Special report,
Provincial Auditor
Ministry of Health and Long-Term Care
Mr Daniel Burns, Deputy Minister
Ms Mary Kardos Burton, executive director, health care
programs
Mr Malcolm Bates, senior manager, patient care services,
emergency health services branch
Mr Fred Rusk, manager, air ambulance, patient care and program
standards section
Ms Allison Stuart, director, hospital programs
Audit Act
amendments
Mr Erik Peters, Provincial Auditor
STANDING COMMITTEE ON
PUBLIC ACCOUNTS
Chair /
Président
Mr John Gerretsen (Kingston and the Islands / Kingston et les
îles L)
Vice-Chair / Vice-Président
Mr John C. Cleary (Stormont-Dundas-Charlottenburgh L)
Mr John C. Cleary (Stormont-Dundas-Charlottenburgh L)
Mr John Gerretsen (Kingston and the Islands / Kingston et les
îles L)
Mr John Hastings (Etobicoke North / -Nord PC)
Ms Shelley Martel (Nickel Belt ND)
Mr Bart Maves (Niagara Falls PC)
Mrs Julia Munro (York North / -Nord PC)
Ms Marilyn Mushinski (Scarborough Centre / -Centre PC)
Mr Richard Patten (Ottawa Centre / -Centre L)
Substitutions / Membres remplaçants
Mr Garfield Dunlop (Simcoe North / -Nord PC)
Mr Steve Gilchrist (Scarborough East / -Est PC)
Mrs Lyn McLeod (Thunder Bay-Atikokan L)
Mr Rob Sampson (Mississauga Centre / -Centre PC)
Also taking part / Autres participants et
participantes
Mr Bruce Crozier (Essex L)
Mr Erik Peters, Provincial Auditor
Clerk / Greffière
Ms Tonia Grannum
Staff / Personnel
Mr Ray McLellan, research officer, Research and Information
Services
The committee met at 1007 in room 228.
The Chair (Mr John
Gerretsen): I'd like to start the meeting right now,
please, so we can deal with some preliminary matters before the
deputy comes in. Ms McLeod, you had a matter you wanted to raise
at this stage?
Mrs Lyn McLeod (Thunder
Bay-Atikokan): Yes, I do, Mr Chairman; thank you very
much. I'll raise it very briefly, because obviously when the
Ministry of Health comes in we'll want to move immediately to the
emergency services issue. I would like to place a motion before
the committee to ask the Provincial Auditor if he would
investigate the cost-effectiveness, value for money, of the
decision by Cancer Care Ontario to have the after-hours clinic
provided through a private clinic as opposed to doing it
in-house, if that motion would be in order. Shall I put it in
writing?
Clerk of the
Committee (Ms Tonia Grannum): Please.
The Chair:
Any discussion? Mr Sampson, welcome to our committee.
Mr Rob Sampson
(Mississauga Centre): Thank you, Mr Gerretsen. It's
always a pleasure to be under your tutelage.
I'm sorry, Mrs McLeod; you
wanted to table a resolution?
Mrs McLeod:
I'm just writing it now, Mr Sampson. I'm not intending to
surprise the committee with it, but it just follows out of the
questions that are being raised about the decision that Cancer
Care Ontario has made to deal with the re-referral program by
offering after-hours radiation treatment in a clinic that is
privately run, as opposed to offering it in-house. I was going to
put forward a motion asking the Provincial Auditor simply to
investigate the value-for-money aspects of that decision.
Mr Sampson:
I don't know that that's a resolution that would be in order for
this particular committee. I don't how this committee can direct
or not direct the responsibilities of the auditor in that
particular instance or any other instance.
Mrs McLeod:
I believe it is in order. The auditor can investigate issues at
his own initiative, but he can also investigate at the request of
the assembly, which would be triggered by a motion of the
committee; that is my understanding.
The Chair: I
understand it's in order as well.
Mr Sampson:
Does Mrs McLeod have the motion in writing here?
Mrs McLeod:
I'm just doing that.
Mr Sampson:
What's the formality? What's the process for your committee, Mr
Chair? I'm sorry, I should have briefed myself on that.
The Chair:
She's putting in writing right now. Perhaps we can discuss it at
that time.
Mr Sampson:
Why don't we wait on discussion till we see the document on the
table.
The Chair:
OK.
Ms Shelley Martel
(Nickel Belt): I'm going to agree to the motion, but if
you want to hold further debate until afterwards, then I'll make
my comments at that time.
The Chair:
Here they are. Welcome. We'll stand down the motion until it's
presented.
SPECIAL REPORT, PROVINCIAL AUDITOR
MINISTRY OF HEALTH AND LONG-TERM CARE
Consideration of section
3.09, emergency health services.
The Chair:
Welcome to the deputy and the other members from the Ministry of
Health as we continue our hearing on the special report of the
Provincial Auditor dealing with emergency health services. We
started the hearings into this matter in December, and this a
continuation of the hearings. The last time we left off, we
finished with the government caucus, so the questioning will
start with the Liberal caucus. I propose that we question for 20
minutes and we can see how many rounds you want to take for the
questioning.
Mrs McLeod, would you like to
start it off?
Mrs McLeod:
Thank you very much, Mr Chairman. The first area I would like to
pursue is where we left off in December in terms of the transfer
of responsibility for ambulance services with the 50-50
cost-sharing to the municipalities.
The first question I would
have is, as of our last get-together in December, there were some
31 outstanding contracts to be signed. I understand those were
all signed by January, but I'm wondering if you could tell me
something about the process that went into finalizing 31
contracts in the last two weeks of the year and what happened with those contracts in
terms of the nature of the successful bidders.
Mr Daniel
Burns: I'm going to ask the ministry staff who are with
us to give the substantive answer that's called for by the
question.
The Chair:
Perhaps you could identify yourself when you start speaking so
Hansard can pick it up. Good morning.
Ms Mary Kardos
Burton: Good morning. I'm Mary Kardos Burton. I'm the
executive director of health care programs for the Ministry of
Health and Long-Term Care.
Yes, last time we were
talking about the transfer and it was just a few weeks. I'm
actually very pleased to report that the transfer went very
smoothly. The contracts are signed. We have agreements with all
of the upper-tier municipalities, the designated delivery
agents.
In terms of the transfer, it
was one of those things where we were imagining, "Is this Y2K?"
or whatever, but it did go very smoothly. The municipalities are
pleased with the level of support they've received from the
province. We've transferred all of the vehicles. We've
transferred the equipment. I think everything has been taken care
of as it should have been, so we're very pleased with the outcome
from the first transfer.
Mrs McLeod:
Can you give us some understanding of the nature of the contracts
that have been signed? Are they primarily with private sector
ambulance providers? Are they with hospitals? Are they with
municipal providers? How many of the former providers are still
providing versus an actual transfer to new providers in those
areas?
Ms Kardos
Burton: We do have that information. Malcolm Bates, the
director of the branch, will give that to you.
Mr Malcolm
Bates: There are now in the land ambulance system 22
private operators, 22 hospitals, 25 directly operated municipal
services, two boards and seven volunteer services.
Mrs McLeod:
Do you have any sense of comparison to what existed before in
terms of that same breakdown, excluding the 10 run by the
ministry?
Mr Bates:
Yes. Of course, the 10 run by the ministry were divested, as
you're aware. There were approximately 65 privates, 67 or 68
hospitals-and again, you'll have to forgive me; I don't have the
specific, exact numbers, but these are about that-somewhere in
the vicinity of 13 or 14 volunteer services and about the same
number of municipal. Municipals are primarily volunteers outside
of Toronto, as you can imagine.
Mrs McLeod:
Thank you. As we looked at the auditor's report last fall, and we
were looking at a number of aspects of the costs of divestment
and the 50-50 cost-sharing arrangement being assumed by the
municipalities, the costs that were in the auditor's report
included-I believe this was an estimated cost at the time-$25
million in compensation to operators for the loss of their
businesses, an estimated $15 million for the breaking of leases,
an estimated $24 million in severance, and then there were also
estimated annual cost increases to bring the services up to the
1996 response time. So the first part of my question around the
cost of the divestment is the one-time costs that have been
experienced. Do you have final costs now on amounts paid to
operators, severance costs and lease-breaking costs?
Ms Kardos
Burton: We do have final costs on some of that, but not
with us right now. We do have costs on what was paid.
Mrs McLeod:
Can you provide those figures to the committee? If they can, Mr
Chair, can that be provided to the committee if the committee is
no longer sitting on this issue?
Ms Kardos
Burton: I just want to be clear: we don't have all the
costs, but whatever costs we do have, we can provide.
Mrs McLeod:
Is that because the reports have not come in? I assume that in
signing contracts, all the severance costs were part of the
signed contracts.
Ms Kardos
Burton: We would have the severance costs. It's the
leases. On some of the leases we don't have the costs yet.
They're not finalized. They're still in progress.
Mrs McLeod:
In terms of the ongoing cost of the contract?
Ms Kardos
Burton: Yes.
Mrs McLeod:
You would have the one-time costs of divestment, though, in terms
of severance?
Ms Kardos
Burton: In compensation.
Mr Bates: In
compensation, yes.
Mrs McLeod:
If we could get those figures, I would appreciate it, please.
The second cost area is the
area you may not have figures for, and that's the annual cost
increases. In the auditor's report-and I think that reflected a
consulting report that was done for the ministry-there was an
indication that it would take $40 million annually to bring
municipal providers up to the response times and another $53
million-and again, that was in relation to meeting the current
standards. I'm not sure if Mr Peters wants to clarify the $40
million and the $53 million, but at that time there was a total
of $93 million in estimated annual cost increases as a result of
the divestment if the 1996 response times were to be met.
Do you have figures now,
based on your contracts? I'm assuming that all the contracts were
based on the 1996 standards being met. Is that a fair
assumption?
Mr Bates:
Maybe I can help out here. At this time, we're in the process of
working with each municipality with respect to developing its
budgetary costs for this particular fiscal year. I think you are
aware that a template was jointly developed through the land
ambulance implementation steering committee as a tool to be used
by the municipalities and the ministry. That template has been
formulated, agreed upon and circulated to all municipalities.
Those municipalities are currently at the stage of developing
their budgetary costs at this particular time.
Mrs McLeod: I was aware of that. We
had all of that information, and we have the template before us.
My assumption was-and please tell me if it's wrong-that that was
the template that was guiding the contract discussions each of
the municipalities was entering into and that the contracts that
have all now been signed successfully are based on the template
and therefore based on the pre-service level.
Are you telling me, then,
that there's no assurance, that the pre-service levels and the
inequities that existed at that point in time have not been
addressed yet by moving to the 1996 standard?
Ms Kardos
Burton: We'll try again. There are two issues in terms
of costing. The template is for additional costs that
municipalities have incurred just by the mere fact that the
deliverer of service has changed. I think we talked about the
fact that they are for things like fuel costs, liability costs,
insurance costs, tax costs etc.
Mrs McLeod:
And the operating of the service at pre-assumption levels?
Ms Kardos
Burton: That's right. The principle was that
municipalities will be getting today's cost at whatever it was at
the time. So if you had a certain number of vehicles prior to
taking over, that's the template. So that is an increased cost
for delivery of service that we've agreed on in terms of what are
the approved costs.
The response time: I think we
have indicated there were preliminary estimates for response
time, but as Malcolm Bates said, we are going through a process
with the municipalities. The response times still need to be met,
if that's what your real question is.
1020
Mrs McLeod:
So the costs that are in place now would be essentially the
pre-divestment costs and then the one-time cost of assuming the
service.
Ms Kardos
Burton: Right.
Mrs McLeod:
That takes me, then, to the template. I think you may have begun
to answer some of my outstanding questions, and those are around
the meeting of the 1996 standard and, as well, moving beyond that
to deal with some of the concerns that the municipalities have
been raising. I guess what you're telling me is you have not
reached an agreement with the municipalities about how to meet
the 1996 standard, let alone how to respond to their concerns
for, for example, going beyond that to have advanced life support
paramedics on every crew.
Ms Kardos
Burton: We've reached agreement with the municipalities
in putting a process in place in terms of the committee. That
standards committee has been in place. We've met approximately
every three weeks since November. Two parliamentary assistants
were supporting that committee. The regional chair of Durham
chairs that committee. There's a commitment in terms of municipal
staff as well as our staff to meet. What we've agreed to is that
each municipality will be putting forward a plan of how they are
prepared to meet response time standards. We're anticipating that
by late spring or early summer we'll have a projection of those
plans.
Mrs McLeod:
As part of your work with the municipalities, you had indicated
in your response to the auditor's report that you were doing a
comprehensive review of response times and that you would be
providing the municipalities with the data from the comprehensive
review about current response times. I assume that review is
completed and you know what current response times are. Is that
information which you could share?
Ms Kardos
Burton: Municipalities have all the response time
information and they know what response times are.
Mrs McLeod:
Is that data that you can now share with the committee, since
that review is completed?
Ms Kardos
Burton: Yes.
Mrs McLeod:
Thank you. Mr Chair, I would appreciate that data being tabled
and circulated to committee members. Is that still
outstanding?
Ms Martel:
Yes.
Mrs McLeod:
I know we raised this issue as well, the Fleuelling inquest,
which recommended that the response times be improved, and that
also the training of the paramedics be improved so that there was
advanced life support paramedic training for ambulance crew
members. Is that something which the ministry is-what I hear you
saying right now is that we're still $100 million short of
meeting the 1996 standard. We've got a budget coming up. We're
dealing with an area which is really critical in terms of life
and death, and that's why it was the subject of an inquest
report, as well as the focus of the auditor's concerns. We have
an inquest report that says we should be expanding the service to
have advanced life support paramedics. I guess my question is, is
the ministry focusing solely on getting up to a 1996 response
time and putting the ministry's share of that in, which would be
about $50 million, or are you dealing with the municipalities in
terms of the need to go beyond that? Because the 1996 response
times are already considered by an inquest report to be
inadequate.
Ms Kardos
Burton: Through the standards committee, our goal was to
go beyond that. We decided to say that the first task for us was
to try to address the 1996 response times but move beyond that. I
think there's a common view that the standard that's in place is
not the standard one would have, and you would devise a standard
in a different way. So we agreed that we would deal with this and
then move on in terms of what the standard should be and work in
partnership with the municipalities to do that.
Mrs McLeod:
Is it still a fact that some of the municipalities, in the
contracts they've signed, have voluntarily gone beyond the 1996
response times and they're paying 100% of those costs?
Ms Kardos
Burton: Yes. Some municipalities or councils have taken
decisions that, regardless of what the province is paying, they
will work on their own toward the standards, and are paying 100%
dollars for that.
Mrs McLeod:
I assume that in your discussions with them, paying 50% of what
they considered to be a reasonable standard is something the ministry is
looking at very seriously.
Ms Kardos
Burton: I think the commitment we've always made is
that, through the standards committee, if we devise new
standards, we will pay 50% of mutually agreed to standards. The
province will pay that.
Mrs McLeod:
Do I have any more time?
The Chair:
You have approximately five minutes left.
Mrs McLeod:
I wanted to ask about the air ambulance. I'm probably going to
come back to the broader emergency services, but I do want to
make sure I get a question about air ambulance in. Of course one
of the issues of concern with the air ambulance that is outside
the auditor's report-and I think it probably occurred while we
were discussing the auditor's report and the concern the auditor
had about there not being dispatch aims and the fact that the air
ambulance was not in the air in a prompt way-is the privatization
of the paramedics who work for the air ambulance system. I wonder
if you could tell us what the status of that privatization
is.
Ms Kardos
Burton: I'd like to introduce Fred Rusk, who's the
manager for air ambulance. I think it's important that he also
give you some context in terms of how the air ambulance system
operates today.
Mrs McLeod:
I appreciate that, but we did get all of the background on how
the air ambulance service works. We know that it is privatized
except for the employment of the paramedics. The issue is, we've
seen the RFP that's gone out for the ministry to divest as the
employer of the paramedics and to privatize the employment of the
paramedics. So I don't think we need a primer on that. I just
want to know what the status is of this next stage.
Ms Kardos
Burton: That's fair. I was concerned that there was some
misapprehension about that. That's fine.
Mrs McLeod:
No, nor has there been from the time we started raising these
questions.
Mr Fred
Rusk: Fred Rusk. I'm the manager of the air ambulance
program for the province.
The RFP closed on December 5.
We're still currently in the evaluation process of the bids. Once
we have the evaluation completed it will go to Management Board
for a decision. Is there anything in particular that-
Mrs McLeod:
So the decision for Management Board is on the acceptance of one
bid over another bid?
Mr Rusk: No,
it's based on the recommendation of the evaluation committee.
Mrs McLeod:
Right, but the decision is no longer, if it ever was, as to
whether to privatize the service; the decision is on who will
provide it.
Mr Rusk:
That decision hasn't been made. The privatization decision has
not been made.
Mrs McLeod:
What will the grounds be for deciding, do you think? I'm
assuming, if you've gone through a request for proposal process
and you're receiving the bids, that there is some serious intent
to divest of the employment of the paramedics.
Mr Rusk:
Yes. We've asked the prospective bidders to bid two ways: one
with the inclusion of paramedical staff along with the aviation
staff and the aircraft, and to bid the other way, with the
exclusion of the paramedical staff.
Mrs McLeod:
So you're looking for a cost comparison between a bid that would
include the paramedics being hired by the private company, and
part of your decision is which is the least costly?
Ms Kardos
Burton: I think a number of factors have to be taken
into consideration when you're assessing those. Cost may be one
of them, but service delivery, ease of operation, a number of
others.
Mr Rusk:
New, improved aircraft and new, improved medical equipment. There
are a lot of things that add up in the response to the RFPs.
Mrs McLeod:
Can you explain to me why in the request for proposal there was a
period allowed of waiving having fully trained critical care
paramedics on the air ambulance flights, I think a period of six
months?
Mr Rusk: We
wanted to give everybody the same opportunity, not only the
incumbents but any new companies that wanted to bid, and to have
critical care medics available to work on the aircraft has a
considerable training period involved. We currently have, right
at this moment, about 30 students in a critical care program here
in Toronto planning for the new contract, because we're going to
be expanding the new program. As well, we have people who are
leaving or have left and we have positions to fill.
Mrs
McLeod: I don't understand this, in all honesty. I'm
from northern Ontario so I know how essential it is to have
critical care paramedics in attendance on any emergency flight
that goes out of northern Ontario, or in those cases where the
flights are in the south. I can't conceive of any way in which
you are not risking patients' lives by having any transition
period in which you do not have critical care paramedics. It
would seem to me that if you cannot even contemplate the
divestment of the employment of the paramedics without having
this six-month period to give people a fair chance, that you
don't want to give the private sector a fair chance when the
consequence is six months without critical care paramedics on the
flights.
1030
Mr Rusk:
No, it's the expansion of the program. The additional six months
will allow them to start off with one critical care flight
paramedic and one advanced care paramedic. There is a difference
in the skills; however, we wouldn't allow any patient to be cared
for with less than what's required. If we needed a third person,
we would have a doctor or a nurse or a respiratory technologist
accompany those people.
Mrs
McLeod: But I'm not sure that is what your request for
proposal says. So are we dealing with the realities of the
request for proposal, which is the basis on which you're going to
be receiving bids, or are we dealing with the good intent of the
ministry? I'm really concerned about how this transition period
is going to take place.
Mr Rusk: I
can't jump to the end of the story right at the moment but our
intent is to have as many critical care flight paramedics as possible on the aircraft at
the change of contract on October 1, 2001. Our plans for the
training program are to train these people so that we do have the
number of paramedics we need on the air program. With the
addition of these 25 paramedics, that will give us a full
complement. We didn't know, going into the RFP-as I mentioned
before, we wanted to give everyone an equal opportunity and not
just have the incumbents have an edge.
Mrs
McLeod: But the incumbent in this case is the
government.
The Chair:
This is the last question.
Mrs
McLeod: Your request for proposal says very clearly that
there can be a transitional period in which you don't have to
have two critical care paramedics on every flight, and you've
explained why you've put that in, but your RFP also says you can
fly with no paramedics at all for just $150 less for the service.
That's in the RFP. How can I not come to the conclusion that it's
possible in this divestment process, for at least a period of
time, that for a relatively minimal cost, if you can't find the
paramedics, you're allowed to fly without them? That's the bottom
line in the request for proposal.
Mr Rusk:
The reason we put that in there, and I know it's been raised, was
to deal with the reality. There are days when we have folks who
don't make it in because of weather, they are ill, or whatever,
and it allows us-because we're the provider of the paramedics
right now. As managers of those paramedics, we were able to bring
in backfill people. When we transfer it over to the private
sector, they have to have the same opportunity. What we were
allowing them to do was, if there was a call and there was one
paramedic available and the other one was either late or sick or
injured or whatever, we could dispatch the airplane on the call
with the appropriate people on board other than a paramedic.
Mrs
McLeod: I just would argue that you don't have to give
the private sector an opportunity if it puts people's lives at
risk.
Ms Martel:
Let me follow up on this. Are you telling the committee that on
air ambulance flights right now you let air ambulances go without
paramedics on board?
Mr Rusk:
No, we don't.
Ms Martel:
Right now, the standard is that there have to be two critical
care paramedics on board when a patient is on board. That's the
standard now.
Mr Rusk:
That's the standard.
Ms Martel:
That's what you live by right now.
Mr Rusk:
That's what we do.
Ms Martel:
Clearly, what you are saying in this RFP-and the government
members should get a copy of this-is that because you're
divesting, because someone has decided it's a better idea to
privatize this service, you're going to let these operators in
the air with fewer than two critical care attendants. Is that
correct?
Mr Rusk:
We would only allow it if the care required for the patient would
need either a physician or a neonatal transport team or an RT. We
will take the resources that we have to have on board to look
after the patient.
Ms Martel:
Do you do it now?
Mr Rusk:
Yes.
Ms Martel:
I just asked you that question and you told me no. I said, "Do
you allow flights to go"-
Mr Rusk:
Our standard is to have two paramedics on board, but there are
times where we can't have two paramedics on board, one because
there are only four positions in the back of the helicopter
ambulance, if you will, with two stretchers. So if we have a
three-member neonatal team, one paramedic has to get out; one has
to stay on board for the safety of the rest of the crew, and they
assist the neonatal team. Truly, there are times that if someone
is ill and we're short for an hour or two and there's a call that
comes in, we would not want to delay the response to that call
because we didn't have two. We will put somebody on board,
whether it be a doctor or a nurse, along with that paramedic to
look after the patient.
Ms Martel:
Two things: I ask that you table before the committee those
periods of time-you can do it in the last year-where you flew
with fewer than the two critical care paramedics. The second
point I'd raise in that regard is if you can provide that
information to this committee. There is nothing in the RFP, and I
have it in front of me, that says the private operator is
obligated, if there is a need, to fly with a critical care nurse
or a physician or anyone else. That's not outlined in this at
all. It says very clearly that during the first six months of
service they can operate with two critical care flight
paramedics, or one and one advanced care.
Mr Rusk:
We put that there to address that reality. We wouldn't allow a
patient on board any of our air ambulances not to have the
appropriate care.
Ms Martel:
If you look at section 7.2, which immediately follows the section
I just referenced-let me read it to you. It says:
"7.2. Reduced flight
paramedic staffing: at any time during the term of service, the
air operator shall have the right to request the ministry, where
necessary for operational reasons, for consent to staff each
staffed aircraft with:
"(a) one flight paramedic,
in which case if the ministry grants its consent to this request,
the ministry shall reduce the service fee by $75 per hour or part
thereof that a flight paramedic is absent; or
"(b) zero flight
paramedics, in which case, if the ministry grants its consent to
this request, the ministry shall reduce the service fee by $150
per hour or part thereof that the flight paramedics are
absent."
I'm sorry but I read this
as your giving the operator the right to fly without the
paramedics, provided they pay a penalty. I mean, how else do I
read this?
Mr Rusk:
Certainly we had to address the reality of folks who couldn't
show up for work. That's the only reason that's in there. The
intent is not to fly airplanes or helicopters without paramedics
in the back; it was to address the reality and put the financial
penalty on them for the cost of the paramedic.
Ms Martel:
Let me ask this: does the government service now fly critically
ill patients in northern Ontario without even one critical care attendant? Do you
do that now?
Mr Rusk:
No.
Ms Martel:
OK, so why are you going to allow the private sector to do that?
You clearly are, and the worst part is that there's not even a
six-month time limit on it. There's no time limit for that second
provision.
Mr Rusk: I
can only tell you it was put in there to address that
reality.
Ms Martel:
What reality? You don't allow it to happen now. You're the
provider right now and the paramedics are paid 100% by the
province. They are public sector employees. You're telling this
committee that right now you would not let one of those aircraft
off the ground without having at least one paramedic. Is that
correct?
Mr Rusk:
To be precise, only if we were to staff the backup aircraft with
pilots and crew, except paramedics, if we had to transport blood
or human tissue.
Ms Martel:
This section doesn't make any reference to blood or human tissue
or organs, right?
Mr Rusk: I
don't quite-
Ms Martel:
It doesn't say you can fly without paramedics in the case that
you are flying blood or organs.
Mr Rusk:
We're in control of the dispatch of the aircraft and we can send
them anywhere in the province for whatever reason: to transport
patients, to transport human tissue, to transport blood.
Ms Martel:
In the case of human tissue, I might see a reason why you
wouldn't need two critical care paramedics. In the case of
someone having a heart attack in the back of that plane, I'm
sorry, but I can see no reason for the ministry to allow a
private sector company to fly with a patient in the back without
two critical care paramedics, without even one, as long as they
pay a penalty. You're compromising patient care.
Mr Rusk: I
don't think I'm compromising patient care if I replace those
people with critical care nurses or doctors or respiratory
technologists in assistance with the single paramedic who's on
board.
Ms Martel:
If I might, Mr Rusk, there's nothing in the RFP that puts an
obligation on the operator to put any of those people on board. I
just read into the record the section that says clearly they
don't have to have one or even any critical care paramedics where
right now they're supposed to have two. There is no reference
here for them having an obligation to have someone else on there
either. So what guarantee do we have, after this thing starts up
in April 2002, I believe it is, that we're not going to have
people who are critically ill in the back of plane without
critical care paramedics? What guarantee do we have that that's
not going to happen?
Mr Rusk: I
can't guarantee that somebody is not going to get ill but I can
guarantee that we've got 25 people in the training program to
fill all the vacant spots. We're doing our utmost to ensure that
that happens, and there are times when we take neonatal teams or
pediatric teams that fill in and support the critical paramedics,
and we'll continue to do that.
1040
Ms Martel:
Mr Rusk, if the government understood that there was a
possibility that critically ill people would be flown and there
would be no critical care paramedics, why would the government
ever have made the ridiculous decision to privatize this service?
You don't allow this to happen right now with your own public
servants but you're going to let it happen when the private
sector runs it. Why was the decision made to go down this
road?
Mr Rusk:
The decision hasn't been made.
Ms Martel:
What do you mean, the decision hasn't been made? All 36 of those
people had to make a choice already. They made their choice back
in October.
Mr Rusk:
We had to do that to comply with the collective agreements.
Ms Martel:
So are you telling us that one of the proposals that Management
Board is going to review is the Ministry of Health's continuing
to pay to have public servants on these planes? Is that one of
the options that's before Management Board, or is going to be
before Management Board?
Mr Rusk:
That's correct.
Ms Martel:
If that's one of the options, can you tell me why you would have
gone down the road to even put an RFP out to the private sector,
if the government is seriously-and I underline the word
"seriously"-considering maintaining this service? Why would you
go down the road to invite proposals to privatize?
Mr Rusk:
Let me try to frame it this way for you: the air ambulance
program in its entirety, the aviation side, is run 100% by the
private sector.
Ms Martel:
We know that.
Mr Rusk:
Seventy-five per cent or better provide the paramedical staff
currently. We're only talking about 45 other positions out of
about 220.
Ms Martel:
Yes, so we're talking about the people who have the most advanced
medical knowledge.
Mr Rusk:
That's correct.
Ms Martel:
The critical care people; they are the top of the line in terms
of providing care.
Mr Rusk:
That's correct. The private sector is operating it now. We
haven't had any issues that have come up like what you're saying.
We wouldn't send an aircraft out. We've got other alternatives;
we have other aircraft.
Ms Martel:
But you're going to let the private sector send an aircraft out.
That's the point I'm trying to make.
Mr Rusk:
I'm sorry?
Ms Martel:
You're going to let the private sector send an aircraft out with
people who are seriously ill. That's what this RFP says.
Mr Rusk:
We had to have that in the contract to allow for that
reality.
Ms Martel:
Let me ask you this: if the government had maintained the
service, would you allow it to happen? Would you allow an
aircraft to take off right now without at least one critical care
paramedic in the back?
Mr Rusk:
Would we allow that?
Ms Martel: Yes.
Mr Rusk:
No, we wouldn't, unless all the other aircraft were busy and all
the paramedics were tied up. Then we would send an aircraft that
was complete with a cabin medical attendant in the back for a
pediatric team or a neonatal team.
Ms Martel:
Can you tell the committee how many times that particular
circumstance might arise?
Mr Rusk:
What, neonatal transport teams? On a daily basis.
Ms Martel:
No, when there's no advanced critical care paramedic on a
flight.
Mr Rusk:
Maybe two or three times a year, but not with a patient on board.
Is that what you mean?
Ms Martel:
Yes, with a patient on board.
Mr Rusk:
OK. No, never.
Ms Martel:
So you must be seeing what I'm trying to say here: right now, the
government operates the service. I think it's an excellent
service. I think these people deserve to remain public servants.
But a political decision was clearly made to divest. You wouldn't
be going down the road inviting RFPs if that wasn't the clear
intent. As a result of going down that road and having this
operated in the private sector, ie, those people being employed
in the private sector, the government is now going to allow the
possibility where a private sector employer does not have to have
either one or two critical care paramedics in the back of that
airplane. That's a pretty significant change from how the
government operates the service now.
Mr Rusk:
But it won't happen that way. The history of this is that it has
never happened that way.
Ms Martel:
Yes, but you're the ones operating the service now in terms of
critical care paramedics.
Mr Rusk:
We still dispatch the service and we're still managing the
service. The reality is that if the operator for some reason
started flying without paramedics in the back-it just wouldn't
happen.
Ms Martel:
Why? All they have to do is pay you a $75 fee per hour to get rid
of one and they pay you a $150 fee per hour to get rid of
two.
Mr Rusk:
That would be the instant penalty, but they would be in default
of the contract if they didn't provide what we were hiring them
for.
Ms Martel:
But wait a minute. How are they in default of the contract? The
RFP clearly states that they have the opportunity to do that. All
they have to do is pay you a fee. How are they going to be in
default of the contract?
Mr Rusk:
They wouldn't be able to meet the transport requirements of
moving patients around this province if they constantly had no
paramedics or only one paramedic in the back. The standard is
two. We had to put the penalty in there in case there was a fault
in the fact that they couldn't provide it. That's why we put it
in there, to deal with the reality of it. The idea of the air
ambulance program is to transport patients, not to not transport
patients.
Ms Martel:
I understand that. The problem I have is the contradiction
between what would happen if these people remain public servants
and what's going to happen as the service is privatized. You
wouldn't let an aircraft in the air without making sure you had
at least one critical care paramedic on board, right?
Mr Rusk:
And don't forget we have-
Ms Martel:
But you're going to let it happen because the private sector
takes it over, and I assume the reason is that you're losing all
of those 36 or 35 paramedics you have now and you won't be able
to staff up the service. Isn't that the problem?
Mr Rusk:
No, it's not. The paramedical staff are quite anxious to hear
what the results of the contract are. These people will be hired.
If the government decides to divest, these people who are already
trained as critical care paramedics, because of their level of
training, will be hired by the contractors who take it over.
Ms Martel:
Can I ask how many have left the service at this point?
Mr Rusk:
One person has left since the RFP and that person is working for
us part-time. He has pursued a different career, but he remains
working part-time for us-one person.
Ms Martel:
What is the government's proposal that will be tabled with
Management Board to maintain this service? Would it be at the
same level of paramedics that you have now and the same rate of
pay?
Mr Rusk: I
can't tell you what the bids coming in are but what I can tell
you is that it's the same number of paramedics with the same
number of aircraft. In fact, we're increasing the number of
staffed aircraft, so there will be a requirement for an increased
number of paramedics. That's the idea of the critical care
training program that's currently ongoing.
Ms Martel:
Let me ask you this question: if you assume that the same number
of paramedics who work with you now will transfer to the private
sector, then why would you put in a clause that would allow the
operator to operate at less? You don't do it now with that staff
complement, right? You've just told this committee that you
assume those people are all going to go work for the private
operator. Why would you put in a clause to allow that to
happen?
Mr Rusk:
To allow for the reality of someone calling in sick, on the
rarity that it happens. When we're down-staffed in the sense
where we have a reduction in the number of paramedics we
have-it's an ebb and a flow to the number of people that we have,
because we constantly have to train to replace these people-it
would be ludicrous for me, who is running the program, not to
take into account the reality of somebody not coming to work one
day. So we had to put it into the contract to ensure that there
was a method that we weren't paying for something we weren't
getting.
Ms Martel:
Let me just back up. I want to be really clear. You've told this
committee that at least one critical care paramedic has to be on
these flights.
Mr Rusk:
That's right.
Ms Martel: That's what you operate
under right now.
Mr Rusk:
That's right.
Ms Martel:
Even when someone is sick, even when whatever else happens, you
take it upon yourself to guarantee that that plane doesn't take
off, doesn't get off the ground unless you have at least one
critical care.
Mr Rusk:
That's right.
Ms Martel:
OK. That's the reality right now that you're telling the
committee you experience, right? But your proposal allows the
private sector to operate without two. I don't understand the
difference in the-
Mr Rusk:
Did you say "without"?
Ms Martel:
Yes, zero flight paramedics, in which case they pay a $150 fee.
You just said to the committee the reality is that right now you
ensure that at least one has to be on board. Why wouldn't you
make that same provision even when this is turned over to the
private sector if that's the reality?
Mr Rusk: I
would ensure that only one would be on board if it was out on a
flight, but if they couldn't provide two or one or none, the
aircraft doesn't fly and I'm not paying for the paramedics, and
that's why it's there.
Ms Martel:
No, no, Mr Rusk, you're missing my point here. You've told the
committee a couple of times that right now if you've got a
critically ill patient in the back of an air ambulance, you would
guarantee that there'd be at least one critical care paramedic on
that flight. You would guarantee that right now?
Mr Rusk:
That's absolutely right.
Ms Martel:
Every day, every flight?
Mr Rusk:
Every flight.
Ms Martel:
No matter where.
Mr Rusk:
Along with whatever-there's another thing that has to play into
this, and that's the base hospital program.
Ms Martel:
No, no.
Mr Rusk: I
have to tell you this-
Ms Martel:
Quickly.
Mr Rusk:
-because the base hospital program is the medical control for the
program. The physician in charge of that flight, of that patient,
would not allow certain procedures to be done unless there were
either two critical care paramedics or a critical care paramedic
and a resident, an RT or another physician or a critical nurse on
board. So the care for the patient would not be compromised, and
that's paramount. The care is paramount.
1050
Ms Martel:
I agree. So what I'm asking is, why is the government not
prepared to apply the same standard that you operate under now
for this very important service to the private sector? Why are
you not prepared to apply the same standard? Because you are not.
If you allow the private sector to pay a penalty and fly without
two critical care paramedics on board, you're not applying the
same standard as you operate under now. Correct?
Mr Rusk:
Well, I don't get penalized if our medics don't show up.
Ms Martel:
It's not the money that worries me. It's the live body in the
back helping the person who is sick, right? I don't care about
the penalty so much as I want to make sure there is someone there
who is supposed to be doing their job to help someone who is
dying in the back.
Mr Rusk:
The standards won't change. It's just the financial penalty we
operate-
Ms Martel:
Of course they do. The standards do. Right now, you will always
have one critical care paramedic on board, right?
Ms Kardos
Burton: There are certain-
Ms Martel:
Always.
Ms Kardos
Burton: Right now-
Ms Martel:
Right?
The Chair:
Let the witness answer, please. Go ahead.
Ms Kardos
Burton: There are only certain circumstances where one
paramedic is on board. We've talked about some of them, but I'll
just repeat them.
The air-based hospital has
deemed it medically appropriate to send one paramedic to provide
for the patient. That's the point in terms of where the air-based
hospital says that.
The second reason would be
that the flight paramedic is accompanied by a neonatal transport
team to care for the patient. If that was the case, that's a
circumstance where you would allow for one.
The third is that the
flight paramedic is accompanied by a medical team: a doctor,
nurse or respiratory technologist to care for the patient.
Air ambulances are
permitted to fly with no paramedics on board only for the
emergency transport of blood or human organs and tissues.
Ms Martel:
Stop right there. The only time you allow that plane to go is if
there is not a person in back who is critically ill, right?
Mr Rusk:
Correct.
Ms Martel:
OK. I'm saying that this RFP allows you to operate without one or
any critical care paramedic on board when there is a patient in
the back, right?
Mr Rusk:
No.
Ms Martel:
Yes. You're darn right. Read the RFP. There is nothing in there
that says they can only do that if they're transporting blood.
Nowhere does it say that.
Mr Rusk:
The standards-
The Chair:
Let him answer and then we're on to the government side.
Mr Rusk:
The standards of care are outside the RFP. There is no change in
the standard of care. There is no change in that standard of
care.
Ms Martel:
Of course there is.
Mr Rusk:
No, there isn't.
Ms Martel:
Here's the section right here: 7.2, reduced flight paramedic
staffing.
Mr Rusk:
That's taken-the word is in the RFP; it's in the contract of the
RFP. I'm sorry that I'm not answering your question the way you
want me to answer it, but the fact of the matter is it was put in
there for the reality of what I've mentioned before. The
standards are the same. We will not-
Ms Martel:
Mr Rusk, I go back to my original question.
The Chair:
It's the last question.
Ms Martel: Can you guarantee to
Mrs McLeod and me that under the section that I just quoted,
which clearly says they can operate without any-and it doesn't
make any reference to only carrying blood or tissue-that when
this is privatized, we're not going to find ourselves in a
situation where a critically ill patient is being transported
somewhere in the north without either one or two critical care
paramedics on that flight? Can you guarantee to us that that is
not going to happen?
Mr Rusk: I
can guarantee you that that will not happen.
The Chair:
Thank you. Now to the government side.
Mr
Sampson: Not to beat a dead horse, but on the theme of
Ms Martel's questioning, what were you reading when you were
reading the list of things that would cause you to dispatch a
plane without two critical care paramedics? What were you reading
from? Was it a standard of some sort?
Let me ask the question
another way. Is there some sort of ministry standard or guideline
or policy that says you don't let a plane go without the
appropriate staff "unless these things happen," or maybe it's
written some other way?
Mr Rusk:
That's correct. That's the standard.
Mr
Sampson: There is a standard written somewhere? You can
actually get a piece of paper or a policy manual of some sort
within the Ministry of Health that would establish this. Is that
correct?
Mr Rusk:
All I can tell you is this is the standard that we go by.
Mr
Sampson: So there is some operating standard, whether
it's encoded in the form of a document or standard practice that
you've lived up to in the past and that you are currently using
as a guideline that says yea or nay on the dispatch of a plane,
because you are involved in dispatching of planes now. Is that
correct?
Mr Rusk:
That's correct. All I was going to tell you is that the standards
of medical care for the patients are set by the physicians and
the medical base hospital that controls the medical care of the
patient.
Mr
Sampson: Right. So somebody has set these standards and
you are then dispatching, currently, based upon these
standards.
Mr Rusk:
Yes, that's correct.
Mr
Sampson: If there is a new world and there is a private
operator involved in the delivery of the service, are they
rewriting these standards? Are they doing the dispatching?
Mr Rusk:
No.
Mr
Sampson: So tell me then, if you can-and as I understand
the questioning from Ms Martel, she actually read from the RFP.
I'd be interested to see the contract, because that would govern
the true partnership relationship between the private operator
and the government.
Ms Martel:
I'd be interested in seeing the contract too.
Mr Rusk:
There's a template.
Mr
Sampson: So under that relationship, who is responsible
for dispatching the plane, saying that this plane, or whatever
the aircraft is, can or cannot take off? Who is responsible for
that?
Mr Rusk:
The Ministry of Health.
Mr
Sampson: And what guidelines will you use to determine
whether that plane should take off or not? Are they any different
from the ones you're using now?
Mr Rusk:
No, they will not be.
Mr
Sampson: Is there any reason to believe they would be
any different from what you're using now?
Mr Rusk:
Not to my knowledge, no.
Mr
Sampson: Does the contract imply, say to the private
operator, you've got to listen to the dispatcher, that you just
can't dispatch a plane on your own?
Mr Rusk:
Absolutely.
Mr
Sampson: Is there anything to believe that what you're
currently doing as it relates to dispatching an aircraft and the
number and the type and the qualifications of the people on board
would be any different in a world where it's a private operator
provider or the world we have now?
Mr Rusk:
No, there would be no difference.
Mr
Sampson: I just want to go back to some numbers that
were talked about before; we were talking about ambulance service
providers. Pre-1995, I think you gave us some numbers as to how
many were doing what. I can't remember what it was; I've got the
numbers. Right now we have 25 private operators, 25 hospitals, 25
municipalities and seven volunteers, give or take a few.
Mr Bates:
We have 22 private operators, 28 hospitals-
Mr
Sampson: Twenty-eight hospitals?
Mr Bates:
Yes. There are 25 municipalities, two boards and seven volunteer
services.
Mr
Sampson: I forgot the boards. How could I possibly
forget the boards? In 1995, what was that breakdown? Were those
the numbers-
Mr Bates:
Yes, those were similar numbers to what I gave Mrs McLeod,
something in the vicinity of 65 privates, 68 hospitals or
thereabouts-
Mr
Sampson: So in 1995 you had 65 private providers and now
you have 22?
Mr Bates:
Yes.
Mr
Sampson: How many hospital providers did you have in
1995?
Mr Bates:
Somewhere in the vicinity of 67 or 68.
Mr
Sampson: And the municipalities were what?
Mr Bates:
The municipalities were about 13 or 14.
Mr
Sampson: And the volunteers and boards were about the
same, were they?
Mr Bates:
About the same, yes.
Mr
Sampson: So there's actually been a decline in the
number of private providers in ambulance services in this
province since 1995.
Mr Bates:
That is correct, yes.
Mr
Sampson: A decline?
Mr Bates:
A decline.
Mr
Sampson: Not an increase; a decline.
Mr Bates:
A decline.
Ms Martel: How many communities
were amalgamated?
Mr
Sampson: I'm just trying to establish the facts.
The contracts that are
written with these private operators and municipal providers, in
1995-because there were private operators and municipal
providers-were there service standards in Ontario, which I gather
is measured by the amount of time it takes to get to a call?
Mr Bates:
There were standards, yes, but now, as a result of a change in
the act, quality assurance-as we mentioned last time, the act has
been changed to more quality-based and there are many more
standards that have been put into place.
Mr
Sampson: Because those standards weren't terribly
consistent across the province. I'm putting words in your mouth.
Was that the case in 1995?
Mr Bates:
No, they were consistent in 1995. They will be consistent as far
as standards now, but there are more standards in place at this
particular point in time.
1100
Mr
Sampson: So this is somehow an attempt to improve the
quality of service of ambulance services across the province?
Mr Bates:
I believe that the quality of ambulance service with respect to
standards-that's correct, the quality of ambulance service should
be improved as a result of the increased number of standards and
the monitoring by the ministry and the local input by the
municipalities.
Mr
Sampson: Is the land ambulance implementation steering
committee going to be charged with some responsibility to review
these standards and the ability of individual providers, whether
they be private or public, to actually meet or exceed those
standards? Who's going to be measuring success or failure in that
area?
Mr Bates:
The land ambulance implementation steering committee has a
standards subcommittee. That standards subcommittee will be and
has been reviewing standards for ambulance services across the
province-these standards across the province, not individual
standards for individual operators; they don't exist. It's a
standard for ambulance services throughout the province. Any
change that is anticipated with a municipality, or whatever group
would like to see it occur, would go through that standards
committee. But in order for a standard to be changed, it would
require the approval of a standards committee of which the
ministry is a part, and our municipal representatives as
well.
Mr
Sampson: Did I hear from some previous question that
there were some providers who were actually interested in
exceeding these standards?
Ms Kardos
Burton: What you heard was that the municipal councils
in some cases have chosen to pay for costs to move out toward the
response time.
Mr
Sampson: "We'd like to do better; we're prepared to
pay." So some people are actually interested in exceeding those
standards-municipal providers.
Ms Kardos
Burton: It's municipal services, and they're interested
in paying to move to get to a response time faster. Increase
their response times: that's what their goal is.
Mr
Sampson: To your knowledge, has that happened in the
past? Was anybody kind of interested in exceeding standards in
the past, or is this somewhat of a new-
Mr Bates:
It was a consistent approach in the past throughout the province.
These standards were followed by everyone in the province in the
past.
Mr John Hastings
(Etobicoke North): I'd like to go back to the question
of standards and the encouragement of the myth that I see so
often in this public accounts committee that whenever any
government, including this one, subscribes to changing the mode
of delivery, somehow or other there is a greater susceptibility
to an increase in putting people at risk, whether it be in this
situation or when MTO changed its delivery services in northern
Ontario for road maintenance year-round. We had statistics back
then that clearly showed-but the myth persists. It doesn't matter
what the facts are, what your measurement or performance
standards are, you still end up that there's only one way to
deliver a service in health care or anything else, and that's the
public sector; there's no other way.
So, Mr Bates, what I would
like to ask you is, when there were a few private providers of
ambulance care, how were they treated in terms of performance
standards? Was it more linked to the compliance with rules that
we had back six, eight, 10 years ago? Would you describe the
delivery of land-based ambulance as more a performance culture or
a rules-obsessed culture in the past?
Mr Bates:
It's very difficult to answer that question, but I can tell you
that in the past, depending upon how long you wish to go
back-
Mr
Hastings: Let's use 10 years ago. You were around then,
were you not?
Mr Bates:
Yes. I think you and I established that the last time. Ten years
ago, there was a consistent approach throughout the province.
Whether it was private, whether it was hospital-based ambulance
service, they were all licensed, OK? That's step number one: in
order to operate an ambulance service in the province of Ontario
you had to be a licensed operator. You had to apply for a
licence, secure a licence and prove that it was necessary through
the Ministry of Health. Once you were licensed and operating in
Ontario, you had a standard ambulance, you had standard equipment
and you were funded by the province for the management and care
of that particular ambulance service.
At the same time, standards
were in place, as they are now, with respect to the ambulance
attendants, the paramedics themselves. The central ambulance
communications centres provided the dispatch of ambulances, as
they do now. The private operators, and any other operator,
provided the staffing for those ambulances, made sure those
ambulances were properly staffed, made sure the ambulances were
properly cleaned and that they were dispatched appropriately.
They were funded for that particular approach in the past.
Mr Hastings: Let me ask you this
question, then: with the emphasis more on a performance-standards
culture and on enhancing the professionalism of the paramedics,
how far along is the ministry in terms of trying to get
paramedics under the Regulated Health Professions Act? Is it part
of the overall plan as well to create better quality assurance
and more effective standards in terms of performance?
Mr Bates:
With respect to the Regulated Health Professions Act, I believe
that was an initiative on the part of the Ontario Paramedic
Association in the past. It was reviewed by the group within the
ministry that reviews it. At this point in time, we are not
looking at that aspect, because we feel the standards that are in
place through the community colleges, through the training that's
provided, through the base hospital monitoring of every paramedic
out there and the certification by the base hospital physician,
through the inspections we carry out and through the
certification of ambulance services-I think you're aware that the
fact of the matter is that paramedics generally are well
qualified for the job they perform.
Mr
Hastings: Again related to operational standards, is
Ontario still the only province that has a specifically designed
type of ambulance vehicle in terms of its platform, the physical
design of the vehicle, different from the rest of North America?
I was trying to think this morning of the design and the specific
criteria as to the type of vehicle. Away back, the private
ambulance operators told me that Ontario had this peculiar design
standard, the physical type, that was not the same as other
provinces or jurisdictions in North America even though we have
four seasons etc. Am I incorrect in that general description?
Mr Bates:
You're not incorrect. Let me explain to you how ambulances are
constructed and designed. There are a number of ambulance
suppliers in Canada. We deal with two, and I think there's an
additional one in the Maritime provinces. Those suppliers also
supply every other ambulance provider, every other province in
this country. The standards for those vehicles when they're
constructed-they are designed by the regulatory authority, and
that's the Ministry of Health. It's the ministries of health in
other provinces as well. They decide what the standard will be.
You're right that there's a difference.
Mr
Hastings: Why?
Mr Bates:
The difference is based, number one, on occupational health and
safety. We spent a lot of time designing the ambulances, and
they're looked upon as a model for North America-again you're
right-because occupational health and safety-wise they are
considered the best. Suppliers of ambulances come to look at our
designs, other operators look at our designs, other provinces
have asked for our specifications.
Another difference is that
they're subjected to crash tests. We have done this. No other
province or municipality or jurisdiction that I'm aware of in
North America has looked at the ambulance to make sure that if
there is a rollover or any type of accident such as that, the
patient and crew are protected to the best of our ability and to
the best of the manufacturer's ability. So you're right: there is
a difference between the type of vehicle we provide and the type
of vehicle we determine is required with respect to standards
versus some other jurisdictions. But those other jurisdictions
are looking at what we're doing. In fact, even the people from
Washington, DC, are looking at that.
1110
Mr
Hastings: They are?
Mr Bates:
Yes.
Mr
Hastings: My final question would relate to the
persistent questioning by Ms Martel about the penalty provisions
in the RFP for changing the delivery mode. Those penalty
provisions, the $150 or the $75, depending upon what type of
health care or paramedic expertise capacity isn't available-is
that a penalty and not a reduction in standards? The thesis I
seem to be getting, listening to her questioning, is that the
penalty provisions are a door opener for a reduction in the
standard of care of the patient from point A to the hospital base
rather than a protection of the standards we've set in the RFP.
Is there a taking out of context, then, without ascribing motives
here? I probably am. Is there a different context, then, when you
look at those sections in the RFP from what you intend to carry
out in terms of the protection of patients when they're either
air or land based?
Mr Bates:
I'm not sure anything is taken out of context; I can't speak to
that aspect of it. But I can tell you that with respect to
standards, the standards are there. The standards are maintained
in a number of different ways. Whether it be land or air, it
really doesn't matter. The base hospital, number one, is going to
make sure every paramedic, whether that be air or land, has the
qualifications. When it comes to air, they don't get dispatched
unless quality care will be there. There's no question about it.
Every carrier who signs on has to tell us who he has available
with respect to the person in the back of the aircraft. That's
our people as well as any other provider in the province. So we
know before they leave the airport, before they leave the
hospital, who is going to be providing care. They will not be
providing care unless the standard is there. The quality must be
there. There are a number of standards, as I say and as Mr Rusk
said previously, to protect everybody-the patients, the province
and everybody else.
You're right, that's a
penalty that was instituted there. It's a formality with respect
to that needing to be put into each one of these RFPs. The
contract is the key thing they're after. Once a contract is
signed, it will be clear that they must have paramedics of proper
quality and sufficient number to provide the type of care that's
necessary. There's no way that the Ministry of Health would allow
the quality of care for anybody in any part of the province to be
compromised. You're right, that's part of the standards.
Mr
Hastings: Do you have adequate staff, when this delivery
change is made in the next year, to supervise that the specs in
the contract, depending upon who the other carriers may become for land-air, are
carried out? One of the contentions usually made by the critics
is that we do not have, whatever the service you're delivering,
sufficient supervisory or monitoring provisions of that given
contract and the conditions and terms set in it.
Mr Bates:
Let me give you a description of what we actually have. We have,
as we indicated before, 22 base hospitals across the province,
including a principal base hospital for air ambulance, which is
Sunnybrook base hospital. They have medical staff there and other
staff who monitor what's taking place. We have one central air
ambulance dispatch centre, fully staffed at all times, around the
clock, 365 days a year, 24 hours a day, monitoring and
dispatching air ambulances. There's no question about it, there
are people there who know what they're doing. They're paramedics,
they're medically based people, so we have both medical control
and operational control.
On top of that, we have
people who are of course looking at the invoices that come in,
the financial aspects of it, to monitor that part of it as well.
We have a manager of air ambulance who will be constantly
monitoring what's taking place, who's a pilot and will be a pilot
with respect to that. We have inspections, and I think at the
last session we spoke about inspections and certification. The
thing that must be remembered is that all air ambulance services,
as well as land, must be certified before they can actually fly
or become operators of air ambulance. They must be certified, and
they will be inspected from time to time. As far as I can
determine, we have sufficient staffing at this particular point
in time to ensure that, as you say, Mr Hastings, the quality of
care will be maintained.
The Chair:
One more question, the final question.
Mr
Hastings: Could you send to this committee, from 1990
onwards up till now, any incidents of air ambulance crashes,
fatalities-land-based as well-for both the private and the public
sector?
Mr Bates:
Absolutely.
Mr
Hastings: However you categorize your incidents. You
know, some might come out of an inquest.
Mr Bates:
Can we clarify that? The number of crashes, the number of-
Mr
Hastings: Crashes or the disappearance or the lowering
of standards of critical care for patients in land-based and
air-based operations for the last 10 years. You won't have
sufficient comparators because all air-based was public sector,
right? You won't have any private carriers.
Mr Bates:
No, the private sector, if you're talking about air-and land-have
been part of the system for many, many years; in fact, since I
have been in the system, since you and I have been talking
about-
Mr
Hastings: Both air- and land-based, any types of
incidents in both the public and private sectors where this
committee could make intelligent comparisons as to whether
patients are put at risk or have been in past history, through
the last decade.
Mr Bates:
Sure.
Mr
Hastings: I want to get a firm base, because the
mythology around here that's continually perpetrated is that
there has seldom been an incident of any kind when the provider
is the public sector. Let's get the stats and see what they
really show for both the private and the public, in both types of
operations. I'd appreciate that.
The Chair:
I've had a request from the researcher as well. Could you provide
us with a copy, with the other material, of the RFP itself? Any
problem with that? Some of the committee members have it, but the
researcher doesn't have it.
Ms
Kardos-Burton: Yes.
The Chair:
Just one question. When you talk about standards, do you include
response time in standards as well?
Mr Bates:
The response time standard is something that's being developed,
as Mary indicated, by the standards committee at this particular
point in time.
The Chair:
So right now response time is not part of the standards.
Mr Bates:
It is a standard. The 1996 response time standard is a standard
per operator, all right? The committee is moving toward, as we
mentioned last time, a full review of what they believe the
standard for land ambulance response should be, so we're
basically in an interim period at this point in time.
The Chair:
Thank you.
Ms McLeod, I suggest 15
minutes for each caucus.
Mrs
McLeod: At the risk of being accused of perpetuating the
mythology, I would like to return to the auditor's report. I
don't have any question about the intent and the concern of the
Ministry of Health. Let me make that clear. What I have a real
concern about is track record in terms of being able to meet the
standards that are supposedly in place, even though those
standards have been seen, by at least one inquest report, to be
inadequate standards. That's true for land ambulance; it is also
true for air ambulance. The auditor very clearly expressed a
concern. I am going to return for a few moments to air ambulance;
I will come back to land ambulance, if you want to switch off and
play some musical chairs here.
I think it was Mr Sampson
who suggested we should take some comfort that the standards
currently maintained by the ministry would still be maintained
even though there is provision in the RFP to have a different
kind of standard operative. There are no limitations on what's in
the RFP. The limitation that is currently a guideline for the
ministry is no longer a limitation. Mr Sampson suggested we
should take some comfort from the fact that the ministry is still
going to maintain its consent process and the dispatch process.
The problem is that the ministry's ability to handle the dispatch
service is one of the most glaring errors or inadequacies that
was identified by the auditor when it comes to the dedicated air
ambulance service, the one which deals with the most critically
ill patients, the one where the ministry is currently employing
the paramedics, was only en route within 10 minutes of accepting
the flight, which is the standard that was in place, 44% of the time.
Only 44% of the time was the dedicated air ambulance service
actually in compliance.
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The auditor expressed a
concern about the fact that there were no standards for the
dispatch, let alone standards that were being met, and asked that
the ministry develop dispatch standards for air ambulance.
I have to tell you, in the
context of that track record, we have concerns about the proposed
changes in the RFP. I suppose Mr Sampson would say, "If the
ministry's doing such a bad job of it, turn it over to the
private sector. They're going to do a better job." I don't accept
that, if that's the reasoning that's being offered.
I want to come back
specifically to air ambulance and to some of the answers that
were given to Ms Martel a little bit earlier. Again, I would like
to take some encouragement from the guarantee you offered in your
last comments in response to Ms Martel that there would never be
a time at which there was an ill patient who was being
transported by air ambulance without appropriate paramedic care.
My concern is that, as reassuring as those words may be, the rest
of the testimony you provided as to why you've provided for a
financial penalty, why you had to have a financial penalty in the
RFP in the event that it simply wasn't possible to provide the
paramedic care, leads me to believe that you think there will be
situations in which there may not be a paramedic available. You
said, "We have to have that provision in there so that we're not
paying for paramedic service if the paramedic isn't available or
doesn't show up for work."
Those are statements; I'm
not asking you to repeat that. You said that a $150 penalty which
would allow an operator to fly an airplane without a paramedic
present had to be in place to deal with the reality that there
may be some situations in which a paramedic wasn't available. We
can go back to Hansard and check the testimony on that. And there
is no limitation on that in terms of, "You may not fly that
airplane without a paramedic unless you are only transporting
organs or tissue."
My further concern is that
we know you have to give severance, that all of the critical care
paramedics have signed forms saying they will take their
severance pay. You have no guarantee that any of those critical
care paramedics are in fact going to be employed by a new
provider. The very process of going through this request for
proposal, the very process of divesting-and surely to goodness
nobody would have gone through this process, as Ms Martel has
said, unless you were going to divest the service. You wouldn't
have gone through the anguish for your own employees if the
government wasn't planning to divest this service. So I assume
you're planning to divest. You know these employees have already
signed their severance forms. You know you have no guarantee of
them being rehired by whoever is the successful bidder.
I suggest that you are on
the verge of creating a crisis, a crisis of shortage of critical
care paramedics, who are already in scarce supply. These critical
care paramedics can go anywhere they want and get jobs tomorrow.
If by the very process of divesting this service you have created
a critical shortage of flight paramedics, then you may well be
having to invoke this penalty clause because you can't get
paramedics to staff the flights, whether it's your intent to or
not.
Two questions. One is, how
can you guarantee that the new provider of the service will have
enough critical care paramedics to ensure that those flights are
properly staffed with paramedics? My second question is, why are
you going through this tortuous, anguished, risky process? Surely
it isn't because the Ministry of Health can't deliver the service
and is only in compliance 44% of the time. Why? What possible
gain to patients is there in going through this divestment
process, with all of the potential risks that are in place? And
you can't give us a guarantee that the risks aren't there, no
matter how much you want to.
Mr Bates:
I think you mentioned that there might be a possibility of an
aircraft flying without paramedics. We can assure you that will
not happen except in the instance-
Mrs
McLeod: So the alternative is not to fly them. How can
you guarantee the paramedics will be there?
Mr Bates:
We do not fly air ambulances without sufficient qualified staff
in the back.
Mrs
McLeod: I'm hearing the words, but you've got a penalty
clause in an RFP without limitation that says you can indeed fly
an aircraft without a paramedic for a $150 deduction. You have
indicated today that you had to have that provision in an RFP
because there is a reality that the paramedics might not be
available-you suggested because they might not show up for work;
I'm suggesting it's because there may not be enough paramedics
available to supply the system. You've not limited the RFP by
saying the airplanes cannot fly if they've got a patient on
board. You can tell me that your intent, your standard, your
guideline is not to fly them, but the only alternative you may
have is not to fly the plane at all, and then what do you do with
a critically ill patient in a northern Ontario community? You
don't have any alternatives.
Mr Bates:
There are alternatives with respect to what happens. Number one,
as Mr Rusk said before, you can utilize the local physician, the
nurses. We can utilize other providers of aircraft. There are
times at which-
Mrs
McLeod: Not with paramedics. I'm sorry. You've got a
newborn baby, intensive care, who cannot be cared for in my home
community of Thunder Bay and has to be airlifted within a matter
of minutes.
Mr Bates:
In that particular case, the base hospital would ensure there's
adequate staff on, and our dispatch would. That could comprise,
as we said before, doctors, nurses, respiratory technicians,
whatever's required for the care of the patient. We work as a
system, all right? You can't look upon it as an isolated
segment-
Mrs
McLeod: Why does your request for proposal allow a
penalty clause to fly without paramedics? If you have clearly stated there will
be no flight that goes and that the ministry will pay the cost of
having alternate medical staff on board in the event that there
isn't a paramedic, why do you need this provision that if the
paramedics aren't there, you're going to fly for $150 less
without them?
Mr Bates:
I'm sorry. Can you repeat the question?
Mrs
McLeod: You have a provision in your request for
proposal that says you can fly without paramedics for $150 less.
You've taken dispatch response times out of the Ambulance Act for
both land and air ambulance. The ministry is not bound by
anything except good intent at this point. You're not telling the
private providers they can't fly without a paramedic. You're
telling them they can fly without a paramedic and you just have
to pay $150 less. Where does it say in anything that is binding
that no aircraft with an ill patient leaves the ground without
appropriate medical staff? Tell me where it says that.
Mr Bates:
First of all, the provider, as you call it, won't fly unless we
dispatch them. That's number one.
Mr
Sampson: Hello?
Mr Bates:
They cannot leave the ground unless they're dispatched.
Mrs
McLeod: "Hello?" Excuse me, Mr Sampson. Hello, as you
interject. The auditor has said the problem is the ministry
hasn't got an air ambulance dispatch response time standard. They
don't track the data. They're in compliance only 44% with their
own response time. Tell me how the ministry is going to decide in
time to transport that newborn child who has to be transported
out of Thunder Bay, to live, within less than an hour-
Mr
Sampson: So your position-
Mrs
McLeod: How are you going to decide, how is your central
dispatch system, which isn't under the act-
Mr
Sampson: I just want to get on the record her position
is that that person should be sitting there on the tarmac. Mrs
McLeod's got this-
Mrs
McLeod: I'm sorry. I want to know how the Ministry of
Health can guarantee that that airplane-first of all, that you
know they don't have a paramedic and, secondly, that you can make
sure they're going to be staffed with appropriate medical staff
and give the authorization for that, as well as telling the
private sector they can't fly. I mean, you've told them here they
can fly. That's the problem. You've told them they can fly. How
are you going to make those decisions to say, "No, I'm sorry. In
these circumstances, forget the $150"-you charge $150, but not
only that, "You can't take your plane off the ground, thank you
very much." That's more than a $150 cost, by the way.
Mr Bates:
Experience and our operational control-there are 17,000 patients
flown every year in Ontario. They all have paramedics with them
when they are flown.
Mrs
McLeod: My second question is, why divest this system?
Why run the risk of having all of your critical care paramedics
leave your service, with no guarantee they're going to be picked
up by a new service? I think there are some problems, that there
are problems with dispatch. You said to the auditor that you're
going to fix those problems, so why divest the service?
1130
Mr Bates:
First of all, there has been no decision on divestment of the
service. That's number one.
Mrs
McLeod: Why would it even be considered? Tell me what
possible gain the ministry sees in divesting this service.
Mr Bates:
I can tell you, by experience again, that there are now private
operators supplying the paramedical staff across the
province-
Mrs
McLeod: Not critical care paramedics.
Mr Bates:
They are providing excellent service at this point in time. There
is nothing to indicate they won't provide every bit as good
service whether it be critical care or advanced care or whatever
care.
Mrs
McLeod: But that's not my question. My question is, what
is there to gain? I would have the same question about the land
ambulance.
Let my question about air
ambulance stand. I'm sure Ms Martel will pick it up. I don't see
that there is any gain, financial or otherwise, to the ministry
for this divestment. I see significant risk to the patients.
On land ambulance, let me
put the same question to you. You have a record of not meeting
the 1996 response standards. You have a record-and this is the
government running the service-of not having put the money in to
meet the 1996 response standards. You have inequities from area
to area-and this is not mythology; this is the auditor's report.
You have no standard, and at this point you have refused to put
into the Ambulance Act a single standard for response times for
land ambulances. You are negotiating them with individual
performance contracts with each of the new providers of the
ambulance service under this divestment, so there's no guarantee
that we're going to have equity from one performance contract to
the other when these negotiations are finished. So you're not yet
meeting the 1996 response times, the money is not there yet to
bring it up to the 1996 response times, you're not going to deal
with the inequities because you're dealing with performance
contracts on an individual basis in terms of response times, you
have already encountered close to $100 million in one-time costs
for the divestment and for the severance. My question is, what
gains do you see in divesting the land ambulance service from the
province to the municipalities?
I would have to agree with
something Mr Sampson was starting to suggest, which is, thank God
the municipalities seem to be saying, "The standards aren't good
enough, and even if we have to pay for it ourselves, we're going
to meet a better standard." But what that says to me-and the
ministry is not yet prepared to acknowledge anything other than
the pre-service level, with all its inequities and all its
inadequacies; so far that's all the ministry is talking about-is
that if there's any gain it's because the municipalities are
prepared, all on their own, to put money into providing a higher
standard of ambulance
care than the government was ever prepared to provide. If that's
not the answer, tell me why there is any benefit to the
divestment of the land ambulance service to the
municipalities.
Ms Kardos
Burton: There's one other benefit I would like to speak
about, and that is the service in terms of the local community
and the commitment to the community. Talking to the
municipalities, first of all, they are now enthusiastic about
providing the service. There is better public education, because
that can be done locally. They are communicating within their
communities in terms of expectations to the citizens of the
community. So in terms of closeness, I think locally is an
advantage.
Mrs
McLeod: That's exactly my point: the benefit to the
patients is that the municipalities, because they are seeing
what's happening, are prepared to meet a standard the government
has not been prepared to meet.
I urge this government, on
record, to at least be prepared to meet the municipalities
halfway and to put in place 50% cost-sharing of the higher
standard the municipalities are looking for and then take that
higher standard and make sure it is equitably applied across
Ontario. I really believe that is the only way we are going to
see some benefits to patients for this entire divestment process,
with all the costs that have already been involved in that.
Mr Chairman, I suspect
you're going to tell me my time is up.
The Chair:
Yes, Mrs McLeod, for now.
Ms Martel:
I'm going to return to the air ambulance situation, because in
our part of the world this does mean the difference between life
and death for many people. So it is important, and I'm sure you
appreciate that.
Maybe you can give me an
assurance, which I haven't heard so far, if I approach it in this
way. Ms Burton was good enough to set out the standard that says
that right now the only time an air ambulance would fly without a
paramedic is in the instance when tissue or organs are being
transferred-correct?-and that in every other instance, if there
is a patient on board there is at least one critical care
paramedic.
Mr Rusk:
Correct.
Ms Martel:
That's what we're operating with right now. We know the RFP
doesn't make reference to that standard. You made reference to a
contract. My question would be, can you tell the committee that
the contract that would be signed with an operator would
guarantee that if there is a patient on board, there will be at
least one critical care paramedic on board?
Mr Rusk:
Yes, because in the contract it says they must abide by all
legislative-and standards for the program.
Ms Martel:
OK, and those were the standards Ms Burton referred to
earlier?
Mr Rusk:
The standards Ms Burton referred to are the standards that are
set for transporting patients, and what she read was correct.
That's set by the medical folks at the base hospital.
Ms Martel:
So on every flight where there is a patient, there will be at
least one critical care paramedic on board?
Mr Rusk:
Yes. Unless-
Ms Martel:
Unless?
Mr Rusk:
Yes. I was just going to go to the blood thing, but-sorry.
Ms Martel:
I want to be clear that it's when there is a patient on board. We
understand what happens when there's not.
Let me ask you, why does
the RFP talk about permitting an air ambulance to be flown
without a critical care paramedic? If that's what the contract
says, and we go by that because we haven't seen the contract-I
don't know if you're in a position to table that with us. If you
could, that would be helpful.
Mr Rusk:
There's a template in the RFP.
Ms Martel:
Does the template indicate that at all times when there's a
critically injured person on board there will be a critical care
paramedic on board?
Mr Rusk:
I'm sorry, I can't answer that without-
Ms Martel:
Could you get back to us on that?
Mr Rusk:
Certainly.
Ms Martel:
If that is in the template, could you table that with the
committee?
Mr Rusk:
Certainly.
Ms Martel:
All right. If that's the case, then we'll take your word for it
that that is the ministry's intention. Why then does the RFP that
went out to private operators, which they are to bid on, clearly
allow for a circumstance when there wouldn't be a critical care
paramedic on board, and there is no mention of, "only in the
instance where we're transporting tissue or organs"?
Mr Bates:
You need to have something like that so they know that if indeed
we ask them to fly tissues or whatever, this is what they are
going to be remunerated for. You have to have something in the
RFP indicating these types of things.
Ms Martel:
I would work the other way, Mr Bates. If the ministry's intention
is not to dispatch that flight off the ground without a critical
care paramedic when there's a patient on board, shouldn't the RFP
say that? Because the RFP allows for an alternate possibility,
which is flying without anyone.
Mr Bates:
It's not going to happen that way. That's all we can say to you.
The operators are well aware of that too.
Ms Martel:
So why would you have an RFP that allows for that?
Mr Bates:
For financial purposes. You have to have in these documents
reference to those types of things where it might happen, in the
sense that if they fly tissues for us, then they have to know
what the penalty might be.
Ms Martel:
If I might, Mr Bates, there's no reference to tissues. The RFP
doesn't make any reference at all with respect to tissues or
organs.
Mr Rusk:
But they will fly when they're dispatched by our medical air
transport centre. The only thing they get to decide is whether or
not they can fly.
Ms Martel: I understand that. I am
saying the section that talks about flight paramedic staffing and
the ability to fly without critical care paramedics makes no
reference at all to only those situations where what is being
transported is blood or tissue-none.
Mr Bates:
They are not going to be dispatched, as I said before, if they
don't have the proper staff.
1140
Mr Rusk:
It allows us also to use the backup aircraft that we can use as
we require. If we needed it to transport an organ or a tissue and
we needed to send the backup aircraft because the first aircraft
was busy on another call, we could dispatch them and it would be
allowed without a paramedic in the back, as well.
Ms Martel:
Just so the committee is clear, what you're telling us today is,
under no circumstance will one of these operators be allowed to
take off with a patient in the back without at least one critical
care paramedic. We should leave this room with that clear
understanding?
Mr Rusk:
Yes.
Ms Martel:
It would be really helpful, if the template has that, if you
could provide that to the committee.
Mr Rusk:
Yes.
Ms Martel:
OK. I would like to move on to land ambulances and to the
downloading costs for municipalities with respect to land
ambulances. The auditor made a point in his audit of saying that,
as of early January 1999, there were about 60% of all operators
who were not meeting the 1996 response time standards. The
ministry entered into some negotiations with municipalities
through the committee and came to some agreements in AMO about
establishing what are approved costs. What I would like to know
is, what was the position of the municipalities during those
negotiations? What specific requests did they make of the
ministry with respect to being a download of service that was not
up to standard during the October negotiations? I understand what
was arrived at; I want to know what was on the table.
Ms Kardos
Burton: I think for the items in terms of the template
that are agreed to, all of the items were agreed-to items. There
were two items, if I can-if you just give me a minute-OK, go
ahead.
Mr Bates:
Yes, there were two items that were not agreed to. One was with
respect to wages, where the government was clear that the wages
that could be allowed with respect to funding were at the 2%
level, and the other, I think, was with respect to the interest
on the completion of buildings.
Ms Martel:
Would it be fair to say that another thing that was on the table
was that AMO was pushing to have the province pay for 100% of the
capital costs for upgrading to 1996 standards?
Ms Kardos
Burton: Yes, that's fair. I thought you were talking
about the template and the two items, but in terms of the
response time, what AMO was asking for were the capital costs at
100% and then, ongoing from that, 50% of the operational
costs.
Ms Martel:
So they wanted 100% of whatever it would take to get up to the
1996 standards that were being downloaded.
Ms Kardos
Burton: The capital costs.
Ms Martel:
And the ministry ended up at 50%. Is that correct?
Ms Kardos
Burton: Because the response time and the approach that
we're using is not totally agreed to in terms of the cost,
there's nothing-I mean, what we were proposing was 50%, but there
is nothing that's been agreed to. The response time is separate
from the template negotiations.
Ms Martel:
Except they're interconnected because, through the template, what
you funded was what was in place at the time.
Ms Kardos
Burton: That's right.
Ms Martel:
For example, the same number of vehicles in the fleet at the time
of the assumption. If 60% of the operations were not up to 1996
standards-let's say even 30%-that meant many of those
municipalities are stuck in a situation where, as they acquire
new ambulances, they are paying 100% of the costs, right?
Ms Kardos
Burton: Right, so that would increase.
Ms Martel:
The parliamentary assistant, when he was here at the last
meeting, suggested it wasn't such a big problem because those
ambulances wouldn't have been available anyway. They had not been
made, they wouldn't have been able to purchase them. Did the
municipalities ask you to grandfather the cost of those vehicles,
so as they came on-stream to be incorporated into their service
to bring them up to 1996 standards, the ministry would still pick
up 100% of the costs as that process unfolded? Is that a request
that they made?
Mr Bates:
Yes, they asked for 100% of the capital costs. That's true.
Ms Martel:
Of whatever period over which it would take to get those vehicles
on stream, for example. Even if they had to order them and it was
going to take five months to get them?
Mr Bates:
Yes. It's understood it's about a 24-month time frame, as you
indicated before Mr Clark stated.
Ms Martel:
So in fact they made a request and it was turned down. They made
a request for 100% to be covered and ended up with 50%.
Mr Bates:
It hasn't been turned down at this point in time.
Ms Kardos
Burton: I think the understanding on the municipalities'
part is that we'll work through this process in terms of the
plans to meet the standards and then the plans would go to AMO
and to the government, respectively.
Ms Martel:
In that respect, then, you're working with municipalities to get
them up to 1996 standards. Has any commitment been made that the
province would assume 100% of those costs, since they were costs
that should have been covered before the download occurred?
Ms Kardos
Burton: There has been no commitment made on anything
related to the response time standards.
Ms Martel:
So in fact a number of municipalities could well be incurring
increased costs to even bring them up to a standard that should have been in
place when the ministry was funding this service, correct?
Ms Kardos
Burton: Yes. They'll be paying costs, yes.
Mr Bates:
Well, they will be incurring, if they wish, increased costs.
That's correct.
Ms Martel:
It's not even a question of "if they wish." I mean, they do have
to at least meet 1996 standards. I'm not even talking about the
group that goes beyond. They will have to meet 1996 standards.
That's the purpose of the exercise.
Mr Bates:
Right.
Ms Martel:
My concern is that a number of municipalities may well be out
money because the government is not paying 100% of those costs to
get them to 1996 standards. Am I correct?
Mr Bates:
No, the government, as Mary said, has not made a decision as
yet.
Ms Martel:
But the government has a template that didn't cover those costs
so far.
Ms Kardos
Burton: Right, and that's partially because-and you're
quite right that they are related, but we were doing this
exercise in terms of looking at the standard and coming up with
what in fact the cost would be in terms of meeting the
standard.
Ms Martel:
Let me ask this: is it likely that the ministry, as it goes
through its review municipality by municipality, is actually
going to fund 100% of these costs, when you didn't already with
the first round of negotiations in October?
Ms Kardos
Burton: I'm very reluctant to speculate.
Ms Martel:
I bet you are. That's a question for the ministry, you're right.
That was unfair to direct to the bureaucracy.
Let me ask, do you have any
idea what those costs are to bring municipalities up to 1996
standards, capital and operating?
Ms Kardos
Burton: The figure that we've talked about in the past
was around $50 million-and again, these are just estimates
because we do need the plans. The capital was approximately $12
million and the remainder was the operating.
Ms Martel:
Sorry, capital was $12 million, and the $50 million was a
reference to?
Ms Kardos
Burton: The total cost. We had done an estimate of what
it would cost to bring municipalities up to response time. It was
in the $50-million area, and that's been communicated publicly
with municipalities. But again, I stress it's an estimate. We'll
have a better sense once the plans are done.
Ms Martel:
Then the $40 million operating is a completely separate item as
well. The $50 million refers to maybe severance, increased
administration costs, etc?
Ms Kardos
Burton: No.
Ms Martel:
Do you want to tell me the difference between the $50 million
total cost that's the public figure and your $40 million estimate
that was referenced in the auditor's account?
Ms Kardos
Burton: Timing, I think. At one time, we may have
estimated $40 million. In terms of the estimate, it's $50
million, but it would be no different. The difference would be
the timing. It would be the same thing in terms of the operating
costs.
Ms Martel:
So we're up about $10 million. Do you have any idea when you'll
get an actual cost of what the difference would be between what
has been funded so far-which we hope will be more-and what the
municipalities are actually out?
Ms Kardos
Burton: We're targeting for completion in late spring or
early summer, so when our standards exercise is completed with
the municipalities. They're all to do plans in terms of-we're
talking about what the response times are-what it would take to
get there, what a municipality would do in terms of getting
there, how many cars it would need, etc and what are the
mechanisms. Once that's completed, we'll have a better sense of
what it takes.
Ms Martel:
Can I ask, what is the nature of the commitment that has been
made to them through this current process? You haven't shut the
door on 100%, but what are they thinking they're doing this for?
In anticipation of receiving what?
Ms Kardos
Burton: They've been very clear about requesting the
capital costs at 100% and 50% ongoing. What they have also said,
which is true, is that the response times have not been met
currently. I think what they're doing this for is certainly
working with us in terms of seeing how Ontario can meet its
response times.
1150
Ms Martel:
This may be an unfair question to ask you, but wouldn't it have
made more sense if we had at least brought everyone up to that
standard and paid for it before we downloaded those costs on to
the municipalities?
Ms Kardos
Burton: There was a desire to look at having the
municipalities have a part in terms of how they meet the plans.
The government could have made some decisions on its own, but the
desire was to have the municipalities involved and ask them to
participate in those plans. It could be a straight mathematical
conclusion in terms of our estimate of $50 million, but I think
there's also a hope that the municipalities would be coming up
with efficiencies and different methods of operating and
innovations in terms of meeting those response time standards as
well.
Ms Martel:
I appreciate-
The Chair:
That's 15 minutes. Mr Gilchrist.
Mr Steve Gilchrist
(Scarborough East): My first question is to Mr Peters.
I've looked through 3.09, which is supposed to be the subject of
what we're talking about here today, and I must admit I can't
find a reference-perhaps you can direct me-to where you dealt
with the issue of standards for base hospitals for the deployment
of critical care paramedics. Am I missing something here?
Mr Erik
Peters: No, we did not deal with that standard.
Mr Gilchrist: Then I guess the
record is wrong. Ms McLeod categorically stated you did that and
had passed judgment on the standards, which seemed to be at the
root of the questioning from both the Liberals and the NDP, and
how the existing standards relate to a penalty clause in an RFP.
There are in fact two RFPs, am I correct? One for fixed-wing and
one for-OK. So we've got to use the plural.
Interjection.
Mr
Gilchrist: It is a 200-page document, and perhaps Ms
Martel's researchers only gleaned certain clauses that were
salacious or what they considered would be salacious. But I'm
looking at schedule A, part I, "Mandatory requirements for the
transfer and non-transfer scenarios." It talks about all sorts of
different standards that are put in there-
The Chair:
Just for the record, Mr Gilchrist, what are you looking at?
Mr
Gilchrist: I'm looking at the RFP.
The Chair:
I see. OK.
Mr
Gilchrist: Forgive me, Chair. It's page 54. The document
reference number at the top of the page is 61-246. I see a very
detailed listing of standards. I think we need to have it put
expressly on the record again: are there existing standards for
the dispatch of aircraft in terms of the involvement of critical
care paramedics?
Mr Bates:
Yes.
Mr
Gilchrist: Will those standards change?
Mr Bates:
No.
Mr
Gilchrist: Are the planes currently operated by private
operators?
Mr Bates:
Yes.
Mr
Gilchrist: Will that be the same format in the
future?
Mr Bates:
Yes.
Mr
Gilchrist: Is the only difference the fact that 36
people who are on the payroll of the Ontario government will no
longer be on the payroll of the Ontario government?
Mr Bates:
I would say "may."
Mr
Gilchrist: Sorry. Following the assumption Ms Martel has
made-I want to be very clear myself-the only privatization that
is being considered is the employment of those 36 people.
Mr Bates:
That's correct.
Mr
Gilchrist: Thank you.
Ms Kardos
Burton: Plus three administrative staff.
Mr
Gilchrist: Plus three administrative staff. Thank you
for clarifying that. In no other way are we changing the
standards by which the air ambulance service is operated, and in
no other way is patient care being altered.
Mr Bates:
That's right.
Mr
Gilchrist: Thank you. I think the histrionics we are
hearing from the other side would certainly have left people,
either watching or listening in this room today, with a very
different impression.
A comment was just made
about uploading-the typical hand grenade thrown in. Correct me if
I'm wrong, but Toronto historically was never paid by the
province for its ambulance service. Is that correct?
Mr Bates:
Not quite. A grant was provided for Toronto over the years, 50%
of approved costs.
Mr
Gilchrist: Did that equal their actual costs?
Mr Bates:
In fact they did spend more money in terms of percentages, and we
provided the 50%. They made decisions on additional service, if
you will, additional vehicles; you've noticed on the road the
buses they utilize.
Mr
Gilchrist: Yes.
Mr Bates:
Those are an example of something they provided in addition.
Mr
Gilchrist: OK. So nothing-no, let me not presume to know
your answer. Is it fair to use the word "uploading" or
"downloading" in Ontario's largest city, or what words would you
use that best reflect the new true relationship in terms of
provincial funding for ambulance service?
Mr Bates:
It's basically a continuation of the method that happened in the
past.
Mr
Gilchrist: Certainly in our largest city, anyone who
suggests there has been a downloading of costs would be
misleading people. Would that be correct?
Mr Bates:
Substantially correct.
Mr
Gilchrist: The other issue I want to raise: I asked the
question as well about the clause Ms Martel keeps referring to,
and I had-perhaps an expanded answer would be the best way to
describe it, from what I've heard here this morning, that if a
particular base were incapable of dispatching a plane or
helicopter with the required paramedics on board, a plane would
be dispatched from another base, but the original operator would
be dinged with a penalty reflective of that amount. So if Nipigon
couldn't dispatch a plane, Thunder Bay might. If, through no
fault of the operator, the only available paramedics were caught
in a snowstorm or called in sick or were injured on the job,
another plane would be dispatched, correct?
Mr Bates:
That's correct.
Mr
Gilchrist: And the original operator would face a
penalty for his or her failure to dispatch a plane.
Mr Bates:
That's correct.
Mr
Gilchrist: Mr Peters, let me ask you point-blank, are
you more or less comfortable with the idea of a penalty clause
built into contracts with people who provide services to the
government for failure to provide?
Mr Peters:
To be fair, I would have to look at the entire contract. The RFP
was issued subsequent to our audit, so we have not had a chance
to look at the whole document.
Mr
Gilchrist: I'm not asking you to pass judgment on this.
As a philosophical question, when the government enters a
contract with someone to provide a service, are you more or less
comfortable with the idea of a penalty clause if they fail to
perform one of the standards they agree to?
Mr Peters:
Normally, yes, we would be more comfortable with a penalty clause
being built in, particularly since, if I correctly remember the reading of
this clause, there is also a discretionary part of this. Am I
correct in assuming that the clause contains a consent by the
ministry?
Ms Martel:
Yes.
Mr Peters:
There is a consent clause, so we really would be satisfied
because both are present: one, a consent-in other words, the
ministry is involved in terms of monitoring-and secondly, if the
performance is not up to the standard the ministry requires, a
penalty could be imposed based on consent by the ministry.
Mr
Gilchrist: Thank you, Mr Peters. I think that clarifies
it. I see a very big difference between a penalty clause and the
suggestion that standards were being changed. I think that's been
clarified, both by you and by the ministry. Recognizing the time,
Mr Chair, those will be all my questions.
The Chair:
There are five minutes left. Is there anybody else in the
caucus?
Mr Garfield Dunlop
(Simcoe North): Just one quick question. Could you tell
me about the inventory you have of air ambulance equipment?
Mr Bates:
Inventory in terms of number of resources?
Mr Dunlop:
The number of helicopters, planes etc that the government and the
private sector operate.
Mr Bates:
All right. There are 11 helicopters now being utilized in
different places across the province. We have a board here that
we would be pleased to share with the committee indicating the
location of every aircraft in the province and how they are
staffed. I hope you can see it.
The Chair:
You'd better hold it up.
Mr Bates:
Here are some illustrations of the helicopters that are utilized
across the province. As you can see, they are painted in the
orange and blue colours, and "Ambulance" is on them. You were
asking about where they are. There are dedicated air ambulances
in Toronto, London, Ottawa, Sudbury and Thunder Bay at this point
in time. There are fixed-wing dedicated in Sioux Lookout and
Timmins, and also in Kenora and Moosonee. I mustn't forget Kenora
and Moosonee from the north. There are also standing-offer
agreements throughout the province, such as Fort Frances,
Kapuskasing, Muskoka and London, as well as Hearst, Island Lake,
Dryden and places like that where we have the opportunity to use
standing-offer agreement aircraft as required, which are staffed
with paramedics as well. So it's a full system throughout the
province, controlled through the base hospital-Sunnybrook and
Women's College Health Sciences Centre-that provides the type of
care necessary for 17,000 patients each year.
Mr
Hastings: Could we get a copy of that data that you have
in disk or pamphlet form?
Mr Bates:
Absolutely.
The Chair:
Before we adjourn, Ms McLeod has a motion.
Mrs
McLeod: I move that the Provincial Auditor be asked to
investigate the value-for-money aspects of the decision by Cancer
Care Ontario to provide after-hours radiation therapy through a
private clinic rather than in-house.
The Chair:
Is there any discussion on that?
Mrs
McLeod: Just very briefly, the reason for asking the
Provincial Auditor to investigate this is that we simply don't
understand the value-for-money aspects of this. If this program
offsets the re-referral program, then there's an obvious saving
in not having to send patients out of their home community to the
United States or to northern Ontario. The question is, if this
after-hours program can offset the cost of the re-referral
program, why would the Cancer Care Ontario agency not have done
that in-house rather than through a private clinic? We're not
questioning that there is cost effectiveness to ending the
re-referral program, if this is a way of doing it, but simply,
what is the cost effectiveness of doing it through a private
clinic rather than doing it in-house with Cancer Care Ontario? I
believe that because Cancer Care Ontario is a provincially funded
agency, it is within the scope of the Provincial Auditor to
conduct that investigation.
The Chair:
Any further comments? Then I'll call the question. All those in
favour? Opposed? The motion is lost.
Is it the intent that the
ministry is to come back this afternoon? Yes? OK. Then we stand
adjourned until 1:30.
The committee recessed
from 1203 to 1334.
The Chair:
I'd like to call the meeting back to order, please. We'll have
another round.
Mr John C. Cleary
(Stormont-Dundas-Charlottenburgh): It was reported that
providing ambulance service in our area has skyrocketed and we're
going to be a few million dollars short this year. I would just
like to have you gentlemen's comments on that issue. It's the
Cornwall area.
Mr Bates:
Yes, Cornwall is the designated delivery agent, as we talked
about the last time. They are working on the-
Mr Cleary:
There was a deal made by the provincial government to give it to
a second-tier municipality.
Mr Bates:
They are developing their budget and will be submitting it to the
ministry. I don't believe as yet they have submitted it. I know
that they have asked for an additional fund to compensate for
some of the difficulties. I think you're mentioning an article in
the paper that came out maybe a week and half or two weeks ago
with respect to paramedic services.
Mr Cleary:
Yes, in the paper and in our office and everything else.
Mr Bates:
Yes. So as we receive the budget, we certainly will give every
consideration to what they're looking for. It hasn't come to us
in the way of indication that they're going to be that much
short, if at all. I may be speaking in advance of the receipt and
a final decision on the budget submission, but I believe it will
be reasonably acceptable to both ministry and municipality.
Mr Cleary:
Have they been told not to expect any additional funds till the
year 2002?
Mr Bates: Not that I'm aware
of. They're going to be getting 50% of the costs, as we've
discussed with respect to the template. If they have a special
circumstance that they wish to submit to us, that consideration
will be given under the template. But I'm sure they haven't been
told not to expect any additional funds.
Mr Cleary:
What I'm told in my office is that other municipalities are
getting extra. Why aren't they in that area? But anyway-
Mr Bates:
Maybe I can expand. I think I know what you're referring to, and
that is the paramedic requirement with respect to changing
on-call paramedics to more full-time paramedics. Other
municipalities around and about, adjoining, have requested that
and have been approved for that as a special circumstance. That
same consideration would be given to Cornwall-
The Chair:
Excuse me for a moment. Could everybody check their cellphones
and turn them off, please. Because there's one going off
somewhere. No longer. Go ahead.
Mr Bates:
Does that answer your question, sir?
Mr Cleary:
Partially, I guess.
Then there's another
municipality on the outside and its first-response criteria
agreement. If the ambulance doesn't land there within what the
provincial guidelines say, they're trying to set up another
service to deal with the patient.
Mr Bates:
There are two different possibilities that you could be referring
to. One could be first response by a first-response team, which
is an accepted practice across the province. The other could be
transportation of non-emergency patients by a non-ambulance
service. I think I need a little clarity, if that's possible.
Mr Cleary:
I'll tell you what they wrote to me.
Mr Bates:
OK.
Mr Cleary:
"Recently, one of the municipalities announced a community
first-response criteria agreement. While I applaud their efforts
in establishing a first-response plan, part of the reason one is
necessary is because the ambulance response time in rural areas
often exceeds provincial guidelines. This team will be dispatched
if the ambulance estimated time on arrival to the scene of a
high-priority medical emergency is over the 20 minutes."
Mr Bates:
OK, that clarifies it. This is a standard that's used across the
province. It has been used for many years, the establishment of
first-response teams primarily in rural areas, as you say, where
the call volume is not sufficient at that particular time for an
ambulance to be domiciled there all the time. So what happens is
the first responders are trained in first aid and medical
response and receive basic, fundamental equipment for the
provision of care until the ambulance arrives. There are probably
in excess of 75 such teams, maybe even 100, in the province at
this particular point in time. It's an accepted practice. It
works well with the local citizens being able to provide the type
of service they need until the ambulance arrives. It certainly
saves lives.
1340
Mr Cleary:
These municipalities are upset because they've not only been
downloaded with ambulance services but they've been downloaded
with many other services too and they just don't have the money.
What they're doing to them in health care right now is
ridiculous. These new hospital plans they're supposed to be
building and everything, the money just isn't there in rural
Ontario. I think it's a disgrace what's happening. In a lot of
the areas the rural residents are going to suffer from what's
happening.
Mr Bates:
What I find is that the first-response teams are a very
economical way of establishing the type of service that's
required in these communities and it's a proven way of doing it.
It involves the local citizens. This is something, of course, for
the municipality to decide upon, if that's the route they'd like
to go, additional first-response teams. If it is, as I say, it's
a proven method at a very low cost. I can't say much more than
that it has been proven to save lives, and I'm sure if you were
to ask a number of communities, primarily in northern Ontario,
that utilize such a service, you would hear accolades from
that.
Mr Cleary:
So I take from you that you're going to pay 50% of
everything?
Mr Bates:
Yes, the template calls for 50% of the approved cost for land
ambulance.
Ms Martel:
I have one other question with respect to the template. It says,
"The Ministry of Health and Long-Term Care will consider special
circumstances, providing the municipality can make a business
case." Can you outline for the committee what those special
circumstances would be, and are they outside of your ongoing
consultations with individual municipalities to bring them up to
1996 standards?
Ms Kardos
Burton: First of all, because they are special, we
haven't scoped the waterfront on what they would be. They would
be any unique circumstances that arise.
The one commitment that we
did make to all of the municipalities, however, was that we
wouldn't do one-offs in terms of giving something to somebody
that we wouldn't give to somebody else. I think what will happen
is that we will be discussing all of the special circumstances
with all of the committee when they come up. They would be
anything unusual that's sort of out of the normal course of
things. That's what we would be expecting.
Ms Martel:
Can you give us an example?
Mr Bates:
I can give you an example from your particular neck of the woods,
Sudbury.
Ms Martel:
A $4-million shortfall. At least that's what they tell me. Go
ahead.
Mr Bates:
I was referring to the fire that you would be well aware of that
took place in the ambulance station and the vehicles that were
lost. That's a special circumstance, I think. It doesn't happen
every day that there's a fire that removes half of the ambulance
fleet and the main ambulance station. So it's something that
would have to be given
consideration by the Ministry of Health for a funding
approach.
Ms Martel:
And their $4-million shortfall, they can deal with you in July on
the operating side, right?
Ms Kardos
Burton: Right.
Ms Martel:
Let me talk to you about redirect consideration and the critical
care bypass, because the auditor noted this in his report. He
said, "The ministry should analyze the impact of redirect and
critical care bypass on ambulance services, including response
times for subsequent patients...." The ministry's response in the
report was, "The ministry addressed the impact upon the Toronto
ambulance service through a 10-point plan" and that components of
it will be extended to other municipalities in the province where
redirect and critical care bypass are extensively used.
My understanding is that
the 10-point plan was announced in December 1999 and proceeded to
be implemented after that. Here's my concern. If you look at the
August 2000 figures for the number of hours that hospitals in the
GTA were on redirect or critical care bypass, it was up 1,101
hours from August 1999. We're up over 1,000 hours from August
1999 to August 2000. The second concern I have is that the
Ontario Hospital Association, in a report which I'm told is
called A Matter of Hospital Resources: An Emergency Care Action
Plan, which was released in September, said that GTA emergency
rooms on redirect or critical care bypass are up 66%, and they
didn't even include the August figure that I just referenced. So
how is it that the ministry is relying on a 10-point plan in the
GTA which, if you use just those two indicators, doesn't appear
to be solving the critical problem we're having in emergency
rooms?
Ms Kardos
Burton: This is Allison Stuart, director of hospital
programs.
Ms Allison
Stuart: Perhaps I can give you a little bit of an update
as to what has happened since the 10-point plan of December 1999.
The 10-point plan included the following. There were flex beds
provided in Toronto and the greater Toronto area. Flex beds meant
that they could be opened for a four-month period during the year
and the hospitals could decide when they needed them the most to
respond to pressures that they were feeling. So there were
additional beds.
We also provided additional
discharge planners. Hospitals would be able to start the
discharge planning process really when a person first arrived at
the hospital so that when they were ready for discharge the plans
were in place.
We also divided Toronto up,
if you will, into three geographic areas and one age-related
area, three networks-the central network, the east network and
the west network-and then a pediatric network. We clustered the
hospitals that were within those boundaries to work with the
ambulance service-in this case the Toronto ambulance service-to
work with all aspects of the system to look at pressures or
issues that they were experiencing and look at problem
resolution. Each of the networks has now produced a document
which outlines their findings, which is being reviewed
collaboratively with the Ontario Hospital Association, the
ministry and obviously the involved networks.
Ms Martel:
Might I ask, does the review take into account that clearly the
measures that you were good enough to outline for us did nothing
to decrease the number of hours that hospitals were on redirect
in the GTA?
Ms Stuart:
I haven't got up to my 10 points yet. I've got some other
points.
Ms Martel:
What I'd like to know is, if all those things that you're
probably going to outline to me were working, how is it that even
in January and February of this year we've got hospitals in the
GTA that continue to be 80%, 90% on redirect? As of January 10,
we had 23 hospitals serving the GTA; 21 were telling people to go
somewhere else, 14 were on critical care and another seven were
on emergency redirect. That's 90%. On January 29, you had 23
hospitals; 87% were telling patients to go somewhere else, 13
hospitals were on critical care and another seven on emergency
redirect. On February 13, 86% were on critical care redirect; on
February 12-and we've got the listing of hospitals that were
doing redirect and critical care bypass, and a most recent one
just this Tuesday at 83% of GTA hospitals; at 12:30 am this
morning, 19% of the 23 hospitals were redirecting patients, 12
were on critical care and another seven were on emergency
redirect.
I've given you some
examples in August, when I would have hoped part of the 10-point
plan would have resulted in a reduction, and then I've given you
as recent as I can, and we still have a serious problem. I'm
wondering why all of the initiatives aren't working.
Ms Stuart:
If I may, I'd like to go through the initiatives, because after
we did the 10-point plan we had another strategy that built on
that. So that people all understand what was being built upon, I
think I need to go through the other points of the 10-point plan,
but I will come to your question.
Ms Martel:
Are you going to get to my point before I lose my space?
1350
Ms Stuart:
Absolutely. So the additional initiatives-we provided each of the
networks with a coordinator so they could help that network come
up with a resolution to issues. We also appointed a provincial
emergency services coordinator to coordinate issues across the
province and bring those forward. We also added to the interim
long-term-care bed complement for Toronto so that people who were
in hospital and waiting for long-term-care placements would have
a place to go and those beds could be used for acute care.
For the ambulance service
itself, we provided them with additional assistance on a pilot
project basis so they could test whether it made a difference
having dedicated ambulances to do critical care transports
between facilities so as not to tie up doctors and nurses, having
highly skilled paramedics doing that transfer, as well as having
additional support in the ambulance dispatch centre to negotiate with hospitals
around what level of service they were able to provide.
Those initiatives were
successful, and we decided to build on those. In July and August
of last summer, the then Minister of Health and Long-Term Care
announced further initiatives: additional beds in Toronto,
additional beds in the GTA, and additional beds-those flex beds I
talked about that were available for a four-month period-across
the province. So we had additional beds in place; we had
additional discharge planners put in place so the discharge
planners we talked about for Toronto/GTA were then available
across the province; we provided the coordinators; and we of
course had the flu vaccine available to all people.
One of the other things we
undertook to do at that time, and this was in response to
comments and feedback from service providers, was a review of the
RDC-redirect consideration-and critical care bypass model, and
whether it was really serving the purpose for which it was
intended. We struck a group of people from the field, including
emergency physicians, emergency nurses and CEOs, to review the
use of RDC and CCB and whether there was something better to
replace it. The issue around RDC and CCB, and I think you've
demonstrated this, is that it was a tool that was developed in
1989 to deal with extraordinary events, events where a hospital
has an internal type of disaster, should it be a fire or a bomb
scare or whatever it might be, and it was used very infrequently.
It was a way of formalizing the need to let other people know the
status of the hospital. As time went on, the use of it increased.
It stopped being as useful a tool, because it was meant to be a
means of quick communication between the ambulance dispatcher and
the hospital emergency department. As it became-
Ms Martel:
Can I interrupt you for just a second?
Ms Stuart:
Yes.
Ms Martel:
I appreciate all of that, but here's the reality. The ministry's
response to the auditor's concern with the 10-point plan-we are a
year later, after the 10-point plan being introduced, and this
week we had another 83% of GTA hospitals sending patients
somewhere else. I regret to say that I cannot see how the
10-point plan has solved the problem.
The second point I want to
make: you mentioned that the minister had announced more beds. Is
it not true that even with the minister's announcement, which was
about 575 beds, we will have a decrease of 498 beds across the
GTA from what we had in 1995? Even with her announcement of more
beds, because of the beds that have been cut under this
government, we will have 498 fewer beds. So we have two problems:
we have a 10-point plan that is not working, because if it was,
we wouldn't see the kind of redirect that we continue to see even
as recently as yesterday, and we wouldn't be in a position where
we actually have fewer beds, which I think is the biggest part of
the problem with respect to emergency rooms right now-that we
just don't have the acute care beds.
Ms Stuart:
In terms of the 10-point plan and then the follow-up emergency
services strategy, and part of that strategy being a review of
RDC and CCB, the difficulty with RDC and CCB is that it is only
useful at that nanosecond in time when somebody has registered
the activity at that point. It's not useful 10 minutes later or
10 minutes earlier when there may have been other changes in the
emergency department. So it gives a false sense to those other
than the dispatcher and the emergency department of really what
it means. Emergency departments are always open. Ambulances
always have a destination, and this was reaffirmed by a standard
that was set that allows ambulances to override the hospital's
position in terms of how accessible they can be at that point in
time if the needs of the patients warrant that.
We have acknowledged that
there are changes necessary to that system, and in fact the
working group that I mentioned earlier, the redirect
consideration/critical care bypass working group, studied this
problem and made a recommendation which is now going through a
consultation period with the field. The results so far are very
positive in terms of a new way of talking between the ambulance
service, the dispatch centres specifically, and the emergency
department, which will allow for, I think, a more accurate
picture of what's going on in emergency departments.
Ms Martel:
So what you're saying to us is that what it's going to allow for
is paramedics perhaps to bring those people in when they might
not have otherwise because of the-I don't want to use the word
"terminology," but maybe that's the best way, that people use to
communicate what the situation is in the ER.
Ms Stuart:
With the redirect consideration/critical care bypass definition,
it was sort of like turning a switch. It was either on or off.
First, in the new system what we're looking at is that every
patient who is critically ill will be brought to the closest
appropriate facility, full stop. For those people who are less
ill, there is room for some negotiation, and if a hospital is
feeling that because of the particular load they're experiencing
at that point in time, meaning that they may not have enough
nurses left over to care for any additional patients at that
point or they don't have the equipment, there is an ability with
this system to alert the dispatch and to start a dialogue there.
They may not be able to take somebody with an undiagnosed chest
pain because they don't have a monitor, but they could take
somebody with an acute belly, something going on abdominally. So
there's the ability to do that, which is much more flexible than
the previous system.
Ms Martel:
You've implemented that, right?
Ms Stuart:
We have not implemented that.
Ms Martel:
When do you expect to implement that?
Ms Stuart:
The consultation process will be finished at the end of this
week, and then the working group will be reviewing the findings
from the consultations and we'll be submitting a final
report.
Ms Martel:
I wonder if this was the same proposal that was referenced in the
Toronto Star on February 8, and I'm quoting: "Health
professionals are praising a draft plan to replace the current
system of redirecting ambulances from busy hospitals, but they warn
it won't solve the problem of overcrowded emergency rooms." Then
they reference a Dr Tim Rutledge, director of emergency services
at North York, who says "`The problem is not an emergency room
problem. The problem is not an ambulance problem. The problem is
a backlogged system.... We don't have enough long-term care beds,
we don't have enough home care, we don't have enough acute care
beds,' adding that a critical shortage of nurses means beds
cannot open."
Is this the same system
that you're talking about? There was certainly wide concern
expressed that, even if you do that, it's not solving what is at
the root of the problem.
1400
Ms Stuart:
I think those comments were made before the consultation process
even really started, before they'd had a formal presentation and
an opportunity to ask questions and get them answered. There is
an acknowledgement that the patient priority system to replace
the RDC/CCB system is not going to somehow make the pressures
that emergency departments feel go away, because there are other
parts of the system in development. We have long-term care beds
that are coming up to speed. While we're waiting for those, there
are people in hospital who would be better served in a long-term
care setting, but they're having to stay in hospital for the
moment. But those beds are under development.
The pressures that are felt
inside a hospital can manifest themselves, certainly, in the
emergency department. Some of those are under the hospital's
control and others of them are more problematic in terms of
nursing numbers, etc.
Ms Martel:
Would it be possible for you to table with this committee the
number of hospital beds in Toronto? The figures I have are from a
Ministry of Health document-but if you want to table something
else, that would be great-which shows that the total number of
beds in 1995-96 has been 11,878, and that even with the
minister's announcement of 575, because there has been a
decrease, we are going to be short 498 from what we had in 1995.
It would be helpful if you could confirm for this committee
whether or not that is the case.
My other question to you is
this-
Ms Stuart:
Could I just respond to that one?
Ms Martel:
Sure.
Ms Stuart:
Certainly, we'll provide the information that we have. But the
other thing that has to be factored into this is that health care
has changed so dramatically; that in fact things that we were in
hospital for maybe even weeks-I go back a long way and I used to
be a nurse. When patients had cataract surgery, they were in bed
with the lights off and sandbags around their heads, lying flat
for seven days. Now it's done as an outpatient procedure.
So the bed number is not
magical. It's not as if we must stick with a bed number as being
the only measure of whether a system can serve the citizens of
the community, because it's not just about beds. There have been
multiple changes.
Ms Martel:
I understand that, but I guess the proof will be in whether or
not the new system that you're going out for consultations on
results in less redirect and less critical care bypass. We
know-
Ms Stuart:
There won't be any such thing as redirect or critical care
bypass.
Ms Martel:
But then your numbers would essentially stay the same, right, in
terms of people jamming up emergency rooms?
Ms Stuart:
When you say "jamming up" emergency rooms, in fact if you talk to
the clinicians who work in emergency departments, people who
require critical care are getting that critical care and getting
it in a timely fashion. People who are using the emergency
department, for all sorts of reasons, instead of other primary
care settings may have to wait. If you talk to the nurses and the
doctors, they see that as being OK, because the impact has to be
on getting the services to the most critically ill first.
Ms Martel:
But if I might, I even looked at the number of hours. If you go
back five years and look at the number of hours that hospitals in
the GTA were on redirect or critical care bypass, there has been
an enormous increase. August 1995, 794 hours; August 2000, 4,861.
That's just in August. If you do the comparable total year
figures, in 1995, 12,726 hours where hospitals in the GTA were on
redirect or critical care bypass; in 1999, 47,694. Something's
happening there that I just can't think is very positive for
patients, doctors or nurses in emergency rooms or people in the
back of an ambulance.
Ms Stuart:
No, and that's why the Ministry of Health and Long-Term Care,
even though you didn't really want to hear about it, did the
10-point plan and did the emergency strategy, because these are
ways of assisting, because it did add more resources to the
system.
Ms Martel:
I guess the difference we have is, yes, you did do that a year
ago, and if you just look in the GTA-
Ms Stuart:
No, we did it six months ago.
Ms Martel:
OK. But that's one small portion. The change that you might make,
which you've already said to me won't make a change in redirect
or critical care bypass-the balance of the 10-point plan has been
in place a year, and the most recent statistics about redirect
and critical care bypass show we're still operating at around 86%
of hospitals in the GTA redirecting or using critical care
bypass. That's a year after the 10-point plan was in place. I
fail to see how the 10-point plan is addressing this problem.
Even eight months after it was implemented, the August figures
for redirect and critical care bypass were up over 1,000 hours
from August 1999. And that's not the flu season, so we can't even
blame it on that. We can't say it's more people coming to
emergency wards or walking in, because the evidence at the
Fleuelling inquest showed that from 1994 to 2000 there has been a
flat line of people or ambulances coming in. So we can't say it's
more people using the emergency rooms; that's not true.
So what is the problem, and
why can't we seem to fix it?
Ms Stuart: I think we are
fixing it, frankly. I mentioned earlier that one of the issues
is, if you have people in your in-patient beds in a hospital who
would be more appropriately cared for in other settings, that's a
way of freeing up those beds for acutely ill people. We know that
by the end of this year, by December, there will be an additional
4,500 new long-term-care beds, and that's going to have an
impact. But, no question, there is a time lag between some of
these decisions in terms of, for example, new long-term-care beds
or reconfiguring a hospital and expanding the emergency
department, expanding the in-patient units or whatever. There is
a time lag because it takes time to build, and that's some of
what we're seeing now. But we're starting to see some of the
results. We do have new emergency departments. We do have
long-term-care beds that are coming on stream.
Ms Martel:
With respect to the emergency departments, can I ask, in terms of
the Health Services Restructuring Commission process, do we have
more or fewer emergency rooms in the GTA now than before the
commission?
Ms Stuart:
That's a good question. We have and we will have fewer emergency
departments. However, emergency departments that are being
rebuilt are being built to accommodate the volume of patients
that were seen by another emergency department that's closed. For
example, North York General Hospital's emergency department has
been expanded, and that accommodates the closure of the Branson
emergency department. We also have sites that are converting, not
into emergency departments but into ambulatory care settings
where they're able to provide a lot of the primary care services
people are coming to emergency departments for.
Ms Martel:
Is the problem that we closed some of these emergency departments
before the new ones were up and running, so we have less in an
interim period to handle the load?
Ms Stuart:
We didn't close any emergency departments before the new
emergency departments were open. The emergency department at
North York General was expanded and opened, and Branson closed.
The emergency department at Wellesley was open; we expanded St
Mike's emergency so they could accommodate the greater volumes
and close the other.
Ms Martel:
When you do this comparison of St Mike's and Wellesley, when you
reopened at St Mike's, did you have more capacity than had been
at Wellesley and St Mike's combined?
Ms Stuart:
We had more capacity, more stretcher spaces at St Mike's than had
been at St Mike's and Wellesley.
Ms Martel:
What about staffing? I'm not sure what you mean by "stretcher
space."
Ms Stuart:
By stretcher space I just mean stretcher bays. I can't tell you
about the staffing, because I just don't get-
Ms Martel:
Let me back up. When you opened at St Mike's, you had more-I'm
going to say-rooms to put emergency patients in than previously
when both St Mike's and Wellesley were open?
Ms Stuart:
Yes.
Ms Martel:
Is that the same with Branson and-sorry, I forget the other
reference.
Ms Stuart:
North York General. I'm going to say yes. I can't remember the
details, but I'm pretty confident the answer is yes.
Ms Martel:
OK. Do you think hospital restructuring has had any impact on
what's going on in emergency rooms in the GTA?
Ms Stuart:
Absolutely. As the hospitals are redeveloped, there's a period of
time when the public is confused. They're not sure where their
alliances are. We can plan all we want, but people decide for
themselves where they're going to receive care. So when a
hospital or an emergency department or a service that they have
been used to at one organization isn't going to be provided any
longer, the individual makes some decisions: "Do I go where my
doctor's going? Do I go someplace that's closer to where I now
live?"-those sorts of things. So there are those decisions being
made.
1410
Also, within a hospital,
when you're making the kinds of changes that have been made
across the province, the hospital goes through a period of
change, as well as developing new services and taking on new
services or maybe divesting services.
The Chair:
Thank you very much for your attendance here today and in
December. We look forward to getting the various pieces of
information that you said you'd provide for us. This portion of
the hearing is adjourned.
AUDIT ACT AMENDMENTS
The Chair:
We do have one other matter, and that deals with the proposed
amendments to the Audit Act. This item is on the agenda at the
request of the auditor, although I fully support him in his
request. I'll give the floor to Mr Peters at this point in time,
and we'll see how we deal with this.
Mr Peters:
It's also on the agenda because the question was raised by the
vice-chair of the committee in the presentation of my report,
that this is an area that should be addressed.
The main purpose of my
presentation today is to ask this committee to support amendments
to the Audit Act aimed at permitting my office access to all
records of certain transfer payments or grant recipients that we
need to perform our duties under the Audit Act.
Currently, we can conduct
inspection audits of grant recipients, which by legislative
definition limits our access to accounting records only. In other
words, we can go into a school board and look at their accounting
records, but we cannot look at any other records that we require
if we want to do a value-for-money audit.
I would like to provide you
with the background and the underlying principles that describe
the primary intent and the advantages of amendments to the Audit
Act. These amendments
are necessary so that the Legislative Assembly, through its
officer-me, the Provincial Auditor-can be provided with
discretionary assessments if transfer payments and grants
amounting to more than one half of the government's annual
spending are spent by the recipient organizations effectively for
the intended purpose and with due regard for economy and
efficiency.
I deliberately mentioned
certain grant recipients because, out of the $44 billion that we
spent in fiscal 1999-2000 in transfer payments, it is my view
that only certain grant recipients should be subject to
value-for-money audits by my office.
There's a brief handout; I
just wanted to highlight that for you. These numbers are coming
directly from the public accounts of the province. You see at the
bottom that they total about $44 billion, and $30.5 billion is
spent through these organizations. The large ones, you can see,
are hospitals, long-term care facilities, child welfare
organizations and child care organizations. School boards
certainly are very large, with $7.7 billion; universities, $1.6
billion; grants to colleges and capital grants to post-secondary
institutions.
I deliberately mentioned
that only certain of these recipients should be subject to audit,
so let me refer to those as the schedule A grant recipients which
receive, as was said, $30 billion, and the schedule B, $14
billion in the fiscal year 2000.
Simply put, schedule A
recipients meet the following two criteria: (1) they must be
eligible to receive a grant, and (2) the government grants the
funds with strings attached. Such strings may entail direct
compliance with relevant legislation, spending the funds
cost-effectively and only for specified government program
purposes. The recipients of schedule A grants-I outlined to you
the larger one when I went through the schedule.
Most of these grant
recipients operate within different but, in most cases, quite
inadequate accountability frameworks with the fund-granting
ministries. This is a very important matter. I note that the
legislation for the management of accountability to the
government of transfer payment recipient organizations, the
Public Sector Accountability Act, which was promised in 1997, has
not yet been drafted. I have no indication where that legislation
stands in the government's priorities, nor should the proposed
amendments to the Audit Act be dependent on introduction of this
Public Sector Accountability Act, because I just don't know when
this is going to happen. I propose that schedule A grant
recipients be subject to full-scope compliance and
value-for-money audits by my office.
Schedule B recipients also
receive grants based on eligibility, but unlike schedule A
recipients, they are not subject to stipulation about how their
grants should be spent and there are no strings attached.
The principal schedule B
grant recipients are general welfare or family benefit allowance
recipients, medical practitioners who receive OHIP payments and
pharmacists who are paid under the drug benefit program. So
schedule B grant recipients need not, and indeed should not, be
subject to audit by my office. In other words, how a welfare
recipient spends his or her money is none of my business. In
fact, it's none of the Legislature's business either.
That all transfer payment
recipients should be subject to value-for-money audits by the
Office of the Provincial Auditor to enhance accountability has
been clearly supported over the last 10 years. It has been
supported by all three parties in the Legislative Assembly. It
has been supported by two private member's bills, of which one
died on the order paper and the other has just received first
reading. It was supported by the standing committee on public
accounts in 1989-90 and again in 1996. In both cases the support
was based on public hearings. And it has been supported by the
Minister of Finance in principle in a letter he wrote to this
committee in 1996. Yet in spite of all the support, including the
motions of this committee, no action has been taken to amend the
Audit Act.
Among the documents
provided to you by the researcher was a letter from the minister
to me dated November 21, 2000. I would like to read to you
salient extracts from a letter I wrote in response to the
Minister of Finance on January 25 this year. In this, I referred
to the fact that:
"...on December 20, 2000,
Bill 180, the Audit Amendment Act, 2000, sponsored by Mr. John
Gerretsen, received first reading. The stated purpose of the
bill, as worded in its title, is: to ensure greater
accountability of hospitals, universities and colleges,
municipalities and other organizations which receive grants or
other transfer payments from the government or agencies of the
Crown.
"As such, the proposed
amendments address the same core issues which you," the minister,
"referred to in your letter of September 26 ... to the standing
committee on public accounts.... Similar to Mr Gerretsen's bill,
my earlier proposed amendments are designed to enhance the
ability of the Legislature to hold certain organizations
receiving government grants accountable for the prudent use of
taxpayer funds by allowing my office to access the necessary
information to conduct discretionary value-for-money audits of
these organizations.
"As far back as 1990," as I
said before, "the standing committee on public accounts has
expressed its desire for the Provincial Auditor to have the
legislated discretionary authority to carry out value-for-money
audits of organizations receiving government grants. In 1992, Mr.
Mike Harris stated in the publication A Blueprint for Learning in
Ontario, that `as recommended by the standing committee on public
accounts, the Provincial Auditor should be allowed to perform
value-for-money audits of ALL'"-and that's his emphasis; he put
it in block letters-"`agencies and recipients of government
funds.'"
"In 1996," as I said
before, "the standing committee on public accounts unanimously
endorsed my proposed amendments."
1420
I'm concerned-I'd say a few
other things; I was told we had to wait for the Who Does What
restructuring in the
letter in 1996. But that was relatively unimportant to this
process, largely because municipalities receive very little in
terms of transfer payments, so Who Does What was not directly
related to that. It may have been related to the fact that
certain other programs may have been shared between the
municipalities. In any event, that was the reason given in 1996
as to why the minister at that time agreed in principle with the
amendments but did not wish to proceed at that stage.
"I am concerned about the
apparent further delays since over a decade has passed since this
issue was first raised, and the amendments are still `under
consideration.' Over the last decade the proposed amendments have
been endorsed by all three political parties and by the all-party
standing committee on public accounts."
The minister also says in
his letter that he would like further consultation with the
stakeholders. Quite frankly, their views were made known to the
standing committee on public accounts in 1996 and again way back
in 1989, and in both cases the committee formed its conclusion
based on their presentations as well.
"All valid concerns
expressed by stakeholders at that time were taken into account in
drafting our proposed amendments that the committee submitted to
you in 1996."
The minister also made
reference to the Ontario Financial Review Commission's
recommendations. I said to that, in my letter to him:
"As well, you have asked
for any additional information on how amendments to the Audit Act
would complement the Ontario Financial Review Commission's
recommendations. I believe that there is an important role for my
office to play in improving public sector accountability which is
one of the key focus areas of the commission's work.
"Amending the Audit Act as
proposed would put my office in line with the legislative audit
offices of six other provinces in Canada whose legislation
permits the initiation of discretionary full-scope
value-for-money audits of transfer payment recipient
organizations. Such audits are designed to independently validate
performance information and to provide recommendations to improve
performance and thereby add value to the public sector
accountability relationships." That is what the Ontario Financial
Review Commission was also asked to examine: how to improve
accountability relationships. "As with other Canadian legislative
audit offices, my office is uniquely positioned and suited to
provide independent assessments and advice on performance and
accountability relationships to both the government and to the
Legislature."
I said to the minister:
"Your support for the
intent of the proposed amendments was indicated in your 1996
letter in which you stated that you agreed with the principles
upon which the draft bill to amend the Audit Act was based.
Accordingly, and with this letter, I respectfully request a
response as to whether you are willing to support amendments to
the Audit Act to conduct discretionary full-scope value-for-money
audits of transfer payment organizations.
"In connection with the
drafting of any amendments to the Audit Act, I would be pleased
to receive advice from ... the Ministry of Finance and of the
Management Board Secretariat on the proposed wording of the
amendments. However, the final drafting of the bill should be the
responsibility of my office and legislative counsel, in a direct
working relationship with the sponsor of the proposed amendments
of the Audit Act."
These are the key points I
made to the minister.
I would now like to apprise
you of the funding and staffing history of my office over the
last 10 years. For this purpose, I have prepared for you three
charts showing the funding and staffing history of my office
relative to all legislative audit offices in Canada in relation
to Ontario's revenues and expenditures, and I have a handout
which has been prepared.
If I may, I'll make one
introductory comment. I'm presenting this to you not to pre-empt
my request for estimates, which, as you know, is dealt with by
the Board of Internal Economy; I'm presenting this to you because
under section 29 of my act also the chair and vice-chair of this
committee are invited to attend the review of my estimates with
the board at that time, and I thought it would be worthwhile in
this connection for the committee to have an appraisal of the
situation, where we stand.
The first chart shows the
comparison of audit office costs per thousand dollars of
government revenue and expenditures-in other words, which we
audit-our budget in relation to that. You will see on the
right-hand side of the chart that Ontario spends six cents per
thousand dollars on my office. Quebec, being the nearest, spends
two and a half times more in relation to their revenues and
expenditures. I take Prince Edward Island out of the equation
largely because it is a relatively small government and therefore
basically having an office provides a large percentage. But if
you go to Alberta, which has been used very often as a benchmark,
we are looking at an office that is funded at over five times the
rate of mine, in relation. So these are the dollars.
If we translate this into
the audit office staff members and the expectation of audit, how
much we expect each staff member to audit, you will see that
Ontario clearly is funded on such a basis that I would expect one
of my staff members to audit over $1.4 billion of government
expenditures a year. The nearest is the federal government, on
this chart, which expects $620 million, and it goes down all the
way to Alberta at $317 million, or roughly one fifth, and
Newfoundland at one seventh, PEI again being an exception.
You can see that my office
in relation to the other offices in Canada is significantly
lower-funded. In fact, I am of quite a bit of concern to my
colleagues across the way, because they are starting to question
how we can be effective.
The last chart I thought
I'd show you is from 1991, on the history of my staffing
complement in relation to government revenues and expenditures. As you
can see from the chart, ultimately, by the year 2000, government
revenues and expenditures since 1991 have increased by about 38%
and the complement of my office has decreased by 25%. I thought I
would just apprise you of this situation.
There were two fundamental
reasons why I did this. Reason one is to illustrate to you that
my office's resource situation is worsening. Regardless of
whether the Audit Act is amended or not, my office requires
better funding to serve the Legislature. Bluntly speaking,
currently we do not have the resources to conduct audit
examinations with the frequency dictated by risk assessments.
Also, when you as a committee, for example, give me special
assignments such as the Bruce deal, I will have to go to the
Board of Internal Economy for extra funds. I estimate right now
that, as a minimum, we will look at $90,000 to $100,000 alone in
money to hire special assistants to deal with that situation.
1430
Also, one other feature
which concerns me is that we cannot afford the legal and
specialist staff which other legislative audit offices can
afford. To give you one example, the federal Auditor General
actually has a number of lawyers and economists, statisticians,
on staff. I can't afford that. I have no legal staff, I have no
economists, I have no statisticians. In fact, I should tell you
that way back when I was an Assistant Auditor General of Canada,
21 years ago, I ran one audit, for example, with 35 staff
members. I don't have anything like that. Here, the maximum we
have on any audit is about five staff members, and at that time I
had five accountants and 30 specialists. They ranged all the way
from fleet management specialists, because we were doing the
Department of Supply and Services, to mathematicians and what
have you. So that was one reason.
The second reason is simply
to ask this committee for its support to allow my office to serve
the Legislature better on two fronts: firstly by amending the
Audit Act so we can conduct discretionary value-for-money audits
of certain grant recipients-that has been supported all along-and
to ask you to support my request to strengthen the resource base
of my office.
With that, I open it up for
questions.
The Chair:
Questions and comments?
Mr
Sampson: Are there particular amendments that you have
proposed to be considered by the committee?
Mr Peters:
Yes, we have, actually. In the 1996 meeting, we provided the
whole proposal, with each paragraph outlined with what the change
would entail. The principal thrust of these issues, of course, is
in the area of being able to audit transfer payment recipients,
but there are also administrative changes.
Mr
Sampson: We don't have those before us.
Mr Peters:
No. I'm quite prepared to provide you with a copy, but I didn't
know whether you wanted to go that far at this meeting.
Mr
Sampson: Let's just talk in generalities. It might be a
bit helpful. Most of these organizations where you would propose
having the value-for-money audit function currently have the
requirement to have auditors in one way or another report to the
shareholders or to the organizational executive on a reasonably
regular basis. Are you proposing to do an audit in addition to
them, in conjunction with them, in lieu of them? How do you see
that role shaping up?
Mr Peters:
We have given quite a bit of thought to that. The statutory audit
that most of these organizations are subjected to-let's be
concrete about it: for example, hospitals or universities-have
private sector CA firms provide audits of their financial
statements. The act as it is currently written allows me only to
redo their work, which of course is a total waste of money. I
quite frankly don't presume that I can do a different-
Mr
Sampson: They're making sure all the credits and debits
are in the right place, if I've got my auditing language correct
from my 10 minutes of MBA.
Mr Peters:
Indeed, you have it correct. But what they don't do is
value-for-money audits.
Mr
Sampson: Is that because they aren't directed to do
those audits in the first instance?
Mr Peters:
For two reasons. The first one is that it costs quite a bit of
money. Value-for-money audits are not an inexpensive kind of
audit; there's no doubt about that. The second one is that
normally the boards themselves are not, as a routine, that
interested in that. The purpose of value-for-money audits, why it
is a unique feature of auditors of the Legislature, is really to
give you, the Legislature, a sense of whether value for money is
achieved, or some assurance whether value for money is achieved
in ministry operations and in other operations. As I said, in
other provinces the legislative auditor has been given the
mandate to do this for these transfer payment recipients as well.
So it would be to report, essentially, to this forum on the
value-for-money audit.
Mr
Sampson: Just to continue with that illustration-and I
don't mean to pick on the hospital sector-you say that the
interest of the boards might not necessarily be a value-for-audit
interest. That may well be the case. I would say, as we go
forward, that we would certainly encourage them to be a little
more focused on the value-for-audit results, especially as they
relate to levels of service for the amount of money we're
spending, or that they're spending on our behalf. So I'm just
trying to understand. Let's assume they become more focused on
quality and value of service in addition to their fiduciary
obligations to make sure the debits and credits are in the right
place and everything adds up. Let's assume they become far more
focused on making sure the dollar is properly spent and not just
spent. Would you see them instructing their corporate, private
auditors to do that role, or do you see your doing that role? I'm
still struggling with-let's say Price Waterhouse is auditing XYZ
hospital, and the board says, "We want you to audit and tell us
whether we're getting good value for the money we're spending as
it relates to service." In your view, is that something they
could do, should do, can do? And what would your involvement be in that type
of assignment?
Mr Peters:
If it were done right now, I couldn't have any assignment. I
couldn't participate, largely because, first, historically, when
one of my predecessors decided to audit universities, the
universities immediately hired lawyers-
Mr
Sampson: Yes, they were somewhat upset with that.
Mr Peters:
They were very upset at that time. They hired lawyers.
Interjection: Hospitals were
upset.
Mr Peters:
Yes, hospitals were upset about it as well. And there's another
issue-
Mr
Sampson: See what lawyers do? They get you into
trouble.
The Chair:
If there are any lawyers there, that's probably why he gets work
done.
Mr Peters:
Or they kept him out of trouble.
The lawyers were
essentially asked, "What is an accounting record?" That's what an
inspection audit is defined as in ours. What they virtually came
up with was that it was the books of account and that sort of
thing. But, for example, they specifically opined that as a
result I would not have access to the reports of other auditors.
I would not have access to even the management letters that were
written to a particular organization as a result of a financial
statement audit. They were not deemed to be accounting records;
therefore, I couldn't look at them.
If the right of access to
information that would be granted under this act would indeed
spawn value-for-money audits initiated by boards of directors, I
would welcome it and I would work with it.
Mr
Sampson: I think we're all driving in the same
direction-believe it or not-that we would like to make sure the
dollars being spent, by whomever in government on behalf of the
taxpayers, are spent wisely and fairly and effectively and
efficiently-all these lovely words. I guess where I have a bit of
a problem is that I wouldn't want boards of directors who are
given that responsibility by government to somehow feel they've
been discharged from that responsibility by saying, "The auditor
will do the audit, so we really don't have to make sure our
auditor looks at it." I'm a bit worried about the usual finger
pointing that can go on as a result of that. I would be a lot
more comfortable with saying to those who manage these little
businesses-don't go ballistic on me, Shelley-with a
value-for-audit type of function right in their obligation and
that you have some ability to look at that.
Mr Peters:
You're making an extremely valid point, and one that really
worries me in this whole exercise. Actually, let me answer in two
ways. First, if, say, the Toronto General were to hire
PricewaterhouseCoopers to do an audit, the reporting
responsibility of PricewaterhouseCoopers would be to the board.
The ministry and, even less, you as legislators would not find
out the state of affairs in that, in regard to value for money,
because the report would be addressed to the board of directors.
That points out the other problem that was identified in
proposing the Public Sector Accountability Act of 1997, that
actually there was no proper, legislated accountability framework
in place for the management of these transfer payment
organizations.
1440
To give you a very extreme
example that I ran into in the beginning, and I think it still
exists, universities is one example. When we talked to the
Ministry of Colleges and Universities, which was at that time in
existence, then stopped and is now in existence again-and the
working relationship is very much improving currently on that
particular front, and I'm pleased to note that. But when the
ministry asked universities for financial statements, the
universities could say, "Go away. We won't give them to you,"
because there was no legislation in place. There was no
requirement at all for the ministry to receive this
information.
Mr
Sampson: We're talking more than just financial
statements, aren't we? The financial statement would just tell me
the money was spent, as opposed to answering the question we're
asking: was it spent wisely? That's the question, is it not? What
I'm saying is, wouldn't it be nice to say to the universities,
"That's part of your obligation"; that in addition to telling me
the money was spent, and it's not sitting in some other bank
account in some other country in somebody else's name, it was
spent properly. That, to me, should be the responsibility, if you
will-it might be the wrong word, but I'll just use it anyhow-of
the person who is in charge of the organization. How your office
responds to those reports and that responsibility I think
probably needs to be discussed. I'm not fully convinced it means
you need to go in and do that value-for-money audit on all these
organizations. It may well mean you need to review those. I don't
know. That's why I asked the question about the amendments. I
would like to see the amendments, to see what exactly it's
asking-
Mr Peters:
I can provide them to you, but the amendments just
straightforwardly say remove the limitations that access
information that I can only look at if I'm-
Mr
Sampson: Is it just access to the information or is it
the ability to do the audit?
Mr Peters:
No, no. The ability to do the audits I have. I have that under my
act.
Mr
Sampson: They just won't let you have the
information.
Mr Peters:
I just don't have the information to do it with.
Mr
Sampson: A slight problem, right?
Mr Peters:
There's a problem in the act, that I cannot have the information
I need to do the audit. I would do it discretionary. I would also
hope very much that this would become simply a catalyst for
action. In other words, I will not usurp the responsibility of
management to manage for value for money-that remains their
responsibility, regardless-but simply the fact that on behalf of
the Legislature I can look at an organization that, say, receives
hundreds of millions of dollars of taxpayers' money and know that they are spending
it actually for the purpose intended.
Mr
Sampson: What would be the reach of this access to
information? Would you see this going to the municipal
sector?
Mr Peters:
No. Quite frankly, I don't, because the municipalities are
separate. Also, currently the way municipalities are funded by
this government, we have gone out of the transfer payment grant
business essentially. So there are no longer strings attached.
Even before that, when we started the debate in 1996, the grants
to municipalities were really unconditional. There's no point in
me looking at how they spend unconditionally granted money,
because the taxpayer has given this to the municipalities and has
attached no conditions.
Mr
Sampson: With the exception that now a lot of the grants
are conditional on certain programs and certain events.
The Chair:
They're starting up again.
Mr
Sampson: There's a certain city in which we're sitting
now that's looking for an unconditional grant. The chances of
that going without any strings are pretty remote, I would have
thought.
Mr Peters:
The minute there are strings attached, the first line of action
is really for the government to empower the ministry that
provides the grant to have some sort of monitoring or supervisory
function to ensure that the money is properly spent. That is
number one. But the audit is just the assurance that it is
happening. To give you an example, let me just illustrate one
particular situation that we ran into in the university sector.
The universities were funded at that particular time on the basis
that they got so many dollars per every student enrolled in the
liberal arts program, so many for MBAs, so many for science
programs etc throughout. The forms arrived at the ministry. The
ministry added them up and said, "Yes, here's the cheque." But
the ability of the Legislature to actually assure themselves,
even as a minimum, that this information had been properly
reflected was not there.
The Chair:
Or that the money was spent for the programs it was supposed to
be spent for.
Mr Peters:
Or was spent for the programs that it was supposed to be spent
for. This is one of the other things that is currently happening,
and which I quite frankly endorse by the government, that our
grants are far more directed now; we are seeing for a specific
purpose. We have long debates, for example, on university
funding, as to whether-you know, the universities are very
conscious of academic freedom and all that sort of stuff. The
ministry is far more aimed in saying, "Yes, we'll give you the
money right now, but you have to create spaces to meet the boom,
echo and the double cohort" and that sort of thing. We would
then, through this, have the ability, if we wanted to-under this
fully discretionary basis. I assure you that out of the 181
hospitals, I don't have the resources. If I can look at one a
year, I'd be really doing well, at least with the current
resource level.
Mr
Sampson: My point is, it seems to me we need to put the
value-for-money responsibility in the right place first, those to
whom we write the cheques, before we unleash somebody to go in to
be able to audit that, because otherwise you'll have the
responsibility resting on the wrong shoulders. Do you see what
I'm trying to say?
Mr Peters:
Yes, I agree with you. I don't want to really audit into a
vacuum.
Mr
Sampson: Yes, and that's what worries me, that you'd be
doing that unless we say to the hospital boards or-what do they
call them in universities?-the boards of governors, "Making sure
the money is properly and effectively spent is your
responsibility. Right? Hello? You got it? Knock, knock." Once
they figure that out, then maybe their audits, where they engage
PW or whoever to do them, would be far more a value-for-money
focus as opposed to taking debits and credits, which you've got
to do anyway to do the value-for-money audit.
Mr Peters:
I would endorse that, but I would say to you that by acting on
amending the Audit Act, that in itself would be a tremendous
catalyst for action to get the other side going in that regard,
because right now it's not getting going. I would love to see it
get going. I don't like very much using the Audit Act as a tool
of that nature, but it strikes me that after 10 years of
wrestling with this, after the government spending $30 billion a
year on this sector, any push we can give to improve getting
value for money for the taxpayer is really-and if the push is
through just simply removing this limitation of scope in my Audit
Act right now, it could very well act as the real catalyst to
moving this ahead.
There have been members
from various parties-I've been continually quoted-who wanted me
to move in. At least three members have phoned me directly about
institutions in their ridings. They wanted me to take a look at
those organizations, whether they are managed properly. I had to
say them, "Look, yes, you can persuade the standing committee on
public accounts to pass a motion that I could look at that, in
this case colleges and universities, but I have to say to you
that they can shut the door on me because they can point to my
act and say, `You can't look.'"
Mr
Sampson: Another one would be to say they've got to hire
PW or somebody to do a value-for-money audit and you get to see
it. That would be another way to do it.
Mr Peters:
That's right. But technically even that could be denied me
because they have legal opinions saying those kinds of reports
are not accessible to me.
Mr
Sampson: OK, but assuming we could get around-I don't
mean "get around," but solve those legal hurdles, right?
Mr Peters:
There's one way. For example, when the Honourable Elizabeth
Witmer was the Minister of Labour, she solved it on the Workers'
Compensation Board in a fairly neat fashion. She wanted
value-for-money audits done at the Workers' Compensation Board
and she simply asked
the Legislature for legislation that said that all
value-for-money audits would be done under my direction but paid
for by the Workers' Compensation Board.
1450
Mr
Sampson: Frankly, that's where I'm coming from too. I
think the universities-it should be part of their job as
governors to make sure the money is properly and fairly spent. In
fact, that should be what some of their auditors are paid to do.
As you and I probably know, very few of them are doing that.
Mr Peters:
Yes. We are in this situation where we have wrestled with this
for 10 years. We have had massive support from this committee; it
has been unanimous every time. The present Premier-who at that
time, incidentally, was a member of this committee-was very
strong on this point.
Mr
Sampson: You mean there's some hope for some of us?
Mr Peters:
Sure.
Subsequently, there was
unanimous consent to do this in 1996. All I can do is urge you
again. I'm saying that it's not extending the powers of my
office. It's not that I want to assume responsibility. It is
simply-
The Chair:
After five years, I've finally found something I agree with him
on.
Mr
Sampson: Then I'm against it. If Gerretsen's agreeing
with you, I think it's a bad idea.
The Chair:
The mere fact that all these other institutions are fighting it
tells me something.
Bruce, do you have a
comment or question?
Mr Bruce Crozier
(Essex): Yes, if they're done.
The Chair:
Oh, sorry. Mr Hastings first.
Mr
Hastings: Mr Peters, thanks for the indicators here. I
must say that while they are somewhat useful, they don't really
help me in trying to make intelligent determinations about how
effective a program is or whether you're getting value for dollar
for a science program over a liberal arts program or more care in
paediatrics over old age, which are not very comparable.
Could you produce for us a
chart that would indicate how much your office has saved over the
years, by ministry, or probably better still, by specific
projects you've been assigned-I know this committee has assigned
you stuff over the years-where you can point and say that of
these three special audit assignments, these recommendations-and
you'd have to list them all-we managed to save $150 million or $2
million or whatever. If you could measure it that way, I think
you'd probably get more support from the committee.
I find this way, where you
have 6 cents for every $1,000 spent or received for Ontario, and
then you look at PEI, which is about the size of Peterborough-a
great city-and you've got BC and Alberta. It's done on a unit
basis. We're bigger, so obviously we're not spending as much
money. Your argument, your business case would be that you need
more money to hire more auditors to carry out some of the things
you want to do and recommend. I know that's the traditional way
of measuring or using indicators to say you're behind, in
essence. I'm saying, yes, it's appreciated; it's got some
validity. But in my estimation, you'd have greater validity if
you could have another chart, some way or other, either by
specific audits, which we know you've done because this committee
recommended it, and we worked at both, and then you did it by
ministry or agency as well. To me, you'd have a more persuasive
business case. That's my first perception.
Secondly, I'd like to ask
you about these transfer agencies, which we still don't have very
much accountability over. Do you think that if the Audit Act
doesn't get amended-it really isn't the way to tackle it for
transfer agencies, is it, that you have to amend each university
act and community college act to do something like Ms Witmer did
with the WSIB? You'd amend the University of Toronto Act or the
UWO act or the Queen's act, to say, "You, the board at Queen's,
are going to have to do an audit function for value for money for
your operations over the last three years, and you're going to
have to pay for it." Is there a way around it: instead of
amending each act, amending the Audit Act under which your office
operates?
Mr Peters:
Let me answer the last question first. The draft of the amendment
to the Audit Act that we have, which we developed in 1996, was
developed together with legislative counsel. This is the most
streamlined way of dealing with the situation, rather than
amending everybody's act that is in there. I described the
Workers' Compensation Board situation as an example. However, the
Workers' Compensation Board is considered a trust. It's not even
included. Technically, it's not a grant recipient; it's entirely
funded by employer payroll taxes. I just cited it as an example
of one way we could have value-for-money audits. We could work
together with a board of directors of a transfer payment agency
and say, "You do the audit. Can it be done under my direction?"
But for that, I need these amendments to the act, because I need
to get at all the information. They have to show me their plans
and whatever is going on.
Mr
Hastings: To cover all transfer agencies.
Mr Peters:
To cover all transfer agencies. But of course, we would be very
judicious. For example, there's no point in my wanting to audit
General Motors of Canada because they receive a $10,000 grant
under some apprenticeship program. As a minimum, I think the
starting point would be an organization that receives a massive
amount of its revenue, as a percentage of total revenue, from the
taxpayer.
The second part: When you
talk about dollars, it's something I'm a little reluctant to do.
The value of my audits-I could argue for you right now, for
example, that when I came in 1994 and persuaded the government of
the day to go to the modified accrual basis of accounting from
the cash basis that was carried out at that time, I have an
indication from the rating services that that shaved as much as
0.5% off the interest we were paying on the provincial debt. If
you want to measure that, you're talking about half a billion
dollars.
Mr Hastings: That's a good
example.
Mr Peters:
That's only one, and my budget is $8 million a year.
The Chair:
Eight billion?
Mr Peters:
Eight million dollars, with an "m."
The other example-in
certain years we have done it. I forget the exact year, but we
identified savings of over $100 million that could be achieved in
one year alone. But-and it's a big "but"-we also must be able to
persuade the organizations to implement the recommendations to
achieve those savings, because I can only make recommendations.
It depends very much on that. I'll give you an example.
When we did the colleges
audit, we identified that the colleges were asking at the outset
for money based on the number of "bums in seats," to use the
colloquial phrase: "We need so many dollars, because we have so
many students in the classroom." We found there was no follow-up
as to whether that number of students actually materialized. When
we did a calculation of some of the colleges, we found that the
taxpayers would have saved $17 million in one year if they had
subsequently adjusted the funding to the actual number of
students that showed up in the college system.
Mr
Hastings: We still haven't done that, have we?
Mr Peters:
Pardon?
Mr
Hastings: That still hasn't been done, the example
you're talking about.
Mr Peters:
That's right.
Mr
Hastings: We've been doing it on the traditional body
count.
Mr Peters:
What I'm saying is, we make recommendations. But I wouldn't like
to take credit for savings that were not achieved because the
ministries didn't follow our recommendations.
Mr
Hastings: Then let me ask you this: the time I've been
on this committee, I get the impression that we are somewhat
frustrated by the presentation of the material at both ends. By
that I mean you have a ministry that comes in and we examine some
slice of that ministry. Right now it's long-term care with the
ambulances. Corrections will be some slight slice-it will be not
the whole thing, but we'll look at a slice of it. That accounts
for as much as you get to look at in that whole operation.
1500
Do you think it might be
better if we reconfigure the way we approach some of this stuff
and you approach it in terms of giving slices of programs or a
whole program? For example, if you had the amendment to the Audit
Act that allowed you to carry out value-for-money audits in the
hospital sector, your traditional approach would be to go and
look at the whole operation, expenditure-wise, of that facility
or of their buildings, if they have them, right? You'd look at
the credits, you'd look at the debits, the number of people, if
they've got interest in certain accounts. It would be a very
traditional fiscal approach, right?
Mr Peters:
No.
Mr
Hastings: No?
Mr Peters:
No. That's what I'm saying: I don't want to duplicate that,
because Ernst and Young is doing that for the Queensway-Carleton
Hospital in Nepean and KPMG may be doing it for the Toronto
General.
Mr
Hastings: But when you do a value-for-money audit, you
are looking at some of the programs in that facility,
correct?
Mr Peters:
In a hospital, we would look at the hospital as a whole.
The Chair:
No, but he's just talking in general; you do it anyway.
Mr
Hastings: What I'm trying to get at is for us to make
better decisions about whether you do get real value for a
dollar, if you did a comparative analysis of a program-for
example, where you have hospitals that have a pediatric function,
they actually have X beds, they've got X doctors and support
staff; they have to have the equipment, they have to have
specialized stuff. To me, even though they might have a
pediatrics program in a community hospital that's pretty
small-there may be only nine or 10 births every 40 days,
something like that, or 15, whereas at Sick Kids they have a
pediatric function, or one of the Toronto hospitals down here,
that can probably handle, I don't know, 40 or 50 births per
month, minimum-to me, if you look at that program for pediatrics
in neonatal care and all of those babies being born, I would get
more understanding of whether we're getting value for money in
that program. Even though your facilities may be a little
different, you're still getting a closer comparative than if you
look at a value-for-money function across a number of programs
within that institution only, because you haven't got anything to
really compare it to. You don't have somebody who was a miserable
failure and somebody at the other ends who was an extreme
success. You don't have those comparatives; all you've got is the
comparative for the money for a certain function within that
facility: Sunnybrook, a university like Laurentian, wherever it
might be. You don't have the specifics, because you're not
comparing the actual activities, responsibilities, salaries, for
everybody in the same unit, even though they may be smaller. Do
you see what I'm getting at? Program effectiveness.
Mr Peters:
You're raising a number of very interesting questions. Let me try
to answer them. Let me just walk you very quickly through the
audit process.
We do a survey of the
particular program. That's why, for example, in the Ministry of
Health you would find today we'd looked at the ambulance
services, as one program.
But we develop the audit
criteria, that is, the benchmarks or criteria against which we
audit, at the outset of the audit. We agree on those with the
management. It's their own criteria. It's criteria that we have
from international standards or wherever these things are
developed. That's why, for example, when we did the ambulances,
we looked at response times for code 4s, standards set in other
jurisdictions etc. "How do we compare? How we know we're doing
well?" That's really the question we're asking. "What criteria are you
using that this program or this particular unit, the pediatrics
unit, is managed well? How do you know that?" We develop from
that our audit program and then we do the actual testing, how we
perform against those criteria agreed upon between the management
and ourselves in that particular program. And the report that
results from that is what you'll see. So we give you a fairly
good snapshot of the performance of this particular program. What
you're getting at in many respects is something that is currently
under development-and we are helping in that development-and that
is performance reporting by management itself on its program
performance, unit performance, whichever segment they choose to
perform on.
Mr
Hastings: Whatever facility.
Mr Peters:
Or facility, or whatever they have to perform. That is actually a
by-product that virtually almost goes by the wayside. But when
you look at, for example, questions that were raised today on
response times and other things, that will then spawn in the
ministry initiatives to look at those. The ministry will say in
their response, "Yes, we're now going to look at response times.
We are going to make them consistent. We are going look at
whether critical bypass is really an appropriate measurement or
whether there are other measurements that should be carried out."
That is what I call the intangible and that's why I can't give
you dollar values for this. But this is what has happened in
virtually every audit that we have done on value for money. It
has focused management on performance, and that I think is what
you want and we want. What we are saying in this Audit Act
amendment is that this is one way of making the transfer payment
recipients focus on performance.
I would like performance
management in the whole system. I agree with you, Mr Sampson,
that it should not be an abdication. There should be performance
management of every program, of everything we do for the
taxpayer, whether we deliver the program ourselves as a ministry,
whether we're using outsourcing or whether we're using a transfer
payment partner to deliver the program.
Mr
Hastings: So conceptually we may be a little ahead of
the curve. It'll take probably another decade then, you're
thinking, to instill this performance culture, standards,
benchmarks, into management of all these ministries and agencies?
Because you can only do certain things at certain times when you
look at specific programs, right?
Mr Peters:
For the sake of the taxpayer, I hope it happens a darned time
sooner. All I'm saying to you is that from my perspective as the
auditor-
Mr
Hastings: You see it.
Mr Peters:
I can see it happening and I can see it getting a better push if
I can look at performance information other than financial
performance information in transfer payment organizations. That's
all I want in my proposal under the Audit Act.
Mr
Hastings: Does that mean then that if you were hiring
anybody you'd need to have some people in place who are more than
just CAs, CGAs; that you'd need efficiency experts from industry?
Do you need that kind of capability?
Mr Peters:
From time to time only, because very often we rely on-we do it in
ministry programs already. Why I'm mentioning, for example, the
Bruce deal is that I don't have anybody on staff-and they're very
rare and few and far between-who can actually assess a nuclear
plant, who can say, "Is this place doing well? Are things going
right?" There are certain specialities where I need that outside
advice, but normally we have relied on the expertise from the
ministries and the auditees, because very often-well, you heard
from the answers today. The people definitely gave the impression
that they were on top of the situation. They were maybe not
getting things done as quickly as we all want them to do but at
least they were doing things and they had started to have a
direction and knew where they were going.
1510
Ms
Mushinski: I think of Agricorp, and I wonder why you
can't do what it is that you want to do now.
Mr Peters:
Agricorp I can do. I can do value-for-money audits.
Ms
Mushinski: That's not considered a transfer agency?
Mr Peters:
No, it's not a transfer partner. The transfer partner is normally
an organization that is not owned by us; it's owned by others. It
has its independent board of directors, like a hospital would
have, for example, or others. Agricorp is a crown-controlled-it's
an agency of the crown. Those I can do.
Ms
Mushinski: So the Bruce nuclear plant you couldn't
do?
Mr Peters:
No, them I can do-
Ms
Mushinski: And Pickering.
Mr Peters:
-because OPG is now fully owned by the Ontario government. It's
wholly owned by the taxpayers of the province.
Ms
Mushinski: So really, then, the things you can't do are
those that may well be funded by the provincial taxpayer but not
owned by the provincial taxpayer. That's what you're saying,
essentially.
Mr Peters:
That is one distinction, but John just made a very valid point to
me. If it's merely crown-controlled, there would also be a
concern that I could only do value-for-money audits based on
instructions from you, and deal with it in some other way.
Crown-controlled I can't, but I can do it with an agency like
Agricorp. For example, we did a value-for-money audit two years
ago of the LCBO. Again, there we can do it. It is the ownership
structure of the unit that drives this.
The Chair:
I think if you look at this list, it pretty well indicates the
type of organizations where you don't have the power now.
Mr Peters:
That's right, yes. Long-term-care facilities, I don't; children's
aid societies, I don't; hospitals, universities, colleges, school
boards, I don't. Some of the organizations involved in-well, some are direct
payments, like-
Interjection.
Mr Peters:
Yes, that's the point. These organizations are not controlled by
the government, but they are spending our money on our
behalf.
Ms
Mushinski: So the governance structures of these
organizations-and there's a whole myriad of them. I'm thinking
non-profit, for example.
Mr Peters:
Over 10,000.
Ms
Mushinski: Yes, there are thousands if you look at
Comsoc, for example. But surely there is some requirement under
the bylaws of these organizations, which usually have community
boards-you mentioned children's aid societies, for example, and
there's a whole string, I would think, of local organizations
that stem from the children's aid societies. Is there not some
sort of overarching provincial requirement for them to spend
taxpayers' money prudently, and how is that enshrined within the
bylaws of all of those thousands of organizations out there?
Mr Peters:
What we found, for example-Comsoc is a very good example. About
two years ago, I believe, in 1998, we did an audit of transfer
payment accountability within Comsoc, where we looked at the
organization. They spend about $2.1 billion on about 3,400
organizations in that alone. It seems to be in a constant flux as
to what the role of the director is. We made a recommendation
outright as to, if we fund the organizations, does the government
actually have a responsibility to do something about director
orientation, training, advising members of boards of directors
what they ought to be doing?
Ms
Mushinski: Liability is another example.
Mr Peters:
Liability was, of course, the first one that came to mind, but
most of the time there is an indemnity provision that they're
indemnified right off the bat.
Governance and
accountability is certainly one area that I have been trying to
pursue directly with organizations. I make presentations to
universities' chairs on governance and accountability and to
various other organizations, the Canadian Mental Health
Association etc, on this particular issue, but that is almost
like a hobby. That is almost outside my mandate, just something I
do.
Ms
Mushinski: Non-profit work that you do for a non-profit
organization.
Mr Peters:
That's about the size of it. I'm delighted to do it, I should
add. But there is no overarching, as you put it, assurance that
there is value for money. What is happening is that the
ministries are actually left to some sort of contractual or
budgetary arrangement with these organizations. For example, they
have a budget stream where they say, "We'll give you so much
money," and then there is an accountability back as to how they
spend it. But, for example, what we found in Comsoc is that the
reliance is entirely on financial statements. Very often they are
big organizations and they don't identify, to come back to Mr
Hastings's example, individual programs. For example, many of
these financial statements will not identify the individual
programs that were actually funded by the government.
In another situation, we
found that they deliberately overstated the budgetary
requirement. We found one organization that squirreled away $1.5
million because they wanted a new capital facility and they knew
they wouldn't get it from the government, so they overstated
their operating requirements, created a fund and then built
it.
Ms
Mushinski: Municipalities have been doing that for
years.
Mr Peters:
Yes, I know. We found one that had the same road under
construction for 20 years, actually funding the salting and-
Mr
Sampson: It wasn't Kingston, was it?
The Chair:
That will be stricken off the record.
Mr Peters:
I don't name names.
Mr
Sampson: The John Gerretsen freeway. Is that the
one?
Mr Peters:
I hope that answers your question, but that's really the best I
can do. I can only come forward and say, "Look." I would much
rather have a sound accountability framework in place, but since
that is a long-term process, if I can give it a push through
amending the Audit Act in this way, I urge you, let's give it
that push.
Mr
Crozier: My comments will be relatively brief because if
you were to go back a few years when I was on this committee-and
besides, I want to get on the record that I want to get out of
here and go see my brand new first grandchild.
Interjections.
Mr
Crozier: You were mentioning hospitals. Our daughter's
at Women's College.
Interjections.
Mr
Crozier: A girl, Emma Claire, yesterday afternoon at
about this time.
Mr
Sampson: So get out of here, go.
Mr
Crozier: Yes. But when you mentioned hospitals, one of
the best has got to be Women's College Hospital.
Anyway, my comments are on
the record from several years ago when I was on this committee.
I've been a supporter of the Provincial Auditor, Mr Peters, and
his staff when it comes to value-for-money audits. I am certainly
a believer in them. I just want to point out that, in my view,
the Provincial Auditor holds a unique position, as does the
Auditor General of Canada-and somewhat to Mr Sampson's comment
about, couldn't some of these organizations have value-for-money
audits? They very well could, but the Provincial Auditor, in this
case, holds a unique position in our democratic and accountable
system. I therefore think there is definitely a role for the
Provincial Auditor to play vis-à-vis private auditing
firms.
So I hope that this
committee supports those amendments. It would appear as though we
have supported them in the past. Interestingly enough, it even
appears as though the government accepts that recommendation but,
for whatever reason, there has always been foot-dragging on this.
I would just hope that this government, which has at least a couple of years
left in its mandate, accepts that this committee supports the
recommendations-
Ms
Mushinski: Minimum.
Mr
Crozier: If that's the case, then all the more reason
why you should want to be accountable to the public, and this is
one way you can do it.
The point is, I support the
Provincial Auditor and I hope this committee does as well.
The Chair:
Can we get the actual amendments-this gets back to something Mr
Sampson raised right at the very beginning-so that at least the
committee could take a look at the actual amendments?
Mr
Sampson: Yes, I think, Mr Chair and Mr Peters, you
should take it that we are extremely interested as a government
in getting value for the taxpayers on money that's being spent. I
think the point I was trying to make is that I'm not too sure
we've got stage one sufficiently done to unleash stage two, which
would be the role of the Provincial Auditor to make sure things
happen. Having said that, I think your point about having a stick
hanging around would be helpful in getting finished with stage
one. That's a very valid point.
I think it would be
helpful, Chair, if the amendments were brought forward again to
the committee, that another approach be made, certainly by your
office to the Minister of Finance, Mr Flaherty, to see if he has
a renewed interest in this, and to start to flesh out how those
roles should be struck between your office and the
responsibilities that I would see, frankly, of the people we
write the cheques to to spend the money properly. I really want
to make sure we've got that working first. Maybe we need the
stick, but in the absence of that I can just see a ton of people
saying, "I'm only here to count beans, not to make sure they are
beans as opposed to carrots or whatever." That's a terrible
analogy but I'll use it.
Is that helpful to you,
sir?
Mr Peters:
I'd be glad to provide these proposed amendments. There are some
updates in it. The fundamental document is four years old. One of
the issues we raised, for example, and it's of interest to
another committee at the moment which is involved in that, is the
access to health records. For that, I voluntarily arranged for
the privacy commissioner to actually draft the provisions that
you find in here. They were drafted by the privacy
commissioner.
Mr
Sampson: The other thing that concerns me, as well-I'll
just interject-is that I wouldn't want to get 7,000 transfer
payment agencies developing 14,000 different ways to approach
value-for-money audits. That scares me a bit. As you probably
know, they can be designed to get the results you want to get, as
part of the design process as opposed to part of the result
process. I would be really worried about each group going off on
its own and establishing its own criteria. So maybe there's a
role to be played by your office in establishing those
fundamental criteria as to what value-for-money audit means, so
we don't get those 14,000 different versions, which would be,
frankly, worse than what we've got now, which is nothing.
Mr Peters:
That's an educational aspect. It's very much a part of it.
The Chair:
Thank you very much. We stand adjourned until 10 o'clock tomorrow
morning.
