Assemblée législative de l'Ontario

MINISTRY OF HEALTH

CONTENTS

Wednesday 18 June 1997

Ministry of Health

Mr Dan Newman

Ms Margaret Mottershead

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)

Clerk / Greffière: Ms Rosemarie Singh

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

The committee met at 1533 in committee room 2.

MINISTRY OF HEALTH

The Vice-Chair (Mr Rick Bartolucci): Could we bring this meeting to order, please. I'd like to welcome Dan Newman, the parliamentary assistant to the minister. As we know, the minister is not available, so Dan, welcome to the committee.

We will continue on from yesterday. The Liberals have 12 minutes left in their 20-minute presentation, so I'll turn it over to Mr Kennedy.

Mr Gerard Kennedy (York South): We left off yesterday with the restructuring commission. I'd like to turn to some of the details of its operation, with the assistance of Mr Newman and the deputy. I wonder if you could tell us, because it's not self-evident in estimates, what is the cost of the restructuring commission? What is its budget? Does it have staff who are seconded from elsewhere? How does it function in terms of its appropriation, how much money does it have and so on? I wonder if you could give us a general outline of that.

Mr Dan Newman (Scarborough Centre): I'll ask the deputy for that.

Ms Margaret Mottershead: The budget for the commission for the year just ended March 31, 1997, was $1.9 million. The allocation for that is in the vote called "hospitals and related facilities." It's not listed as a separate line, just like hospitals aren't individually listed in terms of their allocation. So it's the aggregate amount required for the operation of hospitals and related facilities and ancillary programs like the commission.

The commission, as you are well aware, is an arm's-length organization. The members have been appointed by government, and its staff come from a number of sources. Some are direct hires and employees of the commission and others are seconded from a number of organizations, including the hospitals, the ministry and health care agencies.

Mr Kennedy: How many staff would that add up to in total, and can you separate the ones who are direct employees of the commission and how many are secondments?

Ms Mottershead: I don't have that information right now, I'm afraid. I don't know what their total number is and how that splits out.

Mr Kennedy: Is there any idea about their use of consultants? Would that be something they would pay for themselves directly? We know about the Hayes consulting group, we know about other ones that have been central to a lot of their considerations. Is that budget again part of the $1.9 million we're talking about?

Ms Mottershead: Yes, it is. Professional and consulting services, including technical services, are funded from that budget of $1.9 million.

Mr Kennedy: We understand from the commission that their actual expenditure last year was something like $2.3 million. Can you confirm that while their allocation was $1.9 million, they say the year ended at around $2.3 million? Is that accurate?

Ms Mottershead: Their financial statements -- and they'll have them audited and submitted to the ministry in short order -- have a budget of $1.9 million.

Mr Kennedy: So there's a distinction between the budget they were allocated and the money they spent. You're saying the money they spent is actually $1.9 million?

Ms Mottershead: I believe, and I'll have to confirm this, that the initial allocation was less than $1.9 million.

Mr Kennedy: Could we have made available those financial statements? Is that something that can be made available?

Ms Mottershead: Yes, we can make the audited statements available and we'll commit to do that.

Mr Kennedy: I'd like to talk a little bit about FutureShape. That's the ministry's own internal re-engineering project. Can you tell me a bit about its cost? It's meant to reshape how your ministry functions. Can you give us an idea about what that is going to take in terms of dedicated dollars to bring it about?

Ms Mottershead: We did tender last year for the services of a company experienced in re-engineering to come in and give us some advice on that. The company that was selected was Ernst and Young. Phase 1 of their report with us has been completed. It recommended our looking at a number of areas for re-engineering in areas of information technology, communications, issues management, policy and planning and excellence in organizational structure. In other words, what they've asked us to do is not just to change the boxes on an organization chart but to actually look at how we do our business and how we can re-engineer every aspect of that business.

Mr Kennedy: How much was Ernst and Young paid for that phase 1 report?

Ms Mottershead: I don't have the specific numbers with me right now, but I believe it was in the ballpark of about $200,000.

Mr Kennedy: Is there a further contractual arrangement with that consultant? Will they be involved in phase 2 or the implementation of FutureShape for the ministry?

Ms Mottershead: The tender did specifically state, and they bid on the notion, and so did all the other companies that bid, that there would be follow-on work and phase 2. We haven't concluded the contract on phase 2. One of the issues we're addressing right now, and that's why I can't give you a number, very clearly is related to how much of their time we're going to use in actually doing the re-engineering work inside the ministry for each of those committees and tasks that I have outlined.

Mr Kennedy: Of course, Ernst and Young includes Andrew Vaz as a principal, I believe, of that practice at Ernst and Young.

Ms Mottershead: That's correct.

Mr Kennedy: His typical billing hours are around $2,000 to $4,000 a day. Would that be applicable in the case of what he's done for you or would there be some other rate that we can understand he worked for?

Ms Mottershead: He has his rate, but given that this is a huge project, there was a significant discount that was applied to the rate they normally charge for this type of work. It is the first real re-engineering activity of any Ministry of Health in the country, and for that reason they felt that kind of experience was worth a significant discount to their fees.

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Mr Kennedy: So it might be worthwhile for us to know, given the first-time nature of that, what the costs all-in will be. Will those costs be made public at different times in terms of that particular arrangement? I think you appreciate that it is important for people to know about FutureShape, that there is an effort by the ministry to keep up with health reform by reforming itself. But I also think people in these times of scarce dollars want to know, and you've outlined for us some of the reasons why it's a necessary expenditure, what that cost is going to be. Is there anything you can tell us about what that overall project is likely to cost? You said the exact tender hasn't been finalized, but roughly what do you think it will be?

Ms Mottershead: The contract hasn't been finalized for the second phase. The tender --

Mr Kennedy: Did the original tender specify a range of costs?

Ms Mottershead: No.

Mr Kennedy: Is there anything about the total scope of that cost that you can tell us today?

Ms Mottershead: Again, there are a lot of variables, so I don't want to give you any information that might be construed as misleading down the line when some things change. The variables are directly related to how much effort the ministry, through the ministry staff, is going to be providing versus how much hand-holding by the consultancy, or leadership from the consultancy side, is required from Ernst and Young.

Right now, the ministry is planning to establish three work teams with dedicated ministry people dealing with the issues that I've mentioned, like policy and planning, information technology, communications and organizational excellence. I'm in the process of identifying those resources internally, and we are in the process of having a conversation with Ernst and Young, our supplier, to determine, now that I've identified these many resources, how many additional expert resources we need from the outside company. They're going to have to go through a process with us of determining what skills I'm bringing to these teams, what they offer, and then figuring out exactly what else will be needed. So I can't give you a precise number.

Mr Kennedy: Just around the administrative practices in the ministry, is it the ministry's practice to have secondments from other organizations, people working in the ministry?

Ms Mottershead: Yes, it is.

Mr Kennedy: For example, you recently replaced your ADM for institutional health. Is he there on a secondment from somewhere or is he a direct employee of the ministry?

Ms Mottershead: He's on a secondment from a hospital. It's not unusual. It's not the first time I've hired someone for that position who has come from outside of the ministry and from the hospital world. There have been two other people who have fulfilled the same function.

Mr Kennedy: Just in connection with Mr Sapsford, he was originally an employee of the OHA, if I'm not mistaken, or was he still on secondment at that time? He went from the OHA --

Ms Mottershead: He was a direct employee of the OHA. He left there --

Mr Kennedy: But now he is on secondment from another institution, if I'm not mistaken.

Ms Mottershead: He left the OHA and became an employee of the Toronto Hospital. Subsequent to that, I was able to convince him that a move to the ministry was appropriate.

Mr Kennedy: You have cited precedents. I would be interested to know what they were, so if that information could be tabled, that would be great. But if he is at one time the person in charge of institutional health for the whole province and all hospitals, and at the same time an employee of one of the hospitals, doesn't that create an impression of conflict of interest? Doesn't that give rise to some difficulty in terms of credibility within the hospital community, and how is that handled within your ministry?

Ms Mottershead: It's handled directly. In the secondment agreement we have very, very strict confidentiality clauses. For example, they have to swear to hold everything secret and not to divulge any of that information, and it's quite explicit in their contract. The purpose of that is to totally eliminate --

Mr Kennedy: Would it be possible to table the terms of that agreement here?

Ms Mottershead: I can give you the standard paragraphs.

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

Mrs Marion Boyd (London Centre): I'm sorry that Mr Wettlaufer isn't here and that the minister isn't here, because there was an issue that arose yesterday, and just the way the conversation went, we didn't get back to it.

Mr Wettlaufer had asked a question yesterday which essentially was about the rationing of health care services. He basically asked about the numbers of hip and knee replacements and whether there were some rules that governed who would get those operations, given that there were many more people than the 1,200 that there are dollars for. If you'll recall, the minister sort of did a double take and said this was a tougher question from his own caucus than -- and we just didn't go back to talking about the reality of rationing health care services.

I think we should do that as part of the estimates, because the reality is that we do ration health care services in the province. We fund numbers of procedures -- numbers of heart surgeries, numbers of dialysis, numbers of orthopaedic operations and so on -- and we all have to recognize that there is rationing of health care services.

The minister went on to say that the way in which that rationing is done is it's left up to the physicians. I guess I want to ask the parliamentary assistant whether he believes it is appropriate to leave up to physicians the way in which those decisions are made about rationing health care services. Should physicians be making those decisions by themselves?

Mr Newman: I guess I don't agree with the notion that there is rationing of health care services. I think everyone who needs a particular procedure or medical service provided gets that service in the province of Ontario. So I don't agree with what you're saying, that there is a rationing of services.

Mrs Boyd: The minister didn't seem to have any problem with it. He said very clearly that we cannot provide procedures to everybody who needs them and that, yes, definitely there are guidelines that guide physicians in how to make decisions about that. He didn't have any problem with that question. He said we cannot afford to do everything that we can do for everybody who comes looking for it. We all know that's true. I don't think we should be defensive about that. I'm not trying to put you on the hook on this.

I think the reality is that we can only do so many heart surgeries if the money that's allocated only provides for that many. Isn't that true? So if we have an increasing number of people who require that surgery, there are going to have to be some very serious decisions made about who is going to benefit the most from that surgery. This is not a trick question, quite seriously.

Ms Mottershead: Can I just say that I don't have the same recollection of the minister having appeared to agree that there is rationing.

Mrs Boyd: We didn't use the term, but the term --

Ms Mottershead: What he did say is that there are guidelines and we fund a number of services based on the volume that actually happens, but no one who needs it is turned away in terms of receiving medical care. There is no rationing on that basis, and I think that's what the minister had clearly intended in that discussion.

Mrs Boyd: The minister then went on and he referred to, I believe it was, the member for Wentworth North, that he was present at the opening of his dialysis service and that the minute that opened, there was a waiting list for those services. Right?

Ms Mottershead: We do have some waiting lists, yes.

Mrs Boyd: Yes, and there are certainly waiting lists for heart surgery, we know that, even with the money that you have put in, and there are waits for cancer treatments. One assumes that decisions are being made about who needs to have those immediately and who is able to wait.

Ms Mottershead: That's right.

The Vice-Chair: Mrs Boyd, could I ask you again today -- thank you.

Mrs Boyd: This is a very annoying room to try and work in.

The Vice-Chair: It really is, Mrs Boyd, but we're stuck with it.

Mrs Boyd: Perhaps if that other microphone were on, it would solve the problem.

The Vice-Chair: Could you try that?

Mrs Boyd: I'm not comfortable looking this way when I'm talking to people in this direction.

The Vice-Chair: I understand the difficulty. Let's try the second one and see how it works as well.

Mrs Boyd: I certainly recall the minister saying that we have so many resources and we have to allocate them and that he believed it was appropriate for doctors to be making that decision. We can check Hansard, but certainly that was the sense of his discussion.

My question is, if those decisions have to be made -- and we know from the stories that when those decisions are made and some people don't get a procedure, some people have to wait for a procedure, they in fact die before they get that procedure. The reality is we have the same problem that any other jurisdiction has. If we've got a budget and we've got more demand than our budget allows us to do, what happens? Normally our waiting lists grow. There may indeed be an adverse effect on patients as a result of that. I appreciate that there's every effort to try and deal with that, but there is a reality that we can't serve everybody. All I'm saying is, do you think it's appropriate that doctors alone make that decision?

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Mr Newman: Yes, I do, that doctors make those decisions. When I answered the question about rationing, I guess I hadn't used that term to describe it, because I've always felt that the services are there for those people who need them. But the doctors in the end make the medically necessary decisions.

Mrs Boyd: But let's be very clear. If you have allocated a certain number of dollars -- and let's use heart surgery because it's the one we've been talking about most frequently and the one the minister is most proud of having given more dollars to. You have so many dollars for heart surgeries and those are allocated. Different hospitals are given the number of procedures they are authorized to perform. Say in hospital A they are authorized to perform 26 bypass operations in the fiscal year, and they perform all 26 in the first six months of the year and there are 90 people on the list waiting for this kind of procedure. What happens? Do those people on the waiting list get the procedure or don't they?

Mr Newman: I'll ask the deputy to --

Ms Mottershead: We have some situations in cardiac services and dialysis and so on that if there was a capacity in the system and they were able to do more -- obviously the system works to get all the emergency cases done first and then moves to the next level of severity and acuity, and then it moves to the elective kinds of things. The services need to be done but they could take a year or two years or whatever; it'll ease some discomfort but it's not life-threatening. That's the way the system works.

If, in the theoretical situation that you've presented, a hospital came to us and said, "We know we have capacity that we can do X more," then there is a process of negotiation. In fact at the end of every year, for cardiac services, dialysis, trauma and other volume-funded programs, there is a process of reconciliation so those that have done more get funded, those that have done less lose some of that money to pay for those that have done more.

Just to give you an example on the cardiac side, every year the Cardiac Care Network, together with the hospitals, for example, in Toronto, will sit down with the Toronto Hospital, St Mike's and others and say, "What volume can we handle?" It's not just a question of money and how much we're able to fund, it's a question of the capacity in the system: How many cardiac specialists do we have, cardiac surgeons? How many people are required in the intensive care unit? How much time do we have in our operating rooms and suites and all of that kind of stuff for hearts versus something else? All of that planning is done and a decision is made to do a volume, say, 250 cases here, 500 there, and that's the way we establish the initial planning targets.

Then during the year, because you do have a lot of things -- you have some hospitals that may have doctors who go on leave or you may have situations where someone's committed to do some upgrading on continuous medical education, so there are some shifts that occur based on availability of cardiac surgeons. We do that reconciliation at the end of the year.

I think in terms of cardiac there has been a tremendous effort to put a lot of resources here. I know in a couple of cases we've had to deal with the question of opening up and establishing more operating rooms to deal with the volume because there just hasn't been the capacity, physical in this case, and also the human resource capacity, to deal with the kind of volume we have. Just to round out that picture a little bit.

Mrs Boyd: The point of my question is, you don't believe that this ought to be a public policy decision. You believe it's okay for these decisions about who gets served and who doesn't to be strictly done by doctors. Is that what I'm hearing?

Ms Mottershead: In terms of these procedures being medical procedures, it's hard to think of who else would be better equipped to make that kind of decision. If there are some suggestions on how we can improve the system by actually making some recommendations or giving us advice on who else should be involved, I think the government would be open to having that kind of suggestion brought forward.

Mrs Boyd: I'm not suggesting it, but certainly other jurisdictions have taken a public policy viewpoint in terms of utilization. They've made decisions as a jurisdiction and made very clear and public what kind of limitations there are in service. That's happened in the UK; it's certainly happened in Oregon. This is what I'm trying to get at. What we're saying here and what I understood the minister to be saying -- and this is why I'm kind of pursuing it -- is that somehow we're saying in this jurisdiction that it's okay by us for those decisions to be made strictly by physicians; that this isn't a public policy matter, it's strictly a medical matter.

I guess there's a little bit of a concern about that, particularly where it fits into the reality that we cannot do all we could do. All of us, when we talk to doctors, know that they say if they had X million more dollars they could do X more. There's much more we can do technologically than we do, because we can't afford to fund it, and that makes the decision about how we choose to do what we do that much more important, doesn't it?

I think there should be a combination of medical decision-making and public policy decision-making around how those decisions are made, because particularly the way we allocate our dollars in this province, allocating the dollars to particular regions and particular facilities, how can we have any sense that there's any kind of equity when we cannot provide all procedures to all people? We know we can't. That's just a given. We can't do everything we could do, and we don't seem to be prepared to ask the question, just because we can do it, should we do it? Everybody shies away from that.

I'm just saying that I got a very strong feeling from the minister yesterday that he didn't think this was a public policy issue, and I think it is. I just wanted to get a sense of whether that's where the government is coming from.

Ms Mottershead: The Minister of Health has also stated on a number of occasions the fact that he wishes to implement a quality council. The composition of that quality council will have members of the broader community, it'll have academics, it'll have some professionals and their colleges and so on. Clearly one of the things that we are looking at in terms of a role for the quality council is to look at some of the issues that relate to the physicians alone making the decision without perhaps having all of the right supports or all of the right tools or all of the right research.

In that context, we will be forwarding to the quality council the information that ICES produces in terms of its research that will look at the rate variations in terms of why some physicians perform this kind of procedure precisely this way in this particular area versus slight variations to the same procedure in a different part of the province by other groups of physicians. It's that kind of question. I think once the quality council is established, we will have a much more public kind of discussion in terms of what are all the influencing factors around medical care and decision-making and the like. That body is going to be quite instrumental in trying to bring a better level of stability and consistency in the application of procedures and decision-making by physicians.

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Mrs Boyd: I think one of the issues in terms of the massive restructuring that's going on and the concern that we all have expressed is around utilization rates and the variation in utilization rates and how that affects the availability of a consistent delivery of health care services to all the needy populations of the province, not just some. That really concerns us. We hear stories every day about how people seem to jump queues when it comes to different procedures in their own area because of who they are. Who knows whether those are true or not, but that is sort of common street talk, that in fact who you are counts more than how serious your condition is.

I think the way to counter that and the way to make sure that you get a public belief in your system, that your system is operating in terms of who requires the assistance -- as the parliamentary assistant said, if you require the service, you should get it, rather than, if you happen to be an influential member of the community, you get it. I think that would relieve people's minds if there were some process whereby people understood how those decisions are being made. I think particularly when we get into those very difficult areas of life support, both at the end stage of life and in trauma situations, that kind of decision-making becomes even more important.

One of the things that has been found in jurisdictions that have gone through a restructuring of health care is that if there is transparency around the principles that guide decision-making, and public agreement, public consensus that those are the priorities, and public consensus around the notion that you have to triage your care in some instances and that there are very clear criteria that are followed, I think it builds more acceptance around it.

Emergency care and end-of-life care are the two areas where this is a real touch button. We know it is in Canada, with the kinds of cases we've had around assisted suicide and that sort of thing. We know that we have to start talking about these issues a little bit more openly and really talking about them in the context of whether we can afford to do what we technically can do, whether that really is bringing quality of life and is improving the general health of the population.

The older we all get, the more important that is, because if you have a physician-driven system where physicians are taking the position very strongly that their job is to prolong and maintain life at all costs, you have a very different kind of approach to end-of-life scenarios than you do in a situation where you're not taking as aggressive a position, and certainly a different cost factor, because we all know that the highest cost generally comes in the last six months of life.

That's why we need to start talking a lot more clearly about the principles that we have around palliation, around decisions not to have treatment or to withdraw treatment. We started to get into a bit of a discussion of that around the consent-to-treatment provisions last year and we found that there were really very distinct views within our society around whether you always aggressively pursue cure, even when none is available, or whether you look at a quality-of-life scenario that agrees that palliation is sometimes acceptable.

I think when we're talking about estimates, that's a huge cost factor. It shouldn't be the only factor, but people think it is the only factor if we're not talking about the other factors.

The Vice-Chair: Thank you, Mrs Boyd. Your time is up. We'll move to the government.

Mr Marcel Beaubien (Lambton): I'd like to talk about laboratory services. I guess I can relate it to my community, which is probably a mirror image of what occurs in the rest of Ontario. We seem to have a mishmash of services, some provided by the hospital, some provided by walk-in clinics, others provided by small laboratories in doctors' offices. Can you enlighten me as to how you fund them and why you allow the proliferation of a whole difference of laboratory services in the communities?

Ms Mottershead: We have three types of laboratory services in the province. We have commercial laboratories, and there's a whole host of them that provide that service. They're out in the community, and the funding for those are in the vote called "health insurance." There's that group of laboratories.

We have, as you well know, laboratory services and programs in hospitals. That's another level of laboratory service. We also have government-run laboratory services in the public health area and eight regional laboratories in the province that are funded directly and operated by civil servants. Those are the three levels. In all, if you were to look at the budgets of all of them, it's close to $1 billion that we spend on laboratory services.

In the last year and a half or so, we have looked at what has happened to laboratory services in other provinces; looked at how they have tried to restructure their laboratory systems; looked at how much it's costing us in Ontario versus other provinces in the provision of laboratory services; looked at the human resources issues in that field, where we have laboratory technicians and technologists and pathologists in hospitals who supervise the labs; looked at the changing technology, because laboratory instrumentation is getting to be very sophisticated. We know of at least a couple of Ontario companies on the commercial side that really have become world leaders in terms of robotics and laboratory instrumentation. We have looked at what those changes mean with respect to laboratory services and the human resources side of that business.

We engaged an expert group from outside the ministry that represents a number of laboratory interests -- hospital, public and private -- and the Ontario Medical Association with their laboratory proficiency and testing program to look at how we might restructure some of the system, because there is to some extent some duplication when you have three different players participating in the same field, to see if we can get, over time, to a process where we have a regional laboratory activity where all the high-volume business can be done, and have a distributed network of specimen collection centres where you actually go and get your blood taken. That's very local because that's where the first interface is with the community. You want those to be available locally so it doesn't inconvenience anyone and there is immediate access. But the actual testing can be done in a more regionalized context by only one of the players in the system, not necessarily the three, to have a more efficient system.

That whole process of restructuring on the laboratory side is going on right now. The ministry has a number of papers that have gone out for consultation, and we're basically waiting for some feedback from the players as to the direction.

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Mr Beaubien: I'm glad to see that you recognize the fact there has to be some rationalization in the system, because, as you pointed out, laboratory equipment is very expensive, very intricate, and you need people who are qualified to operate it.

The point that disturbs me is the fact that there is an awful lot of competition in small communities to bleed a patient, to do a CBC on the patient, when two blocks down the road you have a hospital which is properly staffed, but yet we have a doctor's office -- I know the way to get around it is that you pay a high rent to have a private lab operate within your own medical premises. These things are happening. I'm glad to see you've realized that something has to be done. When can we expect something? I don't think we are getting good value for our money with regard to lab services in Ontario.

Ms Mottershead: We are in the process right now, and I believe an RFP has been issued recently, of getting a consultant mediator who can actually look at what's happening in the hospital restructuring communities. We want to also link the laboratory restructuring activity with the kind of restructuring that's going on in the hospitals, because what is happening in some cases is that a number of the larger private laboratories are offering management services to the hospital. They're actually going in and running the hospital-based laboratory services. There's a lot of activity happening there.

As the licensing authority for that we are becoming quite concerned about the number of licence requests we have for moving businesses around. In the restructuring communities, Thunder Bay, Sudbury, London and so on, we hope to get someone in to broker that whole thing, get down to what makes sense in terms of the community, where the central service should be, whether it's hospital based or whether it should be in the private sector, and make those recommendations to us.

Mr Beaubien: To follow up on Mrs Boyd's point with regard to funding and the delivery of services and who supervises it, when it comes to laboratory services, you have a physician who will order certain tests; you have a pathologist who is in charge of the lab. In order to build that number of units -- I don't know what you use today to qualify for transfer payments, but I know a number of years ago it used to be units.

The physician may order a haemoglobin or a white blood count, but the pathologist comes in and says, "Do a CBC on the patient." The reason you do a CBC on the patient is because the lab gets more units. What balances and checks have we got in the system to prevent this from happening? It happens on a daily basis. I'm just talking about a simple blood test. There are other tests that are much more costly that are done and don't do anything for the patient; all they do is elevate the number of units in the hospital so the hospital will qualify for a higher level of transfer payment. What balances and checks have you got in the system?

Ms Mottershead: On the hospital side it doesn't quite work that way, because the laboratory services are funded as part of the global budget of the hospital. Where it does come into play is in the commercial labs. We know what the top 10 billing codes are. We track them on a fairly frequent basis. We do audits and spot checks. In our agreement with the Ontario Association of Medical Laboratories, we have a qualifier on volume discounts so that if too many of these things or certain tests are ordered and produced, then we have a penalty that clicks in and a discount modifier that actually starts discounting a lot of the billings where there is a huge volume that may be questionable. All of those things come into play. We rely on audits. There is a significant recovery activity that happens once we go in and find that kind of thing happening.

Mr Beaubien: But you have no system that micromanages the area or the hospital or the particular lab, you just basically do it on statistics at the ministry level?

Ms Mottershead: That's right.

Mr Beaubien: Do you think that's efficient?

Ms Mottershead: You can't penalize the laboratory itself performing that function. The key gatekeeper in all this is the physician, because it's only the physician who can order the test.

One of the initiatives we have on the books and in play right now is a tripartite committee between the laboratories, the Ontario Medical Association and the ministry to actually look at how we can change physician behaviour, how they can be better educated in terms of what tests are really necessary, how we can influence. Just one simple activity, changing a box on that form, has tremendous implications, because the tendency in terms of providing a diagnosis is, "Let's tick off all the tests we think we should do, because we have no idea at this point what the patient is presenting himself or herself with," and therefore the whole test.

We have done a couple of minor changes in the past on that front, and it has made a huge difference. If we make the physician request the test rather than providing a box to tick, it really has them stopping and thinking: "What could be the problem here? What is the test that is most appropriate to help me or inform me about what's wrong with the particular case?" They have to think about it a little bit more than just, "Gee, I'll do this or I'll do that." That's one of the things we are discussing with them right now. Hopefully that'll have some impact.

Mr Beaubien: Good luck. Because if you don't enforce or be a little more proactive with the process, it's going to be a process of elimination when it comes to laboratory services as opposed to the process of zeroing in as to where the problem or the medical problem may exist.

The Vice-Chair: Just before we go to Mr Pettit, Rosemarie Singh would like to know what a CBC is.

Mr Beaubien: It's complete blood count.

Mr Trevor Pettit (Hamilton Mountain): I'm pleased to see the parliamentary assistant here today.

Mr Newman: I'm pleased to be here.

Mr Pettit: In these times, obviously dollars are scarce and we have an aging and growing population. I guess everyone would agree that we have to make sure every dollar gets to the front-line care. I'm curious what type of fraud control you have within the ministry. Can you tell us if you have any estimate at all in terms of dollars as to how much fraud there is within the system? Do you have any targets in terms of reduction of fraud?

To extend that a little bit in terms of, let's say, a physiotherapist as an example, my doctor says I've got to go for physio. I go and he gives me a TENS machine or a hot pack or whatever the case may be. How does the ministry know, or how do I even know for that matter, that he sometimes does not bring me in two or three times more than I actually need to go? How do you monitor that type of situation to make sure they aren't perhaps extra-billing or giving the extra treatment that I don't need, which in effect is taking dollars away from the system. Is there anything to monitor that other than an honour system within any of those areas?

Ms Mottershead: What you have in the whole spectrum of fraud or misuse or abuse of the system is three elements, basically. The first element is to do everything in everybody's power to prevent that occurrence in the first place. There's a preventive program. In health, that preventive aspect is focused around registering eligible people for their entitlements through the health card.

We have made a number of changes over the last couple of years. Some of it started certainly with the previous government in making sure that the eligibility is really tight, making sure that the kind of documentation that's acceptable when you're registering people is really tight and soundproof. There are times when we get criticized for being too strict, but that's all part of trying to make sure that only those who are eligible for the health card are the ones who get it.

The second component of that is a program we have on monitoring and control. We have a dedicated unit that actually looks at billings, looks at frequency of billings, not just physicians' but other providers' as well; has an algorithm that's been developed to know if that particular billing pattern is consistent with the general population of physicians or other practitioners or whether it's inconsistent. That raises red flags and those names are pulled out.

We have a process of verifying. On a random basis, thousands of letters go out every month to people receiving services to say, "Can you confirm for us that you in fact have received that service," and you'll give us the information we need to know whether a patient record and file and health card has been used by practitioners, when they've only seen them once, to try and collect two or three times. That's a verification process.

We also have through the MRC, the medical review committee of the College of Physicians and Surgeons of Ontario, where the general manager of OHIP is informed through the monitoring process that there are some irregularities with some of the billing practices. They're sent to the medical review committee as well.

At the end of the process, the third stage, is the actual investigative work where there is enough evidence to bring it into the purview of a criminal investigation. The people in the investigation unit have status as special constables and therefore they're able to gather evidence and that kind of thing to prepare a case for court or turn it over to the police and so on.

I believe Mr Newman has some other comments.

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Mr Pettit: I wonder, though, is there any dollar figure put on fraud within the system, approximate or estimated? Has anybody ever tried to speculate, if you will?

Ms Mottershead: There has been speculation in the past, but it's been just that.

Mr Pettit: So nobody really knows.

Mr Newman: What might be able to answer your question is the fact that the minister has hired Norman Inkster, the former commissioner of the RCMP and the current president of KPMG investigation, security division, to conduct a special investigation into health care fraud and to make recommendations for --

Mr Pettit: Is that a result of some rather large figures being bandied about in terms of the fraud in the system?

Mr Newman: It's a matter of the government doing the responsible thing in looking at health care fraud. The minister has asked Mr Inkster to provide a preliminary investigation and to report back to him within three weeks on the scope of the possible investigation that might be needed. The minister's also requested Deputy Minister Mottershead to instruct all Ministry of Health employees to cooperate fully with Mr Inkster and KPMG.

Since 1994-95, the number of doctors registered to verify health cards by phone has increased by over 1,300 to 17,600. The number of swipe verification units in doctor's offices and hospitals has increased from 15 to 179. There are some improvements there. We've also signed agreements with the Registrar General and Immigration Canada, along with other provinces, to ensure our records are constantly being updated.

We've also worked with the RCMP and provincial and local police services to eliminate and retrieve duplicate or invalid health cards. These two initiatives result in over 14,000 corrections per month to our health care records. It's something that's very positive that's been happening. The computerized registration system was upgraded five months after we were elected. That was done to identify and eliminate duplicate registrations that have been happening.

The minister's also taken the unprecedented step of suing a US-based health care company, National Medical Enterprises, to recover the costs of alleged fraudulent out-of-country addiction treatments that took place in the years previous to our taking office in 1995. I think the NDP deserves some credit for stopping payment on these services in 1992.

Mr Kennedy: I'd like to come back to some of the questions we've already talked about in a little bit more detail. Is it possible to get a copy of the plan you have for your ministry for FutureShape? Is that something we could see for a better understanding of what is under way in your ministry?

Ms Mottershead: It's possible to share with you some of the recommendations in the phase 1 work that has been done. That particular piece of work actually resulted in my announcement of a new organization in the ministry on April 7. We are trying to work towards an integrated health system. One of the places we wanted to start the integration was inside the ministry. We moved in that reorganization to put together community services for mental health, hospitals, ambulances, public health, all under the direction of one individual.

Mr Kennedy: Would it be possible to have the actual report?

Ms Mottershead: I can give you some information. There are some elements of the report which at this point are advice to myself that I don't think I'd like to make public. I can give you some portions of it to give you a sense of the direction and what the issues around the re-engineering will be and the approach to how to do it. I'll have a look at it, see if my lawyers agree. There's some proprietary information in there.

Mr Kennedy: You paid $200,000 for the report but some of the information still belongs to Ernst and Young?

Ms Mottershead: Some of the techniques that will be used in that, and also what we call the end state of where we want to be, are in there as well, and I'm not sure at this stage there is any sort of government approval for that. It was strictly advice and recommendations that I wouldn't want to make public at this stage.

Mr Kennedy: But some of the information that has been worked on remains the property of Ernst and Young, the proprietary information of Ernst and Young. Is that what you're saying?

Ms Mottershead: Maybe that phrase is not the accurate phrase. What I'm saying is I want to be clear that it's all right to share some of that information in terms of the approach.

Mr Kennedy: In the instance of Mr Sapsford, who is your new ADM for institutional health, you indicate that he is on secondment. I gather that is from Toronto Hospital. Is that correct?

Ms Mottershead: Yes.

Mr Kennedy: What were his duties with Toronto Hospital?

Ms Mottershead: I believe he was chief operating officer.

Mr Kennedy: What salary would Mr Sapsford be paid?

Ms Mottershead: I believe that information is in the public disclosure that I made at the beginning of the year. I'll have to look that up.

Mr Kennedy: Could we have that information today? Is that possible?

Ms Mottershead: I think it's in the public disclosure. We'll look that up and find it.

Mr Kennedy: I'd appreciate that. Coming back to the nature of the agreement you have with Mr Sapsford, you say you're able to give us some clauses in that agreement on how he's protected from a conflict of interest, so he's able to act fairly on behalf of all the hospitals despite being employed by one. Are there other people who have been in his exact same position before with that kind of conflict to manage and, if so, what are some of the most recent examples of that?

Ms Mottershead: The most recent example was Mark Rochon, and before that, Mr Barry Monaghan. Mr Rochon was president of Humber Memorial and he was seconded for a period of 18 months. Mr Barry Monaghan was the CEO of West Park Hospital and he is still there. He came in for I believe a period of about 18 months and went back to his hospital.

Mr Kennedy: West Park, in my riding.

Coming back to Mr Rochon, is Mr Rochon an employee of the commission or is he also on secondment from somewhere else at the moment?

Ms Mottershead: Mr Rochon is, to my knowledge, a direct employee of the commission.

Mr Kennedy: So you're referring to his period with the ministry when he was also president of Humber Memorial, correct?

Ms Mottershead: He was with the ministry on secondment from Humber Memorial back a few years ago.

Mr Kennedy: And you will provide us with --

Ms Mottershead: I can't give you employment contracts, obviously. They're confidential records, but you are asking for what clauses are in those contracts that protect and we can make that available to you.

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Mr Kennedy: Yes, the public interest. We don't want any private information whatsoever.

Coming to another area, and Mr Newman, perhaps you could help us out here, there was a brochure put out called Putting the Patient First. Are you familiar with that? It talked about the reinvestment concept and the idea is that money that has been spent is being put back in. I'd just like to ask you about that.

In fiscal 1996-97, there were cuts to hospitals of $435 million and only a certain amount of money was put back in. Is it your contention, just to go broadly with this and so on -- there's a lot of listed money here that for the estimates purpose, for the money we're looking at right now, we're basically looking at a wash? In other words, is it your contention that all the money that's being cut is also being put back in?

Mr Newman: Yes. Actually, I think the argument can be made that more money has gone into health care, that those reinvestment dollars are getting to the patients. You talk about the concept of reinvestments. I think the word you might want to use is the reality of reinvestments. We're actually flowing those dollars to patients, over $1 billion in reinvestments, and that's more than twice what we've seen in any savings from hospitals to date.

Mr Kennedy: Then, Mr Newman, we may wish to talk about the definition of reality. In 1996-97, there was a hospital funding cut of $365 million. In the estimates the reinvestments identified are $236 million. The net loss to patient care is $128 million. Again in fiscal 1997-98, there's a hospital funding cut of $435 million and there are reinvestments of $262 million identified and we've also added in the money from one-time growth in northern reinvestment, for a total of $115 million.

A couple of points need to be made. One is that there is a $300-million gap in just over two years between the money that has been acknowledged in the estimates as being cut and the money that is being spent. Even ahead of commenting on those figures, do you consider it reinvestment when the money is announced or when the money is actually spent and available to patients and to the care system? Which would you subscribe to?

Mr Newman: I guess it depends which government is in office at the time.

Mr Kennedy: No, I was asking our own opinion, Mr Newman.

Mr Newman: I'm answering that for you, Mr Kennedy, if you'll give me the opportunity. We changed our accounting methods so that when an announcement is made, those dollars are available. I think it's significant that instead of going across the province and making announcements about reinvestments, we're making announcements and flowing those dollars. That's the difference here.

Mr Kennedy: I'd like you then to comment on the figures. I wonder if you would comment on the reinvestments which are identified in estimates, the figures I gave you, and the gap that exists, which is a $301-million difference between the money that has been cut in real terms, real time, and the money that has actually been put back in services.

Ms Mottershead: I'd like to clarify one thing. The $365-million reduction in the first year and the $435 million in the second year are theoretical numbers.

Mr Kennedy: They're in the estimates.

Ms Mottershead: No, the real number in terms of hospital reduction -- and you can have a look at the estimates because there were some reinvestments made back -- is a much lower reduction.

I want to point out that in terms of where care is given -- I mean, you're sticking with the hospitals but the reality is that care is shifting and therefore all of the reinvestments, the over $1 billion that have been announced so far by the government, more than offset the net reduction of hospitals. I just want you to know that if you were to ask hospitals what they were reduced, they would have to tell you that their overall funding did not go down by $435 million or $365 million.

Mr Kennedy: As you know, Ms Mottershead, we actually asked every hospital in the province, because your ministry, after releasing a list that turned out to be inaccurate, would not release a list for almost two months. We talked to 200 hospitals. They all were cut by significant dollars. Some of them, not all of them, had some money reinvested.

What I'd like either you or the parliamentary assistant to address for me, if you could -- the money that they receive for all kinds of programs, that the whole health system actually got last year, the so-called reinvestments, was less than the money that was taken out. Those are the figures. I'd be happy to see if there is from your ministry a list, using estimates as we have created here, of all the different money that is marked as reinvestment for mental health, for institutional health, population health and so on. We have a total of $262 million and yet the cuts this year are $435 million. I would ask if you could address that for me. Is there another list or is that the accurate compilation?

Ms Mottershead: What I'm suggesting is you can't look at the hospital vote and talk about the reinvestments.

Mr Kennedy: I want to clarify that one point -- I don't mean to interrupt, but on that singular point -- that this is not just about the hospitals, this is about the whole ministry, and all the reinvestments identified in estimates add up to $262 million. The most obvious money cut is from hospitals. We could talk about the drug program, which also has been cut, but we're just talking about hospitals, using that as one example.

It's also in estimates. It's referred to in estimates as a cut. We know it nets out differently, but that's what we're talking about here. How much money was actually put back in versus what was taken out in terms of the reinvestment for the fiscal year that we're going into and the one we just left?

Ms Mottershead: Perhaps you'd like to share your numbers, because there is no way I can confirm or deny, reject or accept what you have just said, because I don't know where you got that information from.

Mr Kennedy: I'd be happy to go through it with you. I'd be happy to provide you with the figures. What I would like to have from you, if possible, is the ministry's figures based on the estimates of the actual money that has been reinvested, put back in. We have a list here that is identified in estimates for the ministry administration: for the senior secretariat, $382,000; the blood program, $8.9 million; clinical education, $3.8 million; reversing the cut to long-term care, $37.6 million, and so on. These are direct figures from estimates taken out where they've been identified as reinvestment.

I think the public has a right to know. You spent a fair bit of money on a brochure, and that brochure tries to identify a lot of different things as reinvestments. For example, it includes things like $170 million in long-term care. We previously talked about it and I'd like to come to it again. When we talk about $170 million -- this brochure, I believe, came out in January. Is that correct?

Mr Pettit: On a point of order, Mr Chair: I would request that Mr Kennedy submit to the committee his list of 200 that he has contacted, along with the names of the people who gave him the information that he's talking about. I would suggest that --

Mr Kennedy: We have it and you're welcome to it. We've already circulated it to the media. You're welcome to have a copy, Trevor.

Mr Pettit: I'd like to see that. Does it list the names --

Mr Kennedy: But I think you're taking up a little bit of my time, if I might, respectfully, Mr Chair. I don't think that's a point of order.

The Vice-Chair: Exactly, and Mr Kennedy, it's no problem. You know that.

Mr Kennedy: Thank you. Coming back to the brochure, this came out in the early part of this year and it talked about reinvestments. But it refers, for example, to $170 million for long-term care. The actual figures in terms of long-term care expenditures, the money that was there for the agencies last year, was $735,000 less, not $170 million more. I wonder if you can help us to reconcile what has happened here.

The minister for months has been talking about -- and he made this announcement in March 1996. That was before the fiscal year commenced. We come to the end of the fiscal year and what we find out in estimates is that the actual expenditure is $2,201,237,923 and that's $735,000 less than the money that was spent in the previous year.

Your ministry told us they were putting money into long-term care, $170 million. In fact, you spent less money on long-term care last year. How can the public reconcile what you mean by a reinvestment when there is less money being spent on long-term care?

Ms Mottershead: The government put the bulk of the $170 million, over $130 million to be exact, into the budget of the Ministry of Health in 1996-97. I would point you to the chart -- that would be, I guess, page 174, it's not numbered -- where we have the actuals in 1995-96 being $1 billion. The funding was increased to $1.163 billion. It was available. At that point it was made available because once the government made the decision to provide it, as in the announcement, the money usually gets put in the budget.

It was just a question of the distribution and, in some cases, it being called for and, in other cases, getting up to speed with further announcements. I would point out that in terms of the year 1996-97, and then the extra $25 million added for this particular estimates, that brings us very close to $170 million in commitments in the actual cash requirements in this budget.

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Mr Kennedy: My point, Ms Mottershead, is that the government said it would spend money last year and did not. The government is telling us they'll spend money next year. We don't know whether that will occur. What people do know, because they've visited their local hospital, they've seen it, is that hospital has been cut. I think there are two hospitals in the whole province, both of them in York region, that actually net a few dollars more. Every other hospital has been cut. That's reality.

The long-term-care dollars you're talking about were not yet a reality at the end of last year. They take time to implement, we appreciate that, but the minister has made announcements which constitute immediate promises which haven't materialized. That's what the figures show us. We spent $735,000 less last year; none of it more. I'd like to ask you --

Mr Wayne Wettlaufer (Kitchener): -- reading those figures.

Mr Kennedy: Thank you for joining us, Mr Wettlaufer. I'd like to ask you about the home care dollars, because home care itself is targeted again. We're being promised there's going to be some money for home care, that it's going to come out.

Now, I think as you probably would acknowledge, Ms Mottershead, isn't that money that has been planned for a long time for the expansion of home care? The home care dollars that are being talked about right now, isn't that the result of a plan started under the previous government and only now finding its way to actualization?

Ms Mottershead: I think the minister has been on the record that while previous governments, including the one before the last government, did make that announcement, this government has in fact put the $170 million into the estimates in last year's budget and this year's budget.

Mr Newman: I just want to say that I think if you even look at your own constituency, Mr Kennedy, you'll see that money has been spent. I think you would have to agree that areas like York Community Services, $500,000 --

Mr Kennedy: Wrong choice, Dan. They're closing down Northwestern Hospital by October in my riding. I lose an emergency room. I lose operating theatres. I've got obstetricians having to deliver babies in one hospital and do gynaecological surgery in another.

Mr Newman: -- York West Meals on Wheels, over $43,000; Nucleus Housing, over $193,000. That's over $832,000 in your own riding.

Mr Kennedy: Well, Mr Newman, I don't know if you're aware, but some of those agencies -- the housing agency -- was promised the money twice: once by your minister in February 1996 and again in March 1997. We're tracking every single announcement to see whether the money has flowed, but there was at least an interval of 11 months and no money, not one dollar, went to house those people.

My point, to which I would appreciate the deputy's response, or your response, Mr Newman, is there is a gap here. I would suggest it is problematic at least. We'd like to know what kind of standard you're using when you send out material to try and get the public of Ontario to believe that somehow the money's going to be there in the community to deal with the cuts that are going on in hospitals. Instead, we're talking about essentially old money that's taking a long time to get spent, to find its way into the community.

What the home care organizations in this province would like me to ask you is: Is there going to be new money for home care? Because the only money that's budgeted for this year is the amount they've been told about for a long time. Will there be new money specifically to respond to the closing of hospitals and so forth?

Mr Newman: It's my understanding that the money is available and if they call for it, the money is there for them to access.

The Vice-Chair: Deputy, would you like to follow up on that?

Ms Mottershead: Yes, the money is available. The money is in the budget and part of the reason for the underspending -- and I think the Minister of Health is on the record on this as well -- is that there hasn't been, in cases where announcements have been made and services have been indicated ready to go, an actual call. I know that at one point there was a lot of frustration on the part of my minister; why weren't we getting the money out? Because he's made the announcement, the money's available, it's sitting in our budget of 1996-97. In some communities it was just that where we thought the services were actually needed, there wasn't a call on it.

In the home care area, there are a number of home care programs and we're just finalizing audits right now, moving into the CCACs example, where there has been significant underspending versus the estimate that they produced themselves.

The Vice-Chair: We'll move to the third party. Mr Kennedy, the time is up. Mrs Boyd.

Mrs Boyd: Just continuing on with this whole issue of long-term care, I had indicated to the deputy yesterday that I wanted to ask about where palliative care fit into this budget because there's no line for palliative care, at least as far as I've been able to determine.

Going back to my previous question, one of the issues for other jurisdictions, and I think particularly of Saskatchewan, when you are going to close hospitals, you have those two problems: How are you going to deal with emergency services -- and we actually had a good discussion here at estimates about the issues around emergency services and how you guarantee people that they're going to have access 24 hours a day to emergency services, at least in the rural area; I think there's still some concern in urban areas -- but the other end of it is what you do in those last days, weeks or months of life, which often tend to be the most expensive parts of the system, and how you manage decision-making around that when frankly we've got a whole community that's really very reluctant to deal with the fact that death is the end stage of life. That really is a huge problem for people.

The palliative care people say that one of the things that distresses them is that when they go to talk about palliative care, the first thing they have to do is assure people that they're life-affirming people. Those of us who've done palliative care know that's true, that it is an affirmation of another stage of life, instead of the denial that goes on.

I wonder, Deputy, if you can give me some figures about where palliative care fits and what the plans are of the ministry to move more vigorously in this area.

Ms Mottershead: You're right, Mrs Boyd, in terms of not having a line in this particular estimate, because palliative care services are provided by a number of individuals. They could be under the professional services component, and in fact a lot of them are there; they could be in homemaking, personal support. It's in all of those lines, where the initiatives are displayed.

It's hard for me, unless you wanted to know, for example, what was happening in what specific community, and to get that information from our community care access centres, to let you know exactly the total amount of spending per the estimates on palliative care.

We did have an initiative, and I believe the impetus came from your government, to actually put together a dedicated program specifically aimed at training and education for palliative care. It's about $5 million that is dedicated. It's not dispersed in terms of who provides and where it is.

I have some information here. The breakdown of that is: Interdisciplinary education, including special initiatives for the native population, is about $1.8 million of that, and the physician education component another $70,000. So you've got about $2.5 million in total on the education component.

What we also have is a volunteer visiting hospice program worth about $1 million. That is also training and it's an initiative that's related to -- a lot of this volunteer. The incredible component of this is the volunteer component, and trying to organize the volunteers and making sure they're available to serve the new cases is labour intensive. Therefore, there was an acknowledgement that we should be funding the coordination. Someone needs to keep the register that these people are willing to provide this kind of support. They need to know where the patients are and where their homes are to be able to make the connections. Quite a few of these agencies -- there are about 14 of them that we fund -- actually have a staff person who does the coordination on a local basis.

There's also $1.3 million that is provided for pain and symptom management teams, and again it's a coordinated effort. A lot of clinical activity goes on in a hospital setting and this particular initiative really deals with making sure that people know and have the best information possible on the kind of management techniques that are out there, how you manage pain. We also have a coordinating group, again, about 14 in the communities, who actually connect with the clinical teams and hospitals, with the volunteers, with social workers and the whole gamut, including chaplains, for example, and link these people together and say, "It's time to visit Mr and Mrs Jones." At this particular point in that person's life they need to have not just pain management, and therefore the clinician isn't the only one to go this time, but maybe they need some emotional support and therefore a different kind of person can go. It could be a volunteer, it could be a chaplain, it could be any number of people. That's what the dedicated program is trying to do.

I have actual information on the amount of dollars related to that: the total now, $4.9 million for those kinds of services, by region, and I'd be happy to table those for you.

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Mrs Boyd: I wonder if you could table that; that would be very helpful.

Certainly my colleague Eric Cline, who is the Minister of Health in Saskatchewan, has been very public and very clear that without their integrated community palliative care program, he does not think he could have closed 58 hospitals. In Saskatchewan, they see the open provision of community-based -- in some cases hospital-based but primarily community-based -- palliative care as one of the mechanisms to deal with the kind of population you often see in some of the small, local community hospitals: end of life, a bit of pediatrics, perhaps some minor surgery. They feel very strongly that the way to deal with this whole issue of how we deal with the end stage of life is to be very open about the need for a direct policy.

We did begin an effort towards that, but quite frankly in relation to the budget it's a very small amount. If you look at institutional budgets and the number of institutions that offer direct palliative care, they're very few and far between. There was a promise that there would be a palliative care strategy in conjunction with long-term care and chronic care. I simply urge you that in terms of the utilization of our services and the open acknowledgement that we need to look at these issues much more clearly, that is a public policy issue and it's one the ministry ought to be addressing as well as the community.

The reason it's a public policy issue is not just a question of when you try to look at budgeting and rationing of health care services, but the whole issue we're all facing in the legal field. The Morrison case in Halifax is going to bring this whole thing to a head again. It's a very different situation, a hospital-based situation. The Latimer case, the Rodriguez case, these issues are not going to go away and there will be a push towards assisted suicide and sanctioned euthanasia if we don't get our act together in terms of supportive comfort care, palliative care.

They had a seminar in Ottawa last year called Death: The Question of Choice. The federal Minister of Justice sent a representative to talk about the urgency of the legal issues, that they can't be ignored by health ministers any more. They talk about the fact that some physicians insist on aggressive treatments regardless of the state of the patient. We know that happens. We know that families sometimes insist on aggressive treatment even when a cure is not possible. We know that there are worries about legal liability, and that's even heightened with what's happened in Halifax.

What I'm urging is that this is not an issue that we can allow to just sort of not be dealt with. It's something that people are very frightened of dealing with, the end stage of life. When we have a budget for a health ministry, when we know that the highest costs happen in the last six months of life and we don't even have a line on palliative care, I think it says something for our ability to really look at how we deal with an aging population and how we deal with some of the questions, not only of older people who are in the end stage of life, but those who have had trauma, those who have cancer, those who have AIDS. Those cases are known to all of us. I don't think there would be anybody in this room who hasn't experienced that to some extent or another.

It seems to me that if you look at those utilization rates, if we keep avoiding talking about this whole issue of how we deal with the end stage of life in a way that isn't a denial stage, that's a life-affirming stage, we fall into that other camp where decisions may be made not in the best interests of patients. The discussions that we had around quality-of-life decisions of physicians in terms of the consent-to-treatment legislation become that much more paramount, because there are assumptions about quality of life for people that have no relation to patient choice and that sort of thing.

This conference came out very strongly saying that one of the issues of public health policy ought to be an effort to provide reliable community-based palliative care to every patient who requires it and that if we had that public policy position we could deal with some of these other difficult ethical issues a little bit more easily. So it's a real issue.

Getting back to the costs in long-term care, I share the concern that you say the minister has about not being able to get these dollars out the door. It is really disappointing that, given the need for community support services, for example, which were budgeted at $129 million, only $110 million were actually spent. It makes it clear why people requiring those services in communities have some suspicion about whether there's a reinvestment.

I need to be very clear about what you're saying. Are you saying that our communities are failing to follow through on requests for funding and actually communities are failing to get their services up and running so that they can draw on those dollars, or are you saying there's some difficulty at the ministry level of effectively making it clear to communities that those dollars are available? I wasn't clear.

Ms Mottershead: It's not simply a case of "Pick one of the above." It's a combination of all of those things. I know that in some communities where the services were offered and in some cases, out of that $170 million, and Windsor comes to my mind, they were offered the money early and the draw just wasn't there because the services weren't being called on.

In other situations it took a bit of time to develop the program and therefore it was a natural thing that they wouldn't be calling for the total value of a year's expenditure but only part of the year when they're able to get their professional services in place and up and running. In other cases it was I think a function of the ministry completing some of the reviews in terms of where else to make those investments based on the DHC plans. It's a combination of all of those factors.

Mrs Boyd: Moving to the population health and community services area of the budget, similarly we see there plans that frankly make my blood run cold in the public health area, which tends to be the disease prevention control area. In some areas like family planning, you are planning to lower that budget by 25%. In terms of AIDS prevention and control, you're planning to lower that budget by 10%, even though you were overspent last year, and you're keeping some of the other very difficult areas without much change. Tuberculosis prevention, for example, was underspent last year. You have allocated the same amount, but we know that tuberculosis is a growing problem not only in the cities but in native communities. I'm really quite concerned about the impact of a 13% reduction in that particular line which, for people's information, is on page 138.

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Ms Mottershead: Let me respond to that by saying that this isn't a function of actually targeting those particular areas. What it is a function of is an agreement that was reached by the chief medical officers of health in all the public health units to actually apply a new equity formula, because we did have disparities in terms of the level of spending in municipalities and public health units. Therefore, a consistent equity formula was developed and that particular initiative had the result of bringing down the expenditure level for a number of public health units -- I believe the number is about 17 -- and that's what's reflected here. It's just reducing the level of expenditure. It's not intended to suggest that we're gutting certain programs and certain areas. It's just bringing it in line.

Mrs Boyd: Can you comment on what you anticipate will happen if the municipalities are forced to assume complete control of these programs?

Ms Mottershead: I believe the government has intentions of introducing a regime to make sure that public health programs and services will continue to be delivered and fully funded by municipalities.

Mrs Boyd: How would you enforce that?

Ms Mottershead: I'm sure there will be some consideration for enforcement provisions in any piece of legislation that might come forward.

Mrs Boyd: The line on assistive devices, which is on page 154, I see it is overspent in terms of the interim actuals from the estimates last year and that you have added 6% for next year. I'm wondering, in light of the announcement that the Minister of Community and Social Services made that indicated the copayment of 25% on assistive devices for those who come under the rubric of the new plan for disabled persons, whether that has been taken account of in this figure or whether we could anticipate as a result of that seeing an additional increase in that line.

Ms Mottershead: Yes, this budget was developed before that announcement was made and there will be funding to deal with the 25% top-up that will be required from the Ministry of Health. It will go up.

Mrs Boyd: In the area of long-term care, where we see underspending is most noticeable in the community services part, and we talked a little bit about that, I'm curious as to how we can ensure that those community-based services that are not currently getting the money you have allocated for them -- what do you see the ministry, in conjunction with its communities, doing to actually get those up and running? With the urgency that is expressed, quite frankly, in all of the restructuring reports, and certainly the public urgency around having those services available, I'm wondering whether there is a strategy to overcome this difficulty you seem to be having in getting these services up and running.

Ms Mottershead: Certainly with the introduction of the community care access centres and the fact that they pretty well all became operational on April 1, I think that will be the vehicle that will make sure the services are in place and they are well coordinated. The funding will be directed to them and in the future they will purchase these services on behalf of the community residents who need them. That's the vehicle, I think. They all know exactly what their requirements are. They have all had to submit plans to the minister responsible for seniors' issues. That whole process is going to expedite and facilitate the provision of services.

Mr Bill Grimmett (Muskoka-Georgian Bay): I'd like to ask a question or perhaps ask for a comment about organ donation and organ transplants. While I've had a lifelong interest in this issue myself as a result of enthusiasm for blood donation and organ donation that my father had, I have also received a letter recently from a constituent. I'll paraphrase so that I can set the tone for the question I have. I won't reveal the name of the constituent but I'll just read part of the letter. You may have heard similar letters from other constituents.

"The specific situation referred to is the severe shortage of human organs for transplantation purposes. Every day in this province, people are dying from various accidents or illnesses and their organs are being buried with them when in many cases the organs could be transplanted into a needy person's body and save lives. The major reason for the supply-and-demand problem facing the medical profession and its patients is quite simply that the number of people volunteering their organs is far less than the number of people requiring a transplanted organ.

"The medical profession in Ontario has made such marvellous strides in the past decade in the field of organ transplantation that the potential for saving lives is real compared to the options available 10 or 12 years ago."

This constituent goes on to say, "This matter involves me directly as I'm currently on the transplant list."

I know from my own experience both as a regular blood donor and also in my rural law practice, where I had the opportunity to discuss the possibility of organ donation with people when they were contemplating their wills, that there really isn't a very high awareness in the general public of this issue. In fact, I've been surprised at the lack of understanding and the lack of consideration that people even give to whether they will make a donation.

I don't know whether you're aware of this, but I think it's a less visible process when you use your driver's licence now because the cards that are being issued by the province are sort of credit-card style cards and there's a separate document that deals with the organ donation.

I have gone through the estimates book in preparing, and I may have missed something, but I can't find any specific references to the issue. I've tried to find items in the estimates that might relate to that, and perhaps you can help us as to whether that's tracked.

I wonder if you would mind, Mr Newman, or the deputy minister, providing us with perhaps some indication of the policy direction that the ministry is taking on this issue and perhaps also some advice on how I might respond to my constituent who has asked just what we're doing.

Mr Newman: Thank you, Mr Grimmett, for the question. I'll have to refer that to the deputy minister.

Ms Mottershead: We have been working with the Ministry of Transportation on the issue of the card. Also on the new health card, the replacement card, there's a swipe, the bar at the back of the card, where we have agreed we would be storing the information for the organ donation. It is not as simple as it was in the past, where you did have a separate document, you signed it and put it in your wallet and generally people knew that it was with your driver's licence and knew where to go for it.

The MORE program, which does all of the coordination in the area of transplantation, has recently had a new chair in the person of Graham Scott. There are plans to actually increase the educational component to do more targeting. With the changes that are coming down in terms of truck safety and so on, I believe some efforts are going to be made as well in that particular strategy to do some communications. That's about all I have to say for now, unless you have more, Mr Newman.

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Mr Newman: I just wanted to let you know, Mr Grimmett, that in March of this year the minister made an announcement of an $11-million reinvestment for dialysis and kidney transplant. That was made in Hamilton. I'm sure the members for Hamilton Mountain and Wentworth East --

Mr Pettit: North -- East.

Mr Newman: I was right. East.

Mr Ed Doyle (Wentworth East): Are you trying to confuse me?

Mr Newman: No. He is from Wentworth East, I know that. They may be familiar with those announcements when they're made in their communities.

Ms Mottershead: Can I just say, though, that it is a public education problem. People who are so distressed at having that kind of fatality happen, really their first thought isn't one to produce consent for organ donation, so it has to be a really critically placed education program.

I must say that the other provinces in Canada are feeling the pinch a lot more than we are in Ontario, so much so that a number of provinces, both east and west, have tried on several occasions to put the issue of organ transplantation on the national agenda, because they want a registry and they want our organs.

We have a population base that's really sustaining whatever transplants we can, but in the smaller provinces it's a difficult question. We do share organs, because there is a national list and we know when patients need it and that is all well coordinated, but they wanted to be a lot more aggressive so that they could have more from Ontario than what they're able to sustain right now.

The Vice-Chair: Mr Grimmett, a follow-up or not?

Mr Grimmett: No, that's fine. Thank you.

Mr Wettlaufer: I would like to ask a question on mental health. You may or may not be aware that in Kitchener we are having an increase in the number of mental health beds. It's actually a transfer from London to Kitchener. Obviously my riding is not the only one where this is taking place throughout the province.

What is it costing us -- do you have the numbers? If you don't, it's okay, if you could just send them to the committee at a later date -- to actually transfer those beds from an area to the home area, where the patients want to be, where their relatives want them? There's that added security because they have their relatives near them, and their friends of course. What is it costing us as a government for that?

Ms Mottershead: I'm not sure if I can answer that question because there's a cost related to perhaps the creation of beds, and depending on which hospital you attach those to, whether there is capacity already, some in-bed capacity, that you could redesignate some of those beds and therefore you wouldn't have a cost. It's just transferring, then, the amount of money that was identified and used in London, for example, in moving it to have the services in Kitchener-Waterloo.

It's a function of, is there capacity in the system to designate those extra beds? If not, we have to perhaps create some physical plant to do that. How much would that be? I don't know. The planning process for that whole thing will start, given the directions of the commission, and we'll be in a much better position once we do the functional program, visit the hospitals and see what the capacity is, to give you that information. But we know what it costs to staff and operate a bed, for example. That will be the same whether you're in London or in Kitchener.

Mrs Boyd: A point of information, Mr Chairman, if I may. I was at the announcement of the final report on the restructuring, and the commission made it very clear that the operating costs will follow those patients from London and St Thomas but that the capital costs, if any are required, would have to be looked at in the context of those areas when the restructuring commission reports in those areas.

The $190 million they have recommended for the London-St Thomas area does not include capital costs that might or might not be connected to Kitchener or to Windsor. They were very clear about that. They couldn't give an estimate because they hadn't done that work with the communities in Windsor or in Kitchener-Waterloo.

Mr Wettlaufer: A follow-up: These changes are planned for this year, so we are not booking anything on our expenses unless we have actually spent it -- not what we've committed, but what we are spending. Correct?

Ms Mottershead: The current estimates that you have in front of you in this blue book are cash estimates, so it's the cash requirements for this year. In terms of the budget, the government has in fact booked -- and it was our estimate -- $850 million based on decisions that had been made by the restructuring commission and anticipated directions. So although you may not have here the full cash requirements, they are booked. When the bills come in, they will be paid, and if it's more than what we have in terms of cash, the cash will be provided.

Mr Wettlaufer: I thank you, because I think there has been a fair amount of confusion this week and last week over the numbers, especially in so far as what is booked and what isn't booked. That has led to some embarrassment, I believe, on the part of the Liberal health critic. So thank you.

The Vice-Chair: That's a little bit of editorializing. I'll let you get away with it. Go ahead, Mr Wettlaufer. Anything else?

Mr Wettlaufer: No, that's fine. Thank you.

Mr Beaubien: We can talk about Toronto hospitals and London hospitals, but I'd like to talk about underserviced areas. I think the Health Services Restructuring Commission has three key ingredients: affordability, accessibility and quality of care. When we look at accessibility of health care in an underserviced area, it's very difficult to qualify. At what level you access health care is a question I'm not going to debate here, but I'm sure it's not at the same level that we would receive in London or Toronto.

We've had a plan for underserviced areas since -- what? -- 1969, some type of plan, and I don't think we have been very successful. I could be wrong and my comments may be somewhat biased, but I can only go by what I experience. Mr Kennedy visited my area not too long ago and I didn't see any concrete solutions to the problems we're experiencing coming from him.

The reality of the difficulty is that in most underserviced areas the physician population is aging, and we cannot seem to replace the aging physicians with younger ones. Furthermore, I think this government, and quite rightly so, has embarked on a program whereby we are pushing for the nurse practitioner.

I'll give you an example with the North Lambton Health Service whereby they were able to hire a nurse practitioner for six months on contract but they did not have enough funding to hire her for 12 months. That particular individual would have been able to access employment in Toronto for 12 months on a contract, yet I don't think Toronto can be classified as an underserviced area. So we're getting a double whammy over here: Not only can we not attract physicians in underserviced areas but we are competing with overserviced areas to attract nurse practitioners.

We have had a plan in place since 1969 which I think has failed small rural areas in Ontario tremendously. How do you envision to rectify the problem in the future?

Furthermore, I would also point out that we are graduating doctors -- I'm told that in the province of Ontario we have an oversupply of doctors, yet nobody has seen fit to close a medical school anywhere. So we're shipping them or exporting them to the States or wherever. How do you rationalize this difficulty that we're experiencing in rural Ontario?

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Ms Mottershead: I think Mr Newman can answer that one.

Mr Newman: I'll take this one. I appreciate the question. I too was in your community last week.

The minister, since we were elected in 1995, has announced a number of initiatives to help rural and northern and small communities with recruiting and retaining doctors.

Included in that is a $70-per-hour sessional fee for working nights, weekends and holidays for physicians providing emergency coverage in selected northern and rural southern communities.

There have been the community-sponsored contracts to ensure physicians' annual salaries and benefits to work in small, remote northern communities that need one or two physicians.

There has been the expansion of the community development office or project in northeastern Ontario, whose role it is to help match communities recruiting physicians with physicians looking to establish practice in underserviced communities. There has been the establishment of a physician job registry to identify and help match communities looking for physicians and physicians interested in moving.

There has been the medical services corps, which is being implemented pursuant to the December 1996 interim agreement between the OMA and the Ministry of Health. The corps will have up to 20 physicians providing locum support in small rural communities in Ontario as well as covering temporary vacancy needs in underserviced communities.

Mr Beaubien: Mr Newman, I'm impressed with this really, but how many underserviced areas have been upgraded to overserviced areas since all this hokey-pokey stuff has been introduced? That's my question.

Mr Newman: It's funny, because --

Mr Beaubien: I know we're trying to make it work, but I don't think it's working.

Mr Newman: Well, I think --

Mr Beaubien: When we talk about trying to attract physicians --

Mr Grimmett: On a point of order, Mr Chair: The questioner is badgering --

The Vice-Chair: I can handle it from the other side. I don't know how to handle it from this one.

Mr Newman: Now I'm really confused.

Mr Beaubien: So am I.

Mr Doyle: Now you know how I feel.

Mr Newman: I have the member for York South, Mr Kennedy, in the Sarnia newspaper saying that Harris is breaking the logjam, we do need change, and my own member saying that, but --

Mr John C. Cleary (Cornwall): Your own member is right, you know.

Mr Beaubien: It could be perception for Mr Kennedy, but it's reality for me.

The Vice-Chair: Would you allow Mr Newman to answer. Go ahead.

Mr Newman: I guess I am going to refer it to the deputy, but when these things get into place -- obviously the problem has been identified. We are taking action on it, and I think it's appropriate action. Sometimes it takes time to actually see the results. It's not that we're not doing anything about it. We are taking decisive action, and I will let the deputy provide you with the specifics about that.

Mr Beaubien: With all due respect, let's come back to the nurse practitioner in the town of Forest, where the Rotary Club had to make an undertaking to pay her for six months of her salary -- it is an underserviced area -- yet this individual could have worked in Toronto where no service club would have had to undertake to pay six months of her salary because it would have been guaranteed by the hospital. Where is the fairness in the system? This is not about politics; this is about health care. I'm sorry, but I want to know.

The Vice-Chair: Deputy, a quick answer if there is one.

Ms Mottershead: In terms of underserviced areas becoming overserviced, we have made great strides in actually making sure those communities are up to complement, and we would be happy to share that information with you.

One of the most significant measures, however, in terms of making sure we continue to try and get people to move out into the underserviced areas is the 25% reduction that is going to be applied to all those folks who graduate in July, 500 of them, when they come into the system. That's a disincentive that works to become an incentive to relocate in communities that really are undersupplied.

The Vice-Chair: Thank you, Mr Beaubien. It's the official opposition's turn, but I don't know if you want it, or do you want Mr Beaubien to continue?

Mr Kennedy: I think we'd be willing to share some time with Mr Beaubien.

The Vice-Chair: Mr Kennedy, will you continue, please.

Mr Kennedy: We'd also like to thank Mr Wettlaufer for his assistance. Mr Wettlaufer brought up the point I was making earlier when he wasn't here, which was that the ministry is not spending the money they are claiming to reinvest. We've demonstrated that's true in a number of areas. I'm quite willing to table -- and I'd like to have that reciprocated; I wonder if I could get a commitment from the ministry. I have here our estimates of the reinvestments for this year and for last. The gap between that is a total of $300 million. So let's not talk about more money being put in; there's less money in the system, according to estimates. You can go through every single page. The reinvestment money is identified to the satisfaction of Mr Wettlaufer and a whole bunch of people who can read these.

In the final analysis, that $301 million is a huge credibility gap for this whole government, because it explains things to each of the communities. It explains things to Kitchener. For example, in long-term care, where you spent $735,000 less, a year after -- March 28; I have a copy of the media release here -- the minister said it was a massive increase in spending. The deputy said the communities didn't want that money. But in point of fact, in the previous year, in 1995-96, this press release from the Premier's office indicates you removed $33 million from the health budget for long-term-care expansion, and you're only putting it back this year.

Will you table a set of figures to show how much money was actually spent under reinvestment this year and last year? Will you do that? You will have my figures. Will you do that?

Ms Mottershead: I think that's an answer for the Minister of Health, and you can ask him about that.

Mr Kennedy: Parliamentary Assistant, would you be able to make that commitment?

Mr Newman: I will bring that to his attention.

Mr Kennedy: I will say clearly that the $301-million gap is a credibility gap that you're welcome to address if you can, but that is $301 million less money spent than the money that has been cut from hospitals, and we don't even touch the drug program, although we will in a minute or two. I'll leave you that as a bit of a challenge, and Mr Wettlaufer is welcome to compile his own figures if he can.

In the instance of tabling figures, Deputy, I wonder if you're aware of the salary that I asked for earlier for your seconded assistant deputy minister. Was that information provided to you?

Ms Mottershead: The information that was provided was from the previous -- it's not current.

Mr Kennedy: Are you in a position to divulge Mr Sapsford's current salary?

Ms Mottershead: No, I'm not.

Mr Kennedy: Okay. We'll have that at the end of the year, then?

Ms Mottershead: That's what I'm suggesting will happen through the sunshine legislation.

Mr Kennedy: I want to talk to you a little bit about your own ministry administration again. Earlier this year in public accounts I asked you a point-blank question about the advertising program, whether there would be a ministry advertising program on television. You told me at the end of February that you didn't know what I was talking about, that there would be no such program. Less than two weeks later there were commercials with the Premier on TV in hospital corridors, Ministry of Health. I'm wondering if you could tell me, were you unaware at that time that those commercials were going to be aired? How much of that money was spent from your ministry's budget last year? What was the reason you gave me the answer you did in public accounts earlier this year?

Ms Mottershead: If you look at the Hansard for that particular session, you asked the question in an interesting way; let me put it that way. Your question was, "Are these three ministries working on these programs?" I can't recall it exactly, but it was the way you asked the question that led me to answer that I wasn't aware that there was this three-ministry thing. I was certainly aware that we were doing something in the Ministry of Health, but I wasn't aware of these other things. It was the way you asked the question, Mr Kennedy, that led me to answer it that way. I think you'll go back to the record -- I certainly have -- and know that you asked it in that context.

Mr Kennedy: Could I have the answer, then, today? How much money was spent by your ministry on television ads last year?

Ms Mottershead: It was a few hundred thousand dollars. We have that information.

Mr Kennedy: Where would we find that in estimates, that allocation?

Ms Mottershead: It's "Ministry Administration." It's in our "Communications Activity."

Mr Kennedy: Could I possibly have a commitment to get the exact expenditure? Would that be in order, to have it provided to this committee?

Ms Mottershead: Yes, we have it. I think it was an order paper question too.

Mr Kennedy: I beg your pardon? Do we have that?

Ms Mottershead: It was an order paper question?

Interjection.

Ms Mottershead: Yes.

Mr Kennedy: I'd like to turn now to the cuts to the drug program. Over the last two years the ministry, through the copayment program, has cut $225 million from drugs for seniors. That $225-million cut was meant to be taken up by the seniors paying out of their own pockets. That was done as a cost-saving measure: $100 million, we're told, could come back in next year. That still leaves $125-million loss to the drug program. Again, when we talk about reinvestments, we don't know if that money's really going to be spent.

I wonder why, in cutting that much money from the drug program, other plans for saving money in the drug program weren't looked at first or -- I shouldn't presume that -- if they were, why they weren't implemented ahead of taxing seniors with that kind of user fee. The Ontario Pharmacists' Association gave a report at the finance and economic affairs committee that suggested nine cost-saving measures that would save your ministry between $197 million and $417 million annually. I'm wondering, what has your ministry done --

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Mr Wettlaufer: On a point of order, Mr Chair: I don't know where the Liberal health critic is getting his $125 million that's coming out of drugs but, for the record, he is comparing interim actuals and actuals, and the interim actuals aren't known by the ministry when they prepare their estimates. So you can't mix apples and oranges.

The Vice-Chair: Mr Wettlaufer, with all due respect, if you allow him to follow through, he may be able to clarify that.

Mr Wettlaufer: He had that clarified last week.

The Vice-Chair: Thanks, Mr Wettlaufer. Continue, Mr Kennedy.

Mr Kennedy: The money that has been cut continues this year. We've got at least a $165-million overall reduction happening over the last two years. We have a program reduction. Incidentally, it says here they're going to spend $45 million more for the Trillium drug program, and in point of fact only $18 million out of $75 million was spent. This is over in the reinvestment brochure. That's what was publicized; what happened was different.

But I'd like to come back to my question. The Ontario Pharmacists' Association said you don't need to tax seniors, you don't need to put the user fees on them, that there are other ways to save money in the drug program. I'm wondering if those have been looked at, evaluated. Have they been rejected? Are they possibly in process? What has been done with those particular suggestions that came forward from Ontario's pharmacists?

Ms Mottershead: Certainly we did look at a number of options. I don't think it's news to anybody that Ontario was the last province to actually require a contribution to this plan. We weren't leading in terms of introducing cost-sharing; we're actually lagging behind.

A number of other alternatives had been looked at. I think there are some good suggestions from the Ontario Pharmacists' Association. We actually have established, with the Ontario Pharmacists' Association, a joint liaison committee, and all of the issues that you'd be aware of are being put at that table. We're actually going to be doing some joint initiatives to deal with the question of better medication, for example, more education, and other measures to better deal with the question of utilization and appropriate medication. So we are looking at those initiatives as well.

Mr Kennedy: Is there any kind of target date for when those will be evaluated, some kind of action plan that might be forthcoming? Is there anything you can give us on that today?

Ms Mottershead: No, because the committee is doing some work. The traditional process is we would bring the ideas to government. The government makes a decision and then announcements will be made. So I'm not at liberty to predict when all of this is going to happen or what it's going to look like.

Mr Kennedy: I'd like to focus a little bit on some of the problems. There has been a lot of talk about expanding the drug formulary. Are there specific measures in place to make sure that the new drugs that come in don't just end up being more expensive drugs than the ones that are already on the formulary and that are therapeutically equivalent? Do you have good safeguards to prevent that from happening?

Ms Mottershead: I think the member will know that we have a very rigorous process when an application is made by a pharmaceutical company to put a drug on the list in the formulary. There is a requirement to produce pharmaco-economic analysis that actually requires the companies to look at the product that's on the formulary now, look at its efficacy, and look at the cost of the current drug versus a replacement drug or a newer drug. That documentation is pretty rigorous, and we require companies to do that. There are companies that are not as rigorous in that process, and we don't accept their drug on the formulary until that is done and until the DQTC is satisfied that that process has been gone through.

Mr Newman: I just want to add that we've added 460 drugs since 1995.

Mr Kennedy: Yes, we're trying to get at that exact thing. Some of the drugs that have been added, according to pharmacists, must have slipped through some kind of process. Let me give you an example. Biaxin is an antibiotic that recently was added to the drug formulary. Each pill costs $1.50 and it's taken two at a time, twice a day. But already on the formulary was erythromycin. It's available generically, does all the same things as Biaxin, according to the pharmacists we're talking to; it costs five cents and it's taken four times a day.

None of us in our lay capacity is going to be able to address it, but how is it possible that pharmacists in the province -- and I have more and more examples of this -- believe you're adding more expensive drugs? What other additional safeguards could there be? Would you look into this list of drugs that pharmacists have provided that suggests more expensive drugs are being added that don't add therapeutic value?

Ms Mottershead: I mentioned the pharmoeconomic guidelines in terms of making sure the product is cost-effective. The other side of that is the quality side. The Drug Quality and Therapeutics Committee is responsible for making sure it's quality. In some cases, you have to do the tradeoffs and you have to go to a higher-cost drug because of its effect, because its formulation is much better than the very cheap drugs there now. I don't want to get into the specific product lines because I don't think that would appropriate for the committee to address here.

Mr Kennedy: What mechanisms do you have for the prescribing habits of physicians? What do you have in place to make sure they use the least-cost alternatives, where that quality isn't an issue? What do you make sure happens there?

Ms Mottershead: We have a number of guidelines that have been developed already. They get circulated to all the physicians' offices. They become part of the formulary binder. We've turned the formulary now into a binder so you can easily slip in guidelines and all of that. We'd be very happy to table here the guidelines that have been sent out to date.

Mr Kennedy: To the Deputy Minister or the parliamentary assistant, I understand it's not legal in Ontario to replace an expensively prescribed drug that's not on the formulary with one that is so that the patient doesn't pay. If it's not in the formulary you can't make that substitute. Is that correct?

Ms Mottershead: That's right.

Mr Kennedy: We hear that there's a request in the pharmaceutical industry to change that. Is there any consideration being given at all to change that substitution capability on the part of a pharmacist?

Ms Mottershead: There have been discussions, but that's all I can say at the moment.

Mr Kennedy: Okay. I'd like to come back to -- we had some discussion before that there's only been one study done about the impact of the cuts to seniors and drugs; it looks only at the gross use of drugs. One of those findings was a 20% reduction in arthritis medication, in the anti-inflammatory section. Is there a follow-up happening? We asked a little bit before about what would be occurring with the agency that produced that report. Are you as a ministry concerned when you see those things happening? It's a first-year program, it's brand-new. Do you have other methods of picking up the impact on seniors than just looking at the top line of how many millions of pills were moved and so on? Will you also be following up the identified concern they had about psychotherapeutic drugs, which went down dramatically?

You may recall that I cited before a study in New Hampshire which says it could cost the health system even more money, because that's what happened there; they ended up using other, more expensive parts of the health system. In addition to the concern for people, it could cost you money. Is there follow-up, specifically by your ministry, on some of those specific things that come out of the ICES report, and what form might that take?

Ms Mottershead: There was immediate follow-up to the ICES report. As part of that follow-up, one of the things we had discussed with ICES is the methodology they used to lead to the conclusions they did. We had some issues with them on that front.

We will continue to monitor. We are monitoring right now. ICES will have an even bigger role in doing that kind of follow-up, because it's very important. It's not just on the effects of cost-sharing or anything else; it's the effects of drugs, and the drug program as a result, on a restructured health care system, when you move from hospital into a community setting or into long-term care. We've asked them to actually do a comprehensive analysis of all of that, and they're doing it.

Mr Kennedy: Who is responsible for what the minister said was a mistake in double-billing seniors for their copayment last year? How did that mistake happen? The minister said he was happy to apologize for the fact that a mistake had been made; that seniors had been charged twice a $100-deductible in the course of eight and a half months. The government has decided after some pressure from seniors and from Liberal members of the Legislature to change that to make it a four-month exemption next year. How did that happen? How could seniors have received that treatment from your ministry?

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Ms Mottershead: I believe it was an oversight. I don't think it was an intended mistake or error. What happened was that the program was intended to start earlier, but a number of reasons, including an OPSEU strike and not having the people there to do all the system changes and processing and so on, created that lag in terms of July, and the system wasn't changed to reflect a shorter time frame.

Mr Kennedy: The harm to seniors -- seniors' organizations wrote to you and to the minister, probably more specifically, in April -- was apparent. Many people were surprised to be paying their $100-deductible -- most of them who use medication had to pay it almost all at once or all at once. It is not unusual to see people paying $1000 a year for drugs now under this system, but that $100 coming at once as opposed to $6 at a time is really the big hit.

It came at them a second time, yet nothing was done about it for 71 days. What kind of safeguards are there in the system? You have a new program like this. It affects some 900,000 seniors, many of whom by definition, if they're using the drug program, have fragile health. How could that happen in terms of how we manage the implementation of that program?

Ms Mottershead: We are issuing an RFP again to bring in some technical expertise to help us on the computer side to make sure we do have the necessary flags on the system. That tender is going out in the next 10 days. That's one mechanism. I think we should be using our computer network to our planning advantage. Certainly if that flag had been raised through that mechanism we probably would have dealt with it sooner.

Mr Kennedy: I'd also like to ask you about the situation for nurse practitioners: Do we have a date when nurse practitioner legislation will be brought forward? Is there a concrete timetable for knowing when that will be passed so underserviced communities like Mr Beaubien's can have more ready access to them?

Ms Mottershead: No. I don't have that information, sir.

Mr Kennedy: There is no such date?

Ms Mottershead: I said I don't have that information. I'm not aware. I don't do direct negotiations with House leaders. As you know, that's a political process.

The Vice-Chair: Thanks very much, Mr Kennedy. There are 15 minutes left in the day. Ms Boyd, would you like to use them?

Mrs Boyd: Yes. I'd like to talk about the drug program as well. I'd like to ask you a few questions, if I could, Deputy. You and I have a fairly lengthy experience around this issue of trying to cope with the drug issue. One of the things I've always been curious about: I wonder if you could explain to us why one of the mechanisms this government used to deal with some of the cost overruns was not a first call on insurance, where people have access to insurance, as opposed to the user fee?

Ms Mottershead: Certainly the Trillium drug plan works on that principle. I think part of the consideration was the fact that we are dealing with a seniors population. They're not employed, and some of them, if they were employed, never did have benefits packages that dealt with supplementary insurance. Therefore, you're dealing with a different set of issues there and a different population.

In the Trillium program, which is anyone to the age of 64, until they become ODB-eligible, you have a population that is employed, where the prospects of having an insurance plan is a lot greater than those who are age 65 and over. That's one of the considerations.

Mrs Boyd: But we all know that there are many seniors who do, as retirees, have insurance coverage from the companies they worked with. Or did the insurance companies simply not carry through with insuring retired people once the Ontario government was picking up the Ontario drug benefit for seniors?

Ms Mottershead: On the $100 deductible, for example, there's nothing there, in terms of policy or otherwise, that precludes a senior from going to their insurance company and saying, "Contribute to this," and getting reimbursed for that. A good portion of them are doing that, those who do have those plans. That's certainly --

Mrs Boyd: It's the same for the $6.11 and the same for any drug they're taking that's not on the formulary, so if they do have an insurance plan there is some protection for those who are otherwise insured against those additional costs. Do you have any estimate of how many people that would be in terms of the numbers who are covered?

Ms Mottershead: No, I don't have that information. It's not something we ask for in terms of their --

Mrs Boyd: There is just not the mechanism the way there is in Trillium.

I have a question about the special drugs program. In the estimates it is well overspent -- not quite double, but well overspent -- in terms of your interim actual for 1996-97, yet the amount remains the same for next year's estimates as it was in last year's estimates, the estimates for both years being $45 million and the interim actuals being over $82 million. Can you tell us first of all what that line is? What are those special drugs? If they are, as I suspect they are, some of the extraordinary, catastrophic drugs provided for people, particularly in hospital, I assume, do you expect there'll be an overrun in a similar fashion next year?

Ms Mottershead: We have the list of drugs. It's quite common and public in terms of what they are. The people who are on them, including AIDS and so on, are aware that this is a special program for them.

The reason the budgets have not been adjusted is because in this particular vote you can allow for the movement of funds between lines. If you look at the Trillium drug plan, we had estimated $75 million; we only spent $18.9 million, almost $19 million. We've protected that $75 million; we hope there will be more takeup, quite frankly, so the money will be there for that. In the special drugs, the budget line was $45 million, the expenditures $82 million, and we've kept it at $45 million. The basic bottom line there is that the combined budgets of the special drugs program and the Trillium drug program is $120 million. The interim actuals amount to $90 million. So there's still flexibility and there's opportunity for growth in expenditures in both those categories. Just look at that as a combined program.

Mrs Boyd: For catastrophic drugs, in the special drugs program, I have had particularly AIDS sufferers but people in other categories in my office saying they have to be on the Trillium drug plan rather than the special drug plan, even though special drug plan has covered the same medication for another person. Is that the case?

Ms Mottershead: What we have done in the special drugs program is that we have frozen the drugs on that list, so as new drugs are available they are on the other plan. What we're doing, basically, is allowing more people who have specific conditions to enter the program for the drugs that were there and take advantage of that, versus trying to cope with adding more people and more drugs when we have the Trillium program.

Mrs Boyd: So the new drugs they're putting out for Parkinson's or MS or the new drug cocktail for HIV will gradually, especially for new people, be on the Trillium plan as opposed to the other plan. Is there any cost-sharing in the special drug plan?

Ms Mottershead: No, there isn't.

Mrs Boyd: So the costs will also shift to new patients who are on new drugs.

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Ms Mottershead: New patients on new drugs, but not new patients on these drugs that we have in the special program.

Mrs Boyd: I know that part of the reason the Trillium drug plan was undersubscribed, if you like -- the minister talked a little bit about this -- was the administrative difficulty the plan had this year. All of us who are members have had people in our offices talking about having to lay out huge costs for drugs for six or eight months before they began to get reimbursed from the Trillium drug plan.

I notice that you increased the salary line in this area fairly substantially over your estimates, but I also see that you've reduced the salary line for next year. Yet I suspect the numbers of people going on the Trillium plan are no lower, may in fact be higher because of unemployment and that kind of thing. Can you comment on whether you think you're going to find yourself having the same administrative incapacity to deal with the demand next year that you obviously had this year, that the minister has admitted you had this year?

Ms Mottershead: On the salaries and wages line, we had our budget. The interim actuals show an increase of over $1.1 million, and that's because we hired a lot of people to try and deal with the question of backlog and get us back on track. We are almost there now. We believe that going back to original level will keep the program going.

We're pretty confident that most of the kinks have been worked out and that the backlog is complete. The turnaround time now is very good; we're at less than a month in terms of the whole process -- unless there is a huge blip somewhere, and then we will deal with it in the same way we did this year, by moving very, very quickly to put the resources into play to make sure there never again is that kind of backlog or problem.

Mrs Boyd: For those who are now are on the program, the shift from the one fiscal year to the next seems to have moved fairly smoothly. We certainly got reports of that from people who had problems last year who were delighted that they didn't go through the same thing this year. I think you may have resolved some of those problems.

Ms Mottershead: Those were some good suggestions that came from the community and people giving us some ideas on how to do it.

Mrs Boyd: Have you been able to deal with this issue of people whose incomes drop like a stone? The old application was based on the taxable income from the year before but they've suddenly become unemployed because of their illness, they have no income, yet their deductible is based on the income they were earning at the time rather than moving that to an annual basis that moves along. Are you getting control of that?

Ms Mottershead: I know staff are looking at that. We're trying to find a way of dealing with it. You know that the information we have is a year out in terms of their income.

Some of the ideas coming forward: What's another appropriate verification mechanism? You can't just have people walk in and say, "Boom, my income dropped and I'm here." There has to be some evidence of that. It could be a letter from an employer, for example, or the letter of termination of employment. We're trying to figure out what works best in terms of maintaining the integrity of the program but also dealing with the real needs that do crop up like that from time to time.

Mrs Boyd: The utilization of drugs was part of the issue, in terms of trying to get the Ontario drug plan into, first of all, a fashion that that could be tracked for people. A lot of the concern from seniors and from physicians was the overuse or the inappropriate use of drugs, the mixture of drugs and so on. Has that problem eased with some of the computer capacity that's there and some of the education that's been done about that?

Ms Mottershead: Tremendously, because we do now have the flags. We know when there is a contra medication indicated, and pharmacists are able to intervene right away. The thousands and thousands of interventions that have been created as a result of the system have had very positive life outcomes. I can't say directly, "We saved so many lives," but I can tell you that stopping someone from taking a medication that was not going to be complementary to other medication they already have from another physician has been tremendous. It's ranged from small interventions to pretty serious ones. We're really quite proud of it.

Mrs Boyd: Can you confirm that most of the things that were delisted from the drug formulary during the last government's time were delisted because of the concerns of overuse of things like laxatives and some of the drugs, on the advice of the committee?

Ms Mottershead: Some were. I don't have the lists that I can actually say they all were that way, but there were some, like laxatives, that definitely were.

The Vice-Chair: Thanks very much, Mrs Boyd. When we reconvene on Tuesday, you'll also have five more minutes to finish your 20-minute time slot.

Mr Grimmett: Could we perhaps take a few minutes to discuss how we're going to deal with the remaining time, Mr Chair? Is it the wish of the committee that we deal with the some 50-odd minutes left for health?

The Vice-Chair: With Mrs Boyd's five minutes, we have 60 minutes. We have one hour left, approximately 20 minutes per caucus. We have a few minutes to discuss that. Any suggestions?

Mr Grimmett: Can I suggest that we do the hour remaining on Tuesday? I understand that Mr Newman is going to be back with us on Tuesday. Is that correct?

Mr Newman: Yes, it is.

Mr Grimmett: I suggest we deal with that on Tuesday and then adjourn and start the next review on Wednesday at 3:30.

Mrs Boyd: Can I suggest that we not meet on Tuesday if the minister is not available?

The Vice-Chair: We've got two differing points. Let's solve them simply through a little bit of discussion first, before a vote. Anyone?

Mr Grimmett: I don't know about the availability of the minister, to be honest with you. Our preference would be to deal with the health matter on Tuesday and get it finished.

The Vice-Chair: Clearly, as the Chair, and an impartial one, it was my understanding -- and I asked the question of the parliamentary assistant -- that the parliamentary assistant was going to be here today. I thought the minister was going to be back on Tuesday.

Mrs Boyd: So did I.

The Vice-Chair: Deputy, could you --

Ms Mottershead: I don't have any knowledge of that. I'm sorry.

The Vice-Chair: Might we suggest a motion be placed that we not meet on Tuesday if the minister isn't available?

Mrs Boyd: I so move.

The Vice-Chair: Any further discussion? All in favour? Opposed? It's defeated.

A second suggestion, Mr Grimmett.

Mr Grimmett: The suggestion is that we finish the health ministry on Tuesday and commence with the next office for review on Wednesday at 3:30.

Mr Kennedy: We want to get in as many of the estimates as we can. I think we're prepared to stand down for the availability of ministers. Is the Premier planning to attend? Is he the next estimate up, or is there someone else?

The Vice-Chair: Yes, it's the Premier's office next.

Mr Kennedy: Is the Premier planning to attend on Tuesday?

Mr Grimmett: I haven't been advised. I don't know.

Mr Kennedy: It's unfortunate we don't have that information.

The Vice-Chair: The legislative committee has written the Premier and advised him that it's going to be Tuesday. He hasn't responded. Having that knowledge --

Mr Grimmett: The office can be here, but I haven't been told who is going to be here for the Premier's office. Our preference is to not have two offices and their staff tied up on the same day. We don't know what time the meeting is going to start, what time we're going to get to the next office. I believe, from what I'm advised, that in the past it has been fairly common to deal with one ministry, complete it, adjourn for the day and then commence, the following day, with the next office.

Mr Kennedy: We could maybe do a friendly amendment, but we have to go back to the Legislature to get -- we could use the extra hour and a half on Tuesday for health. There has been a lot of useful progress with that. I know Mr Beaubien would appreciate the facility.

Mr Grimmett: Failing agreement, I'm going to have to bring a motion --

The Vice-Chair: I know, but let's try to discuss before the motion, all right?

Mrs Boyd: I am little puzzled. If the information has already gone to the Premier's office that their estimates are up on Tuesday, surely they will have planned for that. I don't know how many hours.

The Vice-Chair: Two and a half hours.

Mrs Boyd: Two and a half? So they would then be finished on Wednesday and another group could come in. The purpose of this is that they have to be taken in order, as we know.

Mr Grimmett: The following ministry, I believe, is the Ministry of Natural Resources, and the difficulty is in arranging a time they would attend. We don't want to tie up their staff. As you can see, occasionally we have more than one staff person who comes. From my experience, we had three or four from the Ministry of Economic Development last year. You tie up staff for a fair length of time, and you don't really have a good idea when they're going to be here. That's why we have a preference to either get the proceedings over -- we can forgo the remaining time in health, but obviously you want to deal with that. Our preference is to deal with the health on Tuesday and then --

The Vice-Chair: Is there a concurrence by the three parties that that happen? If not, I would suggest a motion.

Mr Kennedy: It's in our interest to see that we get to as many of the ministries as possible. We have uncertain sitting times beyond the August session. We would prefer to use all the time we have as constructively as we can. It would be our preference to do that. Are we allowed to stand down off an estimate like that, to say they don't need to come in? Do not the standing orders tell us we need handle these ministries consecutively in the time allotted?

The Vice-Chair: Certainly the ministry has to appear before the committee. I guess it's at our discretion whether we have them appear on the Tuesday or the Wednesday. If there can't be consensus, then it's obviously going to be by motion. The ministry has to appear, but it's the timing that now is an issue here. Before we go to a motion, is there concurrence?

Mrs Boyd: May I ask a question? I'm not quite sure why Mr Grimmett keeps saying the timing is uncertain. We know exactly that we have an hour. We know we start at 3:30; we know we have an hour.

Mr Grimmett: We don't always start at 3:30. We usually do, but it could be that we don't start at 3:30.

Mrs Boyd: Yes, but at this point it's --

Mr Grimmett: I've been on committees that have started at 4 or 4:30. It depends what happens in the House that day.

Mrs Boyd: I think people wait for meetings often. Ministry officials are used to waiting on the legislative procedures. They know that the legislative procedure is the major part of our business here, so they're quite accustomed to that.

Mr Grimmett: We're trying to make the effective use of their time. I don't think we're going to find consensus here, Mr Chair.

The Vice-Chair: No, I would suggest we don't. Do I have a motion?

Mr Grimmett: I'd like to move that once we finish the health estimates, the committee adjourn for the day and reconvene on the next regularly scheduled day and begin the next review.

The Vice-Chair: You've all heard the motion. Any debate? All in favour? All opposed? The motion is carried.

This meeting is adjourned.

The committee adjourned at 1804.