MINISTRY OF HEALTH AND LONG-TERM CARE

CONTENTS

Wednesday 25 October 2000

Ministry of Health and Long-Term Care
Hon Elizabeth Witmer, Minister of Health and Long-Term Care
Ms Michelle DiEmanuele, assistant deputy minister, corporate services
Dr Les Levin, senior policy adviser, cancer services
Ms Mary Kardos Burton, executive director, health care programs
Mr John McKinley, director, finance and information management
Mr Daniel Burns, Deputy Minister
Mr John King, assistant deputy minister, health care programs
Ms Kathleen MacMillan, provincial chief nursing officer
Mr Colin Andersen, assistant deputy minister, program policy branch
Dr Colin D'Cunha, chief medical officer of health
Ms Mary Catherine Lindberg, assistant deputy minister, health services

STANDING COMMITTEE ON ESTIMATES

Chair / Président
Mr Gerard Kennedy (Parkdale-High Park L)

Vice-Chair / Vice-Président
Mr Alvin Curling (Scarborough-Rouge River L)

Mr Gilles Bisson (Timmins-James Bay / Timmins-Baie James ND)
Mr Alvin Curling (Scarborough-Rouge River L)
Mr Gerard Kennedy (Parkdale-High Park L)
Mr Frank Mazzilli (London-Fanshawe PC)
Mr John O'Toole (Durham PC)
Mr Steve Peters (Elgin-Middlesex-London L)
Mr R. Gary Stewart (Peterborough PC)
Mr Wayne Wettlaufer (Kitchener PC)

Substitutions / Membres remplaçants
Mr Ted Chudleigh (Halton PC)
Mr Brad Clark (Stoney Creek PC)
Ms Frances Lankin (Beaches-East York ND)
Mrs Lyn McLeod (Thunder Bay-Atikokan L)

Also taking part / Autres participants et participantes
Mrs Sandra Pupatello (Windsor West / -Ouest L)

Clerk pro tem/ Greffière par intérim
Ms Susan Sourial

Staff / Personnel
Ms Anne Marzalik, research officer,
Research and Information Services

The committee met at 1542 in room 228.

MINISTRY OF HEALTH AND LONG-TERM CARE

The Chair (Mr Gerard Kennedy): Thank you all for attending. We will commence this meeting. We now turn to the third party in our rotation for 20 minutes.

Ms Frances Lankin (Beaches-East York): We will be proceeding with some questions with respect to northern cancer patients. I'm going to turn that over to Ms Martel. But before I do, I have one totally unrelated budget item question that I'd like to ask and get out of the way.

With respect to page 69, the Ontario drug benefit program operating cost, you'll see the transfer payments are roughly $1.4 billion. I wonder if you could provide me with a breakdown of what that covers. Most particularly, I'd like to know the estimated amount for payment for the Ontario Trillium plan. Do you have the Trillium number available today? Perhaps someone could look for that.

Ms Michelle DiEmanuele: I'm pretty sure we can give that to you.

Ms Lankin: We'll proceed with the other questions, and if you could give that to me before the end of this 20 minutes, I'd appreciate that.

Ms DiEmanuele: Yes, absolutely.

Ms Lankin: Thank you. Mr Chairman, I'll turn it over to Ms Martel at this point.

Ms Shelley Martel (Nickel Belt): Minister, I'm here today because I continue to be concerned about your government's ongoing discrimination against cancer patients from northern Ontario, and I have some questions in that regard.

The first goes back to when the program was begun in April 1999, when your government decided it would fund 100% of the cost for southern Ontario cancer patients travelling for care in the north or in the States-100% of their food, travel and accommodation. Can you tell me what the rationale was for the government to agree to do that?

Hon Elizabeth Witmer (Minister of Health and Long-Term Care): First of all, I think we need to clearly put on the record the fact that we have two distinct and separate travel grant programs. We have the northern health travel grant, which is a permanent program, as opposed to the cancer care referral program, which is a temporary program. The northern health travel grant was initiated under the Liberals. It was a program you were critical of and which you had an opportunity to improve when you were in office. At the present time, we are reviewing it. But it's also a program that is not available to people in southern Ontario.

At the present time, Cancer Care Ontario has determined that we don't have the capacity in Ontario to treat all our radiation patients who have prostate and breast cancer. They have provided funding to those individuals in order that they can access treatment within the appropriate waiting time either in northern Ontario or in the United States. So it is a Cancer Care Ontario program, it is temporary and it is a program to which all people in the province have access. It is equally accessible to all who need it, if they suffer from breast or prostate cancer and need radiation within a certain time.

Ms Martel: Minister, you said this is a Cancer Care Ontario program. Isn't it true your that government is fully funding 100% of these costs to these patients?

Hon Mrs Witmer: As you know, Cancer Care Ontario is an agency that has been set up by the provincial government. It is an agency that makes decisions regarding the treatment and programs for cancer patients in the province. Yes, the funding that supports Cancer Care Ontario is taxpayer money. That's how the money is provided to Cancer Care Ontario.

Ms Martel: If I might, Minister, this is a special allocation to Cancer Care Ontario to pay 100% of these costs for patients to travel; it's not out of Cancer Care Ontario's base budget that they receive from you. Is that correct?

Hon Mrs Witmer: As you know, Cancer Care Ontario submits to the government requests for funding on an ongoing basis. Obviously, since we have asked them to assume responsibility for the delivery and planning of cancer programs, we are the ones who consider the requests and make the response.

Ms Martel: It's clear it is a special allocation, and Dr McGowan from Cancer Care Ontario confirmed that for the public accounts committee in February. My question was, though, what was the rationale for the government to agree to make a special allocation to Cancer Care Ontario in order for this program to occur?

Hon Mrs Witmer: I think we've said on many occasions-in fact I said it in my introductory remarks, Ms Martel-that it is on the best advice of Cancer Care Ontario. It is health professionals who have determined that we don't have the capacity within Ontario to treat, within the appropriate time, people who need radiation treatment and who suffer from prostate and breast cancer. It was based on their recommendation. These are clinical decisions that have been made by Cancer Care Ontario; they're not political decisions. Based on their recommendation that these people receive services within the designated time period, they have recommended that these people be provided with treatment in other centres in Ontario where there's space or that they travel to the United States. They are the ones who have made the recommendation that there be reimbursement.

Ms Martel: I'm not questioning the medical decision. I am asking for the government's rationale for the financial decision, ie, the decision to financially provide for 100% of the cost for these patients to travel. What was the government's rationale for agreeing to provide those finances?

Hon Mrs Witmer: I'm going to ask Les Levin, who is our senior cancer policy adviser within the Ministry of Health and Long-Term Care, to give you further information, Ms Martel.

Ms Lankin: If I may, Minister, the question is the government's political decision, the cabinet decision. With a lot of respect to Mr Levin-I don't mean at all to suggest he doesn't know a lot about the structure of cancer services-I'm asking, and Ms Martel is asking, what the political decision and rationale were for this.

Hon Mrs Witmer: I appreciate your attempts to help Ms Martel, Ms Lankin. However, this is not-I repeat-this is not a political decision. This was a medical decision. That's why I believe it is very important that Mr Levin have the opportunity to respond as to why we are re-referring.

Ms Martel: With all due respect to Dr Levin, who was before our public accounts committee and has heard me go on about this before, Minister, the question is a political one. Your government, your cabinet, made a decision to provide 100% of the finances for this scheme to occur. That's not a medical decision. It's a financial decision. You had to find the funds to do it and you agreed to do so, and what I want to know is, what was the government's rationale for agreeing to provide 100% of the funds to do so? You could have paid nothing, but you chose to agree to pay 100%. Why?

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Hon Mrs Witmer: Again, I just repeat that these were based on medical decisions and recommendations that were forthcoming from Cancer Care Ontario. If you are obviously not interested in hearing the medical reasons as to why these recommendations were made, it's difficult to make a response. But Dr Levin is here. He's prepared to as fully as possible respond and give you information that was used to make the decision to accept this recommendation. I ask Dr Levin to provide the information.

Ms Martel: I'm sorry. If I might, Minister, it's not a medical decision. So let me ask it this way: did the government agree to fully fund 100% of the costs because you were concerned that these cancer patients had to travel far from home for cancer care?

Hon Mrs Witmer: I just repeat, Ms Martel, this was based on medical decisions and recommendations and, again, without providing Mr Levin with the opportunity to indicate why the decision was made to re-refer cancer patients, obviously the information that I think would be beneficial in helping you understand the decision will not be available to you.

Ms Lankin: Minister, I'm going to ask you one more time to answer the question that has been put to you. I do believe that both Ms Martel and myself and anyone else who has been observing this issue understands the medical reasons that a re-referral program was put in place, and the fact that a person is re-referred to cancer care where it is available may be and is being based on a medical decision. That has nothing to do with why the government decided to compensate someone for their travel costs once they had been re-referred. That is a financial decision. It is not, with all due respect, a medical decision. The fact that they have been re-referred is one thing. The fact that the government cabinet decided to compensate them for travel costs is another. Could you answer why you chose to accept a proposal to compensate people for those travel costs once they had been medically re-referred?

Hon Mrs Witmer: I simply repeat, this was a medical decision that was made. Obviously, it was made after very careful consideration by the Cancer Care Ontario staff and leaders and, based on the information and the recommendations that came forward, we accepted the recommendation in order to ensure that the people in the province of Ontario could receive radiation treatment within the appropriate period of time and that they would be at least provided with the option of going elsewhere to access the radiation treatment they needed. So, again, it was medical decision and recommendations based on those medical decisions.

Ms Martel: If I might, Mr Chair, let me ask Dr Levin, then. Sir, can you tell me, what was the financial decision that was made by cabinet or by your minister to fully fund the cost for these patients who were re-referred?

Dr Les Levin: I would be happy to share with you the basis for the decision that was conveyed to us by Cancer Care Ontario at the time. As you will know, Cancer Care Ontario revealed to us the extent of the waiting list for patients requiring radiation treatment. In about November 1998 they realized that the situation required some remedial action.

Ms Lankin: I think we know that, Dr Levin.

Dr Levin: OK. They requested that we comply with a standard which had been set up by the Canadian Association of Radiation Oncologists. Recognizing the extent of the problem, my understanding is that Cancer Care Ontario wished to place no impediment in the way of any people who wished to take the option of travelling elsewhere for their treatment, and that was the basis on which I believe this decision was made.

Ms Lankin: Dr Levin, could I just ask you by extension, then-the cost of travel to a distant place was viewed as a potential impediment to people seeking care in a timely fashion.

Dr Levin: No. The extent of the problem was such that they wished to make it easy and not place any impediments whatsoever in the way of people who wished to accept that option. I think it's also important to look at this in the context of the other travel arrangements that are unique to cancer patients in Ontario. As you no doubt know, the Canadian Cancer Society does offer cancer patients supplements to the existing northern health travel grant when they travel in the north.

Furthermore, because cancer patients are travelling for ambulatory treatment for very prolonged periods of time, patients in Ontario who travel are almost always given access to accommodation. Therefore, it was necessary to make sure that the accommodation costs of patients travelling to the United States were covered. I believe that the only difference between patients travelling in Ontario and those who are being referred to the United States was that their meals costs were covered at $40 per diem for those who were travelling to the United States. I'm not sure of the basis for that decision. I believe the discounted Canadian dollar might have had something to do with that.

Ms Martel: If I might, you said "impediment," and I'm going to assume that means a financial impediment for cancer patients to seek cancer treatment somewhere else. That is the same situation that faces northern cancer patients every day when they have to travel far from home to go to Sudbury or Thunder Bay to receive cancer care or if they have to leave the north altogether. There is absolutely no difference with respect to the government decision made to deal with southern Ontario patients and the decision the government should make with respect to cancer patients who suffer now in the north because they have to go so far to get treatment.

I didn't expect you to answer, because the question really was for the minister, and it's for the political folks to answer.

Let me ask the minister this question, though. You promised in the House on May 8 that you would do a review of this inequity, and we are still waiting for this five months later. I finally filed a freedom of information request on September 13 and I have been told that it's going to take until November 14 to complete consultations with respect to my request. Can you tell me, Minister, is this report done? I surely believe that it is.

Hon Mrs Witmer: You've certainly heard me speak and you've heard the Premier say that we're doing a very comprehensive review of our travel grant program. It would be our hope that that comprehensive review would be completed this fall, and then the information would be provided to you.

Ms Martel: It was my understanding that the northern health office has completed some work that was probably done by the end of June which would have responded directly to this issue of inequity. Can you tell this committee whether work done by Raymond Pong and others is actually complete?

Hon Mrs Witmer: As I say, we're doing a very comprehensive review of the travel grant programs. As you've indicated yourself, we have not only the permanent northern health travel grant program but we also have this temporary re-referral program that is supported and funded by Cancer Care Ontario. So we believe it's prudent to do the comprehensive review.

Ms Martel: I think Mr Raymond Pong has done a report on this issue. Would you table that with the committee as a separate addendum?

Hon Mrs Witmer: Once the information is ready, we'll be in a position to share all of that information with you.

Ms Martel: Minister, you announced several weeks ago that you're going to send more southern Ontario cancer patients away for treatment. You've asked CCO for an estimate of the costs to do so. Can you tell the committee if you've asked CCO to include the cost to fully fund northern cancer patients too in that estimate?

Hon Mrs Witmer: Again, we did not ask Cancer Care Ontario to send more patients elsewhere. We understand that they are preparing proposals, so any information regarding additional re-referral of patients has come from Cancer Care Ontario and I understand that they may be preparing such a proposal for us, which I have not yet received.

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Ms Martel: Minister, it was my understanding that your ministry specifically asked CCO for the estimate of the cost to send more southern Ontario cancer patients away for treatment, both the volume-sheer numbers-and the cost to pay 100% of their travel to do so. What I am asking you is, given that that is happening, have you also asked them to include the cost to fully fund northern cancer patients, too?

Hon Mrs Witmer: I understand that what's happening is that Cancer Care Ontario is in the process of preparing information for us that would relate to further expansion of the travel program. I have not received the program. I don't know if Mr Levin has any additional information, but I don't have the information that is being or has been prepared.

Ms Martel: Minister, on several occasions you've said this re-referral program and the government's 100% funding of it is temporary. Can you tell me your definition of "temporary"?

Hon Mrs Witmer: Again, this program won't be going on for 10 years or five years. We certainly hope that within the next couple of years, obviously based on the advice and the information that we receive from Cancer Care Ontario, that we'll be in a position to terminate it. I think we'd all like to be able to say, Ms Martel, that next week or next month or the beginning of 2001, we would have the appropriate number of radiation therapists here, the oncologists, the physicists, and that we would be able to treat everyone in our own province, but unfortunately, as you know, that's not the case.

It's not the case in Ontario, and it's not the case in many of the other provinces, as well. We are finding ourselves in a situation, because of a shortage of human resources, that we simply don't have the human resources to provide all of the radiation in the province. But, as I say, we'd like to, and would encourage Cancer Care Ontario to take every step possible to make sure that they do everything possible to ensure that people could receive all treatment in this province. That's our objective.

Ms Martel: Minister, the problem I have is that Cancer Care Ontario was before the public accounts committee in February and told us then that this program would go about two and a half years. That was before the recent announcement of about two weeks ago that the waiting list for some of this treatment was the longest ever, so I expect that we are well beyond two and a half years.

The problem I have with that is that you're going to continue to pay 100% of the costs for southern Ontario cancer patients to access care, which you should do and I agree with, and at the same time you're only going to give northern Ontario cancer patients partial travel costs, 30 cents a kilometre one-way if they travel more than 100 kilometres, one-way, for cancer care.

That discrimination just can't go on that long. What will it take for your government to understand the financial burden that you are placing on northern Ontario cancer patients too, who also have to travel very far from home every day to get care? What's it going to take for us to get you to understand that that situation has to be fixed?

The Chair: Ms Martel, I'm sorry, your time is up. Minister, perhaps in the next round you can provide an answer to that.

We now turn to the government caucus and to Mr Mazzilli.

Mr Frank Mazzilli (London-Fanshawe): Minister, just continuing on that, in relation to cancer, certainly there have been plenty of new stories that outline and highlight the waiting lists in Ontario for cancer treatment. We didn't get into this problem overnight, and somehow most of us would feel that governments would plan for these trends in our aging population, and diseases.

Having said that, what is our government doing to ensure that Ontarians can receive timely treatment in Ontario? Perhaps, to explain that, you want to refer part of the question to Dr Levin to outline how we got into this in the first place.

Hon Mrs Witmer: I'd be pleased to respond, Mr Mazzilli. Unfortunately, this has been, as are many of the health problems, of long standing, and I would indicate that it's not unique just to the province of Ontario. I think for a long, long time there was not a lot of renewal and restructuring within the health system. I think there were responses made to situations that were certainly of an ad hoc nature, but there was no comprehensive long-range planning taking place. In many respects, that's now being undertaken not only by us in the province of Ontario but by other governments throughout Canada as well in the provinces and the territories.

Specifically speaking to cancer, since 1995 we have become aware of the fact that as the population grows and ages, so does the incidence of cancer. The incidence of cancer is increasing by about 3% per year. Since 1995, we have consulted with stakeholders and patients, those who have knowledge of the system, and we have already invested over $160 million into cancer services and cancer care.

I would like to share with you the other statistic. The reason we don't have the capacity for the radiation therapy is that it really had not been expected that the number of people who needed therapy would increase as much as they have. The number of patients receiving radiation therapy has actually increased by 25% since 1995. Since we have become aware of the situation as it relates to cancer in Ontario, we have undertaken several steps. Number one, we set up Cancer Care Ontario in order that they could coordinate standards and guidelines for the treatment of patients. We have increased their funding by 28% since 1997 and are constructing new cancer facilities in St Catharines, Sault Ste Marie, Kitchener, Mississauga and also in Durham. We are working very co-operatively with Cancer Care Ontario in order that we can address the needs and plan for the long term.

Unfortunately I think it's the long term that has been neglected. We need to make sure that not only can we respond to needs today but into the future. I'll let Dr Levin deal with what has happened and what we hope to see happen.

Dr Levin: Just by way of background, radiation treatment is an extraordinarily complex modality. It is likened to a hydraulic system with changes in indication, staffing and machine capacity all impacting on the delivery of this highly complex and highly technical modality.

We all wish we were wise in retrospect, in terms of human resource planning in particular, and we share that with other jurisdictions, as the minister alluded to, in Canada, and also in other countries. The truth of the matter is that there are very few jurisdictions internationally that are able to pinpoint with precision the human resource needs for many components of health care.

When you have a complex modality like radiation treatment to deal with, any deficiencies in the system are going to create backlogs in that particular system. When you manage to resolve one problem, the hydraulic system kicks in and you have another problem with respect to delivery. Despite that, I believe that we are making fairly considerable inroads within the province.

The standard of a four-week wait time for radiation treatment-that's from the point of referral by a surgeon to beginning radiation treatment-was set by the Canadian Association of Radiation Oncologists. Cancer Care Ontario gave us an interim standard of eight weeks while we ramped up capacity in the province and sent patients to other parts of the province or, as need be, out of the country, to get us down to the eight-week standard.

The extent of the waiting problem was first brought to our attention in November 1998. In January 1999, 25% of patients were being treated within the four-week standard. By June 2000 it had gone up from 25% to 38%. In January 1999, 60% were being treated within eight weeks and, as of June 2000, that's gone up to 73%. So I think we're seeing quite considerable movement in terms of the throughput and the efficiency of treating these patients.

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We have a 10-point plan, which I think is already beginning to show some promise, which we implemented in March 1999. We made the necessary salary and workload standard adjustments that were recommended to us by the professions and by Cancer Care Ontario in March 1999. We put in place two of the largest training programs ever for radiation therapists and medical physicists. That is where we're going to reap the most benefit in the medium to long term, by training up our own staff to take care of radiation services. We have very good accruals to those programs.

We funded an ambitious national-international recruitment effort. Cancer Care Ontario have done I think a sterling job in attracting people to this province to help us address our immediate problems.

We knew in April 1999 that there would a problem with regard to capacity in the short term, and that is why the out-of-country referral program was approved, to help us off-load the immediate problem while we were ramping up capacity in the province, which is the desired way of dealing with this problem.

We approved a cost-per-case funding arrangement for radiation treatment. I think that is extremely important. What it means is that Cancer Care Ontario and the Princess Margaret Hospital can treat any number of patients a year and they know they're going to be reimbursed for that by way of year-end reconciliation. There are no financial obstacles for either of these agencies to treat as many cancer patients as they wish.

We struck a cancer human resources committee which is beginning to plan for our future needs and to tie those needs to the training programs, especially radiation therapy and medical physics.

We've worked with smart systems in the Ministry of Health to develop an electronic tracking system that allows us to detect pressures in access to cancer surgery, radiation treatment and systemic treatment, and we're through the first phase of that development. Hopefully we can bring that to fruition within 12 months. That's quite a complicated system.

We provided $4.4 million to Princess Margaret Hospital in May 1999 to allow them to make adjustments to their treatment machines and, by doing that, to increase throughput. As a result of that one initiative, they increased the number of cancer patients treated at the Princess Margaret Hospital by 10%, which is a huge number, given the complexities of radiation treatment.

The minister has alluded to the money that has been allocated for development of new radiation treatment centres in Kitchener, Oshawa and Mississauga. We also have a very bold initiative which is recommended by Cancer Care Ontario. We are looking at a single-machine centre in Sault Ste Marie. That is a bold initiative. We are prepared to provide funding for that. That might change the way radiation treatment is ultimately delivered in the province, moving away from mega cancer centres to the smaller cancer centres and bringing treatment much closer to home for patients.

Finally, the Ministry of Health has been meeting with both Cancer Care Ontario and the Princess Margaret Hospital to look at ways in which we can ensure that the existing complement of machines is replaced according to a predetermined schedule in the future.

That 10-point plan will hopefully deal with our problems in the medium to long term.

Mr Ted Chudleigh (Halton): Minister, last spring it came to light that the long-term-care units in Ontario have never been properly inspected on a yearly basis. I understand we have taken steps in order to ensure that those inspections do take place on an annual basis. I wonder if you could tell the committee what those steps are and where that program is at the current time, as to its coming to fruition.

Hon Mrs Witmer: I'd be pleased to respond to the question, Mr Chudleigh. Our government has indicated that we are committed to very high quality standards in all of our long-term-care facilities in the province of Ontario. There are approximately 536 facilities. About 510 of those are permanent, and the others, as you know, are interim long-term-care bed facilities.

Late last year I asked the deputy to do a review to ascertain whether there had been annual reviews done of the long-term-care facilities in this province in the past and in the present. I was informed by the deputy that unfortunately the long-term-care facilities had not, on an ongoing basis, or ever, been all receiving annual reviews.

I then asked the deputy to prepare for us an action plan to ensure that all long-term-care facilities in the province-nursing homes and homes for the aged-would in future receive annual reviews. I'm very pleased to say that on July 5, 2000, I announced a plan of action which would ensure that for the first time in the history of this province an annual review would be done in every long-term-care facility. We also announced at that time an additional $860,000. Also, we have hired additional compliance advisers.

The action plan included, first of all, a very aggressive tracking system to ensure that the new annual reviews are on track and that corrective action is taking place. I think that is important, that there be a tracking system.

Also, there is now a province-wide reporting process to provide updated information on the reviews. I am also pleased to say that there were five new compliance advisers who were hired permanently to perform this unprecedented task of making sure that each facility would receive an annual review.

I can assure you that we are on track. The ministry has informed me that since July 5, 2000, they have completed more than 53% of the annual reviews, up until September 30, 2000. I have every confidence that by March 31, 2001, there will be complete compliance with the action plan provided to me by the deputy, and that not only this year, but every year thereafter we will see an annual review of our long-term care facilities, our homes for the aged and our nursing homes.

Mr R. Gary Stewart (Peterborough): Minister, permit me just to ramble one little bit more.

The Vice-Chair (Mr Alvin Curling): You've only got one minute.

Mr Stewart: I've only got one minute? I certainly can't ramble in one minute, to say the least, so I'll ask my question the next time around.

If I've only got a minute, I just want to make a couple of comments about the achievements and the dollars that have gone into various areas in my-

The Vice-Chair: Mr Stewart, I made a mistake. You've got about five minutes.

Mr Stewart: Then I can ramble a little bit more. That's great to hear.

Anyway, it's to try to show the dollars going into these areas. Certainly rural Ontario is getting a good number of those, because the ministry has identified the need in some of these small communities.

Yet if I also look at the larger communities, they'll be contributing $107 million for the Thunder Bay Regional Hospital, to build a new acute care hospital, and I think that's absolutely tremendous. In Toronto, the ministry has approved capital projects totalling $563 million to accomplish restructuring and address redevelopment pressures.

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But there's another pressure out there, and I guess it's probably more common in rural Ontario than it is in some of the larger centres, and that is the shortage of doctors. The area I represent is one of them. Communities like Havelock, Belmont, Bethune and Keene are small villages which over the last many, many years have had a doctor. Citizens in the rural area have to realize that the day of having a doctor at every crossroads is not going to happen. They've got to realize that. But there are other areas where the distance to travel is a long way.

The opposition would have us believe we have done nothing to address this important issue. I understand it was the previous government that reduced the number of medical school enrolment positions in Ontario which has helped to amplify the current shortage. Could you please detail some of the initiatives our government has done regarding the recruitment and the retaining of physicians in Ontario?

Hon Mrs Witmer: There was a decision made in 1992, and it was made actually throughout Canada, to reduce the medical school enrolment by 10%. The government of the day made that decision in the province of Ontario as well.

However, we have worked very diligently, beginning with Mr Wilson, who was the minister in 1995, in recognizing that we need an appropriate supply of physicians, appropriate distribution and an appropriate mix. We have identified in particular that there is a great deal to do in the north and in the rural part of this province. I am very pleased to say there have been many initiatives in the north and the rural part of the province to attract and encourage doctors. First of all, $90 million was provided to help over 60 small hospitals with physician coverage in emergency rooms. That certainly was significant.

There was as the joint OMA-Ministry of Health agreement for 20 northern underserviced communities to attract doctors. They were provided with a $10,000 retention bonus if they stayed for three years, double stipends for specialty services, a guaranteed base salary, and $60,000 for overhead costs. Also, they have been provided with a 70-hour sessional fee for physicians who work nights, weekends and holidays in emergency departments in northern hospitals. There were 78 hospitals in the province eligible for that.

The Vice-Chair: I think your time has about run out. Maybe you could put that in a written statement later on.

Mrs Sandra Pupatello (Windsor West): My question for the minister concerns the RFP process for CCACs. I'd like the minister to describe what kind of review she's planning to undertake and exactly why the review. My understanding is that there is an uneven playing field for those who are participating in the bidding process. Could you comment on the effect pay equity legislation has had on these organizations which are submitting a bid to an RFP for CCACs and are not able to submit the same kind of bid, simply because the wage rate is so much higher due to pay equity and there's no compensation from the government in that regard? Apparently they've come forward many times to the government with this issue and it hasn't been addressed yet. I'd like to know why the review and what you feel the problem with the RFP is, and what you're prepared to do to either eliminate the competitive model all together, to rescind it, to change it, what changes and in what area?

Hon Mrs Witmer: Our government is very strongly committed to ensuring that we have high-quality community care services available to all Ontarians. The objectives of the program review are, first, to examine how services are being obtained and delivered across the province; second, to identify the program's strengths and opportunities for improvement; and third, to highlight the issues which are going to require some further investigation, such as what you have just referred to, the request for proposals.

I would call on Mary Kardos Burton to give you some additional details as to the review.

Ms Mary Kardos Burton: Thank you very much, Minister. I am Mary Kardos Burton, executive director of health care programs.

You asked about the RFP process. I think it's important to point out that the process is relatively new. It's only been in place since 1997. I think that we need more experience with it in terms of looking at how effective it is.

In terms of what we've done in the ministry, we've provided extensive training to CCACs in contract management so that they can ensure that there's a strong accountability mechanism. We've also got a managed competition stakeholder committee that actually looks at the practices that are in place. As the minister said, we have a program review in place and we're expecting the results this fall.

Mrs Sandra Pupatello (Windsor West): Could I ask you to comment on the pay equity issue and how you feel this inequity disservices those who are submitting a bid?

Ms Kardos Burton: There are operational issues that have been identified by CCACs. We're certainly looking at those operational issues.

Mrs Pupatello: Is it your intent that you would then pay, or up what you are paying, in order to compensate for pay equity?

Ms Kardos Burton: Every issue that's been identified as a financial issue with the CCACs, certainly our regional offices have looked at them and they have identified some operational issues in terms of the process.

Mrs Pupatello: Is it an issue through the Ministry of Finance or the Ministry of Health?

Ms Kardos Burton: The Ministry of Health is working with the CCACs. CCACs are private organizations as well and they're managing their own, but they have raised issues with us. We are working with them to see whether we can look at their operational issues.

Mrs Pupatello: Some of the CCACs are undergoing their second round now of the RFP process because the contract length is three years. Some feel that's too short. The ramp-up time gives them maybe one and a half years full up once they've gotten going. That's been the experience in that first round.

What would you say constitutes a breach of contract when a company is delivering service and is not able to meet the terms of the contract for a variety of reasons like, they didn't exist in the community before they won the bid; there's a nursing shortage; and those companies are not taking the patients they're being sent by the CCAC, which would obviously be viewed as a breach of contract? How long would you say before the CCAC should get rid of the company that's not obliging the contract they've signed?

Ms Kardos Burton: The CCACs are responsible for working with the providers they have chosen I think in terms of ensuring that the expectations they outlined are being met.

From a provincial perspective the process has been in place since 1997, and we are working with the CCACs. I think the program review will certainly be informing us this fall in terms of whether there can be improvements to the system.

Mrs Pupatello: Given the nature of the high level of training you just spoke of that you're giving the CCACs to go through this contract process, what would you suggest to the CCACs that they do when there are breaches of contract of this nature?

Apparently they are right across the board in Ontario, not just in my own community, where companies are simply not meeting their obligations and are saying no to services when the call comes to take on a patient. The company says, "I have no nurse to send." The company says, "I simply can't do it. I don't have anyone on the night shift. I don't have an ostomy expert."

For all of the above reasons and more, they are not giving service-obviously a breach. There are many issues like nursing shortages that are not up to a company to solve but are much larger issues. What advice do you give as the trainer in instructing CCACs in how this model has to be delivered? What would you tell them?

Ms Kardos Burton: Our priority is that service needs are met. I think that from a ministry perspective, our regional offices are working with the CCACs, they are monitoring the situation, and certainly any issues that need to be dealt with on a province-wide basis will be dealt with.

Mrs Pupatello: There was an issue in the RFP process in the first round that dealt with the weighting given to the RFP on quality versus price. There was a strong feeling that there were a number of issues around companies having no history of service delivery, where other organizations had been around for 100 years and had a significant history in delivery of service, and that those qualitative issues weren't addressed by the RFP. In fact, major organizations like the VON are withdrawn from that nursing service, for example, where a new company, never before in a community, was able to win a bid and then had to start up operation with no nursing staff.

In many examples, like in my own community, the nurses who were employed by VON, for example, did not just move over to the new company. The new company was left with no nurses to provide the service that they signed a contract to provide.

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In that instance, when would you say a contract is breached and the CCAC must do a review to ensure the services are met? In fact, we have met patients where nurses simply did not arrive at the home once they were released from the hospital.

Ms Kardos Burton: You asked about the RFP process. It's conducted to compare service provider organizations on a number of criteria. It's designed so that it's fair and open. You asked in terms of the percentages: 75% is quality and 25% is price in the evaluation process.

Mrs Pupatello: Is that a changed figure that you're giving?

Ms Kardos Burton: No.

Mrs Pupatello: It was 80-20. There's written material that indicated it was 80-20. Is it now 75-25 in the new round?

Ms Kardos Burton: My understanding is that it's 75-25, but we'd be happy to verify that for you.

Mrs Pupatello: Could you speak to breach of contract and what in the ministry's view would be a breach of contract when a company cannot provide the service for a myriad of reasons? I mentioned some that it's not up to a company to solve, like if they can't find nurses to hire.

Hon Mrs Witmer: In response to your question, obviously we have to remember that CCACs have reached an agreement with a provider and it's up to them to make the determinations as to what would constitute a breach of contract. They have the legal responsibility and they have the independence to make those decisions.

Mrs Pupatello: As the minister might know, we've been calling for standards in home care since 1997 and since the CCACs were created because there are currently no standards in the delivery of service in this area. For example, an individual who needs personal grooming or some level of home care and lives in the city of Windsor doesn't necessarily get it as a patient, but if he were to move to Chatham he would get it. The standards there are that the Chatham CCAC would deliver that service, but not the Windsor-Essex CCAC, because there is a difference in standards. This is the case across the board in Ontario. Depending on where you live, it's up to the will of that board of directors of the CCAC to determine how best they will deliver those services. So it does come back to the provincial government to set those standards and say what a patient is entitled to in this province in terms of home care.

As the minister is aware, we've lost 5,000 beds out of our hospitals. Patients, doctors and hospitals all acknowledge that patients are moved out of hospitals much more quickly than ever before, and everyone acknowledges, including the former minister of long-term care, that patients are out sicker and quicker. Mr Jackson has that on the record as well.

What that means is that the delivery of home care to patients is much more acute than ever before, so nursing demands are higher. For example, the Windsor CCAC-and this is the same in many of the CCACs-the contracts they're having to meet are actually 110% in volume of what they had sent out in the bidding process, and yet the funding level has only increased by 2%. So there is an 8% gap of delivery of service under the contract. They can't possibly meet the requests for service.

That, coupled with a significant shortage of nurses in the home care field for a whole variety of reasons: the wage gap, for example, which is historic-people who worked in home care enjoyed the field, so the price differential and wage didn't seem to be as much of an issue. Now the view is that home care conditions for nursing, for example, are so poor that wages are an issue. I would ask the minister to speak to any discussions you've had or considerations you may be giving to address the issue of wages. Are you prepared to set the bar at a different level for nursing, for example?

Hon Mrs Witmer: I think your questions are valid and good ones. I think it's important to note that the issue of home care is one that is being addressed by every government in Canada. Originally the federal government had wanted to provide some leadership in establishing some national standards regarding level of care, and I personally support that. For whatever reason, we haven't seen that happening.

At the present time, people in this province are receiving per capita spending on home care to the tune of $128. That is the most that's being spend anywhere in Canada. Obviously, someone who is living elsewhere is not receiving the same type of support for home care. I think we need to be taking a look at standards; I think we need to be taking a look at consistent levels of care. I would hope the review would address that.

As you know, we have set aside a commitment to make available $551 million for community services by the year 2004. We're well on our way to getting there. We've already invested more than $250 million. We want to ensure that everyone in this province, no matter where they live, has the same type of access. We're also concerned about the issue of-

Mrs Pupatello: Minister, while you are on that point, if I may, just on that same issue: could you turn to page 128 of the estimates book and tell me, then, why the interim actuals are so significantly lower than the estimates for community support services, which you just mentioned you plan to increase; and on that same note, why the area of homemaking services is so significantly lower in the interim actuals than you had in the estimates? That's vote 1406-3. You seem to be headed in the wrong direction in terms of your figures, based on what you've just said is your intent.

Hon Mrs Witmer: I would call upon Ms Burton to respond specifically.

Ms Kardos Burton: Can you just go over exactly which one you were asking-

Mrs Pupatello: Page 128, if you go down to homemaking services, community support services, the interim actual of $423,954,858 is significantly less than $469 million, which was the estimate. The line directly below it, $131 million, is significantly lower than the $159 million. The ministry then is significantly behind in increasing. If the minister's statement is true and you're trying to head in the other direction, then you're actually spending less.

Ms Kardos Burton: I think that part of the spending is less because we've been restructuring some of our programs internally. There is certainly no intention to spend less than that.

Mrs Pupatello: That internal reallocation is only accounting for-well, none of that is being attributed to those two lines, if you look on page 129.

Ms Kardos Burton: I think I'll ask the director of finance and information management, John McKinley, to speak specifically to the areas that you're raising.

Mrs Pupatello: While he takes his seat, I'll just put on the record that it's inconceivable that you could spend less in the area of homemaking or support in the community in this day and age, when you have so many more patients being sent home quicker and sicker, as was acknowledged by the former minister of long-term care in the last term. With all of that, with the political discussion that's been made, the numbers do not bear out that you are in fact spending more.

Mr John McKinley: I'm John McKinley, Ministry of Health, director of finance and information management. The issue we are seeing here is that we have had tremendous growth in the amount of money being made available for community services in both the CCACs and community support services over the last few years.

Mrs Pupatello: Does that speak to the difference between the $469 million and the $423 million interim actuals?

Mr McKinley: This area is very interrelated. The programs that you see in community support services, in support of housing and all of those things are very interrelated in the agencies that provide services for those clients.

Mrs Pupatello: Both of those lines are underspent, according to your documents here.

Mr McKinley: Yes. They are underspent. This is a community development process that we're going through too in terms of developing more and more services for those communities.

Mrs Pupatello: If I may, with respect: the government is constantly making announcements about more money being available to CCACs, for example. We know on the ground that CCACs are having to pay out in excess of 100% of the contracts they've signed and we know that the funding made available to those individual CCACs is not augmented by the same percentage-so 110% of the contract versus an inclusive 2%. We know there are deficits and that the government historically has had to pay out at the end of each year some deficit levels for CCACs. That's not explaining the decrease in funding here on page 128.

Ms Kardon Burton: The $469 million to the $423 million specifically is as a result of shift to professional services and recovery.

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Mr McKinley: In actual fact, if you look at the difference in the 664, those two lines, the 664 and the 469 are both services that are provided through the CCACs. In their activity, they have shifted from having more homemaking services to having more professional services, and that reflects in-

Mrs Pupatello: There's a significant difference in the figure that she just mentioned was shifted to professional services. It still doesn't account for the wide difference in spending in those two lines. What does that mean? I think I understand what homemaking services are, so when they're shifted to professional, what does that mean exactly?

Mr McKinley: The professional services in the nursing or the physio or the OT.

Ms Kardos Burton: Therapy.

Mr McKinley: Therapy services in the home.

Mrs Pupatello: The augmentation of the actual versus the estimate doesn't account for the difference in the homemaking and community support.

Mr McKinley: No. As I say, we have not been able to spend all of the money we have in those areas. It's not through a conscious effort of the government to slow it down; it's a matter of being able to have the services provided by the agencies.

Mrs Pupatello: Are you suggesting, then, that the RFP process is not working and you're still going to the second round of RFPs with a number of these agencies?

Mr McKinley: It doesn't have to do with the RFP process; it has to do with the availability of services.

Ms Kardos Burton: Human resources.

Mrs Pupatello: You're not spending the money that you currently have, and there are organizations out there-the CCACs are an example-that are spending in excess of 100% of the contracts they've signed. So that's being spent. Aside from the issue of nurses not available to meet the increased demand, they are still spending 110% of the contracts they've signed, and organizations are still saying no to a patient who is being offered to them because they can't meet additional demand. So it's not the same.

Just explain to me how, in that context, we are not spending the money when the contracts are being met in excess of 100%, which doesn't even speak to how much more isn't being met because they are just not meeting their obligation to accept every patient being sent their way.

The Vice-Chair: You've got a minute.

Mr McKinley: I think you're talking about two different years, to begin with, because the situation you're talking about did not occur in 1999-2000. The situation in 1999-2000 was that the CCACs spent the entire allocation that we gave them.

Mrs Pupatello: And then some, didn't they?

Mr McKinley: No, not really.

Mrs Pupatello: Well, they were in deficit and you did pay out deficits in the past year.

Mr McKinley: There were individual CCACs that had deficits, but there were others with surpluses. So there was an interim reallocation throughout the province on CCACs, but generally speaking the CCACs spent their allocation last year.

Ms Lankin: I actually will return to those issues at another time. I wonder, before I begin with questions, if there is an answer to the drug benefit program numbers.

Ms DiEmanuele: Yes, there is.

Interjection.

Ms Lankin: It's being typed up, so it will be brought over today? OK, great.

Minister, I had a couple of other short questions on cancer care, and then I want to go on to another area.

I was perplexed when you said that you hadn't asked for Cancer Care Ontario to prepare a proposal with respect to expansion of the re-referral program. You know that I've asked you on several occasions over the last year to consider the addition of uterine and rectal cancers to the classification of cancers that are eligible for the re-referral program. I did that because Cancer Care Ontario and Princess Margaret Hospital were saying to me that in the immediate short term-we all agree we don't want to be re-referring people; we want to treat them here at home-it would help ease the situation. This was over the months when we continued to see the waiting times, while they improved, not improve at the rate you had expected.

I have been informed by Cancer Care Ontario and Princess Margaret that the ministry recently asked them for a proposal on the addition of these two cancers and what the cost would be for the re-referral program, so when you said that didn't happen, I was confused with the information I had received.

Hon Mrs Witmer: I'll ask the deputy to specifically respond to that request for a formal proposal.

Mr Daniel Burns: I think the question is how the discussion arose.

Ms Lankin: It's kind of simple. Do you want that proposal? Did you ask them for it or not?

Mr Burns: The immediate present discussion began with those organizations raising with me, in a conversation, the question of whether or not we ought to reconfigure the re-referral program. We've had an exchange of letters since. In those letters, I did say to them, "If you wish us to consider the reconfiguration of those programs, please put it together in documentary form." I think the minister, in her earlier remarks, was referring to that.

Ms Lankin: Having this issue raised in the House and having it attributed to Cancer Care Ontario and Princess Margaret, perhaps because it came from an opposition critic, heaven forbid that the minister would have asked if there was any merit to the question and/or pursued it. I find it objectionable, quite frankly, but I certainly accept what you have said, Mr Burns.

Minister, these are, I think, quite brief. You said at one point that hindsight is 20-20, and I sure feel that. There are things, I would readily admit, having an opportunity with eight years' hindsight, that I might have wanted to review and then take different decisions when I was honoured to occupy the post that you currently occupy.

I wonder if you could tell me what your government's rationale was-and I recognize you weren't the minister at the time-for cancelling the two new cancer centres in Durham region and Mississauga that had been announced in 1994 and that were scheduled to open in 1998.

Hon Mrs Witmer: I'll ask Dr Levin to respond to that particular question.

Dr Levin: I'm not sure, to be quite honest, of the exact process that took place at the time. I do know that the Ministry of Health was exploring with Cancer Care Ontario various options in terms of increasing capacity for radiation treatment at that time. Some of the options that were being entertained, for example, were whether it would be possible to increase and expand capacity in the existing cancer centres to accommodate the needs of cancer patients in the future. My understanding is that when that happened, the building of the new cancer centres was temporarily put on hold while those decisions were being analyzed.

Ms Lankin: I guess with hindsight being 20-20, it's too bad they were temporarily put on hold, because we would have had two centres operating from 1998.

Dr Levin: If I could respond to that, the problem we have in the province with radiation treatment is not related to the number of machines we have.

Ms Lankin: No, it's therapists. I realize that.

Dr Levin: Having those new cancer centres on stream now would not have made any difference to our ability to-

Ms Lankin: Surely it would have made a difference to patients who could have got treatment closer to home. The minister has told us over and over again that the announcement of the new centres that are coming-which are wonderful and I appreciate that-including the two that the government cancelled, will allow people to get those services closer to home. That would have been a good thing, wouldn't it?

Dr Levin: Obviously treatment closer to home is most desirable.

Ms Lankin: I think I shouldn't be asking you these questions, Dr Levin.

The one other decision that was taken that I found perplexing, given that there were indications around the problem of the shortage of radiation therapists not just in Ontario but, as the minister has said, worldwide, was the decision around the 1997 program and not providing the funding for that year. I could never make sense of that. As a result, we have a year now where we could have had 50 to 70 radiation therapists graduating and coming into practice, and we don't have them. Was that just a bad decision, an oversight at the time, or was there a real rationale not to provide that funding?

Dr Levin: We have actually gone over that in some detail. On June 26, 1996, there was a meeting held between the heads of the radiation therapy training programs in the province and other senior cancer officials and the Ministry of Health. At that point in time, there was an excess-difficult to believe, I know-of radiation therapists.

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Ms Lankin: I believe it. You're talking to the minister who was involved in the decision to take 10% of medical students out. I just want this answer on the record, because the next time the minister accuses me of causing the shortage, I will throw this answer back at her.

Hon Mrs Witmer: I didn't know you were the minister.

Dr Levin: Actually, I just want to make the point that at the time when that decision was made, there was an excess of radiation therapists in the province, and the decision was made to defer enrolment for a year.

Ms Lankin: So, it was actually based on best advice at the time on numbers and projections?

Dr Levin: Absolutely.

Ms Lankin: I'm glad to hear that, because I could not understand that, given that at least three or four years before that there were projections of shortages. That just shows you the wild variation in human resource planning in this field. It's a pretty tough job.

I have one last question on cancer. You made reference to this, and I actually had wanted to ask it, and I was interested that you are doing some monitoring. Can you tell us currently what the status is of waiting times for oncology surgery?

I understand that there aren't the same kinds of standards that there are and that have been developed for radiation treatment. I understand that people are looking and working at that. But what do we know about what's happening in the province with respect to oncology surgery? Is there any concern that you have or that Cancer Care Ontario has that people are waiting any longer now than they might have before, even though we haven't had good tracking mechanisms? Anecdotally, do we know anything?

Dr Levin: No, the short answer to your question. Access to cancer surgery and provision for cancer surgery are addressed within the context of surgical programs within the hospitals and are not tracked discreetly as cancer surgery by Cancer Care Ontario or anyone else in the province to our knowledge.

Ms Lankin: There is certainly work going on in Cancer Care Ontario looking at that. There have been some reports that have been written.

Dr Levin: We haven't seen that yet.

Ms Lankin: You haven't seen any of the articles that have been written or anything?

Dr Levin: No, I haven't seen any detailed analysis of wait times for cancer surgery from Cancer Care Ontario yet.

Ms Lankin: There is some stuff available, but I think it's more in article form as opposed to the final report. Actually, I believe I've got a copy of one of them.

Dr Levin: Perhaps John King would like to-

Ms Lankin: OK.

Mr John King: John King. I'm the assistant deputy minister.

We have been discussing with hospitals some of their surgical workload. Cancer has come up as one of the areas where they're seeing an increase in the workload. The hospitals right now always work through their operating room committees to balance whether they do more surgical cases for oncology as opposed to other cases. That is really being handled within the hospital. We have talked with them about the management of their workload depending on the increase in oncology, but at this time it is an individual hospital choice for their decision on the waiting times for surgery. But for cancer cases, there usually are minimal waits for that.

Ms Lankin: Anecdotally, what I have heard is that there is at least the beginning of concern-it may be in only some hospitals; I may not have a good picture of that-that there is a growing period. There are no standards to say that that's a problem, I understand that. What I'm wondering is, would it not make sense for some more explicit discussion between you and Dr Levin, Cancer Care Ontario, to ensure that if there's an emerging problem-the last thing we want is someone who has waited seven months for radiation therapy, etc, before that, has had to wait an unhealthy period of time for the surgery.

Mr King: We actually agree with you, and this is something we are discussing. It's not only in, say, Princess Margaret that surgery occurs. Almost every hospital does the surgery.

Ms Lankin: I know that. I'm saying that coordination needs-

Mr King: So it's a matter of coordination, so we'll certainly take that. I did want you to know that those concerns are being reviewed right now as far as surgical workloads in the province.

Ms Lankin: What I'm asking for is that the oncology information from those surgical workload reviews get centralized and perhaps provided to members of the committee at a later date. It's not information that's needed this week or next week, but that would be helpful as we start to set targets for the future.

Dr Levin. Perhaps I could just-

Ms Lankin: Could you do it quickly, because I'm actually going to move on to another area.

Dr Levin: Earlier on I spoke about the electronic tracking system we're working on for access to cancer treatments. Cancer surgery is one of those, and obviously the best way of dealing with this is to try to be proactive and to identify when the pressures are emerging.

Ms Lankin: I agree. I was glad to hear that. I also wanted to say that I think Cancer Care Ontario's proposal for the full radiation machine, the satellite, in Sault Ste Marie-and that is a model, if it works-is tremendous. It's a really important step. I think no one has before looked at doing something like that without all of the infrastructure around it. These comments actually go to Cancer Care Ontario, but I think it's a very welcome development and will be very helpful. Thank you both.

Minister, I wanted to ask you a couple of questions on nursing. The vast majority of questions I had were placed yesterday on the record by Mrs McLeod. A couple that I just want to return to-I don't know if the chief nursing officer is-yes, she's here. A lot of the questions that have been asked around the numbers-the number of full-timers, part-timers, temporary, all of that, and that's information that's being reviewed. My understanding is that there was a report that the joint task force on nursing retention and recruitment did that was completed in June of this year, if not before that, and that report is with the ministry. I'm wondering if you could tell us what the findings were in that report, or, if it's lengthy, would you make that report available? In fact, let me ask that, would you make that report, Minister, available to committee members?

Hon Mrs Witmer: I'll have Kathleen MacMillan, the chief nursing officer, speak to that report since she has been actively involved in that work.

Ms Kathleen MacMillan: Kathleen MacMillan, chief nursing officer. I believe the report that you're referring to-

The Vice-Chair: Could you speak up?

Ms MacMillan: I believe the report you're referring to is Ensuring the Care will be There: Report on Nursing Recruitment and Retention in Ontario from the Registered Nurses' Association of Ontario and the Registered Practical Nurses Association of Ontario. My understanding is that this report is public, that you can obtain a copy of that report very easily.

Ms Lankin: Was there not a report that was actually either commissioned by-or maybe this is the same one-or prepared by the joint task force on nursing retention and recruitment? I believe there is a report in the hands of that joint task force that has, to date, not been made public. I would like a copy of that.

Ms MacMillan: I think the one you're talking about may be the one that the joint provincial nursing subcommittee did on community nursing recruitment and retention, which we are actively using within the ministry right now and analyzing issues around community nursing.

Ms Lankin: In fact, that is the report. Could you make a copy of that report available to committee members, please? I would be able to return it next week with specific questions relating to that.

Ms MacMillan: We can share that. My understanding is that we can make that available to you.

Ms Lankin: I would appreciate that, and if we could have that before Friday that would be useful. I'd like to go over it over the weekend.

The other nursing question that I don't think we touched on completely yesterday was the use of agency nurses. I believe there are numbers available-now I'm talking hospital-based nursing-that indicate what's happening in the hospital sector with the use of agency nurses. Could you tell us what you know about that?

Ms MacMillan: We wouldn't have final statistics on that until we actually have gone through all of the audited financial statements from the hospitals. They do report, as part of their reporting to the ministry on the management information systems, the proportion of dollars that go to purchased nursing services.

Ms Lankin: They've done that for a while, haven't they?

Ms MacMillan: They've done that for a while. We can look at trends on that. We're reviewing the operating plans and the audited financial statements now. We wouldn't expect to have that information until November.

Ms Lankin: For which year?

Ms MacMillan: For last year.

Ms Lankin: For 1999?

Ms MacMillan: It would be for 1999-2000.

Ms Lankin: Would you provide us with the numbers from 1995 to 1998-99, then?

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Ms MacMillan: I think we could probably do that. We'd have to run those specifically, the purchased services for nursing. We'd have to run those statistics, but we can probably get those.

Ms Lankin: I think one of the things we would all acknowledge, and I think the minister has spoken to it in her comments, is that with the problem we're having recruiting nurses, in fact, hospitals have been more and more reliant on bringing in agency nurses. I'd like to see if that trend is on the upswing, because it speaks to the bigger problem we're going to have down the road.

Ms MacMillan: That would vary considerably from one hospital to another, based on my knowledge of different hospitals. There are some, as I believe I mentioned yesterday in response to Mrs McLeod's question, that would use no agencies at all, and there would be others that would use agency for just specific areas such as critical care, for example, and would not be using them in other areas. So it would be very much a different picture from hospital to hospital.

Ms Lankin: If you can provide those numbers, the overall trends, if it is easy in the way in which it's kept to run a breakdown by institution, that would be very helpful. I'd appreciate that.

One other question on that general topic. Do you have numbers of nursing vacancies in hospitals? Do they report that to you in any way?

Ms MacMillan: We might get that from the nursing data that they would submit, but we wouldn't have that available right now because we're still looking at nursing plans, so in the nursing plan data that I mentioned I will have in November, I will get some picture-

Ms Lankin: I just might suggest that it's something you contemplate putting into the mix of what you gather from hospitals while you're studying this, because again there appears, from what people are saying, to be a growing number of vacancies that are becoming increasingly difficult to fill. It would be interesting to see what those numbers are. I'm sure it would correlate in the end to the use of agency nurses as well-in certain hospitals, not in all.

The Vice-Chair: You've got a minute.

Ms Lankin: Wow. I wanted to get into my next big area, but I guess I will have to wait on that. So on nurses, the last question perhaps-I think I'll leave it at that. I'm going to wait to get into the next section, when I have a bit more time. Perhaps you could add my minute on next time.

The Vice-Chair: OK. Mr Stewart.

Mr Stewart: I'm not going to ramble this time, Madam Minister-

The Vice-Chair: You've got 20 minutes to do that.

Mr Stewart: -because it appeared that possibly due to my rambling you didn't have the opportunity to maybe complete the question that I'd asked you regarding the doctor shortage in some of the rural areas and certainly the way they are trying to recruit them. As has been mentioned, certainly the way of the past for doctors in every small town and small community in Ontario is not going to be the thing of the future due to the change, as well as the nurse practitioners that could be used in some of the rural areas and certainly in some of northern areas. Maybe you would like to finish or make additional comments on that.

Hon Mrs Witmer: It certainly is our objective to take every step possible in order to ensure that within the province of Ontario we not only have an adequate supply of physicians but that there be appropriate distribution and also an appropriate mix. I guess that's why we originally asked Dr McKendry to do a thorough evaluation of the situation as it exists. He did come forward with some recommendations, and the information that he has provided has now gone to the expert panel under Dr Peter George.

In the short-term, based on the information and the recommendations that were made by Dr McKendry regarding the issue of physician supply, our government did move forward to provide $810,000 to fund 15 additional post-graduate training positions in Ontario to recruit Canadian medical school graduates who receive post-graduate training in the US. We also set aside $1.3 million to increase the international medical graduate program by 50%. That, of course, is our foreign-trained doctors.

Thirdly, we're expanding the re-entry training program and providing funding of $4.5 million for advanced skills training for family doctors to provide specialities such as obstetrics, anaesthesia and emergency medicine. We have also doubled the number of community development officers to help underserviced areas recruit doctors, and have provided $1.2 million to expand by 25% the northern family medicine residency program in Thunder Bay and Sudbury. These were the immediate recommendations we were able to accept from Dr McKendry to begin to address the issue.

Of course at the present time we have Dr Peter George chairing the expert panel. He's looking at providing medium- and long-term recommendations to the Ministry of Health and Long-Term Care. The mandate of that panel-and I think this is very important-is to develop a framework where we can better assess physician human resource needs including a model for measuring and monitoring the supply of physician services and the appropriate mix of specialities.

He and his panel are also examining changes in what's needed as far as enrolment at the medical schools. We're also taking a look at the issue of recruiting additional international medical graduates, and the panel is also advising on changes to the post-graduate medical education system so that the most appropriate mix of physicians is achieved. As well, they are recommending how best to attract physicians to remote communities.

However, we are looking forward; we have not received the recommendations. I might ask Colin Andersen, from the Ministry of Health, to speak further to what we are doing. I think the primary care pilot initiative certainly speaks to increasing accessibility to physicians, nurses, nurse practitioners and social workers. Certainly we have made significant inroads in providing nurse practitioners to improve access in Ontario. I would ask Colin to continue.

Mr Colin Andersen: I'm Colin Andersen, the ADM of policy for the ministry. As the minister mentioned, in response to Dr McKendry's report, the Ministry of Health and Long-Term Care announced on December 22 that it would immediately implement a number of Dr McKendry's short-term recommendations and in fact committed to providing $11 million for a number of initiatives.

We are funding additional post-graduate training in Ontario to recruit back Canadian medical school graduates who have taken their post-graduate training in the US and require further training to meet Canadian standards and requirements. These positions are specifically targeted to underserviced areas and specialities.

We're also increasing undergraduate medical school enrolment by 40 positions or about 7.5%, from 532 to 572 first-year undergraduate positions in the 2000 academic year. We're expanding the international medical graduate program by 50%, from 24 to 36 positions, and targeting all new entry positions to underserviced areas and specialities.

We're doubling the number of community development officers from three to six, to help underserviced areas recruit doctors in their communities, and we're expanding the two northern family medicine residency training programs by increasing the number of entry training positions by 25%, from 24 to 30, and by more than doubling the number of third-year advanced training family medicine positions in areas such anaesthesia, obstetrics and emergency medicine. We're also expanding the ministry's re-entry training return and service program by 15, from 25 to 40 positions.

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As I said, those were an immediate response to Dr McKendry's short-term recommendations. The ministry has also announced the formation of an Expert Panel on Health Professional Human Resources, chaired by Dr Peter George. As the minister mentioned, it's looking at a number of things. It delivered an interim recommendation to the minister over the summer which resulted in the ministry working with the faculties of medicine across the province to immediately increase enrolment by 40 positions. So there are a number of things that are specifically related to the fact-finders' findings and the expert panel, as well as a number of initiatives that exist already to help improve the distribution of physicians across Ontario, a number of those programs that have been underway for a while.

There are a number of initiatives, such as a 70-hour sessional fee for physicians working nights, weekends and holidays in eligible hospital ERs in selected northern and rural southern communities. We have a community-sponsored contracts program that was announced back in June 1996 to address recruitment and retention issues. We have globally funded group practice agreements that were announced in the spring of 1997 and are offered to 29 underserviced communities. We have community development officers, which is a support program provided by the ministry to help rural and northern communities recruit and retain health care professionals. We have a discounted payment policy as part of an agreement that was negotiated between the OMA and the ministry, in addition to a re-entry training program we also have that was part of an earlier agreement with the OMA to offer retraining for return of service in underserviced areas of Ontario.

We announced a free tuition program on July 24, offering $4 million for free tuition and location incentives to new doctors willing to practise in underserviced areas. We have a physician job registry which helps communities to recruit physicians, and a locum program to help those communities that are experiencing shortages of physician services by providing temporary medical services and reimbursement of physicians' travel and accommodation within Ontario.

All of these are in addition to our underserviced area designation program, which identifies those communities that are experiencing shortages of physicians in particular areas. So as you can see, there is a wide variety of programs in existence.

I haven't touched on the specialist retention initiative, which is also available, and the rural and northern medical training programs as well, which help fund medical schools to offer medical students and residents training outside of the teaching hospitals, which are generally in the urban communities, allowing them to get some experience and skills that they need to practise effectively in the work environment after graduation.

There are programs based out of Sudbury and Thunder Bay, the Northern Academic Health Sciences Network. There's the family medicine north residency program based out of Thunder Bay; the northeastern Ontario family medicine residency program based out of Sudbury; the northeastern Ontario elective program, also out of Sudbury; the northwestern Ontario elective medical program in Thunder Bay; the rural Ontario medical program based out of Collingwood; and finally, the southwestern Ontario rural medicine program based out of Goderich. So quite a wide variety of programs are available to address what we certainly consider to be a very important issue with regard to addressing the supply and distribution of physicians throughout the province.

Mr Stewart: Just one more question. Would you care to make any comments about the nurse practitioner experience? Certainly it has been expanded and developed. We happen to have one in my particular riding and I understand it's working well, but I've not heard a great deal about the nurse practitioner experience and how it is developing.

Hon Mrs Witmer: Just briefly, Mr Stewart-and certainly Mr Andersen may have more information to contribute to the discussion-as you know, it was our government that recognized and made it possible for nurse practitioners to practise in the province. I'm very pleased to say that we presently have about 226 nurse practitioners providing health services in Ontario.

In February 2000 we announced the addition of 106 new nurse practitioners. Seventy-six of them are in the underserviced communities. Twenty of these new nurse practitioners are in the long-term-care facilities, participating in a pilot project, because we do anticipate there is a significant role for them to play there. We have five of these new nurse practitioners working in the aboriginal medical centres, and we have five new nurse practitioners in our primary care network.

We believe the addition of all of these nurse practitioners is making a tremendous impact on increasing access to services for people in the province, particularly in the underserviced areas. Certainly we look forward in the months and years ahead to expanding the complement of nurse practitioners in the province. They have been very well received. As you know, they are able to perform many of the same functions as doctors, and in that way they are serving us in areas where people don't have access to a physician.

So I think you can stay tuned. As we expand the primary care networks throughout the province over the next four years, we believe some of the key members of the health professional team will be the nurse practitioners, who will be working hand in hand with the physicians, the nurses, the social workers and other members of the primary health care team.

We've been quite pleased with the public response, and certainly they are giving our health system more flexibility and are allowing for greater access to primary care services.

Mr Chudleigh: Last spring there was some controversy around the amount of money that our government was spending on pressuring the federal government to reinvest in health care systems throughout Canada. I think we asked the feds to reinvest at 1994 levels. I wonder if you could comment on the amount of money we spent, how much money we received from the feds, and what effect that money has had on Ontario's health care system.

Hon Mrs Witmer: First of all, we did receive a reduction in transfer payments in 1994-95 and in each subsequent year. Despite the fact that there was an agreement reached in September of this year where the federal government did commit to the provinces and territories that they would give us back the money they've taken away, it was not a complete restoration to the 1994-95 levels, nor does it take into consideration the tremendous pressures that our health system is experiencing. In fact, we hear in the estimates here about the tremendous growth and the need for additional health services based on a growing and aging population.

As you know, our government did undertake a campaign to pressure and encourage the federal government to restore the money they had cut from health care. I can tell you that all of my colleagues across Canada unanimously agreed that there needed to be total restoration, and as a result of the pressure that was exerted, as I say, we're getting some of our money back. However, we will not see the restoration of those transfer payments until at least April 1, 2001, because the agreement did not contain a clause that would flow the money immediately. The only money that we are going to be seeing in the short term is money for equipment, and I'm going to ask Colin Andersen, the ADM, to share with you the breakdown of the financial resources that will be coming our way, and also when that money's going to be available and how it's going to flow. In some instances, such as the technology money, it's actually going into a corporation. We're not actually going to have the flexibility to make that money available to people in this province in a way that we might deem to be the most appropriate. So, Mr Andersen.

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Mr Andersen: As the minister indicated, there was an agreement that was reached among the Premiers across the country and the Prime Minister in September of this year which breaks down into a number of parts. There was a basic restoration of some of the CHST money back to 1994-95 dollar value levels, and I would want to note here that the restoration of that money does not start until next fiscal year, April 1, 2001. It's not a full restoration at that point in time, and even when the federal government has completed putting the CHST money back into the system that it intends to do so, at the end of this arrangement its funding will only be 13 cents on the dollar for Ontario health care costs, which is-

The Chair: There's about two minutes left on the government's time.

Mr Andersen: -which is still less than the 18 cents on the dollar that it was paying back in the 1994-95 period. There were a few other components to the funding agreement that was reached. As the minister mentioned, there was a component for medical equipment money for across the country which will be allocated on a per capita basis. Ontario will be entitled to about $190 million of that amount this year, and $190 million in respect of the next fiscal year, which we will be able to draw down at some point in the near future.

There's an amount for IT. The federal government is putting $500 million into essentially a corporation which-indications are that we will not actually get a per-province share of that amount of money.

The final component was money, again on a one-time basis, for primary care reform, which will start next year and last for four years. As you are aware, Ontario is, I would say, leading the charge in implementing primary care reform across the country, and we have a number of ongoing needs. We will gladly take whatever money the federal government has to offer. We certainly would wish that it would be on an ongoing basis. We still need to work out with the federal government the exact details of how that money will be allocated among provinces. Deputies from across the country will be working with the federal government over the next number of months to look at those various initiatives.

Likewise, here in Ontario we will be looking at the amount of medical equipment funding that has been allocated to us, comparing that to the needs that we have in this province to provide funding for medical equipment to various institutions, not just hospitals but various others. In the very near future we will be looking at how to allocate that amount of money. It will be up to Ontario to decide how to divvy that up, because it is provided to us on a per capita basis.

The Chair: Thank you. We now turn to the official opposition. You have 20 minutes, Ms McLeod.

Mrs Lyn McLeod (Thunder Bay-Atikokan): Thank you very much, Mr Chairman. I want to turn now to ambulances, which is 1405-4 on page 108 and 109. The first question I want to ask is, I'm looking at a cost of $30.8 million for exit and transition costs and I'd like to know whether or not that is primarily or exclusively for severance costs, as land ambulance contracts have been turned over to municipalities. There was a requirement, I understand, that the municipalities sever all of their existing contracts that they were inheriting by a given date and that there are significant severance costs that have been experienced as a result of that. I would like to know what was the date that municipalities had to end the contracts by, why was that date chosen and are these the severance costs we're looking at?

Hon Mrs Witmer: I'm going to ask Mary Kardos Burton to respond to the questions that you have asked.

Ms Kardos Burton: You asked about the costs on page 108 related to exit and transition costs. Actually, those costs are for more than severance. They are also for close-out audits. They are also for leave-termination. The exit and transition costs, out of the $30 million, total approximately $20 million to $25 million. Those have not all been paid out, but they were up to December 31, 1999. So those were the costs that the government has agreed to in terms of costs for operators.

Mrs McLeod: So is it the $25 million you mentioned or the $30.8 million?

Ms Kardos Burton: Approximately $20 million to $25 million. It has not all been paid out yet.

Mrs McLeod: The balance then is, as you said, rental costs-

Ms Kardos Burton: The balance is the close-out audits, the leasing etc.

Mrs McLeod: So it's fair to say that that entire $30.8 million was in direction relationship to the decision of the government to download the administration of the ambulance service and, further, to require that the existing contracts be terminated so that any requests for proposals could go out. Fair comment?

Ms Kardos Burton: What the government did was offer the municipalities three choices in terms of how they continued the ambulance services. When they took on the ambulance services, municipalities had a choice of either taking it on their own or continuing with existing operators or, in fact, doing an RFP process. They were required by the September 3, 1999, since 1999 was the transition year, to decide on those choices. Those were requirements that were laid out in legislation, and actually those choices have now been made by municipalities.

As you know, January 1, 2001 is the date on which it will be complete municipal delivery. What we've done this year, I am happy to say, is that 11 municipalities have actually taken on ambulance services this year and there will be five more by the end of December.

Mrs McLeod: I appreciate knowing that. I will have some other questions, but just so I'm absolutely clear, regardless of which choice was made, was there an incurring of severance costs, wind-up costs?

Ms Kardos Burton: For the operators that were there.

Mrs McLeod: Yes. Was there a reason why existing contracts could not have been fulfilled before the transition, either to the municipality or to a new operator or to an RFP process took place? Why was there a requirement that those contracts had to be severed before they had expired? Why was it necessary to spend $30 million on it?

Ms Kardos Burton: Because the choice was for municipalities in terms of deciding when they could take on the services.

Mrs McLeod: But they had to make a decision by December 3, 1999, and, whichever choice, they were going to incur severance costs. So they weren't given the choice of being able to continue to run existing contracts so they could avoid the actual payment of severance.

Ms Kardos Burton: When the government extended the year in terms of ambulance services, it changed from January 1, 2000, to 2001; it was a transition year. What we decided in the legislation was that-because it could have been that municipalities could have just taken over January 1, 2001. What was put in the legislation was that there was an option and those who had the capacity and the interest to resume earlier could do so. As I said, there were 11 who took it on in January 2000. But we would never have known that and we had no way of knowing who would take it on in the year 2000.

Mrs McLeod: But my point is they didn't have the option of going later, of having the transition later, so there was a $30.8-million cost incurred for the government in the course of setting that transitional timeline. In terms of air ambulance, which is going through the same thing, I understand that severance cost is $1.6 million. Would that be an accurate figure?

Ms Kardos Burton: In terms of the air ambulance, what's happening now is that the government is going out on RFPs for the critical-

Mrs McLeod: I know what's happening. I'm just asking if you have a handle on the severance costs at this point.

Ms Kardos Burton: I'll verify the severance costs for you.

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Mrs McLeod: So now we have new services in place. The government has decided that it is going to continue to fund 50% of the cost, even as the administrative responsibility is downloaded. There was one news report that said-obviously I would have, if I had time, a whole lot of questions about response times, costs, equipment etc, but I want to boil it down as much as I can. There was a story that said there had been an agreement reached between the municipalities and the ministry that would pay 50% of the costs up to $30 million. Is that $30 million a fact?

Mr Brad Clark (Stoney Creek): If I may, the agreement is actually on the funding template. The funding template was an agreement that was reached between the municipalities and the province. We looked at costs for services pre-transfer, in terms of 1999, to the municipalities, and then the municipalities came back and said, "As a result of the transfer, there are a number of costs that we are now incurring that you, as the province, did not incur," for example, leases and different taxes that were being paid. So we asked them to identify all of the costs that they now had to incur that we as the province did not have to incur. They came back with those. We came to an agreement on the funding template and it's our best estimate right now that it'll be between $25 million and $30 million additional cost to the province.

Mrs McLeod: Is that agreement in the template something that could be made available?

Mr Clark: Absolutely.

Mrs McLeod: I appreciate that.

There is a figure here in the estimates book that shows $20 million for response time commitment. Can I ask, first of all, whether or not those dollars are flowing to the municipalities now or is that part of the new agreement? Secondly, what response times does that fund?

Ms Kardos Burton: The $20-million figure has not been flowed to the municipalities. In terms of response time, what we are doing is a consultation process with municipalities on all standards. The first part of the funding arrangement was the funding template that Mr Clark talked about. There will be a consultation with municipalities on all standards, including response times.

Mrs McLeod: Let me just understand that. The $20 million was a change in the estimates for last year. Am I misreading that? Does that not mean that would have been expected to flow in the 1999-2000 year, if it was a change? I'm looking at page 109, response time commitment funding increase, explanations for expenditure change from the 1999-2000 estimates. So I'm not even looking at the 2000-01 estimates.

Ms Kardos Burton: You do see the $20 million for response time and that wasn't what it was intended for, but it has not been paid out to municipalities.

Mrs McLeod: Even though it was a year old?

Ms Kardos Burton: That's correct.

Mrs McLeod: Can you tell me then, at that point in time, what response time was that intended to support, in terms of minutes, and what is now the commitment in terms of response time?

Ms Kardos Burton: The response time that exists currently is what's in the legislation, which is 90% of what it was in 1996. In terms of the number of minutes, it varies by community. Every community has different-what Toronto might-

Mrs McLeod: I'm not sure that there is a minute time in the legislation, in the Ambulance Act.

Ms Kardos Burton: I'm sorry. The minute time is not in the legislation. What's in the legislation is 90% of what it was in 1996.

Mrs McLeod: So that would be in terms of minutes?

Ms Kardos Burton: My meaning is that Toronto's response time may be eight minutes, Thunder Bay might be 10, Ottawa might be 14. That's what I mean by the minutes in terms of response time. In fact, that's exactly what it is. All of the communities are different.

Mrs McLeod: Is it possible, again, for that to be tabled for us, so we know what it is by community?

Mr Clark: I don't see why not. I think it's important to note that when we're now proceeding on looking at standards with the municipalities, that is the issue that actually came up in the discussions. The standard that we had for 1996 was basically an arbitrary figure saying 90% of the response times in that community will be the standard.

Mrs McLeod: I realize that and that's exactly why I'm asking the questions, because there are some recognized, accepted standards. We haven't been meeting them; the 1996 figures will not show that we're meeting them. I would be interested in any figures you have about what actual response times are, as opposed to what's in the legislation, if you have those figures.

Then what I was wanting to get was, as you work toward an agreement to pay 50% of the costs, it has to be 50% of something and it has to be 50% of an agreed-upon standard. What I need to find out is, in this estimate, when I look at it-not that I can figure out what the shares are because of all the municipal realignment issues. I'm not going to get you into that. I just really wanted to get at the crux of, 50% of what standard?

Mr Clark: Yes. The issue that came up as we were doing the consultations, to be quite frank, was that a number of the municipalities had concerns not simply about response times. As we started to deal with it, it became very confusing. We developed the funding template so we knew exactly where we were and what things were covered currently. Then we decided we would move the standards and response times to a separate consultation so that we could look at a number of standards we think we should be talking about as partners; for example, what type of equipment is needed by the paramedics? What is the minimum standard? You're getting some municipalities that clearly have a significant tax base that are going for the Cadillac, if you will, of defibrillators, whereas other municipalities are saying, "We can't afford that and we're being told this will do." So what is the minimum standard? We're listing those items that need to have standards and we're doing that consultation now, including response times.

Mrs McLeod: I assume that's not available yet, but when it is, you'll make that available?

Mr Clark: It's a work in progress.

Mrs McLeod: Are you also looking at the request of many of the municipalities, or at least some of the municipalities, to have a standard that includes at least one advanced life support paramedic on each team?

Mr Clark: That's under discussion also.

Mrs McLeod: With differences from area to area, I would assume.

Mr Clark: Yes. One of the concerns that have come up, and I should mention it now, is that a number of rural municipalities have concerns because of the tax base they have. They have a lower tax base. They don't have the same population. They don't have the same commercial and corporate; they have farms. If we set a standard for Ottawa, for example-not picking on any municipalities-that says, "This is what we want," then Haldimand-Norfolk says, "That's great. How are we ever going to pay for it?"

Mrs McLeod: I don't want to interrupt. I just have so many areas, so what I'm trying to do is make my questions as precise as possible. When there is public information that you can make available, that would be very helpful.

Mr Clark: No problem.

Mrs McLeod: It will save us asking what might be seen as inaccurate questions in the House in the future. When that agreement is available, I would appreciate seeing it because it's an area of great concern.

I recognize, before I leave ambulances, that of course getting to the scene of the accident is something where you can provide resources but you can't control how long it takes to get back to the emergency department. I'm not going to get us back into redirects or closures of emergency departments, but there's no question that in the increased response time for ambulances that we're seeing, the primary increase is not in the length of time it takes to get to the scene, but to get from the scene to a hospital. That's something we should all be extremely concerned about.

The next area I wanted to ask about-and I'm sorry to be moving so quickly, but we do have an awful lot to cover-is public health unit funding. Dr Murray McQuigge at the Walkerton inquiry indicated there had been a significant cut to public health units. I believe he said there had been a 20% cut. I can give you the vote reference: page 102, 1405-3. I see a cut of $3 million in something called "services." I see a cut of $7.6 million in local health agencies. This is another one where I really don't want you to give me a long story about what part's being paid for by the province and what part's being paid for by the municipalities. I just want to know, when Murray McQuigge says there was a significant cut in public health units, where that cut has come from and how big it is.

Hon Mrs Witmer: I'll ask Dr D'Cunha to respond to the issue of support for public health.

Dr Colin D'Cunha: Dr D'Cunha, chief medical officer of health. Essentially, the 1999-2000 estimates showed a figure for five quarters worth of funding in light of the government policy announcement in March to fund public health costs 50-50. Linked to that was the fact that funding was going to move to the municipal financial year, which is the calendar year. In effect, what you saw was five quarters worth of funding in last year's estimates to cover off that one quarter that was not part of our financial year.

Mrs McLeod: Has there been a cut?

Dr D'Cunha: No.

Mrs McLeod: Then why would Dr McQuigge say there's been a significant cut?

Dr D'Cunha: I would ask you to ask him that question. What I have is that public health funding has gone up. What we noticed in surveys was that public health funding continues to go up. In fact, this year public health funding continues to rise further.

Mrs McLeod: Is it possible, then, that the cut that was being referred to was a cut that was made at the municipal level?

Dr D'Cunha: Dr McQuigge's budget has actually gone up over the three-year period, based on something I looked at in May.

Mrs McLeod: Is that evidence going to be provided at the inquiries now?

Dr D'Cunha: I'll be delighted to present it to committee at the end of the day today or in time for next week's hearings.

Mrs McLeod: I would appreciate that. Thank you.

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I have five minutes left and I have a whole lot of questions on related facilities, which I think includes Cancer Care Ontario, which probably takes me back to cancer care. I'm not going to get to rehabilitation today, but I think rehabilitation is here.

There's $137 million underspent in this whole area of related facilities. Is it possible to pinpoint in one minute or less where that underspending is so I can ask a couple of cancer questions?

Hon Mrs Witmer: What page are you on?

Mrs McLeod: On page 56, vote 1402-1. It's the $137 million underspending. I recognize that we've had a correction on the CCO budget so we're seeing a $29-million increase in CCO's budget.

Ms DiEmanuele: Mrs McLeod, that relates to the funding for hepatitis C. Under related facilities, it relates to the specific funding associated with our commitments around hepatitis C. That $137 million is solely related to that particular figure. I don't know if John wants to speak to it any further.

Mrs McLeod: I know there's been a change in the estimates in that regard.

Ms DiEmanuele: It relates to the payouts associated with that commitment.

Mr King: Compensation for the hepatitis C victims was the major underspending in that area. Then under the related facilities there are a number of program areas in that line including the Canadian Blood Services and Cancer Care Ontario. The major portion that I think you're referring to was the compensation program for the hepatitis C victims. They did not have the uptake that was projected for that program.

Mrs McLeod: I'll give some thought to that and come back to it later.

Could I ask specifically on Cancer Care Ontario, which is funded under this budget line-and it will be quick. The budget shows an increase in the revised figures that you tabled with us yesterday. It shows an increase in the cancer care budget of $29 million. Is that it for 2000-01?

Mr King: That is it for the estimates for that period of time, and that included the increases in the program that was providing for radiation and also for chemotherapy. There would be included in there some out of country. The total spending for this budget-not all of the dollars have been allocated at this point.

Mrs McLeod: As I recall from public accounts, and I think it was for last year's budget, Cancer Care Ontario had requested $50 million in increase and $40 million had been approved. Could you relate this $29 million either to that figure or to this year's request?

Mr King: When we're referring to several numbers, I'd rather specifically get back to you on that because we're dealing with different periods of time. All of the funding that has been requested by Cancer Care Ontario has been approved. It's just the period of timing of the flow of the dollars.

Mrs McLeod: So the prevention budget from last year has now been approved, because it had not been approved last year.

Mr King: I'm sorry. On the dollars you were referring to on the re-referral program, the increase in the radiation costs that were provided by the minister and also the increase in chemotherapy for that period, we did flow. I'm nervous about referring to numbers that you are throwing out without coming back-

Mrs McLeod: Fair enough. I'm going to run out of my time. I was referring specifically to the total request of Cancer Care Ontario and how much of that budget flowed. They didn't get everything they asked for last year. I guess I'm looking to know how $29 million-but I appreciate the time frame and I'll wait for it.

Two very quick questions, then.

Mr King: If I could, I would rather get back on that number, because all of the dollars requested last year did flow to Cancer Care Ontario. I think it's important that we have that for the record.

Mrs McLeod: There is another record. We can compare the two in terms of public accounts. We'll see if we're on the same page.

The re-referral program appears to be doubling this year. I'll give you my page reference, page 67. There's an extra $17.28 million. I just want to confirm that the program is doubling.

Mr King: On the re-referral program, actually there was an extra maximum amount and a maximum number of patients in that program. Those dollars are in two divisions. They are in my division and also in the assistant deputy minister for health services division, so there are two numbers in that line. That re-referral program has not doubled. We are still working on the numbers that were previously approved through the minister.

Mrs McLeod: There is an increase of $17.2 million, so perhaps you could give me a comparative so I know to what extent that's doubling or a change. I know there was a public accounts figure of $23.1 million.

Mr King: Just on that, because I think it's important, the total program was $23 million; $17 million basically comes from the health services division for the cost of physicians and hospital services, and $6 million of that program comes from my division. So it is $23 million for the re-referral program.

The Chair: Thank you for your answer. Now to Ms Lankin for the beginning of your 20-minute period. You have 20 minutes. We obviously won't finish today.

Ms Lankin: We won't get through it all today, that's right.

Could I ask leg research about the number of things we have asked for the ministry to provide, whether we could get a list of things so we can check off the materials as they-

Ms Anne Marzalik: Yes, we have an itemization.

The Chair: I'll take the opportunity before you start, Ms Lankin, to acknowledge that a drug breakdown of costs between ODB, Trillium and special drugs was provided by the ministry. Please proceed, Ms Lankin.

Ms Lankin: Thank you. I appreciate that information having been provided.

Minister, I would like to ask some questions about community health centres. That vote item is on page 97. The estimates for this year are roughly $111 million. Let me indicate that I understand the community health centre program very well. I understand the goal of delivery of accessible health services, of population health needs, of base programming, of health promotion. I really do understand the program.

It's nice to see a planned enhancement of their funding of $4.7 million. Specifically, my first question is, could you tell me what that money is dedicated to?

Hon Mrs Witmer: The enhancements are part of two initiatives, Ms Lankin. There is $3.1 million for new CHCs and there is $1.6 million in operating cost increases due to capital projects. The increase of $3.1 million in 2000-01 provides some base funding for the implementation of programs and services in three communities: (1) the Grand Bend and Area Rural Community Primary Health Care Centre, (2) the Centre de santé communautaire de l'Estrie in Cornwall for a satellite in the town of Crysler, and (3) for the Kitchener Downtown Intercommunity Health Centre.

The expenditure increase of the $1.6 million is identified operating cost increases in 2000-01 related to 14 community health centres that have completed capital projects to expand in order to meet the increased volume of service demands.

So those are the projects and new initiatives that have been undertaken with the additional funding.

Ms Lankin: In the $1.6 million, the expansion of operational dollars based on expanded capital needs and program volume, is there any money in that that will allow CHCs to provide for salary enhancements to their employees? Many have said there has been no increase in salaries for eight years now, I think. Does that money address that?

Hon Mrs Witmer: I'll ask Mary Kardos Burton to specifically speak to the issue of salary enhancements within the $1.6 million funds.

Ms Kardos Burton: In response to your specific question-the response I gave in terms of the CCACs as well-we are looking at community pressures. If there are operational issues that have been raised by CHCs-

Ms Lankin: The $1.6 million, does it have any salary enhancements in it? You may have to meet that in the future, but does that money-

Ms Kardos Burton: No. It was the operating for the CHCs.

Ms Lankin: For the operating. OK.

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Ms Kardos Burton: Yes. But in answer to your question, we would look at any pressures that CHCs or community agencies would look for.

Ms Lankin: Is it Grand Bend? The Grand Bend and Kitchener ones, are those brand new CHCs?

Hon Mrs Witmer: The Kitchener one is totally new, and Grand Bend.

Ms Lankin: That's really terrific. I'm a big fan of moving aggressively on the expansion of CHCs now that there is budget room. There are over 70 communities; I think it's up to 75 now. There are a couple more every week. A lot of them are in underserviced communities. Some of them are within the GTA high-needs communities that have expressed an interest in establishing community health centres. The association, as you know, has put together a proposal. It's roughly $115 million that would double the number of community health centres in the province. That proposal is with the ministry and has been under review for some time.

I know you can't make an announcement today, but $115 million, given the size of your budget and given the kinds of programs you announced, could have a tremendous impact in those communities in delivering accessible health treatment as well as population-based health needs programs as well as good health promotion programs. I'm wondering, are you favourably disposed to that kind of program, Minister?

Hon Mrs Witmer: The fact that we have encouraged, I guess, the establishment of these three new CHCs certainly speaks to the fact that we do support the concept of the CHC, and you're right: it does respond to the needs of people in the underserviced areas. It also responds to the needs of people in some of the downtown areas where you have people with some very unique and special needs.

Ms Lankin: That's what I refer to as the high-needs areas as opposed to underserviced areas.

Hon Mrs Witmer: That's right, and as we move forward and we take a look at what we now call the primary care network, in many respects the way they would be structured would bear a great resemblance to the community health centres, where you'd have-

Ms Lankin: You've come right to my next question.

Hon Mrs Witmer: That's right, and that's where I do believe we're moving. I personally support the concept of having teams of health professionals working together to identify all the health needs of patients.

Ms Lankin: Can you tell me then: with the eight pilot projects that are currently in place for the primary care pilot project, are we looking at ensuring, for example, that there must be multiple health professionals involved in the delivery of that care, not just group physician practices? Are we looking at ensuring that there must be health promotion programs, not just illness treatment programs? Can you tell me, within those pilot projects, how they're structured, those elements of primary care reform, as opposed to simply paying doctors differently and having the offices open 24-7?

Hon Mrs Witmer: That's right. Certainly, when we talk about primary care networks, we're talking about teams of health professionals working collaboratively together to address the health needs of people in this province. It includes physicians but it also includes nurses, nurse practitioners, social workers and psychologists. Obviously each community network is going to have an opportunity to identify what is needed in that particular community. As well, we now are in a position where we would flow funding to the primary care networks that would enable the providers to be reimbursed, and have incentives provided to deal with health promotion and illness prevention.

Ms Lankin: Can you tell me, in the pilot projects, though, what the structure is? Who's the network versus the providers? I know there are some 120-odd providers who have signed over to the concept, but how's the network constructed?

Hon Mrs Witmer: I'll call on Mary Catherine Lindberg, who's been involved with the original pilots, but at the same time I should mention to you that we're now working on the implementation of rolling out the primary care networks throughout Ontario. As you know, it would be our hope over the next four years to have 80% of all eligible family physicians practising in these networks.

Ms Mary Catherine Lindberg: Mary Catherine Lindberg, Deputy Minister, health services division. We currently have eight primary care networks up and running and we're proposing to go to 11. They're physician-sponsored primary care networks at this point because we're working with the OMA and we developed these over the last three years. They range anywhere from having three physicians to 19 physicians in each one of those networks. On average, there are between eight and 10 physicians in each one.

Ms Lankin: Can I just ask you, ADM Lindberg, about the one with three: what other health professionals are practising in that one, for example?

Ms Lindberg: Each one of these has a nurse practitioner with them. Each network has the funding for one nurse practitioner, so there is one nurse practitioner. That's in the rural area of Kingston.

Ms Lankin: Beyond that, who else?

Ms Lindberg: We have not gone beyond that with other providers at this point.

Ms Lankin: Here's my concern. As this rolls out, and I come back to community health centres and essentially your vision for the role of community health centres and primary care reform, what I see happening is, with all due respect to my wonderful friends in the OMA-but you know, there are a few of them who like me. We have a fee-for-service system which was described by many health reformers as problematic because it was a physician gatekeeper. The new primary care networks that are being established, these pilot projects, are physician-led and physician gatekeepers. Having done the negotiations in the context of the OMA and these pilot projects being set up, those of us who want to see community health centre models as primary care networks and a multi-team approach-there are HSOs, there are other models that we've experimented with and we see the strengths and weaknesses. This concerns me, where we're at.

Perhaps it's not fair to ask you; perhaps I have to ask the minister. How are you going to wrest back the vision of primary care reform as opposed to simply alternative payment plans for physicians, which these pilot projects in their early days are beginning to look like?

Ms Lindberg: Our model, the Ontario model, as we call it, is built around a multidisciplinary team. It's built around flexibility. It's built around voluntary, which means physicians can voluntarily enter those networks and the patients move voluntarily-

Ms Lankin: So is it fair to say that the pilot projects you have don't actually meet the criteria of the Ontario model at this point in time?

Ms Lindberg: The model we've put up was established as a joint initiative between the OMA and the ministry, and we are evaluating it.

Ms Lankin: What happened to community health centres? What happened to all the other practitioners who should have been at the table?

Ms Lindberg: As we move on primary care and the implementation, HSOs, the CHCs, we're looking at those models, which will fit into our flexible model. As I've been telling the CHC association, we're not closing doors; we're opening doors within the flexible model to bring that model within the primary care model.

Ms Lankin: I think you should close the door on the group physician without the multiple practitioners model, because that's not primary care reform.

Let me ask you, in terms of CHCs: apparently there are fee-for-service physicians who have expressed an interest in moving over into CHC practices or joining networks with them. Is the agreement with the OMA flexible enough to accommodate that?

Ms Lindberg: Yes, it is.

Ms Lankin: Mr Chair, I'll resume, since I have some time left, when we come back on Tuesday.

The Chair: Yes, we're adjourned for today. About eight minutes left.

Ms Lankin: That'll be great. Thank you.

The committee adjourned at 1759.