I would have to assume that with this technology today -- it's a technology that didn't exist a few years ago and now it exists -- it puts a great strain on training medical doctors who have the ability to do this kind of an operation. Plus, as people age, it must provide waiting lists. If people have to have a knee replaced then and they age, the waiting lists would be growing because there are not that many people who are capable of doing it. Do you have any kind of figures on that?

Hon Mr Wilson: It's a good question. We may have to generate that for you in terms of exactly how many people in the province would be on a waiting list. We have announced that we're going to work towards a registry for hips and knees because we don't have a good figure. Individual specialists and doctors keep their own waiting lists right now.

Mr Doyle: Yes.

Hon Mr Wilson: Unlike the Cardiac Care Network, and soon Cancer Care Ontario, where we're actually creating an integrated system -- let's not let anyone say the government hasn't moved on integrated systems; I could point to integrated systems today that have been developing over the years and are coming around.

We have announced money recently to try and get a better handle on the needs, not only to try and serve those who are waiting today but we can also do a better job at planning, projecting in the future, if we get a better handle on exactly what the demands are.

Of course, in a publicly funded system you do have to prioritize patients, which medical doctors do; there's only so much capacity in the system to do so many operations per day. Our end of it is we're funding it and I hope soon we'll be able to give comfort to people that there's better coordination of these services. I can't give you an exact answer now. Frankly, it's not rocket science how one might have to find out that waiting list. We would have to phone key specialists in the province and the hospitals and ask them how many are on their waiting lists.

Mr Doyle: Yes, sure.

Hon Mr Wilson: We do that from time to time. For example, when we did the $8 million, when we were planning to spend that, we certainly phoned around to find out, and then we have a committee -- maybe the deputy will explain that -- on where we're going in terms of trying to integrate this system, because it is one area where we can certainly do a much better job at coordinating and making better use of resources so we can serve more patients.

Ms Mottershead: In terms of making the reinvestment announcements the minister has with his Hamilton example, we have some information that comes to us from a committee. It's not a formalized structure like Cardiac Care Ontario, but it is a committee of the ministry with the OHA, the relevant hospitals that are involved in doing the procedures, and we have some information about what the demands are and what some of the pressures are. It's called the life support committee because it deals with not just hips and knees but with dialysis and other chronic illnesses.

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Mr Doyle: With technology going the way it's going, there are going to be new procedures in the future, and as the population ages these procedures are going to be required by more people. I guess this relates to what you said earlier, that you're going to get more complaints because there are more people and because there are going to be more procedures, and it's going to put a great drain on the system when it comes to both waiting lists and financially.

Ms Mottershead: In addition to some of the information we have from the committee and the setting up of the network for hips and knees, including the registry, one of the key initiatives that will be helped by ICES on this particular issue is the question of latest technology, not just in terms of procedures but in terms of the material that goes into some of the apparatus. ICES is also looking at a methodology for us and the hospitals to do bulk purchasing, so if we can reduce the cost of bulk purchasing, we can actually buy more joints and more units to deal with a larger population. Those two initiatives are coming on stream very quickly.

Mr Pettit: In the estimates you almost feel like an opposition member sometimes. You get to fire a lot of questions.

Hon Mr Wilson: It feels like that from this end sometimes.

Mr Pettit: Let me ask you about physiotherapists and chiropractic care, if I might. I've had a number of physiotherapists come to see me. In fact, I sent a letter off to you recently, and I just wonder where we're going with physiotherapists. They're wondering, are the caps going to be lifted? Is there going to be an increase there? There doesn't seem to be as much hospital physio. Where are we going in that direction? Also with chiropractic care: I know personally I've had a lot of success dealing with a chiropractor as opposed to a physiotherapist, yet in my view you get better financial coverage through physiotherapy than you do through a chiropractor. Is there any intent of increasing the coverage for chiropractic care, and where are we going in those two areas?

Hon Mr Wilson: The quick answer is the same negotiator who led the team for the doctors' negotiations will lead the team to have the negotiations with the other providers. Actually, we've had a few rounds with physiotherapists, chiropractors, optometrists and others where we extend partial payments, unlike physicians, who are fully paid by OHIP. With these other providers, of course, not all of their income derives from billings from OHIP, so we thought in fairness we would have a negotiating process with them.

I don't have the figures here but we have already announced, without making a big deal of it, that we've taken some of the clawback off because it was going to end anyway. It was supposed to end after the social contract for the most part. Mr Kennedy saying we've relieved the clawback -- well, we didn't forgive the doctors one penny of their social contract obligations. That's still there until February 29 next year, so they'll continue to pay social contract. It was spread over a longer period of time than some other groups under the social contract, but in terms of physiotherapists and the other providers, negotiations have either begun or will begin shortly.

Mr Kennedy: Minister, I was just wondering, the undertaking I was asking for is whether you would provide us with the ministry's own accounting for the cost of the doctors' deal and whether you would provide us with a briefing on the same. Is it possible to have you confirm that?

Hon Mr Wilson: The bureaucrats would be happy to provide you with a briefing -- the deputy minister. There really aren't other figures to give you at this point. Part of it, you have to understand too, if you don't mind, is utilization. Ms Boyd hits the nail on the head every time. You'll have a better argument next year at this time, perhaps, when you see the actual year-ends. No one can predict where utilization will go. In some years it has actually been lower than forecast; in many years it's higher.

I think what's exciting about the deal is that their individual caps are lower than previously; and second, because of what I said about the growing aging population, I think a very genuine commitment from the Ontario Medical Association on behalf of its membership to seriously work with the government on a number of fronts, all trying to deal with utilization.

I will be happy to report to Parliament throughout the year to let you know how we make out on those fronts. But everyone now realizes, since we're in the 1990s and about to go into the new millennium, that it's not business as usual and that every dollar has to be spent to serve more patients. We can't afford to waste any of it, and as Ms Boyd was saying, we can't afford to do any unnecessary referrals or anything. Every dollar is needed to serve people who absolutely need the services.

Perhaps the deputy would give you some comfort. I don't know. Obviously, anything I say on the deal you don't believe.

Mr Kennedy: I think you underestimate yourself, Minister. Every word of yours is duly noted here.

Hon Mr Wilson: Yes, I noticed that.

Mr Kennedy: One feature of the deal that I think has been a little underestimated is that under the appendix to the deal, if the fee-for-service numbers plus the 1.5% increase are over in this year or the next year, you retain the ability to bring back clawbacks and other measures. Under the agreement, section 6, clause 7, it says that all these deductions, restrictions, clawbacks, limitations and unilateral decreases won't happen so long as the total fee-for-service billings are less than or equal to the amount you've authorized.

You've authorized 1996-97 as a billing base year and you've said 1.5% increase on that, but in that amount is the reduced clawback. I know you're saying utilization can't be predicted, but you took the clawback off for five months last year and that didn't allow the full impact; next year you take off the 2.9%, and you end up with 10% implication in terms of the clawback.

When we look at that, we say that given current utilization rates, you're looking at a cost of some $438 million, yet in your budget you've only provided for $242 million. Minister, that leads to concern. Are you going to end up in another battle with doctors because this won't work, because it's not set up to work, or have you plans you can tell us about today that will delist certain services? There's certainly reference to that in the deal with the modernization. You may not like that term, but people are anxious to know.

The date for that was set; it was supposed to happen on 28th, it was supposed to happen on the 14th. We're waiting to see. In short, where is the money going to come from to pay for a deal that costs roughly $438 million this year, $539 million next year? You've only got $242 million, according to estimates, put away for this purpose. That's your figure. Where will you make up the rest? How do we get an assurance that this deal won't fall apart? You've got the ability to put clawbacks in, if that's your choice. I suspect it's not your chosen method, based on other remarks you've made. How will you pay for this deal?

Hon Mr Wilson: Your assumptions are all wrong. We estimated the cost of the deal at the time of publishing the estimates, and that's why you see a figure in there. We have new money from treasury for health care -- the health care budget's up -- so that's partly how we're paying for it. The other correction I would make is that one utilization method we did rule out -- it's the only one we've ruled out in that appendix. There shouldn't be the word "clawback," because earlier in the agreement it certainly says we can do anything except clawbacks, because they don't like clawbacks.

Mr Kennedy: It's a little bit nervous-making, but it's in there.

Hon Mr Wilson: It's not nervous-making at all. It said earlier in the deal that we would not -- I don't have a copy of the deal in front of me, but I know every word of it. It took most of my life. The clawbacks were ruled out, but anyway, it's perhaps splitting hairs for the purposes of the argument.

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Mr Kennedy: The implication is important. We'll come back to it once we've had the briefing in other venues.

I'd like to turn now to the restructuring commission. I'd like to ask you a basic question. Do you take responsibility for the restructuring commission?

Hon Mr Wilson: I certainly established the commission and take responsibility for the commission in that sense.

Mr Kennedy: Do you acknowledge as well that under Bill 26 you retain the power as minister to act to direct hospitals? Through regulation, you have loaned those to the commission, but you retain the power to act should you so choose. Is that correct?

Hon Mr Wilson: That would be a fair assumption, except you have to add into that that the policy decision -- you might want to have our lawyers in to confirm, but a minister of the crown cannot fully delegate his authorities or give them away. I've given a delegation of ministerial authority, but there still has to be a minister of the crown and I still have to retain some of that authority to do the investigations in Peterborough hospital and other things going on around the province right now.

Obviously, this black-and-white argument doesn't make sense if you understand the law. Yes, we've delegated authority equal to the minister to the commission, and as a matter of policy we've said we won't interfere with that. We've tried to set out a process in the law that enables us to make sure we don't interfere with it. It enables the public to have transparency in the government's relations with that commission. In other words, all our utterings to the commission are made public. They're done through the deputy minister so it's not at the political level. We've taken extreme safeguards to try and get the politics out of this restructuring. And in the decision-making process, which is the important part of the process, there'll be no politics.

Now, at the end of the day, we will go to the voters in two years. I will knock on the doors, as you will, and the voters will hold the government accountable for all of the actions, probably everything that happened in the province during the time we were in government. I'm not naïve enough to believe otherwise.

Mr Kennedy: Minister, I think we can agree on that. We can also probably agree that it's a good idea that the minister retains responsibility for the commission.

I want to ask you about some of the things that don't fit well with the commission's mandate, like national unity, like the issues that are attached to the Montfort Hospital. Are you prepared to step in on Montfort? It has larger implications; it's been talked about. Tomorrow you'll find out that the Franco-Manitobans have joined this debate because they have training taking place at that place. You know it's been a front-page headline in Quebec. You know it's been talked about at first ministers' conferences. It represents a huge gap in the policy, particularly to do with francophones in this province, that the commission is dealing with. Will you step in with your ministerial powers and will you deal with the Montfort if it becomes necessary?

Hon Mr Wilson: We are going to respect and implement all the decisions, directives and advice from the Health Services Restructuring Commission.

Mr Kennedy: Minister, does that mean you will not take -- here's an issue where you have the authority. I don't think you pretend that the Montfort or national unity is something that was supposed to be handled by a commission of volunteers and so forth. Do you not see yourself having a role to fill that gap to deal with the Montfort so we can take care of that dimension, those implications that people are suggesting? Do you agree that the Montfort has implications beyond straightforward health care, that it has special implications for francophones who live in this province and even francophones elsewhere in the country?

Hon Mr Wilson: First of all, we'll have to see what the final directives of the commission are before anyone would comment on those directives, other than to say that in our letter of transference to the commission from the deputy, we've made it very clear that buildings don't cure people. People cure people. Many of the services that the francophone patients receive in Ottawa-Carleton are not in that particular building. They're scattered throughout the buildings. The heart institute is on the other side of town, for example, as do many of the other surgeries that take place.

If anything, we want to make sure -- and I'm confident at this stage that the commission's mind and heart is in the right place too -- that the francophones receive health services in their first language, in French, at the place they receive those services, not in one isolated building, but right across Ottawa-Carleton, as they deserve, and as is their constitutional right in this country. That is the goal of this government and that's the goal of health care and it's certainly the goal of the commission, from anything I've heard articulated from them.

Mr Kennedy: You're very close to endorsing the commission's current position. You know there's a final decision. I think it's important that people know you're keeping an open mind about whether you have to be involved in this. The Montfort certainly does not believe -- unless you give the resources to the control of a francophone hospital, not a bilingual hospital but a francophone hospital, you are depriving them of health care.

I don't know if you care to agree or disagree with that, but that is the message that a lot of Ontarians are looking for you to appreciate and, in your political capacity, to discharge.

Mr Pettit: On a point of order, Mr Chairman: It would seem to me -- maybe I'm wrong -- I don't see where this line of questioning fits in with this committee. It seems to me that this line of questioning should be best left to question period. We're supposed to be dealing with the estimates. Don't you agree?

The Vice-Chair: Mr Pettit, whenever you have your 20 minutes you have latitude. We've allowed latitude for all three parties and will continue to allow this latitude.

Mr Kennedy: Would you like to comment, Minister, about whether you recognize that point of view currently there on the part of Montfort and so many other concerned people, not only francophones but particularly francophones?

Hon Mr Wilson: Certainly I'm aware that a number of groups and individuals have made that type of submission to the commission. They will take that into account.

Mr Kennedy: I think it is part of a theme here about what's missing with the commission. In other words, yesterday the commission released its London report. It cut the amount of money that it said it could save by 35%. That's not a small error. That's a very large change --

Hon Mr Wilson: Excuse me, it wasn't an error --

Mr Kennedy: Minister, I will give you an opportunity to respond, I guarantee you. It was a very large change. It's related to the methodology this commission is using. You refer to yourself in the House on occasion as a layperson. I certainly don't have any other title myself. But we all know that the commission you've given your power to -- loaned it; you've retained your power but you've loaned it to them -- is using certain devices to evaluate hospitals. They're going around and taking beds away from communities, a few of which are empty but most with patients still in them, and they're using tools. You've developed these tools. Your deputy minister, your ministry, has developed the tools.

For example, one of them is called the PDST, planning decisions support tool. It sets standards around what kind of achievements there should be by hospitals. That tool has been used by your commission to justify clinical efficiencies. Most of the money for clinical efficiencies and then almost all the other savings that follow have been that aggressive tool. Your own ministry, when it produced this tool, said, "Users of the PDST are cautioned to perform further investigation and analysis and not reach conclusions based on this set of indicators."

We have seen the Montfort Hospital come and tell you that moving them will cost money. We have seen Women's College come forward and say you've overestimated the savings and underestimated the capital that's required. If you compare the DHC reports and what the commission has come up with so far, you see a great variance in terms of where there can be savings and how much more capital it will cost.

We want to keep this in layperson's terms. Are you aware of the measures you've given to the commission and the way they're using them? If they make mistakes, will you use your ministerial power and step in? How are you monitoring to see if the commission makes these mistakes, as are now starting to be evidenced?

Hon Mr Wilson: It's really quite misleading to say that mistakes were made in London. The commission listened to the community. They said, "We need more beds than the benchmarks you've used." By the way, the benchmark is not set strictly by the PDST; the commission is getting worldwide advice on benchmarks.

You're welcome to read all the submissions. People send me copies and I spend nights reading them. You're getting to be more knowledgeable in health care and I respect that. I'm sure you're reading a number of them too where there are deviations from the PDST recommended, for good reasons, and the commission has listened. In London there are about 200 more beds, from interim report to final report, and there are more mental health resources, because they listened. I think it's evidence that the process is working.

Yes, your initial projected savings is lowered. But given that the government's agenda isn't to save a whole bundle of money on restructuring but to put it into proper, front-line, expanding services, I think the report was a success in that regard and I fully endorse it.

You're perfectly free, as we did last year, and I made this offer at the beginning -- suggestion. I can't make the offer; I can't compel the commission to come here, but you can. You're a committee of the Legislature and you can compel anyone to come here if you really wanted to. You could have the commission come in again this year and explain how it arrives at the decisions it makes. It's been very honest. I think they give as many speeches or more than I do and more than the politicians do. Duncan Sinclair and Mark Rochon are probably out two or three times a week, some weeks anyway, explaining themselves ad nauseam, from little tiny Rotary Clubs up through to huge OHA meetings. They're not afraid to explain to anyone the methodology used by this commission.

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Mr Kennedy: Minister, I appreciate that what you're saying there is true, in the sense that the commission is not unwilling to go out and talk and so on. But are you independently monitoring their decision-making, and if they make mistakes will you use your ministerial power to step in?

I'll give you another example. In Lambton your commission received instructions, or at least indication, from you that there would be a policy re small rural two or three days before the report was due; in fact, I think it was less than 48 hours. That initial report was the closure of a small rural hospital. We've heard you talk before about small rural policy, but that was down to the last minute as to whether that report was going to go ahead.

We want to know, and I think it would be very comforting to the people of Ontario to know, are you monitoring for these kinds of errors if they're made? If "errors" is too strong a word, at least errors of omission and so on? There's been change in the methodology of the commission. There's been a dramatic change in the finding in London. Are you monitoring and will you step in if those decisions aren't rendered properly? That's what I'd like you to address, if you wouldn't mind.

Hon Mr Wilson: The policy of the government is to respect and implement the decisions and advice of the commission. It's hypothetical to think --

Mr Kennedy: What if they're wrong, Minister?

Hon Mr Wilson: It's hypothetical to think otherwise.

It's a good question in that analysis is not only done by the commission but by outside consultants. Sometimes they go back to the very people they're restructuring and say, "If you don't like our analysis, you do the analysis and hand it in to us." The ministry, on the bureaucratic side, is also a resource for the commission to do analysis.

I would say it's probably the most studied commission in the world, that I'm aware of right now, certainly in our province. It receives the utmost scrutiny, which is why its final directives have been easily supported by the government, because they make so much abundant common sense in any of the cases we've seen to date. You'll note that where final directives have been issued in this province they've received editorial support in every community. They've received local members' support, of all political stripes, where final directives have been issued.

It's an extremely hypothetical question right now which I will not answer, whether the government would ever have to step in, given the scrutiny and the painstaking methodology that's used in this process and the willingness to date the commission has shown to listen and respond to community concerns. I'm certainly very confident with the process we've established.

The Vice-Chair: We'll move to the third party.

Mrs Boyd: To segue from that, although that has happened when final directions have come out, I think it's a little overstating it. I don't believe the member for Renfrew is entirely happy with the final report in Renfrew, and I certainly don't believe that the member for Fort William expressed any pleasure about the final report in Thunder Bay. Yes, that has happened in some circumstances. Certainly in London -- we discussed the London restructuring situation the last time I was here -- there is good reason to support many of the conclusions the final report comes to.

With respect to the estimates, you indicated just moments ago here that you intend to follow the advice of the commission.

Hon Mr Wilson: Yes, and we have been. It would be unfair to follow their directives and not their advice, because their advice is, for the most part, the reinvestment. It's absolutely crucial to follow their advice in addition to their directives, or you wouldn't have restructuring.

Mrs Boyd: I would agree with you that it is absolutely crucial to follow their advice. Although originally, way back in the early days, we were having some difficulty getting you to commit to that, I'm delighted that you can. That's good, because that means something else.

With respect to psychiatric hospitals, of course, the advice is because you have retained that power. Bill 26 only gives the commission power over public hospitals, not over the psychiatric facilities, which you own and operate. I'd like you to put on the record, do you intend to accept the advice of the commission with respect to the facilities you own and operate even though it's within your power obviously not to do that?

Hon Mr Wilson: Yes.

Mrs Boyd: Then with respect to estimates, we're looking at an enormous amount of money in London, $190 million of capital to accomplish what we want. I think it's fairly clear from the report that the commission is convinced that's the amount of capital that's necessary to generate the long-term savings and the long-term ability to provide state-of-the-art medical care in all areas. So I think that's fair.

How does that fit in? We talked a little bit about this earlier and about what's retrospective and what is forward-thinking in terms of restructuring dollars. We know there's going to be a report in Toronto; we know there's going to be a report in Hamilton and Ottawa. How are you going to manage, with respect to your estimates and the government's overall estimates, the kinds of investments the commission is advising you to make, and how can we be sure the dollars will flow in a timely fashion, unlike Thunder Bay where they did not flow in a timely fashion and created some real dissonance in terms of need, as you admitted in the House last week? I wonder if you can help us with that.

Hon Mr Wilson: That's a very fair question. Thunder Bay was our first experience with this process. The reinvestment announcement wasn't as timely as it could be, but when it did come, I think it was a pleasant surprise. Even before that announcement, we had already been making investments in Thunder Bay, so the total dollar figure was higher than the commission was recommending by the time all was said and done with the various announcements that were made in Thunder Bay.

One of the reasons, obviously, that we've set up the $2 billion in extra money over the next three or four years or whatever it takes to spend that money is that we want to see restructuring occur as quickly as common sense dictates and as quickly as is reasonably feasible.

We know from the other provinces that once you get some momentum, you have to go quickly. We're seeing that in some of our hospitals now. I know you've been raising in the House some of our Toronto hospitals -- the doctors themselves tell me at everything I go to that certainly they're planning to move because there's no sense setting up a practice in a hospital that may close, and we've been saying to them personally and officially: "Don't go anywhere yet. You don't have final directives." But human nature being what it is, people are planning ahead and we've seen some movement. It's absolutely crucial that we not lose the momentum -- and patients would fall through the cracks -- and that we keep going.

The commission, which I think wanted the assurance that government, whoever is in, would follow through and not leave institutions in the lurch -- which happened so many times in the past, where things got half done -- requested that we set aside a great deal of money, and the Treasurer did that in this budget.

I'd like the deputy to comment on it, though, because regardless of who sits in this chair, the ministry has lead responsibility for implementation once the commission has made final directives in an area working with local partners and local councils that are set up -- and our care teams. Don't forget we're leaving behind on the ground our communities achieving restructuring excellence teams. The membership will be announced soon for Thunder Bay.

The newspaper ads went out some time ago and résumés have been coming in, which is a helping hand under the HCs and the hospitals themselves and really an oversight body, which we've already announced in Thunder Bay and in Sudbury -- the actual people on the committees will be announced soon -- to make sure that citizens have some prominence in identifying any gaps that may be occurring or giving advice to the ministry and the minister to make sure we get the restructuring done properly long after the commission is gone.

We are leaving that on the ground as part of our local partnership to make sure the services are there for this growing and aging population that we're trying to prepare for. I'd ask the deputy to maybe give you a bit more detail on that.

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Ms Mottershead: On the London issue -- the $190 million is a huge amount of capital -- the majority of it will be related to the closure of the South Street site. We've known that for a very, very long time. It has been in our capital plan for a couple of years, even before the commission made its decisions in that area.

I'd like to point out the way capital works. It takes a number of years for the projects to come to full maturity, ie, to have a building up and running and functional. The first phase of it will be the scoping out of the size of the building and what kinds of programs will go in that building, and for that phase of the project which we'd call the planning phase, the money would flow immediately.

In terms of the estimates this year, our capital budget is over $218 million. That's real cash. If you look at the London decisions or the Thunder Bay decisions or the Sudbury decisions, only a small amount of money will actually flow in year one. The budget obviously is going to increase next year and the year after as capital construction starts and the costs get ramped up and the money is called. So we see that in years two and three of the capital, the estimates of the ministry are going to include a huge amount to deal with the bills that have to be paid. We think the allocation this year is appropriate to the bills that will accrue from decisions made in 1997-98 and indeed part of last year.

Mrs Boyd: One of the issues I've always been a little puzzled about: The commission itself is setting up a number of advisory committees, or decision-making committees in some cases, as a result of each report, requiring the kind of integration of management that is necessary if we're really going to have an integrated regional health system.

In the London report a number of these committees are set up with the players in the committee, like the faculty of medicine, the CCAC, the various hospital facilities being represented. I'm interested in knowing how this new oversight body you've announced is going to interact with those ongoing management committees that have been set up on the advice of the restructuring commission.

Ms Mottershead: They actually are going to be the overall community eyes and ears in terms of monitoring the progress of restructuring. They will report to the ministry and at the same time to the commission to let them know what the community feelings are, in their view what barriers are being posed as a result of some of these changes, how well the community understands the kinds of changes. In a way they are the one window for the community to go to and say: "We feel that this particular change is going to have these kinds of consequences. Please help us understand it or notify the ministry or the commission of either lack of progress, or maybe it's too aggressive in terms of the speed with which some of the measures are implemented." That's the whole point of the care committees.

We know the commission has established task groups to deal with specific issues, whether they're labour adjustment or human resource plans, for example, whether they are looking at establishing paediatric networks with Sick Kids and other hospitals around it, a University Avenue review of how more integration is required there. Those task forces will report back into the commission and they will keep monitoring to see what can be done to improve the system don't take away from the care committees that have oversight of the whole restructuring effort in their communities.

Mrs Boyd: You really answered the question I was concerned about. The only real concern in our community around the restructuring, the only really serious concern, is the speed with which all this is supposed to happen. All this is supposed to be accomplished by December 1999, which is a very short time away. When you talk about flowing money and in the first year somehow all this money is going to be encompassed within $218 million, if there isn't a shovel in the ground, meeting that December 1999 deadline becomes very difficult.

What I'm concerned about is that I have a feeling of great urgency in our community that because we have been cooperative, because we have managed to keep people on board in a way that some other communities haven't, we could lose that cooperation very quickly if we see the same kind of problem in terms of implementation that we saw in Thunder Bay. We know that implementation is one of the more difficult aspects of governing. Good policymaking is seldom the problem for governments. Implementing policy tends to be a real challenge. Getting money out the door, I think, is the description we always had when we were going through estimates and saying, "But why is this underspent?" "We had trouble getting money out the door."

One of the real issues for us when we are undertaking a massive restructuring like this is, how can we be sure that a ministry that has not had a reputation of being able to get the money out the door in a timely fashion is going to be able to this time around?

Hon Mr Wilson: That's a very good question, and the deputy understands it. I'll give you my general comments. We've dramatically -- I'm not overestimating that word in this case; I'm not exaggerating at all -- improved the capital improvement process. It's not going to take years any more. I am surprised and give full credit to the deputy and others who have implemented this, and when push comes to shove, the bureaucracy has restructured in that particular area and it's working very well. We're approving capital projects now in a matter of months and some stages are going in weeks, four-week turnarounds, five-week turnarounds, which would have taken -- without exaggeration we've had projects seven, eight years on the books. It took that long to get through. So the turnaround time is crucial.

One concern we have is that we are about to enter the largest phase of hospital construction in the history of the province. Think of the $2-billion fund; it is bigger than the Canada-Ontario infrastructure program -- for the entire nation. There are only so many architectural firms that do medical buildings, only so many construction firms.

You're absolutely right in the "capacity" of the system to do this. It's a balance between the need to restructure quickly, to keep the momentum going and make sure there aren't gaps in services. A program can't move over a number of weeks, it has to move over a number of hours, and ambulances have to move patients from one building to the next in a number of hours, not weeks, and things have to move very quickly. But we have the brain power in this province; we have the willingness. South Street is a good example. I think it was one of the first meetings I had as minister with Tony Dagnone and others saying, "We've got to get moving on South Street." They have their pencils sharpened already, I think they're ready to go, so less worry about London.

Thunder Bay is not a slowdown, if I may say, on behalf of the ministry. There are still just discussions going on in that community about whether it would be a green site or a new hospital or a redeveloped hospital. We're ready to go with the commission's directives and the money is announced and we're free to spend it.

Certainly behind the scenes it's my understanding that the hospital corporation is being cooperative on two fronts. They still haven't given up the idea of a new green site hospital, but they're also producing the functional plan and other requirements to move ahead with the redeveloped site and they're being very honest with the community on the two-pronged approach that I think they're taking.

The deputy would also like to comment on the capacity of the system, the ability to get the restructuring done as quickly as we can.

Ms Mottershead: I was just going to add to the minister's comments about London to reinforce the fact that the leadership in that community has been extraordinary, including the hospital leadership. The capital plans have been worked on since the Thames Valley DHC made the original recommendations, which was over two years ago. Therefore, the time line may seem tight in terms of December 1999, and it is.

The community has also told us in very recent discussions, notwithstanding the final decisions and directions of the commission, that they want to move quickly, and not to lose the momentum. That's why the minister yesterday put out a press release supporting and endorsing the final directions of the commission.

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Mrs Boyd: That's great. It's very helpful to come in and get that feedback. It's probably not as hopeful a situation when we look at Ottawa or Toronto and potentially Hamilton where, for a lot of different reasons, there certainly isn't the kind of cooperative commitment to restructuring there has been in our community. It would do a great disservice to the people in those communities to suggest that they would suffer because there is real difficulty around the kind of restructuring that's being required.

At the same time that I'm very proud of my own community for being in the position they are in, I would hate to see them held up as an example to other communities that don't have the same community of interest and haven't developed the same capacity to cooperate. For various reasons, we did. We were in a different position. Every hospital was a teaching hospital, for example, so you didn't have the push and pull between community hospital and teaching hospital. In fact, probably our greater problem is making sure those teaching hospitals maintain a community hospital quality of care, which I think everybody acknowledges.

That's not true in Metro Toronto. You have a lot of controversy here, a lot of reluctance, a lot of concern around the actual delivery of care that is not a concern in London. In fairness, I think it's probably less of a concern in either Sudbury or Thunder Bay than it is going to be in Toronto.

Since you're trying to do all this at the same time, when we talk about the capacity of the ministry to do something enormous like work with a community that's already cooperating, how do you think it's going to work where your community is being dragged kicking and screaming in front of the law courts in terms of restructuring?

Hon Mr Wilson: Generally I would say that while we tend to concentrate on those hospitals where the building may be closed and the media and question period tend to concentrate on certain institutions -- you've got to remember there are over 30 institutions, 34 out of the 44, although I think a lot of my numbers are wrong, because with some of the corporate mergers recently we probably don't have 44 any more. Anyway, the vast majority of hospitals in the new city of Toronto, Metropolitan Toronto, are very supportive of restructuring. They are poised to say that. They've said it. They've had many press conferences to which nobody ever showed up. Immediately after the interim decisions by the restructuring commission there was a press conference held by many of the administrators, CEOs and physicians of the hospitals that have for years -- I didn't think up this idea, your government didn't think of it and the Liberals, who started it, didn't think of it. Hospitals themselves have been crying for restructuring. They know they can't continue the way things are going.

We will have many great leaders out there who will make it happen, and I have the confidence because they've asked government to do this. I'm truly convinced of that. The easiest thing, as I've said so many times, would be to do nothing and say no to them all. But how are you going to say no to a hospital that's desperately trying to get more money into front-line services but continuing to run physical plants for buildings that shouldn't have to be maintained because they're empty?

The opening of the new Peter Munk Cardiac Centre at the Toronto Hospital is a very good example where now with the new unit there's the capacity to tear down some of the old part of the hospital, which they very much want to do. You'll see that around the province.

It's no secret that when I was in opposition, Wellesley and others in some of those older buildings approached the government for millions of dollars for upgrading their boiler systems and for infrastructure. It's no secret that your government said, "No, because you will be restructured." We didn't think this up to pretend in question period that all this came because of the commission. It is just not true. In fact, some of the people on the commission are the very people who have worked with the health care community, like Dr Duncan Sinclair, who has probably devoted most of his life to talking about restructuring and integrated health care. So there are a lot of people out there very willing to make it happen. The politics is difficult, the politics of the individual institutions is difficult, but doesn't that tell you something about the non-system we have, that institutions are fighting each other right now? All we want to talk about is the seamless continuum of care that politicians have given speeches about for so many years, and we can't do that unless we restructure the system.

The Vice-Chair: We'll move to the government side. Mr Grimmett.

Mr Bill Grimmett (Muskoka-Georgian Bay): I'd like to continue the discussion about hospitals, maybe in a different direction. I think in my riding most of the people in each of the small communities have friends and relatives who either work in hospitals or who have some connection with the local hospital. Certainly since I've become a member there, I've had the opportunity to find out a little bit more about how the ministry deals with applications for capital projects.

I've also found out that over the years the ministry had assembled a list of approved projects. Recently we in our riding went through the difficult process of having one of those capital projects -- instead of being approved, we were told there was no money to fund the project because most of the capital money the ministry had set out in its budget was going towards restructuring. I assume, from looking at the estimates, that's going to continue to be the case.

But in my riding we've gone ahead in a very positive way in the hospitals that are in the communities that I represent. For example, in Penetang and Midland the hospitals have gotten together and formed a joint board and done a series of restructuring on their own. In Bracebridge, the project that had originally been approved by two previous governments and could not be funded by our government, the South Muskoka Memorial Hospital, is going to go ahead and fund the project itself.

I wonder, Minister, if you could perhaps talk to us for a moment about how your government approaches routine capital projects in hospitals where there has perhaps been some restructuring or where perhaps the implications of restructuring are not quite as significant as might be the case in some of the projects that have been talked about.

Hon Mr Wilson: I know, Mr Grimmett, this is a question that's dear to your heart. You made a very concerted effort over a number of months to bring to my attention the community's desire to do some redevelopment at the Bracebridge hospital, for example.

Unfortunately perhaps, we did draw a line in the sand -- but there will be better days ahead when we'll be able to move ahead with some of these routine redevelopments. There was closer to $3 billion than $2 billion worth of capital projects, funding letters going back to -- and I blame all governments. I've had letters shown to me from communities beginning -- the earliest one I think was 1984, so does that get everybody on the hook?

It's true. I've seen yellow, tattered ministerial letters saying, "Go ahead and build your centre," and they went up exponentially before campaigns were announced, so you tend to get a flurry. You can just tell that there was an election coming in 1985, you can certainly tell there was one coming in 1987 because of the flurry of these funding letters at the end of 1986. We don't do that anymore. With the accounting system we have now, when we make an announcement, the money is booked. As the deputy and I have explained many times here, it flows out as we receive invoices and as the cash flow is required, but the commitment is there and you can literally take the letter to the bank now.

Unfortunately, we did have to draw a line in the sand, though, in terms of putting the government's resources, the taxpayers' resources for the next period of time into restructuring initiatives. I'll ask the deputy to comment on the criteria, but generally we were looking for expansion of services. We've even got out of really a lot of the maintenance and cosmetic stuff that used to be done, putting all of our resources, some $2 billion of real money over the next few years -- much of that is capital -- into making sure that we can live up to and implement the directives and advice from the restructuring commission, which is our priority.

So we've set priorities. It doesn't mean that Bracebridge hospital, at some point down the road, won't get looked at again, or all of the other projects, but we did have to say no, unlike any government I am aware of in history, to several dozens of institutions and community groups. We just said: "No, I'm sorry. This doesn't fit in to our priorities of a restructured and integrated health care system at this time." But I will ask the deputy to be a little clearer on what the criteria were in terms of the noes and yeses that we had to issue.

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By the way, I just want to put on the record, the previous practice -- because this isn't new; the last two governments had to deal with this too and they stayed silent. What we did was check the computer banks on everything that had been booked for over a decade. I asked for that report and I said, "Those that don't make it, let's stop stringing these communities along."

Fund-raising has been going on for decades. I know in one of my communities they've been fund-raising forever and yet the case for the redevelopment of the emergency ward or whatever wasn't made every year because they already had this letter that was 10 years old, saying, "Some day we're going to pay for it." Times change and you have to make the case every year now and you have to fit in with the restructuring that's going on.

So we bit the bullet and we said no. A lot of groups have frankly been strung along for a great number of years and perhaps my personal popularity is reflected in the fact that I had to say no to so many groups. But I'm proud of it in one way because I don't believe people should be out fund-raising for projects that may never receive government approval, or it may be so far down the road that it's not really fair to those involved in those projects. I'll ask the deputy to comment on the criteria.

Ms Mottershead: There are three criteria that we have put together to make the determination of eligibility for capital. One is restructuring: To what extent is the restructuring commission or other restructuring initiatives of the community going to impact the particular hospital in terms of moving programs or services or beds and therefore capital is required? So the number one criterion was directly related to restructuring of programs and services.

The second criterion is: To what extent is the particular capital request or redevelopment going to result in increased capacity for increased services in a particular community? Examples of that would be long-term care beds. How many more are we adding to the system and providing the capital dollars to deal with that? We funded some community health centres because their volumes have increased tremendously as a result of adding new physicians and other services.

The third criterion is: To what extent do they contribute to facilitating critical care and priority projects? They're necessary because we have those critical programs like cancer. There are a couple of projects that are still on the books in terms of the east and west of Metro for the expansion of cancer services and things like heart surgery. The minister has mentioned a few times about the capacity in the system. People are working night and day, and in some cases the expansion of the reinvestment dollars will actually result in having to add two or three more operating suites. The capital will be provided to do that so that in fact we can have the benefit of those critical care reinvestments.

Those are the three criteria that we're using in terms of making final decisions on capital.

Mr Grimmett: Just to follow up on that, I want to assure the minister that I've been in constant contact with the South Muskoka Memorial Hospital in their current project, which they are funding themselves. I've certainly passed on their good wishes to you because they are quite appreciative of the quick approval that your office was able to provide when they chose to go ahead with the project.

I wonder if you might comment, because you represent a rural riding like I do, on the willingness and the ability of some of these rural community hospitals to fund their own projects; whether there are other examples, for example, other than the one in Bracebridge, where what you might refer to as routine capital projects are being funded on the local basis, rather than on the basis of pushing for provincial funding, as had been the case in the past.

Hon Mr Wilson: I don't want to mislead anyone and say that it's an automatic rubber stamp of approval to go ahead just because it's an "own funds." I think Mr Wettlaufer, sitting in front of you, will attest that we put St Mary's Hospital through the grinder for well over a year before we allowed them to renovate their obstetrical suites because it had to meet criteria.

The worst sin in the world I think, and we saw this in the not-too-distant past, is where hospitals, in the name of own-funds projects, were doing fund-raising, but then you see the restructuring commission come along and say, "Yes, but that building's not going to be around any more."

We don't want to do that, and any project, including your own in that, we would ask the hospital to have a direct discussion with the restructuring commission to make sure it fits in with their thinking. I'm at arm's length, so we always, in every case, and we did it with St Mary's and we'll do it with others and we'll do it with Bracebridge, almost regardless of the size of the project we ask them to check with the commission. It's all taxpayers' money. Whether the hospital raises it or we get it out of taxes or we go out and raise it somehow, there's only one taxpayer, and we have a moral obligation I think to make sure we don't mislead people along the way.

Those are my general comments about own funds projects. On a weekly basis at least one member comes up to me, it doesn't matter which party, saying: "It's their own money. Let them go ahead and do it." Yes, well, their own money built beautiful atriums and wings in the odd case in this province and now they're empty because they didn't fit into the planning. In many cases the planning wasn't as forward-thinking as it is now, and that's a great credit to the commission. We can now go to the commission and have us say to the hospitals, "Please check with the commission and make sure there isn't something" -- Even when we approve them, every funding letter has a paragraph saying, "This still doesn't exempt you from the Health Services Restructuring Commission."

Those would be my general comments. While we absolutely cannot run the system without those volunteer fund-raising efforts, without the volunteers in the system and the fund-raisers, we still all, regardless of whether we're in the ministry, we're the MPP or we're the fund-raisers, have an obligation to, as I always say, pull on the oars in the same direction and make sure our eyes are always on patient care and to make sure, whatever we do and however we spend the money and wherever it comes from, it all points towards integrated health care and better health care for people.

Mr Doyle: Minister, last week you touched on this briefly but I'd like to mention it again because my riding was affected by this, and that is dialysis. In my riding there's a new dialysis unit that is up and running right now, has been for several months, and is serving the community very well. I know there are other projects that are similar to these dialysis units and I'm wondering if you could give us a rundown on what kind of reaction we're getting to the dialysis units and what kind of service the new units are providing on a province-wide basis at this point, and areas other than dialysis, if you wish.

Hon Mr Wilson: Mr Doyle, it's a good question but I want to save the accolades until we address what Mr Cleary has talked about in terms of finishing the dialysis expansion across the province. We still have, because of a court matter, one area of the province that needs to receive the expansion.

Mr Doyle: Yes, I understand that.

Hon Mr Wilson: So we're not going to pat ourselves on the back yet. Having said that, I don't have the figures in front of me, but the growth in dialysis has been about 10% a year and we'll find out in just a minute how that translates in terms of the number of patients. But it does translate into -- I forget; it's a small-hundreds number -- 250 additional patients able to get those services closer to home.

This started for me, as you know, with the private member's bill in 1993 -- December 1993 I guess it passed in the Legislature -- in trying to get expansion of services. If you ask the very direct impact it has on people's lives, you know, from the opening of the services in your area, the stories --

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Mr Doyle: Yes, I've been there.

Hon Mr Wilson: The stories you hear from people are just phenomenal and it makes you wonder, what happened to these patients before? They're just almost coming out of the woodwork in terms of the growth; it's been phenomenal. Like in your clinic, we no sooner get it set up than we get waiting lists, and right across the province. It's a sign to me of the growing and aging population.

End-stage renal failure is often caused by diabetes, one of the major causes. That's a disease that often comes later in life. We're supposed to have growth between 8% and 10%, and with the new integrated system we're putting in place for dialysis services so that we don't have to keep playing catch-up in the future, we're planning closer to the 15% mark now in annual growth. Of course as that population of seniors triples in the next decade and a half, we're asking the experts now what the growth demand will be. It's going to be phenomenal, so there will be a lot more clinics. Of course the idea was to get these life-sustaining services as close to home as possible because people were having to travel far too great a distance, often during the wintertime, frankly, to stay alive. This isn't an optional service for people.

The Vice-Chair: The government has one minute left and rather than going over to the official opposition -- or would you like to begin today, Mr Kennedy?

Mr Kennedy: Sure.

The Vice-Chair: Do you want to begin today? Fine. There are seven minutes to go today.

Mr Kennedy: Minister, I'd to ask you about a comment you made earlier in these proceedings, your reference to a number of policies, and it has to do I think with the believability around small and rural. There's a policy being made by your ministry about small and rural hospitals. Most people now know what's in it, even though it hasn't been officially promulgated.

But for some that seemed a bit convenient, in the sense that there was a lot of agitation in different communities. I know Mr Wettlaufer's community is not one of them, but he saw what it looks like in terms of St Mary's. A number of people want to know why we don't have similar policies for francophone issues or women's issues in terms of health, why we don't have those health policies.

Now, we called the commission. I made a whole list of those last time and we called the commission. The suggestion you made was that they had those at the commission and they were already part of how they were addressing their job, but they say they've never heard of them. So there's a little bit of communication there.

But there have been various comments that people have made. Your colleague Elizabeth Witmer talks about St Mary's being a hospital that will continue to serve that community for years to come, even though at one point it was on a recommendation to be closed, very unfortunately. In the Alliston Herald, you talked about the Stevenson Memorial meeting the criteria, that it's positioned geographically and financially to continue. There was the suggestion you made in Meaford that "we're going to look after rural hospitals," and then of course the situation in Burk's Falls leads to confusion on people's part.

Is the government taking responsibility for policy, whether it's small and rural or whatever, or is there some other kind of influence it's having, or will we have policies that will deal with the various challenges this commission is facing? I wonder if you would address why we have a small and rural policy and not a policy for the francophone community or for communities the size of Mr Wettlaufer's or for other communities that are facing what they really truly believe are unique health circumstances.

I'll throw in for you the situation in Pembroke, which as you know is an issue that now many believe affects women's health. There is a question of governance there that could very well lead to a much, much larger issue. In each case, I'm wondering, where are you exercising your responsibility as minister, and could you comment on that in the context of the policy you have made and other policies we might expect from you in the future? Because on the converse, some people are wondering if this isn't just political on your part to have a small and rural policy.

Hon Mr Wilson: I'd ask you, are you opposed to it?

Mr Kennedy: Minister, if you can tell me that there will be policies for francophones' health, for women's health, for these other communities, then I think we'd be happy to help you to develop those. What we're concerned about is whether these are being done in a fashion that really meets all of the province. We congratulate you for a small and rural policy. We want to know, will you extend the same courtesy and the same respect -- and Mr Wettlaufer saw this in Kitchener, that hundreds of people came out to a gymnasium there -- to the other citizens of Ontario or do they just get the commission and that's it, and no reference to their particular, unique circumstances?

Hon Mr Wilson: I'm absolutely shocked at the answer of the commission, and I wish I had the freedom to call them, because there are manuals on the PDST and the benchmarks, and they fill shelves. There is policy on Mr Wettlaufer's area and the DHCs have had those manuals for years. So I'm just shocked. Bill 8 is the most comprehensive policy in the province covering French-language services, so French services is covered extensively for all government departments.

Women's health: good point. I always say our health care system is primarily centred on women and children because they tend to be the ones that make the -- I'm not sexist but the mother of the family still often is the one who brings the kids to the doctor, and so many of our new and expanded programs have been for women, in terms of breast cancer and cervical screening and our cancer initiatives, period.

Cardiac: During my term, the recognition by the professionals themselves that there has to be more done in terms of sensitivity to the particular needs of women suffering with heart disease and the treatment they receive. That's a wonderful development I think.

Could we have a women's health policy? Yes, we could package up the myriad of programs, and I know our women's issues minister will be talking about that actually very shortly, within days, in terms of women's initiatives across government, and many of those issues are centred in the Ministry of Health.

It was the commission itself that pointed out -- and you're absolutely right, it was when they were doing Lambton. They said, "We don't have any manual to deal with Lambton," frankly. So we took the challenge. We didn't want the politicians to do it again. I think you're aware of the expert panel, and I don't think there's any debate. We didn't ask them their politics. They come from the various rural organizations, municipal organizations, physicians and nurses. I don't want to exaggerate it, but a great sigh of relief at the -- I guess I saw them at their third meeting, when they had finished the policy. I wasn't at the first two meeting because, again, we didn't want politics. We locked them in a room and said, "Get us a rural health care policy; the commission needs one," and they'll all swear on a stack of bibles that the process was squeaky clean.

I saw them to thank them at their final meeting, and they were thanking me. They just couldn't believe that a government would finally listen. These are rural emergency health care physicians who have had frustrations, front-line nurses who have had frustrations over the years. So where we were told we were lacking policy, we've moved quickly to fill that gap.

Mr Kennedy: Minister, they're saying the same thing for urban communities. The Wellesley Hospital tried to hold its own urban policy conference. Doctors Hospital really feels that the multicultural community that they worked years to establish connections with is being underestimated. Will you commit to doing similar things for those communities? That is the question of fairness I think that's being put to you. Is there a possibility of that occurring?

In terms of women's health that you mentioned, is that something concrete you're prepared to tell us today will happen and will take into account Women's College and that particular conglomeration of unique services? Will it happen in time to affect that decision, what you've referenced on women's health, and will there be something for urban health, just as two examples that I know have been brought before the commission and you probably are also aware of?

The Vice-Chair: A very quick answer, Minister.

Hon Mr Wilson: Very quickly, on women's health, of course in addition to what I've said in terms of getting better coordination and understanding of all the programs provided across ministries, which is currently a task being led by the women's issues minister, we've also established in the budget, at an annualized cost of $10 million, the women's health institute, which will certainly be guiding us. That's far more money that's spent on specifically women's research.

Mr Kennedy: But will it affect Women's College? Will it be done in time to affect Women's College?

Hon Mr Wilson: It will be an evolving process and very much involve people who are associated with Women's College. Specifically the deputy, because she was here for the development of all that previous policy, would like to comment on this general area.

The Vice-Chair: You may have an opportunity to do it tomorrow, Deputy. It's 6 o'clock. We will adjourn for this evening. The Liberals will have 12 minutes to finish tomorrow, then we'll move to the third party.

The committee adjourned at 1800.