CONTENTS
Tuesday 24 June 1997
Ministry of Health
Ms Margaret Mottershead, deputy minister
Mr Dan Newman, parliamentary assistant
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 1543 in committee room 2.
MINISTRY OF HEALTH
The Vice-Chair (Mr Rick Bartolucci): Welcome back to the final day of estimates. We will continue our rotation. The NDP have five minutes left in their 20-minute presentation. We'll move to the government side, then we'll move over to the official opposition, and end off with a 15-minute question period by the NDP. Then we'll go into the vote. Any questions?
All right. Mrs Boyd.
Mrs Marion Boyd (London Centre): I'd like to ask the deputy about the issue of people who do not have health cards and how they are able to access medical services. This has always been a big concern, but we're certainly finding, if we talk to those who are serving the large and growing population of street people, that a large number of them do not have access to identification. Many have had to leave their place of residence without being able to get it. Others have had it stolen from them, which is unfortunately a fairly frequent experience.
When they need medical care, which is only too likely if we think about the indicators of health -- these are people who suffer poverty; they often have poor nutrition, little opportunity for appropriate hygiene and that sort of thing -- can you tell us what the process is and what you think needs to be done to improve it? We understand that it's extraordinarily uneven throughout the province.
Ms Margaret Mottershead: I think the first decisions that were made around accepting people for care without health cards were made through the establishment of community health centres. They were set up primarily to deal with vulnerable populations, those who don't have the wherewithal to understand or have an ongoing relationship with a physician, and those community health centres are available throughout the province.
Secondly, no practitioner, doctor or hospital can refuse emergency health care, regardless of whether a person has a card or not. It's an obligation to serve and a duty to serve and provide that service.
In the Ministry of Health, to make sure that people are not turned away because they don't have a health card, because they're homeless, because they're vulnerable, we've taken steps not to penalize a provider who provides the service. In fact, we will pay claims that don't have a health number attached to them. There is an obligation on the part of individuals to continue to provide the service, recognizing that there's no penalty directly to them.
Mrs Boyd: Is that true of hospitals as well? Because we have heard many, many stories from a wide variety of hospitals, from those community health centres, I would say, where in fact emergency services have been refused to people on the grounds that they didn't have any health card and they didn't have the money to spend.
Ms Mottershead: Certainly if you look at the large urban centres, there are many hospitals that serve the needs of vulnerable people and the homeless. I can rhyme off a whole lot of those hospitals here in Toronto: you have the Wellesley, you have St Mike's, you have St Joe's in the west end, and there are many others. They do pride themselves, and you'll find that it's right in their mission statement, on the fact that they will provide those services to the vulnerable populations. So they have made an explicit community commitment to do that for the populations.
I'm not aware of people being turned away because they have been destitute while they have an emergency situation that has presented itself. If people are aware of something like that going on, please let us know, because they have to provide the service. The hospitals and the doctors have to be available to serve.
Mrs Boyd: I think what distressed me was exactly those hospitals that I too believed had a mission to serve the homeless. Several of the stories involved St Mike's, Wellesley and even Doctors Hospital. I was quite concerned because that was a surprise to me and certainly not what we had been led to believe in terms of their vigorous campaign to keep their hospitals open.
The process then would be that the primary health care provider, in these cases places like Anishnawbe or any of the other health clinics, need to provide a very urgent complaint directly to the minister or directly to the deputy?
Ms Mottershead: That's correct, particularly when you mention community health centres, because that was one vehicle outside of the traditional institutional care that was established to deal with the primary care needs of the vulnerable populations. We had funded them on program funding based on the fact that they will be dealing with that particular kind of caseload and they weren't going to be physicians doing fee-for-service billings on the people who didn't have a card. That was the intent, and I would welcome any opportunity to try and rectify a problem if there is one.
Mr Trevor Pettit (Hamilton Mountain): I think it was last Thursday, maybe Friday, that there was an article in the Toronto Star about a visually impaired person's access to assistive devices services. In that article, the Ombudsman had indicated that this particular person had experienced some difficulty in travelling to an assessment centre. I'm wondering if you can tell us what the assistive devices program is doing to improve its services to visually impaired Ontarians.
Mr Dan Newman: The Ombudsman's report calling on the ministry to pay travel costs to and from vision assessment centres in the province stated that Ontario is one of only three provinces to offer universal access -- in other words, there's no income or means test -- to assistive devices such as wheelchairs, hearing and vision aids etc. Copayments have existed in the system since 1982, so it's not something new. It's been there since 1982. The only other provinces that offer universal access to assistive devices are Alberta and Quebec.
Ontario's universal program is one of the most comprehensive in Canada. The program is far more comprehensive than the programs offered by Alberta or Quebec, and Ontario covers over 15,000 devices. Ontario is the only province in the country that even covers vision and communications devices, let alone paying for travel to and from assessments. Maybe that's something we ought to keep in mind.
In addition, the Ministry of Health's northern health travel grant program actually does cover the cost of northerners to travel to ADP assessment centres if the program criteria are met.
However, rather than expanding our payment mechanisms to cover individuals' travel costs to and from assessment as requested by the Ombudsman, the ministry is expanding the number of vision assessment centres in the province to ensure that access to assessments is improved for everyone. To accomplish this goal of improving access to assessment, since June 1995 we have doubled the number of vision assessment centres in the province from four to eight by opening centres in Sudbury, which I'm sure the Chair would recognize are there, in Ottawa, in Hamilton, which would be in your part of the province, Mr Pettit, and in Toronto. We plan to create another four in the coming year, which would triple the number of centres that existed under either of the two previous governments.
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Mr Wayne Wettlaufer (Kitchener): Mr Newman, in the last few weeks of these hearings, the Liberals, particularly the Liberal health critic, the member for York South, have been criticizing us for everything under the sun in so far as health care spending, the restructuring of hospitals, the role of health services restructuring, the sustaining of our drug programs, development of the health care policy in so far as rural Ontario is concerned, mental health.
I have a particular concern from the standpoint that if I was a member of the public looking on these proceedings, I would be somewhat sympathetic to his concerns. Yet here we know that they talk out of both sides of their mouths regularly. I was just wondering if you have any examples of how they might flip-flop on issues in health care.
Mr Newman: I happen to have --
Mrs Boyd: Such a surprise he happens to have it.
Mr Wettlaufer: It doesn't surprise me at all.
The Vice-Chair: Take good notes, Mr Kennedy.
Mr Newman: I guess that's the sign of being prepared, Mrs Boyd. But I just happen to have some.
Mr Wettlaufer: I thought you might.
Mr Newman: I thought Mr Wettlaufer might ask that question of me.
In terms of the federal Liberal government, because they are the ones who are actually cutting health care spending in Ontario, former federal Liberal health minister David Dingwall endorses Ontario's approach to health care. He did that when he appeared on the CBC Radio news on January 30, 1997, and said, "The Ontario government, from what I have seen and from my conversations with them, are very committed to the principles of the Canada Health Act and are trying to provide top-quality care to their citizens." That's the former federal Liberal health minister saying that.
We have the member for York South, Mr Kennedy, calling for a special rural health care policy. In the Niagara Falls Review of March 26, 1997, Kennedy said the formula to make cuts to health care across the province "wasn't one designed for small hospitals, but for larger ones in larger centres. `It (the formula) is experimental and should not be applied to small hospitals.'" That's what we have Mr Kennedy saying there.
I know one of the ones I talk about a fair bit in the House with respect to education is the Liberal red book of 1995. The Liberal red book calls for the creation of an arm's-length body to assist in restructuring of the health care system. I quote it on page 39:
"A Liberal government will create a Health Care Reform Commission made up of health care professionals, providers.... The commission will recommend reforms in law and in the administration of Ontario's health care system; point out gaps...in service, investigate inadequacies in the system, and comment on proposed new initiatives."
But it doesn't stop there, Mr Wettlaufer. Mr McGuinty, the Leader of the Opposition, calls for savings in the health care system. In the Hamilton leadership debate on September 21, 1996, he's quoted as saying, "I think clearly there is going to have to be some savings found, some efficiencies in our health care system." Again, we have the Leader of the Opposition saying that.
We also have the Leader of the Opposition endorsing hospital closures. In the Toronto Star, December 13, 1996, it says here, "McGuinty says he might close hospitals as part of a plan for better integrated health care services across the province." His precise quote is: "I would have, as an overriding objective, improvement of our health care system. A component of that might be the closure of a hospital."
We also have Mr Kennedy when he was running for the leadership in Ottawa on September 11, 1996, quoted as saying in the Ottawa leadership debate: "We want to look at a combination of patient responsibility and doctor responsibility. We want to make sure that we take some of the non-essential stuff out of the health care system." So he's saying that as well.
We have the former Liberal health critic -- I guess at the time she would have been the health minister, now the federal member for the riding of Thornhill -- in November 1988, Elinor Caplan: "We have in place right now a system of copayment for chronic care. I believe that there may be other appropriate copayment opportunities which are not a deterrent to appropriate services."
We have some things there that are mentioned by people who are in the federal level of government and in the provincial level with respect to health care on the part of the Liberals.
The Vice-Chair: Mr Wettlaufer, follow-up?
Mr Wettlaufer: I have a follow-up. The parliamentary assistant, Mr Newman, mentioned that the Liberal red book had specifically spoken about certain things. The Liberal red book also mentioned that $17 billion a year was a target for health care spending. As you know, we're spending $17.8 billion on program spending. We've never heard from the Liberals how they might have restricted spending to $17 billion. All we hear is criticism. Do you have any comment on that?
Mr Newman: I've heard many times from the Liberal health critic, and I guess all members of the Liberal Party and opposition parties, talking about what we're spending in health care in this province. As you've rightly pointed out, Mr Wettlaufer, we are spending $17.8 billion. That's $400 million more than we had even promised in the Common Sense Revolution, which was released in 1994, when we guaranteed funding of at least $17.4 billion. Yes, you're absolutely correct, the Liberal red book did say $17 billion. So if we're to take them at their word and have them say that they were going to spend $17 billion, that would be $800 million less than we're spending today in Ontario.
The Vice-Chair: Mr Wettlaufer, anything else? Okay, we'll move over to --
Mr Marcel Beaubien (Lambton): How much time do we have left?
The Vice-Chair: We have exactly 10 minutes left.
Mr Beaubien: For this side?
The Vice-Chair: Yes. You don't have to use them if you don't want to. Mr Grimmett, any other questions?
Mr Bill Grimmett (Muskoka-Georgian Bay): Yes, I'll ask Mr Newman about the breast-screening program. Recently you were in my riding to make an announcement about the breast-screening facilities. They're expanding one of the hospitals in my riding. I wonder if you could comment on the theory behind the breast-screening program and the development that has occurred recently in the ministry.
Mr Newman: Yes, I had the good fortune to be in your riding in Bracebridge at the South Muskoka Hospital to make that announcement on behalf of the minister. With that announcement and several others across the province -- I think there was one in Listowel a week after that -- the breast-screening program is serving more women in our province. It's an ongoing program. I think the deputy can confirm that. That isn't just the screening, but it's a yearly --
Ms Mottershead: It's an annual program. It's ongoing.
Mr Newman: It's an ongoing program to monitor breast cancer in our province, which is a leading killer of women in our province.
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Mr Beaubien: Just a brief question. Lately we've heard that the government has spent an awful lot of money investing in MRI, magnetic resonance imaging, and there seems to be some competition for, I guess, the secondary level competing with these machines. It's not only a major capital investment to provide the machines, but it costs an awful lot of money to operate them on an annual basis. How much money have you allocated in this year's budget for new projects?
Ms Mottershead: Just a second.
Mr Beaubien: I don't expect you to have it readily available.
Ms Mottershead: I don't have that because the ministry just provides a one-time support grant to the hospital. The ongoing operations for the MRI are the responsibility of the hospitals and it comes out of their global budgets.
The only variation on that was a recommendation by the Health Services Restructuring Commission in their Thunder Bay report to suggest that the government should invest $1 million for MRIs, that given all of the consolidations of hospitals, that would be something the government should consider supporting on an annual basis.
Mr Beaubien: Would it be fair for me to say that the average cost of operating a unit is approximately $150,000 a year?
Ms Mottershead: The $150,000 is our contribution. Depending on the volume of the service, I think it would be a lot more than that. What's happening with the MRIs is that the hospitals which are participating actually share the costs of that service. If there are three hospitals in the community and one hospital's referrals are coming from the inpatients of those other hospitals, there's a chargeback to the originating hospital, the requesting hospital, for the cost of that service. So it is a shared cost and shared arrangement.
Mr Beaubien: So to the opposition -- this is the point I want to make and make clear -- hospital services are changing continuously and in a very costly manner, and I think there is a need for health services restructuring in Ontario. I strongly object when I get a member from the opposition coming into my riding and playing on the emotions of people.
Mr Ed Doyle (Wentworth East): They're experts at it.
Mr Beaubien: If we are concerned about the health care of the residents of Ontario, I don't think you come into somebody else's riding and play on the emotions. There are facts and figures that the services are changing today, and consequently we have to find some services.
You don't drive the same car as you did 10 years ago, so why should you expect to have the same level of health services that you're receiving today? I think the sooner we realize that the life and the health of the people in the province is first and foremost, above politics, the better off all the residents of Ontario are going to be.
The Vice-Chair: Any other questions?
Mr Beaubien: It's not a question; it's a statement, I guess.
The Vice-Chair: You can use your 20 minutes any way you want.
Mr Wettlaufer: Mr Newman, we've had it stated by the minister last week or the week before that approximately 460 new drugs, I believe, were added to the drug formulary this year.
Over the course of the past year or 18 months, I've had personal experience with making recommendations, as a result of phone calls with my constituents, that doctors who were recommending two or perhaps three pharmaceutical drugs for treatment of an illness, drugs which have been replaced by one drug and which would save the health care system money -- I know I've written to the ministry a couple of times, and those drugs, these new pharmaceutical drugs, have been added to the formulary.
I wonder what process we're using to review new drugs which are put on the market. How are we reviewing them to ensure the drug formulary adds those new drugs?
Mr Newman: That's a very good question. I would like to refer that to the deputy.
Ms Mottershead: The first process starts with the federal government. A pharmaceutical company has to make an application while they have conducted trials for the product to be originally given a notice of compliance. In other words, you have to describe what the product is, what its intended outcome is and, having gone through a trial process, that it is effective to deal with the problem it's intended to deal with.
Once they get their notice of compliance, the manufacturers make submissions to all provinces, Ontario included. They normally start with Ontario, being the largest market in the country, and they actually make an application. Through that application process, there is a requirement to produce what we refer to as pharmaco-economic guidelines.
What that particular submission entails is the production of evidence in terms of other drugs and what their intended result is, matched against the current drug in question to show that it is a better product or it's the same product but it's got properties that are more helpful; for example, there could be less acidity in the drug versus something else, but they have exactly the same properties. They have to go through that process, first of all, of documenting effectiveness as a drug and then also effectiveness and efficiency in terms of its cost, so that it would replace products, it would improve products, it would change the dosage or other properties. That's all documented in the submissions.
Once the submissions are received and analysed by the ministry, we have the Drug Quality and Therapeutics Committee, which is an arm's-length body that provides advice to government on whether or not certain drugs should be listed and what the benefit is both to health care and to the economy. It's that process of validation by the experts. We have scientists, we have doctors who actually know the properties of the drugs and the chemical compounds that comprise them, and they give us their advice. It's another validation. It's not just a Ministry of Health review, but there is an external review.
Once that's done, the government has been moving very quickly to update the formulary, to add the new drugs. Whereas it used to be sometimes an annual process of changes to the formulary, or maybe every six months, we're moving very, very quickly to make the changes within three months. That's why you see a lot of the products being added a lot more quickly.
Mr Wettlaufer: Is there a possibility that we would be adding another couple of hundred before the next six months?
Ms Mottershead: I couldn't give you an answer with certainty on that because our bringing the drugs on stream, on to the formulary, is as good as how quickly the products become available to market, the notice of compliance, and how quickly manufacturers move to try and place them on the formulary. But there are changes. There are more drugs that are going to be listed in the next couple of months, yes.
The Vice-Chair: We'll move over to the official opposition.
Mr Gerard Kennedy (York South): I would like to thank the members of the government, I believe, for providing scrutiny to the official opposition. This is our time for estimates and looking at the government, but I appreciate you think it important enough to include that. But what I was hoping when I heard there was a list of things that were going to be mentioned was that we might have some of the information that was asked for earlier.
For example, I want to know, Mr Newman, will you be tabling today the reinvestment tally from the ministry, an official tally of what the reinvestments really were last year? I provided my list of that. It showed a deficit of $300 million. Will we have that other information today, if it exists? Because the information I'm using is from the estimates. Will we have that today?
Ms Mottershead: No, you won't. Not today.
Mr Newman: There's been so many of them, they're still compiling a list.
Mr Kennedy: Will we have that list eventually? Will this committee receive that list of reinvestments, the official tally from the government for the fiscal years 1996-97, 1997-98?
Ms Mottershead: Mr Kennedy, through an order paper question a few months ago, a response was already provided in terms of the government's reinvestments, so it's on the record already.
Mr Kennedy: Is there a problem to having a response here today? I've tabled information which suggests there's a $300-million deficit, money that has been cut versus money that's been put back in. There's a $9-million advertising plan that's been out there saying things to the contrary. This is an opportunity, Mr Newman, for you and the ministry to establish the bona fides of what the minister has been saying. Unfortunately, it doesn't seem to be forthcoming. Is that correct?
Mr Newman: I think it was answered in the order paper question.
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Ms Mottershead: That's correct.
Mr Kennedy: We've asked for that. Could it be provided to this committee?
Ms Mottershead: Mr Kennedy, I don't know whether you have tabled your numbers here --
Mr Kennedy: Yes, I have.
Ms Mottershead: I haven't personally seen them. I don't know what has been tabled or where the numbers came from. All I can tell you is that what you have in the printed estimates, it's the government's intention to spend that money in the votes in the areas that it has so indicated.
Mr Kennedy: Sorry to interrupt, Ms Mottershead, but it does indicate a gap, and that is the crucial question. I was hoping that we might have some government response to it, but I don't know if Mr Newman is prepared to provide that.
Ms Mottershead: The government has a period of time in which to respond to the questions that have been raised, and I'm sure the government will consider responding within that time frame.
Mr Kennedy: Would we also be able to receive within that time frame, or I was hoping perhaps even today, the parts of the agreement with Mr Sapsford which will show us how he, as an employee of Toronto General Hospital, is not in a conflict when it comes to dealing with all the other hospitals in the province? You had indicated there would be extracts of confidentiality agreements. Given some of the interest I've had from people outside of this room, I think that would be important to have as soon as possible.
Ms Mottershead: Yes, staff have been working on it. All your requests have been noted. We did follow up with the Hansard. I should point out that Hansard didn't arrive in my office, after making several phone calls, until this afternoon in terms of verifying all of the commitments that were made to provide information. So I would say that for all of the commitments that were made to you, there will be an undertaking to provide that information.
Mr Kennedy: Okay, just one clarification. I understand that applies to any previous requests. You suggested, I know, some qualifications and some proprietary parts, but were there elements of the $200,000 report done by Mr Vaz about the future shape of the ministry? Is it going to be possible for you to provide some parts of that? I think you were going to review that. Were you able to do so based on the proprietary information?
Ms Mottershead: We'll provide some of the information in that report. The awkward part about this is that some of the recommendations in terms of the future state of the ministry deal with the broader government issue of restructuring government. The government hasn't considered the whole report or the whole context and I wouldn't be at liberty to disclose that.
Mr Kennedy: Some of the other parts we could have?
Ms Mottershead: Yes.
Mr Kennedy: Great. Terrific.
Mr Newman, I'm wondering if you're able to tell us whether the government approves of what the Humber Memorial Hospital is doing to Northwestern General Hospital. Just to refresh your memory, that is where there's a restructuring report, a draft recommendation to close the Northwestern hospital site by June 1999, but the Humber hospital is substantially closing that site -- they're going to remove emergency and surgery and so on -- by September of this year.
Just to refresh your memory again, the minister said he didn't believe any of the restructured hospitals should be closing for about two years because human resource plans had to be put in place, capital improvements had to be made and so on. But in the case of this hospital, it's happening now. In fact, on July 15 obstetrics is going to be sent to one hospital, gynaecology left at another.
Is there a view on the part of the minister as to whether this is acceptable behaviour on the part of the hospital, and will you, because this has been raised now a few times in the House, be following this up in any way? What kind of assurance can you give to the people who are served currently by Northwestern hospital about how the minister will be dealing with this?
Mr Newman: I'll refer that to the deputy.
Ms Mottershead: I'm sure the member knows the nature of that merger. Three hospitals came together on a voluntary basis. Nobody forced them. It was well before the commission came to Metro Toronto. They formed an alliance. They applied for letters patent. They actually incorporated as a new corporation that would run three sites. The fact that the board -- one single governance -- has decided that it will move out of one of those sites and put the services in the other two existing sites is a decision that's been made by the corporation, by the board of directors, which is accountable to the community. Given that it originated as a voluntary endeavour, I think it's quite logical to conclude that the proposal will proceed.
Mr Kennedy: That's very disappointing to the people in the community. Ms Mottershead, as you may be aware, the board of this hospital has no community members on it. Further, this board has no residents of the city of York, even though it principally serves the city of York, on its board. There are no votes from the community controlling it. Tonight will be the annual meeting at which they will confirm a bylaw which says only the board members have any vote on any of the proceedings of this hospital. It is completely unaccountable to the community. The community wants to know, will the ministry step in?
We have a report from your Health Services Restructuring Commission which says it will take two years to empty that hospital; it will take $50 million worth of renovations to transfer the services. Are you saying, and we'd like to hear it clearly today, the ministry approves of this rush job to empty Northwestern hospital? This is going to see an emergency department down the road have to handle double the capacity. It is going to see obstetrics and gynaecology separated. The physicians at Northwestern say it's going to put patients at risk. Are you saying you approve of this, from the ministry's standpoint?
Ms Mottershead: I don't recall having a distinct proposal in terms of the time frame and moving forward with that kind of speed, as you've indicated. But again I just want be very clear that if that decision was made on a voluntary basis and people want to go ahead with that scenario, it's only right that they go ahead and do what they feel is right for the community, hopefully in a way that doesn't jeopardize any services or programs. That's what we would be interested in looking at. We'd be interested in looking at the plan and want to be assured that there would be no disruption or loss of services.
Mr Kennedy: Ms Mottershead, some of those services were supposed to be moved this week. They've been postponed. The doctors there refer to the whole process as a shambles. Could you clarify for us: Where in this process will the ministry be involved? Will it give approvals? Has it given any approvals to date around this transfer of services to these other hospitals which have had no renovation, no change to be able to receive these services? Will there be any intervention by your ministry at all?
Ms Mottershead: I'd have to get back to you on that, Mr Kennedy. I'm not aware of any kind of formal approval process from the ministry to this point. Staff may have information back there.
Mr Kennedy: It's very disappointing information if there is not.
Ms Mottershead: I don't have the latest information.
Mr Kennedy: The minister said in the House in answer to this that the ministry would be monitoring this, that they'd prefer that this happen under the restructuring.
Ms Mottershead: We definitely are doing that.
Mr Kennedy: We were very disappointed to learn a week later that there's nothing at all that the ministry has done and only vague things about what it might do to protect the patients who are involved in this. This is the first hospital to be closed in Metro. It's being closed in a hurry, in a rush, and we'd like to know why. That board won't respond. They will not take deputations at their meetings, and now unfortunately it doesn't seem like you will either.
Ms Mottershead: Mr Kennedy, I don't think we have any indication that there are services being put at risk or patients being put at risk at this point. I don't know where your evidence is that that will be the case. I think the hospital -- you have to give them some credit as an organization that runs these services -- would be in a fairly good position to know exactly what their plans will do for the patients they're obliged to serve. My view is that we should be giving the hospital the benefit of the doubt that they know what they're doing. We will be monitoring, there's no doubt about that, but we're not in a position at this point in time to say, "Hold the phone."
Mr Kennedy: As I said, it's disappointing because I've met with the obstetricians in that hospital. They say patients will be at risk. They say that this is a shambles in terms of what's happening. You're going to have gynaecologists doing operations on one site and babies being delivered on another site. It's a reduction in the quality of care. It's a big rush.
Deputy Minister, I'd like to ask you one thing. The minister has referred on a number of occasions to the budgets of hospitals not being fixed, not being set, that operating plans are reviewed. Are you offering any transition money -- I understand there are also issues at Women's and Wellesley because they went ahead with an alliance, condoned, they believed, by the ministry and the restructuring commission. There will be financial issues there. There are financial issues apparently driving this rush job taking place at Northwestern. Do you provide funds -- and if so, under what criteria -- to hospitals that are undergoing the transition to being restructured hospitals and perhaps closing further down the line? Are those funds available from the ministry and how are they accessed?
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Ms Mottershead: There are funds available to all hospitals that are undergoing restructuring. We indicated here over the last number of weeks that the government is making available over $2 billion over the next couple of years for hospital restructuring. That's to cover a whole array of costs that they might incur, ranging from severances to training and adjustment to legal fees to communications to consultants. They need expertise, medical consultants and others, in terms of the clinical programs that are being transferred maybe from one site to another. There's a whole array of costs that are eligible for this restructuring fund, and that $2 billion is being made available and will be there when hospitals call for it.
There is from time to time a need to have a look at specific circumstances, and we have. You might be aware that I've offered to provide for a program review in Windsor. In meeting with all the hospitals in that community, they said: "We feel that our budget is not adequate. We feel going into a restructured environment that you need to have a look at the costs." I did offer to have a program review commence almost immediately. The hospitals, all three of them, just recently have indicated they would like to wait to see what the commission has to say.
I'm just saying that in circumstances we indeed do an operational review, we do a program review, we do a funding review where there is a case that is made for us to have a look at specifics.
Mr Kennedy: What is your position on hospitals running deficits? Do you have a list of how many hospitals are being forced to run deficits on their operating budget this year? Do you have that for the province?
Ms Mottershead: The staff review the operating plans of the hospitals. The hospitals are aware that we have a policy which basically says, "You have to make sure that your revenues and expenses are lined up, that there is a balanced budget." That's the policy.
Part of making sure this policy is adhered to is a function of reviewing the operating plan to see whether hospitals have looked at every possibility to match up their operating line with their revenue line and to make sure the services that are being considered for change do not in any way have an adverse effect on patient care, that there is a good review in terms of administration and overhead and those kinds of infrastructure costs to make sure those are the areas where some tightening can happen and not in areas of patient care.
So the operating plans are being reviewed. Staff have been looking at them --
Mr Kennedy: How many hospitals submitted deficit budgets this year? Can you give us an estimate?
Ms Mottershead: I can't give you a number, no.
Mr Kennedy: The last question I'd like to focus on: The member for Lambton talked about MRIs. I wonder if you could confirm that the way the MRI funding works is that there's a grant from the ministry of $150,000, but the operating of $300,000 or $400,000 is picked up by the hospital adjusting its budget. Is that not correct? Also, the approximately $1 million, give or take, capital fund is also provided by the hospitals from other funds. Is that not accurate?
Ms Mottershead: The one-time startup grant is provided by the ministry. That's $150,000; you're correct. The ongoing operating of the MRI is handled by the hospital global budget. There is however a business case that must be produced by the hospital before an MRI is awarded.
Mr Kennedy: But in essence the business case means they have to justify taking funds from some other part of their operation. To get an MRI, they have to show that they can support getting those funds somewhere else, but that's what happens: They have to take it from the rest of their budget. They also have to come up with $1 million to provide it. For $150,000, they have to enter into all those other costs in order to support an MRI at their facility. Isn't that correct?
Ms Mottershead: No, that's not correct.
Mr Kennedy: Could you enlighten us as to how it's done?
Ms Mottershead: I will try to. The whole point of having MRI technology is not just to make sure that people have the latest technology possible to help in the health care system, but it is also to make sure, in reviewing the business case, that we don't have added technologies, added procedures and added systems.
The new technology is there to replace something else. It's not an additive equation here. It is to replace other functions performed by outdated technology, X-ray or whatever the case is. Therefore there is a direct displacement. In some cases, the use and the acquisition of an MRI is much more efficient than the dispersed operation of a number of X-ray-type equipment all over the hospital. What this does is bring together the unit. I don't know that people fully understand that you need a whole infrastructure: You need neurologists, you need specialists, you need a whole --
Mr Kennedy: You need a building.
Ms Mottershead: To be able to read them and all of it, you need that infrastructure. Not all hospitals will be eligible for an MRI. The business case has to do two things. It has to document that you've got the infrastructure, you've got the specialists, you've got everything already there. It has to document that it's a cost-effective technology because it does replace some existing and outdated pieces of equipment with quite often very high maintenance costs, because they break down; they're 10 years old, or whatever the case is. That's part and parcel of that.
Mr Kennedy: I don't know if it would surprise you to know that most of the places that are getting MRIs that I've spoken with say they have to sacrifice some other essential service to make room for it, that the $1 million they have to find to pay for it is very, very onerous in terms of what they have to do. They would wish, they would look forward to -- there was really faith in the ministry that it would assume the responsibility for making sure this didn't happen at the cost of other services. That's not part of how they see that today.
Mr Newman: Can I ask which hospitals?
Mr Kennedy: I could provide you with --
Mr Newman: Because when I was in Timmins to open the MRI there, they were more than happy. They have raised the money in the community. They don't have to travel to Toronto. It doesn't affect their family life --
Mr Kennedy: Everybody is happy to have an MRI, Mr Newman. The fact is, you're cutting money from their budgets. You cut Timmins hospital by at least 6% over the last two years. You've cut all the hospitals in the province, including every single riding except, I believe, one in York-Mackenzie that hasn't actually been cut last year. Everybody else has lost money, so it factors into their whole ability to sustain things.
You're providing $150,000. The $300,000 to $400,000 worth of operating has to be found by the hospital, and $1 million to provide the MRI. The capital cost of the MRI has to come from the hospital as well. It's the hospital that's making the MRI happen. Only a small amount of that has to do with what the province is doing. I think it's important that the people of Ontario know that. It's hospitals struggling with your budget cuts that are finding the extra money.
Mr Newman: Are you saying that hospitals shouldn't have MRIs?
Mr Kennedy: They should have the MRI, but they should have it without the cuts to their operating base that are making it more difficult.
Mr Newman: We'll have more MRIs in Ontario than in the rest of the provinces combined.
Mr Kennedy: You've also got people lined up in your hospital emergency waiting rooms. You've got people there for three or four days. We had a case the other day of somebody still waiting to get transferred on their sixth day of waiting in an emergency room of a hospital because the beds aren't there because the funding for the beds isn't there. We can have all the fancy equipment we want -- and we want to have that available -- but it's a phoney game if we're not able to provide the fundamental services. That's the point these hospital administrators are making. It's too bad that we don't have a program on your part that would recognize that and not take the MRIs so much out of their base budget, because you've already cut their base budget.
Mr Newman: Pass on those hospital names; I'd be pleased to see them.
Mr Kennedy: In terms of the other aspects of the MRI and the other ones you've done, the other part that is very concerning to the hospitals has to do with their basic emergency services to do with ambulance. Ambulance, to the people who run it, is already an integrated health service. It already is in contact with all different parts. You're proposing to download that; you're proposing to give that to the municipalities. You've yet to table the policy by which you're going to do that. I know there was some discussion with people around the province, but there's very big concern.
How are you going to be able to run an integrated ambulance service when the municipalities are going to be the operators of it? How is that going to be at all possible?
Ms Mottershead: I just want to make a comment. Yesterday and today, ambulances leave a destination and end up at hospitals. They go from somebody's home or an office or on the street, wherever the accidents happen, and end up at a hospital. Tomorrow, with the changes that will be made -- and by tomorrow I mean January 1998 -- those ambulances will have exactly the same destination. Nothing has changed. In terms of an integrated system and a service that will be available, the service will be available. What you have is a different funding relationship between municipalities and the operators, but in effect nothing changes.
The Vice-Chair: We'll move on to the third party: 15 minutes.
Mrs Boyd: Why don't I follow up on that question, because I think it's an important one. It's true that the ambulance will pick someone up at whatever the location is and take them to a hospital. The issue is that when you balkanize the funding by municipality, this is an ambulance that may travel to another municipality through several municipalities. On what basis is the cost of the ambulance going to be assessed: Where the person lives, where the person receives hospital treatment, where the accident happened? That's the kind of question that not just opposition members but ambulance drivers and emergency physicians are asking.
They want to be sure that a small municipality which happens to have a corner where there are a lot of car accidents isn't going to suddenly have to pay for the ambulance transportation from those accidents, because probably the reason for the accident in the first place is that they didn't have the money to repair the road. This is a serious problem that people have. Nobody can figure out how you think this is really going to work when people go across a municipality and so on. Can you enlighten us at all?
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Ms Mottershead: There is no doubt that it is a complicated issue. We will over the next several weeks and months be consulting with the ambulance operators, the municipal leadership, and working through some of those issues on the community health and social services implementation team. There are a number of ways of dealing with that. I know we have been looking at a number of ways to try and get to the question of who funds, what municipality funds what services, but I think it's only fair to have that discussion with the municipal leadership and with the ambulance operators before I venture out with some possible suggestions.
Mrs Boyd: In relation to ambulances, your own ministry said on March 26 in the Globe and Mail that the purchasing power the province currently has in terms of ambulance vehicles and equipment is going to disappear with this plan. Would you agree that's a problem?
Ms Mottershead: In our discussions with municipalities, we could in fact find a mechanism of retaining the purchasing power without retaining the funding power. I think if people want to be creative and want to find efficient ways to deliver those services, there will be an opportunity. We're certainly not closed to any possibility to allow efficiency to continue to occur in the system, and flexibility, to make some creative things happen.
Mrs Boyd: So essentially what this decision means is that the Swimmer report is dead. Is that true?
Ms Mottershead: The ambulance operators in the first instance are the employers for ambulance services. We also have about 60 hospitals that will continue to be the employers of the ambulance services within their jurisdiction, and we have 10 ministry-run operations that we're looking at having discussions on with municipalities in terms of what to do with those.
For some of the committee members who are not familiar with the Swimmer report, the Swimmer report recommended that there should be one provincial agency run by the government, with government employees running all of the ambulance services. This particular initiative with municipalities and private operators certainly doesn't contemplate the adoption or acceptance of that particular recommendation for a province-wide agency.
Mrs Boyd: I'd like to move to the HSTAP program and the abruptness with which it was cancelled. I understand there has now been a commitment that those people who were caught betwixt and between are going to be looked after in some way.
I have a case of a constituent of mine who agreed to a separation which was to occur in April -- I believe April 11 was the separation date -- and on May 6 finalized with her worker at HSTAP by telephone her plan, which she had been working on since then. Of course, nothing was signed. Would she still be among the 420 or so who you indicated you expected would fall into that category even though the finalization was verbal rather than written?
Ms Mottershead: It would certainly sound that way from how you have described the situation. What we have told the HSTAP board in writing is that not only approved plans but plans that were in transit for approval and not yet approved would be funded. They are to get back to us on how quickly they can process and work on it.
Mrs Boyd: That's good, because this particular constituent, whose name is Nora Lewis, had attempted to get that kind of confirmation from the minister's office and wasn't able to get it. I have a package of material with all her material attached which I'd like to give to you today so that you can look into it. This is a 23-year employee who has a great deal of talent and would not have accepted the settlement she accepted, which was very low in terms of severance, had she not been assured of HSTAP.
The other issue I'd like to talk about is the whole issue of women-specific health services. We talked a little bit about that with respect to Women's College. There continues to be real concern about the availability of women-specific services, given the reality of the experience women have had in terms of their health not being given the same priority, not taking into account different symptoms and different causative effects.
I'd like to talk to you about the substance abuse programs. I have had approaches now from three different women's substance abuse programs -- the Amethyst program in Ottawa, Hope Place in Burlington and the House of Sophrosyne in Windsor -- all of which report that this whole process of looking at substance abuse appears to be focusing on a generic service, a family counselling approach as opposed to a women-specific approach, even though there's been a lot of research and a lot of outcome research to show that women do better in women-specific programs simply because of the nature of the experience they've had in life and the base of their substance abuse.
Could you comment on whether the ministry is fostering this notion of generic services or whether there is a commitment from the ministry's point of view on women-specific services where they have proven effective?
Ms Mottershead: As part of the review process, what we did with the consultants was to document their recommendations and send them back out to the field. We wanted them to have a reaction to what was being recommended before the government would consider adopting those recommendations in a more province-wide approach.
I have heard from those services as well, and I think they make a good case, so we'll have to look at exactly what the final product is and what the reaction is from the field. I know they're very, very strong in terms of their conviction that these programs work better in that kind of setting. Once we receive their feedback in writing, we will take that into account, bearing in mind that we are working on a women's health strategy that looks at every component of health care as well as research in the province. We wouldn't want to give a wrong signal that while we're working on a broad strategy, we're not dealing with the sensitive issues around substance abuse.
The end of July is when we expect to receive the final submissions, the feedback from the communities concerned. Then we'll take a couple of months in the fall to finalize a provincial strategy, but it will be very sensitive to specific needs and tailored services where they have been proven to be effective. We're not here to change just for the sake of change. It has to be for the better.
Mrs Boyd: One of the real issues here is that 80% of the programming that is available is run for men and generally on that paradigm. That was really the base of a lot of addiction services. Women came very late to addiction services and they clearly have fewer numbers of identified addicted people, although there is some question about whether the identification is clear or not. So I guess it's a valid concern that this would become swamped by the kind of care practices that may very well be effective for men but may not suit women when they have children to look after, when they may have suffered sexual abuse, and large numbers of them apparently have in the samples that those three organizations have collected over many years. That's why they're concerned.
Ms Mottershead: Yes. Thank you.
Mrs Boyd: Earlier the minister and certainly the parliamentary assistant talked about the cuts in health care not affecting patient care. I have a communication here from a Gwen Sutherland, who is talking about a situation in which surgery for an aneurysm, a fairly serious condition, was delayed from December 22 until January 17 because of lack of staff at a local Toronto hospital. It goes through detail about this person actually being prepped for surgery, being IV-ed, going to the operating room, and the surgery being cancelled because there wasn't a bed or the staff to look after them when they came out. I will table this for your information.
From everything we hear, this is not a specific instance in a specific hospital, although it's presented in that way. This is the kind of concern we're seeing. Have you had any sense from the hospital community, from the surgeons in the community in particular, of how common this procedure is of having someone actually admitted and prepped multiple times for surgery that then doesn't take place?
Ms Mottershead: It's certainly not something I would consider common at all. It's hard to imagine that a person could get to that stage of preparedness for an operation and then someone realizes that the nurse isn't there, the bed isn't there, having been admitted and going through the whole process, unless the surgeon, for whatever reason, got called for a more critical emergency operation.
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Mrs Boyd: That happened in one of these instances.
Ms Mottershead: Then I can see that happening, but not because there wasn't a bed available or because staff wasn't there. You would know that staff wasn't there before you started putting this person through that process. We'll certainly look into it. It's the first time I've heard of someone going through that process. We'll see about it.
I have to make a comment, because I have been in the system and in government for so long that I have quite a long history and quite a good recollection. Some of these issues that are being brought forward have been in our health care system for decades. There's nothing new here. The odd mishap does happen. It has always happened. It's unfortunate when it does. No one wants those kinds of things to happen, but occasionally they do.
If you go back to Hansards from 10 years ago, 20 years ago, five years ago, six years ago, three years ago, last year, you will see that there are these occasional things that happen that people hope would never happen but do. That's just a fact of life, because we have a complicated system. We have lots of specialists; we have lots of doctors; we have ambulances. It's very complex, and those things are bound to go amiss from time to time.
Mrs Boyd: I agree, but when there are so many changes happening at the same time, the concern is this maintenance of quality control and, I would say, better information to patients about what is happening and why it is happening.
I had another constituent, a man named Alec Jackson, in my office on Friday. He has a hole in his heart. He has congestive heart failure. He is a very ill person and he needs to go to hospital frequently to have an intravenous diuretic in order to ease some of the pressure. Normally in the past, these people would have been admitted for that process. Now people are trying to do it in the emergency department and keep them from being admitted, but it is quite traumatic for an elderly person who has no one to care for him at home to go through that. As we go through these changes, one of the biggest changes that has to happen is that connection between home and hospital and information to the patient to make this work smoothly.
While I can certainly understand why that might very well be the appropriate decision on the part of the hospital, because it hadn't been communicated to him and he hadn't been connected into community services in a way that would give him support and ease some of the fear, which is quite dangerous for him, he was very angry and was pointing that anger specifically at the government and seeing it as a cutback issue when it may partly have been cutbacks but it may partly have just been some of that change in medical care. It really concerns me that that's happening.
The Vice-Chair: Thank you, deputy.
The 12 1/2 hours of dialogue, discussion and deliberation has come and gone, and now it's time for a vote. There are six votes. Let's try to deal with them all together.
Shall vote 1401 through to 1406, inclusive, carry? Carried.
Shall the estimates of the Ministry of Health carry? Carried.
Shall I report the estimates of the Ministry of Health to the House? That's carried as well.
We have a few housekeeping matters we have to deal with before we adjourn. First of all, I'd like to thank all those people who tabled documents, reports. Deputy, you will ensure that all commitments will be tabled and given to the different members of the committee?
Ms Mottershead: Yes.
The Vice-Chair: Thank you very much.
We are going to meet tomorrow. Somebody from the Office of the Premier will be here. The Premier has informed staff that he will not be in attendance; however, the committee Chair is still trying to determine who will be available from the Premier's office. But we will be meeting tomorrow.
Mr Grimmett: Mr Chair, do you have a copy of the letter of June 20 addressed to Mr Kennedy? I was copied on that letter from the Premier. I've written on my copy, unfortunately. I'll read it to the committee if you like.
The Vice-Chair: Please.
Mr Grimmett: He's written to Mr Kennedy as the Chair of the committee.
"Dear Mr Kennedy,
"Thank you for your letter of June 19 informing me of the rescheduled time for review of the estimates of the Office of the Premier.
"As you know, the review was originally scheduled for June 18. Unfortunately, as my staff indicated yesterday to the clerk, I'm unable to attend the newly scheduled time. Mr Tony Clement, my parliamentary assistant, would be pleased to attend in my place. Mr Clement will be prepared to make opening remarks and to answer any questions the committee members may have.
"I hope this is satisfactory to the committee. If, however, the committee would prefer to defer consideration of the Premier's office estimates to a later date when I would be able to attend, please feel free to let me know. Thank you.
"Sincerely,
"Michael D. Harris, MPP."
The Vice-Chair: Let's spend a little time on it. The committee does not have a copy of this. I certainly don't; Mr Kennedy indicates he doesn't.
Mr Grimmett: I just got this from my staff today, but I understand it was faxed on the 20th. It could well be that it got sent to the wrong office.
The Vice-Chair: Committee clerk, have you received it?
Clerk of the Committee (Ms Rosemarie Singh): No.
The Vice-Chair: Nor has staff, so can we look into it? Are we in favour of having Mr Clement come tomorrow?
All in favour? All right. Let's go ahead with it.
One other matter: We will be meeting tomorrow with Mr Clement available, but we should determine today, because there may be some confusion -- one never knows -- when we're coming back. In order to allow the ministers to prepare properly, can we get consensus that we will be meeting the first week back in August? Is that a fair commitment to make?
Mr Grimmett: That's agreeable.
The Vice-Chair: The week the House resumes in August.
Mr Kennedy: In case that changes.
The Vice-Chair: Yes, in case the date changes.
All in favour of that? Okay, that's great.
Two things left. One, I'd like to thank legislative staff, certainly Rosemarie Singh, Alison Drummond and definitely Pat Girouard for their excellent work. Staff always sit here but very often don't get the recognition they deserve. You work very hard and we appreciate it.
Finally, this will be the deputy's last opportunity to present herself to estimates, as she's moving on to new challenges. Over the course of 31 years, it's obvious to me as a first-time member of estimates and certainly to everyone here that you certainly have a wealth of knowledge and a degree of dedication that you should be very, very proud of.
I'm happy and I'm sure committee members are very happy that you will be able to spend more time with your two children, ages 12 and 17. You have a full-time job right there. We hope any new challenges you pursue will be successful to you, that you will find satisfaction in them, and that your many years of service will continue to always be very fruitful for not only the people you serve, but also yourself. Thank you very much, and good luck in the future.
Ms Mottershead: Thank you very much for the kind words.
Mrs Boyd: Mr Chair, I wonder if we might also say how very helpful Ms Mottershead has been throughout this process, and also say she must have started her public service awfully young.
Ms Mottershead: That's right. Child labour.
The Vice-Chair: Absolutely, no question.
As a final comment, I think Dan Newman, the parliamentary assistant, said it best. He said, "Certainly, I'd like to say she was a big help."
We stand adjourned. We'll meet tomorrow.
The committee adjourned at 1650.