Assemblée législative de l'Ontario

ORGANIZATION

MINISTRY OF HEALTH

CONTENTS

Tuesday 9 June 1992

Organization

Ministry of Health

Hon Frances Lankin, minister

Michael Decter, assistant deputy minister

STANDING COMMITTEE ON ESTIMATES

*Chair / Président: Jackson, Cameron (Burlington South/-Sud PC)

Vice-Chair / Vice-Présidente: Marland, Margaret (Mississauga South/-Sud PC)

*Bisson, Giles (Cochrane South/-Sud ND)

Carr, Gary (Oakville South/-Sud PC)

*Eddy, Ron (Brant-Haldimand L)

Ferguson, Will, (Kitchener ND)

*Frankford, Robert (Scarborough East/-Est ND)

*Lessard, Wayne (Windsor-Walkerville ND)

*O'Connor, Larry (Durham-York ND)

*Perruzza, Anthony (Downsview ND)

Ramsay, David (Timiskaming L)

Sorbara, Gregory S. (York Centre L)

Substitutions / Membres remplaçants:

*Sullivan, Barbara (Halton Centre L) for Mr Ramsay

*Wessenger, Paul (Simcoe Centre ND) for Mr Ferguson

*Wilson, Jim (Simcoe West/-Ouest PC) for Mr Carr

*In attendance / présents

Also taking part / Autres participants et participantes: Arnott, Ted (Wellington PC)

Clerk: Greffier: Carrozza, Franco

The committee met at 1602 in committee room 2.

ORGANIZATION

The Chair (Mr Cameron Jackson): I would like to call to order the standing committee on estimates. Since I see a quorum, I'd like to dispense with a little bit of committee business before inviting the minister to resume her estimates.

Our clerk has submitted the report of a subcommittee which met on Wednesday, June 3, and the report is before you for your consideration. This report was necessitated by the fact that the current legislative calendar will not allow us sufficient time to complete the full estimates. Therefore, the subcommittee has recommended that a two-week period commencing August 10 and August 17 or, alternatively, the week starting September 8 and the subsequent week starting September 14, be set aside for estimates during the recess. If approved, this would be communicated to the House leaders for their approval and support. Are there any questions about the report?

Mr Gilles Bisson (Cochrane South): For the record, I just received that now. As you know, last week I was in Ottawa on government business and was somewhat aware that it was coming forward, but I didn't know it was coming forward in the committee right now. I would ask that we have an opportunity as government members to take a look at that and come back tomorrow. We can basically let you know how we'd vote on it.

The Chair: Okay. Mr Frankford attended on behalf of your caucus and ably represented your caucus at that meeting. He undertook to communicate to what I understand were most members of your caucus. For that reason, we would really like to deal with the motion now, if possible.

Mr Larry O'Connor (Durham-York): One point, Mr Chair. I received a notification in the mail about a one-day sitting in September, something to do with the 200th anniversary of Parliament in Ontario.

The Chair: That is correct.

Mr O'Connor: Is that on the Thursday or the Friday of the second week of September?

The Chair: That is a Thursday, as I understand it.

Mr O'Connor: So that could interfere with us, or would we move then with the committee to --

The Chair: We would adjust accordingly.

Mr O'Connor: I just wanted to place that for consideration.

The Chair: I believe what's recommended is that we would give the House leaders the flexibility to choose a two-week period of either of those starting dates of August 10 or September 8, and the schedule is appended for your consideration. With that schedule, we would be able to complete all estimates.

Mr Bisson: That will be all 12?

The Chair: That is correct.

Mr Bisson: How many? I just read the memo. I think there were only three that we would be hearing in that time period of two weeks.

Interjection: Five.

Mr Bisson: Five? Okay. Again, as the whip for the government side of the committee, I would ask that we bring this back tomorrow rather than forcing it to a vote, and we could discuss it then.

The Chair: Okay, that's fine.

Mr Ron Eddy (Brant-Haldimand): I wonder if the recommendation would be considered by the government members in light of the possible sitting of the Legislature in July. Does it make any kind of difference if in fact the Legislature were to sit till the middle of July or later?

The Chair: To answer your question directly -- if we were to sit in the month of July, then this committee would continue its schedule of hearings. I believe our schedule would invite the Ministry of Housing to begin the first week of July, and then the subsequent ministries in that rotation, and we would end when the House rose.

However, today was our caucus meetings and all three parties had ample opportunity to discuss just exactly what was happening. We also know that those decisions are quite clearly outside the control of this committee. We are simply required to submit to the House leaders if we require time for the summer, to get that submission in now or as soon as possible so that we're given due consideration.

I respect the request from my colleague to have this matter dealt with tomorrow.

I sense we're now ready to begin estimates -- and the clock will recognize that it is seven minutes after the hour of 4 -- which is the commencing of the Health ministry estimates, unless there are other questions. If not, fine.

MINISTRY OF HEALTH

The Chair: When we were last together there were six hours remaining for the Ministry of Health. Where were we in the rotation?

Clerk of the Committee (Mr Franco Carrozza): We had finished with the Minister of Health, so we go back to the Liberals.

The Chair: Very good. The minister, I believe, has a couple of items she would like to table for the committee's consideration. Minister?

Hon Frances Lankin (Minister of Health): I have answers to questions that were directly raised or inferred in the opening statements by the two opposition party critics on June 2 and answers to direct questions posed by members of the committee on Wednesday, June 3. I should indicate that there are, I think, two questions still outstanding that we are working on answers to and we will probably be providing those to you within the next day or so. If I can table these with you at this time.

The Chair: Thank you, Madam Chair -- I mean Madam Minister. I'll trade you salaries and positions actually. Are we ready for the official opposition to begin questioning?

Mrs Barbara Sullivan (Halton Centre): I would like to continue to pursue the line of questioning my colleague introduced in the last immediate session, following in relationship to the organization of your office and the involvement of consultants in the affairs of your office and in the ministry. The member referred to the involvement of Ted Ball, a health care consultant, in participation in the dialogue on health care issues.

We would very much like to know what his involvement is with the ministry in a consultancy fashion: where he has access, what number of hours he is under contract in one or more contracts and where he sits in your operation in terms of the advice and policy development and/or other areas where his services are used, or those of his company.

Hon Ms Lankin: I will undertake to table a response to that.

Mrs Sullivan: We would also like to know the nature and extent of any other consultancy services available to you in the minister's office or in the ministry, including the companies or individuals which have consultancy contracts, the nature, extent, value, duration and any other issues associated with the contracts that have been issued.

Hon Ms Lankin: I would just ask on this point if you are talking about consultants' contracts, whether they are in the ministry or within my office, who would perform services directly related to issues that I, as minister, am working on or services I require as opposed to, for example, a consulting contract that may be in the area of information technology in the Kingston OHIP division.

Mrs Sullivan: I think we'd like to see all of those contracts and information relating to all of them. Naturally, we're most interested in the areas relating to policy issues in terms of detail, but it would also be useful, for example, if you're speaking about contracts associated with OHIP, for us to have a view of the nature and extent of people exterior to the ministry who might be involved, for example, in updating the data system or in bringing proposals forward in that area.

I suggest that would be valuable information in that we know health service organizations have had a very difficult time in analysing and utilizing data coming through the OHIP system because of its presentation. We also know that over a period of time there has been some concern about the efficiency of the data system and it might also provide us with an inclination of some additional changes that may be required in a more advanced health card system. I think some of the other information would be useful as well.

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Hon Ms Lankin: What we will attempt to do is provide you with a response to the detailed requests that you made in the first phase of your question in fairly short order. I think we can do that. In general, in response to the broader application of your question, we will undertake to give you information about the key areas of activity with respect to the use of consultants. I think we can indicate to you the overall dollars that are being expended and areas where we've taken dramatic steps to take reductions in the use of consultants and the amount of dollars being spent. We can perhaps provide the committee with some direct information with respect to the issues raised around how we collect data and the health registration card -- for example, innovations with respect to smart card technology and contracts and pilot projects around that -- if that would be of assistance. That might take us just a bit longer to pull together, however.

Mrs Sullivan: I would also like to follow up on the questioning of my colleague in relationship to consultancy on the Public Hospitals Act. On Saturday, June 6, on page A21 of the Toronto Star, an advertisement had been inserted by the Ministry of Health asking, "How Do You Think Your Hospitals Should Be Run?" The response is directed to Barbara Hibbard at (416) 925-6529. This is not a ministry number. Indeed, it's a home number where there is an answering machine. We have responded to that today and discovered a telephone answering service indicating that this person, whom I know and who has been an employee of the Legislature in the past, is away from her desk until 4 o'clock.

We are wondering indeed how serious you are in terms of public consultancy in relationship to the hospitals act and if this is the kind of appropriate way of people indicating how they can be involved in hospital decision-making and how hospitals can be more open and accountable to the communities they serve, with an indication that people's views count and they should make sure they're heard. I'd like your response to that question.

Hon Ms Lankin: I want to assure members that we are very serious about hearing from people with respect to changes to the Public Hospitals Act. The advertisement that the member speaks about is to let individuals know about public hearings that will be forthcoming and to find out how they can participate or get more information.

I will be glad to follow up on the information she just provided me with at this point in time with respect to the individual who is the contact person and her availability. If there are steps that need to be taken to ensure that the public gets a prompt response, we will take those steps.

But I can assure her and the other members of the committee that we are serious about reaching out to communities. We're attempting, through community development initiatives, to bring forward people from community organizations and groups who may not otherwise find a way to participate in this debate or have enough background about the two years of task force study and the recommendations to be able to participate in the debate fully and to respond to some of the pressing questions that will be facing members of the Legislature as the government develops its policy and tables legislation. Our attempts are to ensure they will be able to participate, and I think we've taken some additional steps to ensure that. If there are problems with that or there are further recommendations that members have to assist us in that effort, I'll be pleased, as will the parliamentary assistant to the Minister of Health, who is here and who will be conducting those public hearings with the assistance of other members of the provincial Parliament.

Mrs Sullivan: Naturally, one of the questions we are interested in relates to the contract of Barbara Hibbard. What is apparent is that there is more than one contract in association with the organization of the Public Hospitals Act public hearings process. In addition to Jack Layton, Barbara Hibbard is clearly on contract, working from a home office. We would like to know who else is working on the Public Hospitals Act consultancy. Why isn't Mr Wessenger's name involved in this advertisement? We understand that he is to be the chair. Surely his office could be involved and surely some other people in the ministry should be able to do this work. How many other people have been hired on a consultancy basis to be involved in the Public Hospitals Act consultation?

Hon Ms Lankin: The initiative that was taken from my office with respect to the hiring of Mr Layton involves a contract that has services of Mr Layton and an assistant who works with him. Outside of that I'm unable to give you any further information whether or not there are any individuals in the ministry who are contract employees as opposed to direct civil servants who are working on this project; I'm not sure.

For example, up until recently, when we switched to the chief of the legal services to head up this project, the lawyer who was working on this was someone who has had a long-standing relationship with the ministry who has always been in a contractual relationship or fee-for-service relationship. Those kinds of employment situations I find have existed throughout the years in this ministry in relationship to various departments and people doing work for the ministry.

With respect to the point I think the member of the committee is getting at in terms of initiatives undertaken by the minister's office to bring in assistants in organizing community participation in the public hearings, the only contracts I am aware of are the contracts that have been taken out for services with Mr Layton and his assistant, which you are already aware of.

Mrs Sullivan: You've indicated that the person who was heading the Public Hospitals Act process was a ministry employee in the legal division. I expect that you mean Linda Bohnen, who has now left the ministry?

Hon Ms Lankin: She was a person who was working on a contractual basis with the ministry. She was not a civil servant.

Mrs Sullivan: Was she under contract from the Attorney General?

Hon Ms Lankin: I'm not sure. Most lawyers have their employment relationship, whether it's contractual or otherwise, in any ministry in government through the Ministry of the Attorney General, so it's quite possible the paperwork was done through there. The distinction I'm making is that, unlike some lawyers who are direct employees of government, Ms Bohnen was in an employment relationship that was on a contractual fee-for-service basis as opposed to an employee status. That was a long-standing relationship that existed under the previous government as well as under our government.

Mrs Sullivan: Who is now heading within the ministry the consultancy program or the development of the Public Hospitals Act from the government point of view?

Hon Ms Lankin: It is not a consultancy program, but the responsibility for the development of policy and the legislative proposals within the ministry is Gilbert Sharpe's.

Mrs Sullivan: I think you will understand that we have raised these issues in the House and are raising them again in committee because there is enormous unease about the nature of the consultative process itself -- the time lines, the perceived bias -- in relationship to the development of what will be changes clearly needed in the Public Hospitals Act. The process itself appears to have been tainted.

This Toronto Star advertisement is simply another indication of a tainted process where there appears to be a public process occurring that isn't occurring in an appropriate manner, so we would naturally want to hear more from you in relationship to the process of consultancy, of where Mr Wessenger actually fits and of who else is involved behind the doors in association with the policy development. I think these are matters of public concern and are readily understandable in terms of public interest.

I also wanted to ask you if you would speak to the questions associated with statements you've made in relationship to governance and what you mean in terms of the Public Hospitals Act by democratization of the system. People are confused and, from a policy point of view, want a further understanding of what you mean and where you see a democratization that perhaps involves staff, including physicians or other health care providers within the system of hospitals, and how you see a fit between the steering committee report and the words you have given on several occasions in relationship to being enthusiastic about further democratization of the public hospitals boards.

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Hon Ms Lankin: I think there are three distinct parts to the questions you raise, starting with your opening comments and your assertion that there's great concern and that somehow there has been a change of process with respect to public consultation.

I don't agree with you that there is great concern out there. My discussions with members of the various health professional groups and associations like the Ontario Hospital Association, both prior to and post the kind of furore that was raised in the Legislature by the opposition around the hiring of Mr Layton, gives me great confidence that there isn't the kind of concern you indicate. In fact, I think it's more the opposition throwing up straw men to try to create an issue where there is none. If the process becomes tainted, it is by that and not by any action that I or members of my office have undertaken.

Your assertion that to try to do community outreach work and involve people from the community who may not otherwise be heard in this process in public hearings and in giving their input to government somehow presents a bias or represents a bias on behalf of government is an interesting assertion on your part as well. I'm not sure where you think the bias is -- for or against. It seems to me that if there is a bias, it's being indicated that it is a bias on behalf of hearing from individuals and hearing from the community and of ensuring that we give people enough information and background to enable them to participate as well as offering them the opportunity to organize and join with each other to discuss and develop opinion so that they can participate in this process. I think that's a bias in favour of people and in favour of communities, and if you declare that to be a bias, it's one which I'll defend with pride.

With respect to issues of governance and democratization, I've been asked what I mean when I talk about governance issues -- specifically the relationship of our hospitals and the boards that oversee the affairs of our hospitals and their relationship to their communities, both their local communities and depending on the role of hospital regional communities. There are a number of issues that must be addressed and I don't think there are simple answers.

One of the reasons why I am quite interested in having a first go-round and just hearing some general response to the recommendations of the task force is that this leads into your third question, Ms Sullivan, about the relationship between the steering committee report and the comments I've made around governance and around democratization. I think it is important for us not to assume that easy answers like elected boards will get at the issues of accountability and democratic governance. For example, we all know situations where, in communities, election to particular governance bodies could mean the representation of a single point of view.

With respect to the delivery of health care services, where we are dealing with access to ensured services as a right and it's something we value and want to protect, I don't know that this is what might appear on the surface to be an easy answer. It's an answer that a lot of people have been proposing. I'm not sure it is necessarily the best answer.

What I have been suggesting is that the steering committee report provide a basis of very valuable work and very valuable thought and input into this process. But there are a couple of areas in particular that I would like to see people comment on and give us their best advice on, one being governance. What is the relationship? How do we put together the governance bodies of our public institutions? What are their relationships to their communities? As you know, the task force has recommended such mechanisms as the development of a social contract around the delivery of services. That's an interesting concept. Flesh it out; what does it mean? How would communities grasp hold of that idea? How do they see it working? Does it meet their needs? What's the relationship between the service deliverers, like our public institutions, and their governance bodies and planners, like district health councils, for example? There are a lot of issues involved in that. With respect to the issue of democratization of the institution, as you may know, again the steering committee report has made some recommendations that suggest that those people who are in direct employ or whose services are directly employed within the hospital setting should not be direct members of governance structures but should have avenues to feed in their best advice.

In the real world, what that means is a shift in what's happened in most hospitals, where the medical staff have had a very active voice and participation in governance structures, to a system where they would be part of an advisory committee and provide professional advice through their advisory committee to the board, as would other groups within the hospital who currently don't have the same relationship with governance structures -- with boards, in the current situation.

For example, nursing and other health care professions and staff of hospitals would have advisory committees where they could provide direct advice through to the board. This is a very interesting departure from how things have been done in the past. It is one proposed model of achieving greater involvement or perhaps moving to more multidisciplinary involvement and advice-giving to a board. It certainly defines the role of the medical profession and other professionals apart from the administration, the chief executive officer and that person's relationship to the governance structure.

I think these are really interesting ideas that need to be explored. Again, a lot of people have suggested that the way to find greater democracy inside the institution is for all employee groups to have direct representation on the board. That's an alternative model. These are the sorts of questions that I, in particular, have asked people to address as they are participating in the public hearings, along with some of the very important issues that are highlighted in the task force report, in which I think the recommendations of the committee go a long way to answer some very needed problems or provide solutions to some very necessary problem areas, such as fiscal responsibility, the roles of trustees, our ability to assure that another St Michael's Hospital doesn't happen where there's a lack of clarity around the roles of the various parties. I hope people will be providing us with comments on those areas as well.

Mrs Sullivan: Are you going to be providing any signals that are more substantial before going into public hearings about what would be acceptable, in your view? By example, I think of the reservation you have already raised about public elections of hospital boards. I have other reservations, including the politicization of the health care delivery system through hospitals, given public elections. Are you going to be providing signals as a guide in terms of policy before those hearings begin?

Hon Ms Lankin: It has not been my intention to do that other than, I guess, by the various kinds of questions and answers I undertake in sessions such as this and with other organizations, at conferences and other gatherings I attend. As we explore opinion and ideas, I suppose some people might take from that indications of a direction, although I would like to assure the member that there have been no policy decisions taken on this issue within the ministry and I certainly have had no direct discussions with any of my other colleagues in government about directions other than the general directions of reviewing the steering committee report recommendations with members of the public and using that reference and that information we receive in the development of ministry policy.

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I can honestly tell you that I do not have firm conclusions with respect to some of these issues at this point in time. I'm anxious to get more feedback and to hear a bit from people what they think about these recommendations, at the same time as I'm reviewing the recommendations and understanding them myself.

The member will be aware that well over two years of work went into the steering committee's deliberations in developing these recommendations. I myself, having been in the portfolio for a year, have learned a great deal with respect to the hospital system, local planning through district health councils, relationships between communities and hospitals, and relationships between groups within hospitals. I still continue to learn as we go along. In discussions about the task force recommendations I'm provided with an opportunity to focus those deliberations and discussions and hopefully gain from people's advice and their own experience with respect to these issues.

At this point in time I don't have conclusions about the direction government should head in. I will be working on that over the course of the summer and looking forward to hearing from the parliamentary assistants and other MPPs who participate in what is admittedly a very quick and short round of information gathering but will, I think, be important to help us develop at least a first indication of the direction of government policy and a foundation for legislation.

Mrs Sullivan: In the continuing discussion in relation to the Public Hospitals Act, do you at this point see a need for a different approach in terms of governments and other very important issues that are included in the hospitals act for tertiary and teaching hospitals versus community hospitals?

Hon Ms Lankin: Could you be a bit more specific?

Mrs Sullivan: Do you think there would be a need for perhaps even a separate act for the tertiary or teaching hospitals, or special provisions in comparison to community hospitals?

Hon Ms Lankin: The point you raise is an important one, particularly as we talk about issues around governance. I attempted to indicate that I saw the definition of "community," when you talk about community accountability, as differing in some cases from institution to institution. For example, when you talk about tertiary or specialty hospitals, if you take the Hospital for Sick Children, the community that Sick Kids and its governance structure are accountable to is not an easily identified community on a geographical basis. There is a province-wide constituency, in fact a national and international constituency.

I would be interested to hear suggestions and comments on those areas. I expect I will, particularly from the teaching hospital community. I'm receptive to ideas for differential approaches if that is seen to be necessary as we review these recommendations.

Mrs Sullivan: Have you agreed to the proposal of the hospital association for a role study for small hospitals?

Hon Ms Lankin: I think it would have been proposed through the joint committee with the OHA and the ministry. I am advised by the deputy that we have received it. We haven't responded at this point in time.

Mrs Sullivan: When would that decision be made in terms of determining whether you would concur that there was a need for, and that you would proceed with, a role study?

Hon Ms Lankin: I'm sorry; I'm unable to answer that question. I haven't seen the materials that have been submitted or the proposal at this point in time, so I can't tell you when I would be prepared to provide a response on that.

Mrs Sullivan: I wanted to lead from that position into the role study of the chronic care hospitals.

The Chair: You have three minutes in which to do that.

Mrs Sullivan: Given three minutes, I will ask a short question. First, when do you expect to see the chronic role study? How have decisions associated with consultation on the Public Hospitals Act and on closure of chronic care beds been made before that role study has been received in your ministry?

Hon Ms Lankin: We expect to receive the final results of the chronic care role study by December of this year, I believe. There have been no decisions with respect to the Public Hospitals Act that would be directly related to the chronic care role study. Various institutions have taken decisions with respect to acute care and chronic care beds across the province in light of their budget setting and priority setting and in consultation with other regional hospitals and district health councils as planning vehicles. Those decisions have not directly been related to the role study being undertaken at this point in time.

Mrs Sullivan: I guess that's it, Mr Chairman.

The Chair: Thank you very much, Mrs Sullivan. Mr Wilson.

Mr Jim Wilson (Simcoe West): Minister, I've tabled with the clerk many written questions I and my colleagues have, and I'd ask him to give you a copy. I won't be referring too often to that document in the next half-hour. I have some fairly real-life, general questions for you.

The first one is regarding the future of the psychiatric institution referred to in question period today by the leader of the Ontario PC Party, Mike Harris, and that's the Oak Ridge centre in Penetanguishene. Minister, 14 staff members have recently been given pink slips and there's currently a rumour in the community that because of the downsizing at that institution perhaps the institution is slated for closure. Over the years promises were made -- I understand from my colleague Mr McLean, anyway -- that in fact the institution was to be expanded and rebuilt; parts of it are quite old. I was just wondering if you've got any general comments at this time on the future of that particular institution.

Hon Ms Lankin: Yes, I can tell you that three successive governments have attempted to deal with the issue of Oak Ridge and the future of Oak Ridge. I am sure you are well aware many reviews have looked at the relationship between the Ministry of Correctional Services and the Ministry of Health and the responsibilities for that facility and/or the use of that facility. We have not gotten any further in this government than any other government has with respect to plans around the future direction of Oak Ridge.

One of the things that is perhaps different as we face this continuing problem -- I guess there are a couple of things. First, the economic situation the province and the community faces means that ongoing employment is probably even more critical than it would be in the good times -- even though I think it's always been critical to that community, so that's perhaps not much of a difference.

What is different is the legal atmosphere with which we look at the issue of incarceration and/or detainment of patients under Lieutenant Governor's warrants and those kinds of warrants. With decisions like the Swain decision, with the need for government to be able to respond more quickly through the judicial system and health system to be able to house these individuals, move them very quickly to appropriate long-term accommodation for treatment and appropriate assessment in terms of levels of security required, it's clear that our system, as it is currently in place and as it has been for a number of years, is not capable of meeting the demands that will be placed upon it as a result of the Swain decision.

Therefore, we're taking some steps to attempt to correct that. The first step is to enhance in a number of centres across the province our capacity to deal with medium security forensic beds. That is the highest priority we face. As you know, the Oak Ridge facility is a maximum security forensic situation. In fact, even within that there are individuals who have been assessed as requiring lesser security than is provided at Oak Ridge and I think we are under considerable pressure as a ministry to respond to that and to move them out to medium-security facilities once those become available.

Mr Jim Wilson: Can you assure the community there that, with the decline in the number of staff, the community is safe and that those residents are where they should be: in the institution?

Hon Ms Lankin: With respect to the security of the facility?

Mr Jim Wilson: Yes.

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Hon Ms Lankin: Well, in all of our facilities there are no doubt incidents that happen from time to time, and always have, that would give rise to community concern. But in all of our facilities the decisions that are taken with respect to levels of staffing and any change in levels of staffing give first and foremost consideration to the issue of security, the welfare of both the patients and of the community the facility is located in.

The issue I thought you were going to with respect to assuring the community is that one of the other issues that's been of concern to the community is the ongoing presence of the provincial government in that community and the jobs that are associated with that and what that means to the economics of the community. I can certainly assure you that I'm well aware of that and sensitive to that. I think that is one of the issues that has bedevilled three governments now with respect to the future of Oak Ridge.

There's no doubt that there have been numerous reports and studies and opinions offered within the system itself to suggest that the facility at Oak Ridges is not the ideal kind of facility we would want to continue to use for any patients within our system.

Mr Jim Wilson: Minister, I'm having a little problem ascertaining the answer, really. Can you assure the community that over the term of your mandate, for the next three years, Oak Ridge will not close?

Hon Ms Lankin: What I've indicated is that I am very sensitive to the needs of the community. At this point in time there's no decision, or even an inclination right now, to close Oak Ridge. There have been many reports suggesting Oak Ridge should be closed. My challenge would be to determine with government what sorts of community initiatives would replace an Oak Ridge, if that were to happen. At this point in time there are no plans to close Oak Ridge. However, I cannot project two, three, four years down in the future.

Mr Jim Wilson: Okay. Thank you.

Minister, I'm disturbed by an article that appeared in today's Globe and Mail, and I am sure you've seen the article, entitled "Surgeons Go South to Find Respect." The article stems from the question I asked you in the Legislature in December when, you'll recall, I listed a number of top specialists, including Dr John Kostiuk, a spinal specialist who has left Toronto Hospital and has gone to Johns Hopkins in the United States; Dr Steve Esses, a spinal specialist who has left Toronto Hospital and is now in Houston at Baylor hospital; Dr Peter Armstrong, a children's orthopaedic surgeon who's left the Hospital for Sick Children and is now at a hospital in Salt Lake City; Dr Debbie Bell, a children's orthopaedic surgeon, now in Detroit; Dr Peter Brooks, Dr Bob Jackson, and the list goes on and on.

I just want to quote from the article. It quotes Dr John Wedge, chairman of the University of Toronto's department of surgery, who says, "We're losing the superstars, the highly qualified, highly specialized individuals."

Dr Marvin Tile, an orthopaedic surgeon, goes on in the article -- well, I'll just point out what his reasonings are. They're paraphrased in the article. It says:

"Dr Tile pointed to other reasons why 27 orthopaedic surgeons have left Ontario in the past two and a half years. As hospital beds close and resources become scarcer, Dr Tile said, medical `hassles' increase, operating room access becomes shorter, quotas are put on certain operations and doctors are less involved in decision-making."

I guess succinctly, Minister, the question is, first, is the ministry tracking those top specialists who are leaving Ontario for other locations? Second, what are you doing to stem the exodus of these highly renowned specialists?

Hon Ms Lankin: As when you raised the question in the Legislature, the situation we actually experience in Ontario is not quite as might be inferred from reading an article such as this. There is actually a flow in and out of Ontario with respect to doctors in general, specialists in particular, and even our most experienced and some of the most highly qualified and talented specialists.

For example, you may have read recently another article which gave a story of quite the opposite impression, and that is of a top surgeon who has come from the United States to Toronto to head up a lung transplant team, an academic researcher and a surgeon highly qualified, highly trained. So there is a to and fro that happens with respect to this issue.

Having said that, I think if you read the article carefully, in addition to the comments you indicated or paraphrased, what you will find, interestingly enough, throughout the article is a very consistent reference to the issue of how doctors are paid and to the disincentive some medical practitioners find in the fee-for-service structure of physician payment to practising high-quality medical care and/or to being able to engage in high-quality research activities and having to make the income through the fee-for-service process. In fact, many of the issues I've raised with respect to the problems we have around shortage of specialists in some areas, around higher quality delivery of services, relates to that structure of payment of physicians.

It may be of interest to you to know -- maybe reassuring; I hope it's reassuring to you -- that we are currently in negotiations with health science centres around this very issue. I think that in our academic health science centres we have realized that in fact the ability for research to be carried out has been funded by the necessity to do clinical work under the OHIP fee-for-service schedule and that this is perhaps an inappropriate way to fund that kind of activity. As we speak, we're looking at negotiations attempting to achieve, with those academic health science centres, an alternative payment plan that gives recognition to the various kinds of problems that are raised in here.

Mr Jim Wilson: So you will be moving away from fee-for-service to flat salary?

Hon Ms Lankin: To funding envelopes with respect to the activities that are being undertaken in the academic health science centres, and the payment of physicians within that may well be salaried with respect to their research work, for example. It is speculative only because the negotiations are ongoing; they have not been concluded.

Mr Jim Wilson: Who's undertaking these negotiations?

Hon Ms Lankin: The ministry is currently under negotiations with the academic health science centres, although there are representatives of the Ontario Medical Association who are involved in part of that. They represent physicians with respect to the current income of physicians. Some of the issues under negotiations with the academic health science centres, of course, are broader than that and the OMA doesn't have jurisdiction for that portion of the negotiations.

Mr Jim Wilson: There is a lot of concern out there, as I know you appreciate, and the article speaks of and quotes Dr Tirone David, who certainly is a leading heart surgeon here in Toronto. He's resisted the urge to go to the US, the article points out, but a lot of the specialists haven't. You say negotiations are ongoing. Will you, in the near future, be in a position to assure the people of Ontario that you have a plan to ensure that these specialists find it worth their while to stay in practice in Ontario?

Hon Ms Lankin: Again, I want to correct the impression that there is a mass exodus going on. I think it would be unfair to leave the committee with that impression. It is a two-way street. We are in fact attracting --

Mr Jim Wilson: How many have left and how many are coming in then?

Hon Ms Lankin: In the last numbers I saw with respect to specialists across Canada and in Ontario, slightly over 100 had left in the last year and one more had come than had left. Last year, when we reviewed the figures with respect to the question you raised on orthopaedic specialists, we had benefited from 10 more who had come into Ontario to practise than who had left. So there is a coming and going that takes place.

Mr Jim Wilson: I appreciate that. I am pleased to see that the ministry does do some numbers-tracking, but the point is that we're losing world-renowned specialists who have made a tremendous contribution and learned their trade in Ontario and are spending probably their most productive years now practising in the United States. So I'll leave it --

Hon Ms Lankin: Again, I think you give an impression that is not entirely correct with respect to what's happening out there, because we are actually also attracting very high-quality and talented people. Now, as I said to you, having said that, I do think we can organize the way in which we pay physicians and that we pay for academic research in a way that's much more conducive to high-quality research and better quality health care than using the fee-for-service system. Again, I point you to the article you make reference to and can see at least three or four quotes from different people interviewed in here, different specialists who have left who talked very directly about preferring to be in a salary situation than attempting to have to use clinical fee-for-service practice to make up for the research.

Those negotiations are actively being pursued right now. I hope they reach some conclusion in a timely fashion. I don't know if that will be in the next two months or four months, but there is a plan where the ministry is attempting to address this. We have entered into negotiations. We have commenced those discussions and we're actually quite hopeful of a successful conclusion from the point of view of the academic health science centres, these very important specialists, and from the point of view of the public and the ministry.

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Mr Jim Wilson: There continues to be a great deal of concern out there concerning the issue of delisting certain services now covered by OHIP. I guess the concern stems from the memo that was sent from the health insurance division of the Ministry of Health back on September 30, 1991. In that memo electrolysis was mentioned, which now has been delisted, and I think there was really all-party agreement for that, so that's not an issue at this point.

But other services that were under consideration, I guess, and I assume still are under consideration for delisting, were removal of tattoos; sex reassignment surgery; sterilization; reversal of sterilization; in vitro fertilization; reduction mammoplasty; augmentation mammoplasty; repair of torn earlobes; newborn circumcision; male mastectomy, benign, and about six or seven that are on the page of the memo I have a copy of. Once again, I think it's important, Minister, that I give you the opportunity to clear the air on this. Can you assure people these services won't be delisted over the term of your mandate?

Hon Ms Lankin: I appreciate your giving me the opportunity to once again reassure you that the process we have undertaken with respect to this and any other issue we look at in terms of insured services is one that will be based on, first of all, good, documented, epidemiological evidence as well as full and thorough discussion with affected parties.

I have said time and time again that I will not be dissuaded from asking questions about how we can better organize ourselves to deliver health care services and what are appropriate services and what may not be. I tell you that the list was generated as a result of one such question. I asked the question at a certain point in time, what did we pay for or cover in Ontario that was different than in other provinces, in both directions, ie, what might other provinces cover and consider appropriate as insured health services that we don't and what do we cover that other provinces don't? That generated that list and I think it is interesting to take a look at that question and it is right to be able to explore that.

Having said that, I'm not at this point in time actively pursuing delisting of any particular insured service. I do think there are some questions that can be raised with respect to what kind of criteria have been applied with respect to various insured services, whether or not we're getting good results for the resources we invest, and that is an issue that is much broader than that particular list.

Mr Jim Wilson: Minister, I don't think --

Hon Ms Lankin: I'm not finished yet, Mr Wilson; sorry.

Mr Jim Wilson: You've had a great deal of time to answer the question.

Hon Ms Lankin: That is the issue that is being explored by the establishment of ICES at this point in time, which is the Institute for Clinical Evaluative Sciences.

It's fine by the sort of tyranny of fear etc to say, "Don't look at anything; everything's sacred," but I think it's really important as we go through this period of time to really be allowed to look at things and to involve people in discussion. I am not at this point in time moving ahead with delisting of any further insured services.

Mr Jim Wilson: Okay, I appreciate that. I don't think people are arguing with the parameters you speak of and I don't think people are arguing that we shouldn't look at certain services. I think everyone would recognize that's your right as health minister.

The concern comes from, who are you consulting with other than ICES? Who else are you consulting with? We see the example in Oregon. They came up with their list of services, those that the state would cover for those previously uninsured individuals in the state and the list the state would not cover under its medicare plan. Our concern is that you're not discussing with the public.

I'm going to ask you, before you delist any services other than electrolysis, which has been delisted, will you undertake a comprehensive public consultation, much like that which was carried out in the state of Oregon? They had citizen senates and spent several years -- I think three good, solid years, it could be argued, and more -- reviewing this, looking at the data available. I know you're generating the data now. That's a good thing. I don't think anyone argues with that. But will you undertake extensive public consultation?

Hon Ms Lankin: Not of the Oregon type, because we're not going to undertake, I hope, an Oregon exercise in this province. I hope we never get to the point of having to make those kinds of decisions of an absolute cutoff above and below a line and a list of what's covered and what's not. When you say we're only undertaking consultation with ICES at this point in time, if I could just clarify, we have asked ICES for information and epidemiological studies with respect to various kinds of insured services. That may lead to some appropriate adjustments with respect to medical guidelines and standards, as we've put out recently a guideline for the medical profession with respect to cholesterol and other testing.

I think that may and should occur as a result of this process. It may not be something for which we would undertake three to four years of comprehensive public consultation. If we were to undertake to delist a major insured service like psychotherapy, a very large activity which is not on the list -- psychotherapy is not on the list; I'm using that as an example that's not on the list.

Mr Jim Wilson: No, but psychoanalysis is.

Hon Ms Lankin: Psychoanalysis is a form of psychotherapy. I'm using the broader definition. I'm suggesting that not to read into it that we're looking at delisting it. We are not. It's just one code activity. If we were undertaking any initiative with respect to something that is as widely accessed as services, we would have comprehensive consultation with the public. If it is something that is a more narrowly accessed service, then we would attempt to consult with those people in the communities who are directly involved in accessing that service.

Depending on recommendations and what comes forward, we would tailor the response. But I would not see a major initiative of delisting of numbers of items without having a large public consultation.

Mr Jim Wilson: I do want to ask you a question specifically put to me by my constituent Mr Donald Alderson from Alliston. It involves the government's recent decision to tighten the rules for residency for those seniors who spend a great deal of their winter months in Florida, the residency requirements now in Ontario so that they can retain their OHIP privileges. I just want to read from Mr Alderson's letter. It says:

"Most winters I spend approximately 170 days in Florida. As a result of this new residency law, I'm unable to visit another country or even another province in Canada for a period of three to four weeks. This certainly will hamper Canadian tourism."

He goes on to talk about the significant contribution that seniors make, that it really isn't possible to spend any less than 170 to 175 days per year in Florida because of the cost of maintaining a residence. He argues that one has to be allowed to stay there for a lengthy period of time. His final comment is, "There seems to be a constant erosion of the privileges afforded seniors." It goes on to another topic.

Do you have any comments on that? What message will you send to seniors? Actually, I have several letters; I just picked one from one of my own constituents.

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Hon Ms Lankin: I think the administration of our health insurance plan has been an issue that has plagued a number of governments and has begged to have some clear rules and consistency in application.

I think the steps we have taken with respect to restriction on out-of-country payments is one on which initial concern was raised by a number of people. But I feel from the correspondence I've received that public opinion and even the opinion of those most directly affected, like long-term semiresidents or visitors to the state of Florida, has come around to support the direction of the government with respect to having a consistent application that supports access to services at the same rate you would have if you were here in Canada.

The reason for that has been our attempt to ensure that we are not subsidizing a for-profit American hospital system with Canadian taxpayers' dollars. With respect to the residency requirement, it arises --

Mr Jim Wilson: Which was my question.

Hon Ms Lankin: I'm sorry, Mr Wilson, it is all related to out-of-country and to the changes that we made on out-of-country OHIP application. I think it is in that context that the question needs to be answered.

As the previous government made a decision to move from OHIP number to an individual health registration card and health number, it became necessary to define eligibility for the health number. That eligibility has always been defined as someone who is a resident of Ontario. The definition of resident therefore became a question and had to be clarified.

We thought a fair definition was someone who spent at least six months here as an active member of the Ontario community, economy, society and that would be a viable definition of residency. We have certainly indicated that where an individual has a case to make if a claim is denied on the basis of lack of eligibility on the residency clause, that can be appealed.

Individual circumstances can be taken into account. I just suggest to you that if the cutoff was five months, there would be some people who would make a case. If the cutoff was four months, there would be some people who would make a case. It is a question of defining what an Ontario residence is. If public opinion suggests this is wrong, and I haven't seen that, I'm willing to look at it. But we think a definition of half of the year is a reasonable definition of residency.

Mr Jim Wilson: Thank you, Minister. Mr Chairman, I believe my colleague Mr Arnott has some questions.

Mr Ted Arnott (Wellington): How much time do we have?

The Chair: Four minutes.

Mr Arnott: Minister, I have a couple of questions. I hope I can get the answers I require. With respect to the ministry's announcement of the Guelph hospital redevelopment almost a week ago now, the statement in the ministry's news release stated that the ministry has reserved $58.6 million in capital funding for the Guelph hospital. Can you tell me as clearly as possible what exactly that means, that the money has been reserved?

Hon Ms Lankin: I'm not sure I understand your question. There has been an allocation of capital dollars to achieve the redefinition of the roles of the two hospitals, which necessitates capital redevelopment to consolidate all of the acute care and ambulatory care services on one hospital campus and long-term care services on the other. The planning process needs to be undertaken to actually accomplish that. That planning will be done within the allocation of $58.6 million.

Any approval of capital dollars in the Ministry of Health -- traditionally there is a capital allocation that's made based on the first assessment of what capital dollars are required. Then the parties move into doing the actual planning, the capital and architectural and functional planning which may require some amendment to that capital allocation.

Mr Arnott: Do the people of Guelph and Wellington county have absolute assurance that there is $58.6 million that's going to be there for the purpose of hospital redevelopment within the next three years?

Hon Ms Lankin: Based on the functional plans and the planning process, if that money is required, yes, up to $58.6 million. We will not say, when we get in and plan with them, that if what's needed in the community actually produces a plan that would cost less, the other money would be spent in an unnecessary way. But that money is secure and is in place, yes.

Mr Arnott: Does the ministry have a timetable setting out realistic deadlines for each stage in the planning process as we move ahead?

Hon Ms Lankin: We will be guided somewhat by the community and the partners themselves in that.

The next step is to try to deal with the issue of board governance and the transfer of responsibilities there. We believe we will receive ongoing assistance from Mr Blundell in that respect. We're hopeful to move ahead in an expeditious way at this point in time, but we actually need the communities to be involved in setting those deadlines.

Mr Arnott: Is there any possibility that this project will be fast-tracked by the ministry in any way given the receptiveness you have received to plan with and the comments you have made in the past?

Hon Ms Lankin: I actually don't know how to answer that question, Mr Arnott, because I'm not sure what will be required in the planning process until Mr Blundell has a chance to work with the two boards to see how easily we can facilitate the process of transfer of responsibilities. We will continue to work away at it. It won't be put on the back burner. Whether or not it will require any expediting I'm not sure either.

Mr Arnott: Thank you very much.

Mr Wayne Lessard (Windsor-Walkerville): Madam Minister, recently I met with members of the AIDS Committee of Windsor. They were interested in pursuing a proposal for a needle exchange program in Windsor. I think this is an AIDS prevention and control program that our government supports.

It's my understanding that the funding for those types of programs rests with the public health branch. I think that as far as the estimates book is concerned, that's what is on vote item 2003-6. That's the one that deals with the public health section of the ministry and it funds support services to health units, for example. It's my understanding that as a result of the funding being in that section of the ministry, that funding can only be provided through local health units. In the example of Windsor, that would be the Windsor-Essex County Health Unit.

The health unit takes the position that they would only operate this needle exchange program at the offices of the health unit. It would be on the second floor of their offices, which is located on the main street in the city of Windsor. The members of the AIDS committee, who are part of an AIDS and injection drug-use working group, don't think that's an acceptable place to have that program. They've proposed to have it at a different location, but they wouldn't be able to do it at a different location because the health unit wouldn't be able to provide them with funding to do it there. That's the reason the health unit was proposing to have the needle exchange program at the health unit office, because it requires the staff from the health unit, pursuant to the collective agreement, to administer the program.

It seems to me -- and this is the way it was explained to me by the members of the AIDS committee -- that the only way to try to resolve this is to be able to have the funding available from a different branch of the ministry so that it could go directly to a community agency rather than through the health unit branch.

I have written to you with respect to this issue. I haven't received a response so far and I wonder whether you've had an opportunity to consider this.

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Hon Ms Lankin: Yes, thank you, I have seen the letter you wrote. In fact, I have signed a response. You should be receiving the response soon.

There are a couple of ways to try and get around the problem you flag in your question. The suggestion that perhaps in the future money for needle exchange programs flow directly to community-based organizations that could carry out the programs is one possible way of handling the situation. Another is what I think is actually happening, from my understanding, in Windsor: The community and the public health unit have continued discussions and have been trying to work out the problem with respect to the place of delivery of service and the classification and collective agreement implications for the staff who become outreach workers to deliver those services. I'm hopeful that a solution has been found in the Windsor area that actually gets around the problem and that we will see that program delivered.

If we can find those kinds of flexible solutions, to continue to flow the money through public health is an appropriate activity. It is a responsibility of public health. They are community-oriented, prevention-oriented health deliverers. If we find, however, that our ability to provide sensitive service in the flexible way that needs to be done around programs such as needle exchange is inhibited because of the vote activity -- where the money is placed -- then I think we can address that in the future.

I look forward to your keeping in touch with this issue. I think the discussions have proposed a possible solution. That will be discussed in the very near future with the AIDS committee. If it's acceptable to them, we won't have a problem. Perhaps you can keep me informed as to the result of that.

Mr Lessard: All right. Thank you very much.

Mr Paul Wessenger (Simcoe Centre): Minister, I have been meeting with various representatives from district health councils. There seems to be a concern among many of the district health councils that they don't have adequate resources to carry out the planning duties that appear to be given to them. Also, I note that the district health councils have no legislative recognition.

I'm wondering if you might indicate what plans you have or what you're considering with respect to either expanding the role of district health councils or giving them some further defined role in the whole planning process in implementing our health strategies in Ontario.

Hon Ms Lankin: I have on a number of occasions delivered the message of my intent to rely on health councils as a very integral part of the planning process, through verbal means and written requests, sending directions to the hospitals and the health councils to undertake certain cooperative planning initiatives together.

The issue with respect to the lack of a legislative framework for district health councils has been raised on a number of occasions when I've been out visiting district health councils as well. It is an issue of concern to them. Again, some suggestions have been made that they might find a home within revisions to the Public Hospitals Act. That's something I hope you will take into consideration when you and other MPPs are on the road and hear from DHCs. I haven't a response at this point in time to say whether that's appropriate or not, but certainly I see them as being ongoing and continuing partners with hospitals with respect to planning and also to the whole continuum of health services and planning in their communities. It may be that the Ministry of Health Act might be a more appropriate place for them to eventually find a home.

I don't believe the lack of a legislative framework is a problematic barrier to their playing an important role. I think it's the nature of the support that the ministries and other partners in the health community give to the DHCs and the seriousness with which we all take their advice and their recommendations that will help them develop to their full potential in the process.

With respect to the issue of resources, of course this is a time where there are not a lot of dollars flowing around for enhancing transfer payments to various organizations. However, where we are asking DHCs to undertake specific and intensive processes, we have been able to assist them where they have required that assistance. In some cases the DHCs have been able to undertake from within their own resources various tasks we've requested of them. In other cases they have not been able to. For example, just recently we transferred $500,000 to the district health council that is undertaking the process with the Windsor hospitals of looking at planning for further rationalization of services and community consultation to undertake that community consultation.

So we have, where it is required, attempted to deal with the resource issue. We haven't been able to do it across the whole vote for DHCs at this point in time.

Mr Wessenger: Minister, just on a different point, I don't know whether this is really something you can answer, because it relates to other ministries as well. It's a question of the public health units. As you know, they are financed jointly by both the Ministry of Health and the municipalities, and generally Ministry of Health dollars flow in accordance with the municipal funding in many instances.

Hon Ms Lankin: I'm sorry, public health or district health?

Mr Wessenger: Public health. The provincial funding is dependent, in many instances, on the level of municipal funding, and I know there have been some concerns expressed by various public health units that because of the cutback in municipal funding they're not able to fulfil their mandate. At the same time we're looking at the disentanglement process, and I'm wondering if this is an area of discussion with respect to the disentanglement process that could be one of those areas that could end up becoming a provincial responsibility.

Hon Ms Lankin: I'll ask the deputy to add to my response any details that may be helpful to the committee. There is a difference from municipality to municipality. Metropolitan Toronto is funded at a different ratio than other municipalities.

I think you're correct to flag it as a potential issue for disentanglement discussions. It has not been an issue that is central to those negotiations at this point in time, although it is one I have flagged for the government ministries that are involved in those direct negotiations with the Association of Municipalities of Ontario as a potential issue -- that they should remember there is a joint jurisdiction here.

On the one hand, while the public health units are experiencing some problems as a result of differential treatment from municipality to municipality in terms of municipal decisions, I want to assure you that with respect to mandatory programs we have continued to finance those, and this year, again, at 100%. The new money is going in for new mandatory programs, expectations that the province has, and the funding has been put in place. But it still remains an issue, and that is overlapping jurisdiction and accountability, and I know that gives cause for concern to some public health units.

Mr Michael Decter: I would just add that Dr Schabas, our chief medical officer of health, and I met recently with the leadership of the association and we addressed a number of concerns, but we have assurances that the money that's in our budget for this year will be able to be flowed, that there won't be a situation in which provincial dollars are not capable of being spent because the municipal matching isn't there. We wanted to be certain of that, and we have those assurances.

Mr Wessenger: Thank you. I appreciate that.

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Mrs Sullivan: I wonder if we could move on to an area that I think is one the last government put some attention to and about which there is still great difficulty in the communities, and that relates to cancer treatment.

We certainly know and have a lot of evidence from individual case requests that frequently, even after surgery is done, whether it's a situation of being referred to a regional centre for chemotherapy or radiology, those services are not available for some time and without a number of waits, to a point where, in some cases, patients are at risk.

We also know that frequently there is enormous travel time required because a space may be available within a regional centre for the delivery of treatment services in another community that is not available at a regional centre closer to the home base of the patient. In my community, by example, two patients within the past very short period of time have had it suggested to them that Sudbury is available for services, for radiology services in particular, and that basically is the only option available to the patient. There doesn't seem to be an ability to shift resources from one centre to another in terms of extension of services that could be offered at a regional centre because of population demand, and there's no consideration, of course, for a southern patient in terms of transportation assistance. There are additional costs associated with housing. To be away from home base and from family at a traumatic time is considered to have an impact on the patient recovery alone.

I wondered if you would comment on those issues and indicate how, whether it's through the treatment and research foundation or through other of the cancer delivery centres, the government is intending to address those issues. They're clearly widespread.

Hon Ms Lankin: Again I'll ask the deputy to fill in, in terms of additional information that may be of assistance to the committee.

Let me begin by acknowledging that the management of treatment of cancer patients is an important priority for government, has been since the days of the previous government and continues to be under this government.

I want to assure anyone who read press comments with respect to concerns raised within the report of a public inspections panel that went into the Northeastern Ontario Regional Cancer Centre that 293 patients were being referred out of province to the United States for treatment that the comments are completely incorrect. There is not a case in which patients are being referred out. In fact, if you read the clippings of Sudbury papers of the last day or so, you will see a complete retraction on the part of the administration of the treatment centre and an explanation that the panel misunderstood their remarks and that they were talking about additional capacity, people they could treat with staff being added to their facility.

A very successful strategy that was undertaken by the previous government with respect to management of provincial resources was with respect to cardiac care and the cardiac care registry that was set up, which allowed us to identify capacity in the system on a provincial basis and to match patients requiring treatment to that capacity where it was available in the province. I think that is a model that is to be commended and has served Ontario well, and it is a model we are implementing with respect to the ability to redirect cancer patients for treatment to where there is capacity in the province.

I'm sure the member will understand that where we have at this point in time growing requirements for capacity, it needs to be an ongoing issue to be managed in terms of enhancement of services through the administration of the regional treatment centres under the Ontario Cancer and Treatment Research Foundation. That is an ongoing issue in terms of their budget-setting and their plans for enhancement.

You will be pleased to know with respect to the issues you directly raise of your constituents that there is an additional linear accelerator coming on line in Hamilton within the next couple of months. It's in the process of being brought up and running now, which will provide excess capacity to treat people in that part of the province. Additionally, there is a machine in the Northeastern Ontario Regional Cancer Centre in Sudbury that has not been funded by the ministry through OCTRF and has not been up and running. We recently gave approval through OCTRF to undertake the hiring of staff. Those discussions around the budget, setting the budget and implementing it in order to hire staff, are taking place right now.

I don't have the most recent update. As of a week ago, we were awaiting budget information from the centre. I don't know whether that has been received or whether the ministry has responded, but we expect --

Mrs Sullivan: Could you just clarify that again? I gather there was a fund-raising campaign in the Sudbury area, or something, to raise the capital for a machine, and the ministry has provided or has guaranteed provision of operating dollars. Is that what you're saying?

Hon Ms Lankin: That's under negotiation in terms of the number of staff and the budget, the actual amount of operating dollars. The machine itself, just so you know, was provided locally and put into the regional centre without being part of the provincial plan of where the next expansion of services should be. The example I gave of the next priority was for us to get the Hamilton machine up and running in terms of matching capacity to demand in the provincial area.

The Sudbury machine is there, however, and we have now given approval, about a month ago, to put the operating dollars and the staff in place so that there will be greater capacity. At the same time, we're working with OCTRF on the cancer network.

Mrs Sullivan: That goes back to all sorts of arguments about lithotriptors and things and CAT scanners from previous days. I think I'll just leave that one alone.

The Chair: Yes, I would.

Mrs Sullivan: Some of them went into my community.

Hon Ms Lankin: I was going to say, the member sitting beside me has very definite opinions about lithotriptors so perhaps you would save me from that.

Mrs Sullivan: The other area moves beyond cancer to hospitals generally: I'm thinking particularly of Princess Margaret Hospital and the redevelopment situation there. The announcement of the redevelopment of Princess Margaret indicated there would be capital dollars available. It talked about the $126 million that would be flowing and the 16 new radiation therapy machines, the availability of those machines to accommodate 7,000 new patients a year. However, somewhere in this release it says the hospital must find ways to fund the operating costs of additional beds through innovative use of its current operating budget.

A very similar kind of sentence is being included in all your public hospital capital announcements. I'm particularly interested in this question in relation to cancer services. Has there been any analysis done within those institutions or within the Ministry of Health to suggest that in fact after your government leaves, the next government won't be called upon to provide those operating dollars?

Hon Ms Lankin: Specifically with respect to Princess Margaret, I'd like to make a couple of opening comments and then ask the deputy to provide you with information, because he was directly involved in discussions with the parties there. I'm actually very pleased about the process that was undertaken arriving at that determination, that we could provide the capital dollars and rebuild the institution and the services could be provided within the existing operating allocations.

I want to assure you that the principals of the hospital, the district health council and other health partners in the Toronto area and regional area that were involved in those discussions, felt it was a good process to arrive at that conclusion and recommendation. What they wanted most from the ministry, once they had arrived at the decision to recommend it, was a very quick response assuring them of a go-ahead on the project, which we did. As you may know, the sod-turning was on Friday of last week. It was a very important and exciting event for the community of the Princess Margaret Hospital.

Perhaps the deputy can give you some more information about the process we undertook there.

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Mr Decter: Yes. This project was at tender when the guidelines were announced in January and the tender should actually have been received, so we had a very short period of time in which to look at the question of the additional beds and the increased operating cost that was sought in the original approval.

We asked a panel of three talented individuals to have a very quick look and meet with all the parties involved and to give us an answer really to the question of whether the project should proceed as planned, should proceed on some other basis or should go back to the drawing-board.

The three individuals were Dr Edmond Clark, who is the chief operating officer of Canada Trust, but has served previously in the government of Canada and sits on the board of one of the other hospitals in town; Patricia Main, who had some distinguished service with the Toronto DHC, and Murray MacKenzie, who had the dual talents of being a CEO in a hospital -- I believe North York but someone will correct me if I'm off -- and had also been the chair of the Ontario Cancer Society, so someone with a good working knowledge.

They met with all the parties involved, the Princess Margaret and the adjacent hospitals, because the question we were faced with was, if there are beds vacant in Mount Sinai and Toronto Hospital, why would you build new additional beds on University Avenue, why wouldn't you enter into cooperative arrangements to utilize beds that are already there?

The answer we got back was that there are already strong linkages between the Princess Margaret and the other hospitals and those can be built on and enhanced. The advice we received was to approve the current level of beds in the new facility, but to build out the full building; that is, there will be a capacity, some additional space, in the new building that could be allocated either to beds or to additional research space. The trend in cancer care is towards outpatient, as it is in other areas of treatment, and we're hopeful that by the time the building is up that space may well be required for researchers because of the enviable reputation of the Princess Margaret for attracting the best and the brightest and also the resources to support them.

It would be a decision to be taken down the road as to whether, if additional beds were required, additional operating funds would be required, but as it stands, what the Princess Margaret will have is a new and first-class facility with the same number of beds. We believe and they believe that can be operated within the existing operating budget. In a new building there are some economies, logistical and energy efficiency and so on, but we will continue to work with them on the detail of the budget, as we are working with other hospitals that have new buildings coming on.

So it's not inconceivable that down the road there might be a decision by the ministry and the minister to review that. We look at everybody's operating budget as circumstances change, but we think that it's affordable within the current resources. That's our best view and confirmed by an independent group we had confidence in.

Mr Jim Wilson: Mr Chairman, you had indicated to me earlier today that you had one question you wanted to ask. I wonder if we could get all-party consent to --

The Chair: Yes, if it's in the 15 minutes left that are allocated to Mr Wilson's caucus, do I have unanimous consent of the committee for me to use a moment of his time to put a question? Otherwise, I'll leave the chair and go through all that. Is that okay, just a brief question?

Mr Jim Wilson: The NDP wants to screen your question first, Mr Chairman.

The Chair: Seeing no objection, Minister, Mr Wilson raised a question earlier with respect to the residency requirements for an Ontario health card. I believe I may have heard you correctly when you indicated that certain polling data and public opinion supported your adjustment.

In the last two days my staff have been in contact with your ministry and we're having difficulty getting some answers. So, with your permission, I'll put a couple of these questions on the record for your staff to consider, if you could get back to us.

It's my understanding that the dates for classification for residency were moved from eight months to approximately six months. That's a substantive adjustment. If you could indicate to the committee the basis on which the decision was made, when it was made and what cost implications are there -- we're talking about disfranchised. We're not talking about not paying the medical fees of someone who's out of province; we're talking about them being ineligible for an Ontario health card.

We could be talking about a substantive number of Ontario residents who, by virtue of days or months or weeks, may be disfranchised from all their benefits. If that is in fact the understanding, were you able to do an economic impact on that and could you share with the committee what your projected numbers and/or savings are -- which could be translated into the number of Ontario residents who previously enjoyed an Ontario health card and who now would be relieved of it -- and could you indicate what efforts your ministry has made in terms of public notice of this matter, in fact how they were informed that the residency date was changed?

Also, I'm hearing that the concept of what constitutes a residence has been changed. It would be helpful if you would clarify that, because most trailer parks in Ontario are open for five and a half months and since the six months becomes a benchmark --

Mr O'Connor: I asked this question last time.

The Chair: Well, no. Frankly, I don't really want to do this in the House. I have a whole series of things I would prefer to just put on the record, Mr O'Connor.

Could we get some very clear language in terms of what constitutes a residency? And since you're responsible for long-term care, could you be rather specific with what we're understanding is your encouragement for families to live together outside of institutional care so that they can have family members supporting other family members? It would almost appear that one ruling pulls at the direction of the nuclear family growing a little and getting us through the deinstitutionalized future that we're being told is at the core of community-based health care.

Finally, could you indicate if there are any legal examinations with respect to the Canada Health Act and the spirit of the Canada Health Act where someone's call, for any reason, to be out of Ontario in another province would constitute grounds for them losing their Canada Health Act benefits in their so-called resident province, because it's possible for a Canadian to not be disputed as a Canadian but, residency catch-22, become ineligible for health care benefits. Perhaps you could share with us any legal opinions that no Canadian could be so disfranchised.

Ultimately, if it's of any value, was there any consideration of the free trade agreement which now says that Ontarians can pay their taxes in either jurisdiction, and is that somehow tied to your government's decision?

I appreciate the opportunity to get those on the record and I'd be pleased to discuss with the deputy in further detail any studies, notices, proper definitions and cost savings, if any, and the impact on the Canada Health Act.

Thank you very much, committee. I'll turn this back to Mr Wilson with his 10 minutes remaining, in recognition of the fact that the House may call us for a vote at about 10 to.

Mr Jim Wilson: Thank you, Chairman. I note with humour that your question is about as succinct as the minister's responses.

Hon Ms Lankin: I'm glad you noted it.

The Chair: You shouldn't have given me the chair.

Mr Jim Wilson: But an excellent question, Chairman, and I'll be looking forward, as you are and as our constituents are, to the response from the ministry.

Minister, I have a couple of questions really concerning long-term care redirection and the policy of your government. I want to do this sort of in a non-partisan manner. In the consultation paper issued last December, one of the goals of the process which were listed was a "continued preference for not-for-profit service delivery."

Minister, I'd like to hear your opinion whether the emphasis is on continuation or on the preference. Specifically, do you intend to continue maintaining a balanced system with a mix of not-for-profit and commercial providers, or do you plan to prefer the not-for-profit agencies by changing the system so that it tilts more in their favour?

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Hon Ms Lankin: In the process of the consultation we undertook, Mr Wilson, we actually heard extensive opinion on this particular subject. It may be because it was one of the issues that was flagged in the consultation paper, and it may be fair comment on anyone's part to suggest that, but I have to tell you that the opinion we heard back from the community out there and from seniors, their families and providers was overwhelming in terms of the preference for not-for-profit delivery of these services.

We have some problems with the current mix of commercial and not-for-profit delivery mechanisms in place right now that I think you will appreciate, if I can share some of them with you. It's a challenge in terms of the long-term care redirection and enhancement of services.

You asked a specific question, whether my preference is for expanding not-for-profit or a continuation of the current mix. The problem we've seen over the last number of years, particularly since 1986 and the implementation of the integrated homemaker program, is actually a very rapidly shifting balance towards the commercial sector in certain geographic areas in the delivery of service -- these are in-home services I'm talking about -- in particular in large urban areas as opposed to the harder-to-serve rural and geographically dispersed areas.

It has a particular challenge for public policy and government provision of services or ensuring of provision of services: to find a way to keep the not-for-profit sector stable with a sizeable or significant enough market share to be able to continue to deliver the services to the hard-to-reach and more expensive delivery of services in rural and northern parts of the province when large parts of the market share are being taken up by a relatively small number of commercial operations in large urban areas.

I don't have a solution to this yet, but through the consultation we heard from many of the not-for-profit operators -- the Victorian Order of Nurses and others -- about the need to ensure stability in the not-for-profit sector to be able to make sure we can deliver in those areas that the commercial operators are not delivering services in. To be fair, we also heard that there is a need for the not-for-profit sector to be more flexible in the way it delivers its services. I think there are some interesting challenges on both sides of this issue that we need to grapple with.

Mr Jim Wilson: You envision continuing the mix, as I understand your response. Can you give assurances to the commercial agencies that are currently operating that there isn't a movement in your ministry or from you to put them out of business? Frankly, that's the language they use when they write and speak to us. They are very concerned. Frankly, I don't know whether it stems from any reality or whether they're extrapolating from what they believe to be NDP philosophy in these areas.

Hon Ms Lankin: Okay. I think the first statement you made was that you took from my answer that we're going to continue the mix of services. I think the answer I gave you was identification of a number of problems with the current situation. I don't think we can continue to have a --

Mr Jim Wilson: I was being nice to you.

Hon Ms Lankin: But I want the record to be clear that I didn't say that, because I see our being presented with some problems that we have to figure out some policy answers to. No, we're working on the policy answers, and decisions haven't been taken that will have an immediate impact on those sectors.

Mr Jim Wilson: Well --

Hon Ms Lankin: Let me answer the second part of your question, which was, can I assure people that I'm not taking decisions right now that are immediately going to put them out of business? You indicated that you're hearing a lot of concern out there. I'm surprised at that, because there really are, in terms of substantial activity in the commercial and home service sector, four commercial operations involved here. Although they are taking over a growing share of the market of delivery of services in large urban areas, their activity with respect to government-funded delivery of services is not the majority of the business they're in. It's less than 50% of their activity.

Mr Jim Wilson: But it's a significant part.

Hon Ms Lankin: Yes, I think that's fair. It varies from company to company, but it's less than 50% of their activity. They are involved in enhanced delivery of services. I think there is a continuing market for those firms, depending how much they are involved with government-funded services.

I've been very frank to put on the table for you the kinds of issues we face, from a policy perspective, in terms of ensuring continued quality of care across the province and in terms of ensuring that we have a viable not-for-profit sector involved in the delivery services, particularly as we continue to shift the institutional services that are currently covered under the Canada Health Act and assured to be non-profit administration to the community delivery of services, and which of those services should be maintained within that sphere. There are a number of policy issues there that need to be sorted through.

Mr Jim Wilson: Minister, I don't think that's a lot of assurance for the commercial agencies that are currently operating. I guess I don't understand where the problem is with having the mix we now have. Can the private sector not be involved in health care and deliver it efficiently and effectively?

You mention that you're worried about ensuring that the not-for-profit sector is stable. You worry me when you say that although you believe there's a continuing market out there for the commercial delivery of services, you're a little less clear on whether the government will continue to use commercial agencies to deliver services.

Hon Ms Lankin: I think I've said to you very clearly that in the consultation these issues were put squarely to the government and that the overwhelming recommendation was that we should be delivering all our services through the not-for-profit agencies. What I've identified for you are some of the policy reasons that lead people to make those recommendations, and they're issues that government needs to grapple with. You say you don't understand some of the concerns. Maybe I can try and articulate them again. Over the course of the history of enhancement of in-home services, and particularly since 1986 and since the introduction --

The Chair: Is this a short history, Minister? We've got about half a minute before we're called to the House.

Hon Ms Lankin: Yes, it is.

The Chair: Good.

Hon Ms Lankin: Since the introduction of the integrated homemaker program, we have seen a very rapid escalation of the activity of the commercial sector, so rather than talking about continuation and activity, they have been taking over more and more of the delivery of services.

Mr Jim Wilson: Is that good or bad?

Hon Ms Lankin: It's a problem because they're doing it particularly in large urban areas where the unit costs of delivery of service, because of geography and other reasons, are lower. What it means is that the not-for-profit only delivers in the more expensive areas of delivery of service, where geography and others place challenges to the cost per unit of delivery of service. You have an instability happening with the ability of the not-for-profits to maintain market share and maintain their ability within the same funding per diems of services that the commercial sector has. I think that should be a problem for all of us so we're trying to grapple with that right now.

Mr Jim Wilson: I understand --

Mrs Sullivan: Are you only concerned about integrated homemakers? Is that what you're just saying?

Hon Ms Lankin: No. I'm saying that in-home services, which is homemaking -- in integrated homemaker it's broader but it has become a more noticeable trend since integrated homemaker has been introduced. That's where the biggest growth of the commercial activity has been since the introduction of that program.

Mr Jim Wilson: Minister, just this final comment, then, very quickly: Could it not be, though, that during the consultations on the redirection paper, as you say in your own words, you had an overwhelming impression or overwhelming number of recommendations, from people who partook in the consultations, raising these concerns about stability and continuing viability of the not-for-profit sector, I guess, mainly because, in your own admission in answer to the question, you note there aren't that many in terms of numbers of commercial agencies delivering these services? Could it be, if you're just looking at numbers and the numbers of recommendations you receive, that a lot more people are involved in the not-for-profit sector and took the opportunity to speak and voice their concerns at the consultations?

Hon Ms Lankin: I think that in terms of sheer numbers as opposed to percentage of activity, you would be right in making that comparison. I should point out to you that we heard those comments very clearly, not just from not-for-profit providers who would talk about the issue of instability -- without doubt they would raise that -- but also from consumers, from seniors and their families in terms of a preference for the way in which services should be delivered to them in their communities. So it was more than the not-for-profit sector itself that was saying this, but I would acknowledge that in terms of numbers of voices, the commercial sector would be a smaller number of voices, although it has a growing share of the market activity.

The Chair: Perhaps, Madam Minister, it would be helpful to the committee if there's any information you can share with the committee with respect to any committee or any group within your ministry that is studying the issue of the commercial participation in health care: if such a committee exists now to discuss these matters and if it has terms of reference or a budget or a guideline.

Hon Ms Lankin: I think this comes back to the allegation that there's a secret task force. There is no secret task force. As a result of long-term care consultation, some of these issues have in fact been raised in the consultation. They are policy issues, along with a lot of others that government is currently working on. When policy decisions have been taken with respect to the long-term care redirection, we will be providing that to members of the Legislature and the public.

The Chair: Had you allowed me to finish, I would have indicated, if anybody is studying these matters, if those individuals who are in fact studying them or considering them or analysing them or have been contracted out to do same, if you could -- I don't doubt that there is no secret operation. I'm just simply saying that either this stuff is collecting dust in a file cabinet or somebody is looking at it and analysing it and putting it into a synthetic arrangement for you to consider. That's merely what I said would be helpful for the committee.

Mr Jim Wilson: I have doubts.

The Chair: Well, the Chair doesn't have doubts. He just seeks clarity from time to time.

If there is unanimous agreement, we will adjourn until 3:30 or immediately following routine proceedings tomorrow to reconvene for the estimates of the Ministry of Health. This meeting is adjourned.

The committee adjourned at 1755.