Assemblée législative de l'Ontario

MINISTRY OF HEALTH

CONTENTS

Tuesday 5 October 1993

Ministry of Health

Hon Ruth Grier, Minister

Michael Decter, deputy minister

Michael Ennis, assistant deputy minister, corporate management and support group

STANDING COMMITTEE ON ESTIMATES

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

*Vice-Chair / Vice-Présidente: Arnott, Ted (Wellington PC)

*Abel, Donald (Wentworth North/-Nord ND

*Bisson, Gilles (Cochrane South/-Sud N)

Carr, Gary (Oakville South/-Sud PC)

Elston, Murray J. (Bruce L)

*Haeck, Christel (St Catharines-Brock ND)

*Hayes, Pat (Essex-Kent ND)

Lessard, Wayne (Windsor-Walkerville ND)

Mahoney, Steven W. (Mississauga West/-Ouest L)

Ramsay, David (Timiskaming L)

Wiseman, Jim (Durham West/-Ouest ND)

*In attendance / présents

Substitutions present/ Membres remplaçants présents:

O'Connor, Larry (Durham-York ND) for Mr Lessard

Sullivan, Barbara (Halton Centre L) for Mr Elston

Wessenger, Paul (Simcoe Centre ND) for Mr Wiseman

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

Also taking part / Autres participants et participantes:

Bradley, James J. (St Catharines L)

Marland, Margaret (Mississauga South/-Sud PC)

Clerk / Greffière: Grannum, Tonia

The committee met at 1540 in room 151.

MINISTRY OF HEALTH

The Chair (Mr Cameron Jackson): I'd like to call to order and reconvene the standing committee on estimates. When we last sat, we were in the process of consideration of the estimates of the Ministry of Health.

I remind the committee that we have two hours and 52 minutes remaining of the time that has been allocated to us by the House to complete these estimates. From our last sequence of rotation, I believe we'll begin, if it's agreeable, with a half-hour segment for Ms Sullivan and the official opposition.

I would like to welcome Mr Decter, the deputy minister, to the table because he was unable, with other responsibilities, to be with us at the front end of our estimates. I would like to officially welcome him to these estimates along with the minister.

If there are no questions at this point, I'd like to proceed. Before Ms Sullivan, though, are there any items which were raised during the previous time allocated for estimates that the ministry came today with any responses to? Have any of those been prepared?

Hon Ruth Grier (Minister of Health): My understanding was that we'd addressed most of them. I'm not aware of any outstanding ones. Certainly I'm sorry; I have not come with any today.

The Chair: No, that's fine, Minister. If those persons who made requests would like to raise that issue, they can when it comes to their time in the rotation. I'll recognize Ms Sullivan.

Mrs Barbara Sullivan (Halton Centre): The first issue that I want to turn to is the impact of Bill 48, the social contract bill, and the recent regulations on ambulance service in Ontario.

As you know, under the Ambulance Act and the regulations to the Ambulance Act, there are specific definitions of an "emergency." I will read from regulation 19 of the Ambulance Act which says, "`Emergency' means a situation where delay in responding to a call for ambulance service could endanger the life, limbs or vital organs of patients."

The social contract bill indicates that where an employee performs a critical function as prescribed by the regulations and the employer is unable to meet those critical functions through the unpaid leaves of absence, the employee can be deemed to be critical under the regulations and the employer has the option of initiating special leaves.

We were all quite taken aback, and I understand that the ambulance operators in fact only latterly have received the regulations, to discover that in the regulations under Bill 48, "`Critical function' means services or activities that, in the opinion of the employer, must be performed in order to prevent the injury to or the death of people or the destruction of property, or to provide an emergency intervention to prevent the worsening of an injury or an illness."

The regulations go on to say that there has to be adequate training and so on. Clearly, the adequate training is covered by the regulations to the Ambulance Act. I have several questions with respect to this decision which to me seems to be fairly sloppy thinking on the part of the government.

The first is, why is the government not deeming or declaring by regulation certain employees to be exercising critical functions? The leader of my party has indicated that the ambulance attendant is one who, for all purposes, would be understood to be exercising a critical function, as would be firemen or policeman in the course of their duty. I'm particularly speaking about the ambulance attendant who, by the regulations under the act, is clearly operating with a critical faculty associated with the work.

Why then, in the first question, has the government not declared the ambulance attendants to be a critical function? Why are they leaving that to the employer? What standards therefore does the government intend to ensure are put into place with respect to the critical functions associated with the work of the ambulance attendant? Does the government concur that a situation in Mississauga, which has been reported to the House, where ambulances are being sent out on a first-call-response basis with only one attendant to the site of an accident or to answer a call -- does that kind of situation meet the government's responsibilities?

I want to know what the government's standards are with respect to the provision of emergency services and what the government sees as critical and what the standards are, therefore, for ambulance services in providing those services.

The second area, with respect to the same question, is that, as you know, the government has removed substantial operating dollars from the overall ambulance budget as a result of expenditure cuts, and has added a few, but not all, of those dollars back in terms of redistributing resources to those services which are particularly stressed. Despite that redistribution of $6 million out of the $10-million cutback, there are ambulance services where the operators are, on their own, going to the banks and borrowing money to ensure that the services are operating, and many of them, including several that you will know about and many that I know about, are operating in a deficit position.

I wonder what impact studies you have done with respect to the delineation of the ambulance services under the social contract, what kinds of direction you are providing to the services with respect (a) to their deficit and (b) to the standards of service that are being provided, and where you intend to go from here. Are you intending to put ambulance services out of business in communities or to put people at risk? The services in fact will not be able to operate at the standards which were previously required.

Hon Mrs Grier: Let me respond, and perhaps some officials from the ministry then can provide the member with additional detail. Let me assure her categorically that it's certainly not our intention to diminish the level of services provided. In fact, the entire intention behind the social contract was to preserve services and protect jobs.

Let me remind her that the regulation under the Social Contract Act was only about compensation. The regulations and standards of service under the Ambulance Act have not been changed in any way. The purpose of the regulation under the social contract was to assist employers in dealing with the impact of the reductions as a result of the social contract. The member didn't mention, but I'm sure she's aware, that the emergency services did not sign the social contract, and so the impact upon them was greater than if they had.

The definition, even under that regulation in the Social Contract Act, is quite clear that a critical function means services or activities that "must be performed in order to prevent the injury to or the death of people or the destruction of property, or to provide an emergency intervention to prevent the worsening of an injury or an illness."

I think that's a fairly clear set of criteria which enables an employer, as they apply the changes in the social contract, to identify which employees are performing critical functions and which ones are not, and to take advantage of the provisions under the social contract that allow them to defer some of the time off without pay in the case of those who are performing a critical function.

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Mrs Sullivan: Could I interrupt, Mr Chairman, because the minister is to a certain extent reiterating some of the factual detail that I had included in my question. Let me go to some additional factual detail.

The social contract target for ambulance services was well over $3.3 million per year. Over the course of the social contract, we're looking at some $10 million which will be basically clawed back from ambulance services, and which will become due and payable if it can't be met through leaves of absence by emergency attendants at the end of the period.

In the meantime, the number of people who can be laid off, whether by special leave or whether under the original terms of the social contract bill, in fact only meets 50% of the target. With the number of people who can be safely laid off and still provide ambulance service at the reduced rate that you have required as a result of the expenditure control act, they will still only be able to meet 50% of the social contract target. In other words, there will be an additional reduction for 50% of the work that will be, I am told, 44,500 hours of work or 2,782 eight-hour vehicle shifts.

Where are you going to make that up? How are you going to ensure that the standards of emergency care provided through ambulances and ambulance attendants in every community are going to be met? I put it to you that with the regulations, with the expenditure cuts that have already taken place and with the provisions of the social contract bill, you are endangering people in the community because it will be impossible to meet the standards that are required under the Ambulance Act.

Hon Mrs Grier: That's the member's point of view, and I suspect that's the point of view of the ambulance operators --

Mrs Sullivan: And the attendants, Madam Minister.

The Chair: Mrs Sullivan, please, the minister has the floor.

Mrs Sullivan: Thank you. I hope Hansard got it, though.

The Chair: We allow one interjection; you've had your one interjection. I'd like the minister to be given the time to have a full response.

Hon Mrs Grier: What we have asked all ambulance operators to do is to submit to us a plan that can be reviewed to ensure that as they deal with reductions -- the member uses words such as "clawed back" out of their budgets. What in fact has occurred is that the amount of transfer payment that they might anticipate has been reduced, and they have been provided with mechanisms to accommodate that reduction by way of salaries and wages. We then encourage them to look at their entire operation and ensure that they can maintain service while at the same time reducing the amount of payroll they have.

We believe that it is possible for them to do that, and that in many cases the plans submitted to us have not looked at every aspect of their operations to see if there are savings or streamlining or administrative changes that would assist them in meeting the renewed targets. We want to work with them to do that.

We had indicated to them that we did not want them to lay off people until we had completed the regulation-making process under the social contract. That has now occurred. In the interim, there was in fact a $6-million reallocation of funding to enable many of the private sector operators not to have to go to the bank and borrow, which again in their worst-case scenario was what the member had suggested.

In response to the question, at this point predictions that there will be a significant diminution in the level of service by emergency service is not substantiated, and we now believe that we have the mechanisms in place and can work with the operators to make sure it doesn't happen.

Mrs Sullivan: Madam Minister, I suggest to you that if you are indicating that in a health service, an emergency service which is highly dependent on human resources, on trained individuals to carry out the work of providing the service and where the capital equipment requires, under the act, continuous updating and safety precautions, there is going to be a reduction in the payroll, to assume that service will not be reduced in a comparable way is to be living in a dream world.

Every dime that is taken out of payroll is a dime's worth of value in reduction of service. If you, as many people, already suffer from delayed ambulance service -- in my own community there is no longer ambulance service to one of the communities where service had been on -- as a result of expenditure cuts, additional to that will be a situation where the reduction in payrolls will mean that in the two major population centres in my community there will be increasingly reduced service. That is not unique to my community.

In virtually every area of the province, whether it's Mount Forest, Simcoe, Barrie, Ottawa, Hamilton -- Hamilton is in a crisis; we know that you've flowed them $250,000 on the deficit issue -- on the deficit issue there's still $2.3 million worth of deficits left for which there is no funding. You have left the operators on the hook. To the guy who needs the ambulance service or to the woman who needs the ambulance service, your answer is not adequate. If they cannot get the health care they need in a timely fashion with the trained personnel they need, then you are in fact placing those people at risk with these decisions. A critical function means more than simply a method of compensation. The critical function is described both in the Ambulance Act and in the Social Contract Act and the regs under the Social Contract Act. It is more than simply a compensation scenario by the words that are in fact even used in the regs. I suggest to you that you have not taken into account what in fact is becoming a province-wide emergency.

Hon Mrs Grier: Let me respond to a number of the points the member has raised. First of all, let me point out to her that 21% of emergency health service employees are part-time workers earning less than $30,000 a year and are therefore exempt under the social contract agreement. And let me remind her of a statement that I think was made by somebody from the Metro emergency services in the press yesterday, while complaining about the social contract and cutbacks, acknowledging that, at least in Metro, a vast majority of the use of the service was for transfers between hospitals.

We should make a distinction between the blanket assertions the member is making and those sections of the service that are not emergency service, service that has to be provided for the benefit of the patients, I acknowledge, but where there may well be opportunities to look at more effective ways of providing that service. I suspect the member, as I have, has also been at scenes or with emergencies where you had the fire, the police and the ambulance all arriving at the same time in response to one emergency call. That is in many cases necessary. In others, there may well be ways of looking at a better coordination between emergency services and a more effective administration of the services that will enable them to work in a cooperative way. I, as somebody with an emergency -- the first response was one person who came to provide service while the ambulance got there. So different communities do it in different ways.

What we anticipate will happen in many areas as a result of the social contract, and what we encourage employers to do, is to discuss with their employees better ways of providing the service and ways of accommodating the reduction in the payroll. I hope that all of the ambulance operators for whom the member speaks -- and I suspect it is primarily the private sector operators -- are involving their employees, unionized or non-unionized, in all of their decisions and in their discussions, because, let me assure the member, it is only through cooperation and involving the employees truly in the decisions that affect them that the best decisions can be made and changes can be accommodated in a way that protects both jobs and services, which is our intention.

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Mrs Sullivan: The minister, with her response to queries that I have put, goes to the root of the problem. There indeed is no strategy with respect to what is an appropriate way of approaching expenditure reduction in this entire sector. The minister has pointed out that indeed full-fledged ambulances are used for transferring patients from one health care setting to another. Why wasn't there an option presented by the Ministry and the Minister of Health to allow operators to introduce a secondary level of service and to be compensated for that secondary level of service that did not require indeed the fully trained ambulance attendant during that period? That is a strategy lack that has not been addressed.

The minister speaks of police, fire and ambulance reaching the site of an accident or of an emergency at the same time. Why hasn't the minister undertaken a full emergency services review that combines all of those services in a scenario that looks at the various response teams at the levels of activity that could be appropriately taken? Has the government even looked at the entire transfer of ambulances to the Solicitor General? Are these things on the table at all? Certainly they are discussed in the community and they are strategic questions that could well have been addressed in terms of meeting the targeted expenditure reductions or approaching the targeted reductions rather than in a way where, under the existing legislation, people can be put at risk.

The minister has reiterated the $30,000 level. In the ambulance services that is moot. Ambulance attendants, on average, are paid $34,000 a year unless they're in government or non-profit or municipal services, where their average is significantly higher than that. So we're talking about dollars that are being removed from compensation to skilled health care professionals that cannot be made up in any other way, where there is an admitted deficiency in funding from the ministry. The ministry would not have put the $6 million into the system if it did not recognize that deficiency. And the person on the street who is facing an emergency situation is subject to being placed at risk.

Hon Mrs Grier: Mr Chair, I think the deputy can add, perhaps, to some of the long-range issues that the member raised.

Mr Michael Decter: Yes, just to comment, because we are here at estimates, the estimates presentation shows that our actual spending on the ambulance service was $167 million two years ago, $170 million last year, and it will increase, we believe, subject to the survey that's going on in the social contract, to somewhere in the order of $174 million. So there is not an expenditure reduction in this area; there is actually an increase. I won't get into a debate on the adequacy of that. We're working very closely with the ambulance sector to manage the social contract issue.

I should be clear that we have not put $6 million or any other amount back in in some form. What we have done is recognize a number of pressures that existed prior to the social contract, as we would in any other year, so that is not an unusual event. That is an adjustment to the base that goes on in every year as we reconcile.

I should make two comments on longer-term things. One is that the Ministry of Transportation is leading some work looking at the broader issues around what I think it's calling community transportation. The second is that under the framework agreement in the health sector we have an ambulance review. The Swimmer report of some time ago has enormous support from the bargaining agents in the ambulance sector, but so far we've not been able to convince ourselves that it could be implemented without significant additional cost. However, we have a very focused review going on over the next 90 days involving all of the participants to get at that very question: whether a new government structure could be accomplished within the budget for the next three years. I think we would be as happy as anyone if that review demonstrated that we could improve the service with the new governance model without adding to its cost. We are in fact looking, through those two reviews, at a number of issues here.

I should just underscore that this is a very difficult issue because of the nature of the service, but it isn't the case that every person in an ambulance service or in our own emergency services is someone who is performing a critical function. The real impact of the critical function regulation is that it allows a deferral of the liability to the end of the social contract period.

The operators have been worried about that building as a liability that they would face down the road. There is some offsetting impact; that is, the wage freeze for the three years in the social contract has a larger impact over time as people exit from the top end of the pay scale and enter at the entry level, and the freeze on movement in grid also mounts up. In deferring a liability through the critical function regulation, there is also an accumulation, if you like, of a benefit through the period.

We are out on a survey of all of our agencies because of the policy decisions on the LICO, low-income cutoff, the part-time issue and the charitable issue. So all of our steps to date have been interim and we will make some adjustments as we get information back this month from the survey.

We are as a ministry trying to work very closely with the sector and we are very respectful of the obligations that exist for the sector under the Ambulance Act and also those that exist for the ministry. If legitimate deficits are incurred, that liability rests with the ministry, which is why we do an adjustment after the year. But a legitimate deficit can't be created by ignoring the provisions of the Social Contract Act in this circumstance.

Mrs Sullivan: I think that it's clear, from the amount of my allotted time on this issue, that there is enormous concern, that there is not a sense of comfort in the approach that the government has taken with respect to the ambulance services and that there is a sense that this should be a clear priority.

Just in a very short question which I have in the time left to me today, I have been interested in reviewing the chronic care role study and the OHA and chronic care hospitals' response to that role study. The response from the hospitals and the chronic care hospitals has been quite adamant in underlining that a level-of-care tool should not be used but that a client-focused level-of-need tool should be used in the assessment of people as they are moving into the long-term and possibly the chronic care situation.

The argumentation is that the individuality of the patient should be taken into account, that there can be much greater ease in providing a continuum of care for the individual through a level-of-need tool rather than a level-of-care tool. I'm wondering what consideration you are giving to that proposal and when you will be able to respond to the kind of question and the direction implied if a change from the care tool to the need tool were implemented.

Hon Mrs Grier: I'm glad to have a chance to talk about the chronic care role study. The purpose of the study was to develop an inventory of existing services within chronic care facilities. It was really the first time that this had ever been done within the system. So in July 1992 the most extensive survey of hospitals ever undertaken in Ontario was conducted to develop that inventory. There were extensive consultations and a very hardworking committee that undertook all of that.

I met with them in May when they presented the chronic care role study to me at the end of their work. We have distributed their report widely, to hospitals and district health councils, consumers as well as providers, and I'm sure the comments that you make reflect the comments they are sending back to us and the comments they have as a result of that. We are in the latter stages of analysis of the role study as well as the recommendations it contained, as well as some of the response that there has been to it. Within the next couple of weeks, we certainly expect to be able to provide a response to the study, and the issues that you raise will be addressed by that.

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I should say that despite having been engaged for over a year in this study, planning processes that were under way or indeed have been initiated in a number of chronic care facilities have not been held up. Both Riverview in Windsor, which is under consideration as part of their restructuring, the Perley Hospital in Ottawa, St Mary's in London, St Joseph's in Guelph and St Peter's and Chedoke McMaster in Hamilton, as well as Riverdale in Toronto, are all in the process of doing planning and looking to their own futures. Our task will be to mesh that into an overall approach to chronic care within the system. Of course, part of that will be identifying a way of better evaluating the needs of the people in those hospitals so that we can make some clearer determination and definition of chronic care, who needs chronic care and what is required to provide that care.

One more point: What was particularly interesting to me in the study was the emphasis on the need for rehabilitation and the shortcomings of our system with respect to providing rehabilitation to people in chronic care. I think one of the real challenges for us is going to be to address those recommendations in a way that can be done and make the best use of existing facilities as well as identify where there are no facilities for rehabilitation.

Mr Ted Arnott (Wellington): Minister, I have a concern I wish to raise with you -- this is something we've discussed informally in the House; we've also corresponded on this issue -- in the form of a letter that I'd like to read to you from a constituent of mine named Reina Todd from Fergus. She'd written me a letter back in March of this year, addressed to me:

"Dear Sir:

"Having tried all the normal and accepted avenues to obtain funding and assistance from established government agencies and failed, frustration leads me to write to you.

"In 1985, my husband, Mark Todd, and I were involved in a car accident caused by a 17-year-old drunken driver in another vehicle. Mark sustained massive head injuries. He was 24 years old at the time, an athletic, healthy young man with a promising future ahead of him as a musician. We had been married for just over a year. Mark is now reduced to a vegetative state, unable to speak or care for himself. Our ensuing struggle to obtain our right to live with dignity in our own home has proved long and bitter. I am still battling for aids for daily living.

"Following the accident my husband was treated at Sunnybrook Hospital in Toronto for eight months, but their prognosis for Mark was so hopeless that I took him home to die. My parents-in-law (Ontario residents of 20 years) transferred to Calgary, Alberta, and offered us a home with them. Mark was transferred to Foothills Hospital. Mark received excellent attention and defied the death sentence passed on him by Sunnybrook Hospital (leading me to question the quality of care that Mark received).

"On his discharge, the Alberta aids to daily living program provided a hospital bed, table, wheelchair, air mattress, sheepskins and other supplies I needed to take care of Mark at home. I have taken care of Mark at home for the last eight years. By doing this, I have saved this country a total of $16.77 million, based on the average daily cost of hospitalization of a chronic care patient multiplied by eight years.

"In 1992, we decided to return to Ontario with our 18-month-old son to be closer to my family. I was led to believe Ontario was a leading light in the field of disability programs. It seems I was labouring under a grave misapprehension. I am appalled to find that the Ontario assistive devices program provides no assistance for beds or equipment. I was instructed to find a bed anywhere I could. It proved no easier to acquire a wheelchair. After many fittings, an appropriate chair was found for Mark at a cost of $6,000. This cost I was expected to pay myself, because the Ontario ADP would not cover the cost. Apparently, the chair is not for my husband but for me, because my husband is unable to operate the chair himself. I am astounded to encounter discrimination of this nature and in such circumstances. The Ontario ADP is discriminating between levels of disability; the less disabled a person is, the more likely they are to receive help. The more severe the disability, the less help is available.

"I am told to lobby for funding. Why, I ask, should I have to? It is your obligation to provide a wheelchair, with no excuses. In the meantime, Mark is suffering. Without a suitable wheelchair, his seating position is changing. This means that to fit him, any wheelchair will have to be so specialized that it becomes increasingly more expensive the longer I have to wait. I approached the Ontario March of Dimes for a chair, only to find that they follow your guidelines and can only supply one if Mark can move it himself. Of what use is this program if it can only supply people who are already eligible under the ADP program? United Way should be looking at the distribution of their funding and the March of Dimes should be changing their mandate.

"The issue is still that ADP is discriminating on the levels of disability, as is the March of Dimes. I should not have to stay up until 2 am writing letters so that my husband can have a chair. I have saved you a vast amount of money and still cannot have a chair that every Ontario citizen is entitled to, should they have the need.

"Upon contacting the Human Rights Commission, I discovered that my husband has no case because they are only able to determine human rights between able-bodied persons compared with disabled persons; to compare two disabled persons is not within their terms of reference. How is this so? Are these people subhuman because of their disabilities? This is a concern, not just for me but for all Canadians who do more than pay lipservice to the belief in human rights. I intend that my plea will be heard provincially, nationally or internationally if need be.

"As things stand now, my husband has been deprived of mobility and a chance for me to maintain a normal level of social involvement for him. I want to provide a secure family environment for my young son, and that includes having his father as an integral part of his life. It is despicable that it should be necessary for people to battle in order to receive some assistance from a government that is ready to offer aid to any Third World country that asks for it. I am asking for something now.

"Because Mark is unable to verbalize and direct his own care, I must remain in the home with him. I am housebound and forced to live a disjointed life. Your policies are, in fact, disabling my life as well as his. I am not asking for very much, just some funding to ensure that I can continue to keep my husband at home with his family. I only want to give Mark a small measure of happiness; he has already lost so much. The alternative is to split my family, place Mark in an institution (at enormous cost) for the rest of his life.

"I appeal to you that this problem be addressed immediately, not only for my sake but for all others placed in this untenable situation. The drive in the `90s' is to move people from extended care situations into their own homes. How can this ever be accomplished when the `red tape' inhibiting the existing programs makes it impossible to satisfy the demands that are, and will be, made of them? The loopholes in the net of home care need to be mended before this can be accomplished.

"Constantly, we are encouraged to integrate the disabled into our lives, not to treat them as anything other than worthwhile members of our society. I'm asking for your help to see that I can do exactly that. Thank you.

"Yours truly,

"Reina Todd."

I went to see Reina Todd, actually, when she phoned my office, and she gave me this letter. I can personally attest to every fact in this letter, that it's true. We've written you, we've brought this to your attention, and I'm not satisfied with the response we received. What can you advise me to tell Reina Todd?

Hon Mrs Grier: Mr Chair, I'm sure the member will be aware that for me to get into discussing an individual case is not appropriate, and I have responded to his correspondence with respect to this constituent.

I have to say to him that the assistive devices program, which has now been in place for, I think, 10 years in this province, is intended to give the kind of support that he suggests is necessary in this case, but I acknowledge it doesn't meet everybody's needs and it is a program that pays up to only 75% of the cost of eligible devices.

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I have to say to him that when it was begun in 1982, it was originally restricted to those aged 18 and under. It has been growing since then, and between 1986 and 1990, coverage was greatly extended. In fact, it's grown from a $2-million program 10 years ago to $89 million in 1992-93 and, as he has pointed out, we still don't meet everybody's needs for everything that they require. The number of people served has increased from 2,000 to 135,000, so as I say, I think it is a program that goes as far as we've been able up till now to meet the needs of people. I grant you, there are some people who may not qualify. If that lack of qualification is due to some anomaly in definition, then that's perhaps something I can look into, but I don't think I want to leave you under the impression that, yes, it's a program that will do everything that somebody requires.

We believe it is a good program. As we look at long-term care, we will obviously have to look also at assistive devices and at the other elements of the system that will help people to maintain their independence and the aids to independent living. That's, quite frankly, what the reform of the long-term care system is designed to do. As you know, it's something that after years of discussion we have now begun.

We have some distance to go, but we will be adding more funding to the $2 billion we already spend on long-term care over the course of the next four or five years in order to, in some cases, address the issue of how you compensate people who do care for disabled and chronic-care patients at home as opposed to having them in an institution. It's the first time anybody has addressed that issue. So as we wrestle with expanding the long-term care program and making it more flexible and more designed to meet the needs of individuals, there will be changes in the future.

With respect to the specifics that you raised, I can't in this forum say any more than I have said to you in correspondence.

Mr Arnott: Do you think it's sensible that the assistive devices program discriminates on the degree of disability the person has, such that someone who cannot move a wheelchair is denied assistance?

Hon Mrs Grier: That's what I meant when I said I wasn't sure of definitions. Michael Ennis, who is the ADM with respect to that program, is here and I could perhaps ask him to come forward, Mr Chair, and see if he could help us with that particular question: the rationale for the definition that we have and how that is administered.

The Chair: Mr Ennis has been before the committee; welcome, Mr Ennis. You were present for the question; please respond.

Mr Michael Ennis: The question of criteria and eligibility is correct as has been defined. At this present time the rules that are applied to assistive devices are that if an individual's not able to move the chair or carry out certain motions that allow the individual to actually move the chair, that's one of the criteria that is applied indicating that they would not qualify for that type of wheelchair for that assistance.

That's one of the criteria at the moment and, as the minister's indicated, as we move forward with the broader initiative of long-term care, we need to look at all those criteria in terms of assistive devices programs and, as you in fact have outlined, the other supports that can be available to an individual to remain at home.

In summary, that's one of the existing criteria at the moment. We have thousands of applications and that criterion is used.

Mr Arnott: What would you do -- if, for example, someone is a paraplegic and can propel themselves in the wheelchair versus someone who is a quadriplegic and cannot, that would seem to me to be a clear-cut case of discrimination on the basis of the level of disability that person has, such that the person who is more disabled gets nothing and the person who is somewhat disabled, in that he only has the use of two limbs, gets assistance.

Mr Ennis: I'm responding by saying that is one of the criteria that's used. You're saying it's a discriminating criterion. I wasn't agreeing on that; I was agreeing on the fact these are the criteria that are used at the moment in the program to invest the thousands of dollars that go into a mobilized wheelchair. One of the criteria is: Can the individual make any movement or motion themselves? Then they would be considered eligible for the motorized wheelchair to a certain subsidy level.

The Chair: Mr Wilson.

Mr Jim Wilson (Simcoe West): Thank you, Mr Chair. I think Mr Arnott will have another question in a minute or two, but I just wanted to touch --

The Chair: I'm sorry; Mr Arnott, do you have some additional questions?

Mr Arnott: I'm just not at all satisfied. I hope that indeed the commitment that has been made that you will review this matter is such that resolution -- that it will be looked into and that, in the context of your review of existing programs, something will be done.

I find it totally unsatisfactory that the government can't in some way assist this individual who literally has looked after her husband in their home for eight years. She's just a young woman we're talking about; she's only 29 years old. She's a saint. The cost that would have been incurred by the provincial government, whether it be Alberta or Ontario, had she just simply said, "I'll put him in some sort of an institution," she has saved the government considerable money because of the love she has for her husband. If the government can't support her in some way, the government is extremely heartless.

Hon Mrs Grier: No, I'm acknowledging that there are cases like that and that they have never in the past been served by the programs that exist. As part of looking at chronic care, where there are some interesting proposals for providing chronic care out of an institutional setting, which would mean that we would then have to put in place the programs that would allow the kind of support you're suggesting, as well as looking at the entire long-term care, that will lead us to a review of those policies to deal with the anomalies you identify.

With respect to the individual case that you identified, I guess we are concurring that yes, as the program now stands that is the eligibility criteria. But I think the deputy wanted to add something to that.

Mr Decter: Just to make the point that we sometimes become focused, as would be appropriate at estimates, on the $18 billion that we're before you seeking. The reality is that most care in this society is still provided on a volunteer basis by family members in the home, largely by women. So our government-insured system and our programs do perch on top of this.

Now, in most cases that's an issue where some of us take a day off when a child is sick, and it's not a huge incursion on our lives. In the case you describe, there has been an obvious and major burden on the family. But I'd just like to stress, because I think we sometimes feel that because of $18 billion and 31% of government spending we ought to be able to solve all of the problems out there, that I think we try pretty hard to spread the resources. The long-term care reform really does look at it in a broad sense. In the interim, our assistive devices program is a program that's grown by adding additional devices, by expanding categories over a little more than a decade, but we are far from a universal insured program in assistive devices.

I'd just be a little careful. We're not discriminating in the sense of the Human Rights Commission. We do provide for some products and not for others, and I think the case you bring forward simply underscores how far we have to go on the long-term care side to really provide for this burden not to fall back on women in the home, which is I think a fundamental issue in the long-term care reform. We don't have any easy answers for you on this, other than that this is why we're undertaking the long-term care reform.

Mr Arnott: I'll defer to my colleague, but I'm not finished with this issue.

Mr Jim Wilson: I want to begin by touching on the subject of ambulance services in the province. I agree with Mrs Sullivan's remarks earlier. Minister, indeed I think you've got a crisis brewing in the province with respect to the provision of ambulance services, both emergency transfers and non-emergency transfers, and I take some exception to your comments with respect to non-emergency hospital-to-hospital transfers.

I want to convey to you a story that occurred in my riding some two weeks ago when I had the unfortunate opportunity to contact Metro ambulance services. I had a patient who was brought into the hospital late one evening in Toronto for a number of emergency tests. The patient was ready to be discharged from that hospital and transferred back to the Alliston hospital at about 4 o'clock in the morning. The family called me in the wee hours of the morning because they were waiting several hours. I think they'd been waiting for probably five hours for an ambulance transfer before they called me at my home on a Sunday morning. I therefore, on their behalf, called the Metro ambulance dispatch, the out-of-town dispatch, and talked to the communications supervisor. He spent, surprisingly to me at the time, the first 10 minutes of our phone call complaining about the NDP government and the social contract.

Hon Mrs Grier: As I said, everything but the weather is the fault of the social contract.

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Mr Jim Wilson: Maybe that is true, and maybe we will get to the weather in this province at the rate things are going.

There I was trying to convey the seriousness of this issue on behalf of my constituents and I allowed this gentlemen, who in the end turned out to be very helpful, to tell me for 10 minutes about the shortages at Metro ambulance services. There has been a 33% reduction in services alone at Metro. He told me that it is not uncommon now, for these hospital-to-hospital transfers out of town, to expect families and patients to wait in the corridors of a Toronto hospital for up to 12 hours. I know the system wasn't all that great in the recent past, but it's certainly getting ridiculous.

For you earlier to, in my opinion, slough off the seriousness and the anguish that families go through when they are literally waiting in the corridors -- as you know, when it's a hospital-to-hospital transfer, as in the case experienced two weeks ago, the patient is left in the corridor of the emergency room for up to 12 hours; in this case it wasn't quite 12 hours but it was a number of hours, and they were told by a communications supervisor that they were absolutely powerless to do anything because they simply did not have the ambulance crews, ambulance officers available to do anything about it. We're told that you have to wait for an out-of-town ambulance to come in, on a Sunday in particular, when they weren't expecting any ambulances. Somebody jokingly said, "Perhaps we have to have continual car accidents in the Alliston area so we can ensure that ambulances are going to Toronto on a regular basis to bring back these non-emergency transfers."

I can tell you at first hand the anguish experienced by this family, and it's the third time since I've been an MPP that this sort of situation has arisen. They are not happy with the service that this government is providing and they are very much concerned about both the non-emergency transfers and the emergency transfers. We read in the paper that the time people will spend lying on the pavement waiting for an ambulance is ever increasing. I think you've a real crisis on your hands.

I want you to comment again on the non-emergency transfers, hospital-to-hospital transfers, which in the eyes of the patient and in the eyes of the family are emergencies. This patient was quite seriously ill.

With respect to what you've done under the regulations of the social contract concerning the designation of "critical function," I do have a question that was asked of me by ambulance operators, and that was why the onus had been placed on employers to designate their employees as a critical function.

Secondly, I want to talk to you about these unpaid days off or special leave provisions. But first I need your comments on the transfers and also on the critical function.

Hon Mrs Grier: I'm sorry; I was distracted and didn't hear your last sentence.

Mr Jim Wilson: I'd just like you to respond to the situation I put forward with respect to the Alliston-Toronto transfer and, secondly, why the onus was put on employers to designate their employees as critical function.

Hon Mrs Grier: Let me respond to the situation that you describe in Alliston, which I don't deny for a moment is very troubling. I was interested that you said that this is the third time in your career as an MPP that you'd been faced with this kind of situation. I think that flies against saying it's all because of our government and the social contract.

Mr Jim Wilson: But it's getting worse, Minister. We never had 12-hour waits before.

Hon Mrs Grier: To suggest that for a 4.5% reduction in salary expenditures there's a 33% reduction in service is, to me, quite out of balance. If the first 10 minutes of the conversation with the dispatcher was taken up in complaints about the government, I think that's perhaps not a particularly good use of his time.

We have a very good emergency service in this province. We have in fact a record of acceptance and public acknowledgement of its value that is higher than in many other jurisdictions, and people come to this province to look at our ambulance services. They are run by a variety of ways, not all by the ministry, and that means there's a complex web of decisions that goes into any request for a transfer.

If somebody, as you say, was seriously ill and was left in a hospital corridor for 12 hours, I think that person has a legitimate cause for complaint. To say that the primary cause for that complaint was because that at that particular time and on that particular day there was not an ambulance available, I'm not sure I'd say that was the only reason for that happening.

Mr Jim Wilson: That is the only reason. There was no ambulance available to do an out-of-town transfer, nor was there one expected in a reasonable period of time.

Hon Mrs Grier: Okay. Then I would ask, as a member of the family, why were they in a corridor if they were seriously ill? Where was the doctor? Where was the hospital? Why were they left in the middle of the night to call their MPP? That raises some serious questions.

Mr Jim Wilson: I can answer those.

Hon Mrs Grier: I'm not sure I accept your conclusion that it's all because 4.5% was taken out of the wages of the ambulance system by either the province or by how Metro established its priorities for that.

Mr Jim Wilson: Minister, just to be fair, it wasn't my conclusion; it was directly from the ambulance service itself, which said that it was a direct result of the social contract, that we now are second-class citizens in rural Ontario and have to wait up to 12 hours for a non-emergency transfer. That is unacceptable. I had my own riding association secretary last year wait 14 hours for an ambulance, and she didn't call her MPP. I guess it's a "who you know" health care system now. It's become absolutely unacceptable.

With respect to -- well, I'll get into that in a minute. Have you finished your comments?

Hon Mrs Grier: With respect to the critical function estimate definition, I think in my response to Mrs Sullivan I indicated that the regulation is to provide employers with the tool to implement the social contract in a way that recognizes the critical function performed by some of their employees and to give them some guidance as to what the definition of "critical function" is. I don't think the ministry or whoever's implementing the social contract -- the Ministry of Finance has the primary responsibility -- is to go in and say, "This employee performs a critical function during their entire shift and this one doesn't." It's the employers and the employees together who, we believe, are best equipped to work out how in fact the social contract may be implemented.

Mr Jim Wilson: With respect to the 33% cut I referred to earlier, that's right out of the Toronto Star on October 2.

Hon Mrs Grier: Oh, it must be completely accurate.

Mr Jim Wilson: It says, "The number of ambulances on the road in the late afternoon has been cut by about 33%, with less severe reductions in the early morning hours." This is quoting somebody from Metro ambulance.

Hon Mrs Grier: That's exactly the same story that ended up by saying that the vast majority were non-emergency transfers.

Mr Jim Wilson: That's right. I guess the point I'm making with you as strongly as I can is that non-emergency transfers, when the family's in anguish, when the patient is left in the corridor -- you asked where the hospital and the doctor were. The doctor's done with the patient; he's gone on to another patient. The hospital said, "Ambulances aren't our problem," and it gave them the phone number of Metro dispatch and said, "Here, you bug the dispatch and see if you can't get an ambulance faster." The hospital is not responsible for the ambulance service. It's Metro ambulance, as it's referred to.

Very quickly on this, I want to talk about, with respect to the social contract, one thing that has bothered me in the area of emergency services. I'm glad the deputy minister is here, because he negotiated the social contract. It is with respect to these unpaid days off. Correct me if I'm wrong, but it seems to me -- I use the term "stacking." The deputy, in his comments earlier today, used the term "deferring a liability." It seems to me that ambulance operators, effective March 31, 1996, are going to be owing their employees perhaps 36 unpaid days off. Because they took 36 unpaid days off during the three-year term of the social contract, these days are stacked and there'll be a huge bill to ambulance operators and to the province of Ontario. I think we see that in other areas too with respect to the stacking of unpaid days off or special leave provisions for firefighters and police and a number of other emergency services.

My contention is that your designating the ambulance sector employees as a critical function is not going to save any money, that at the end of the social contract there indeed will be, as the deputy calls it, a deferred liability, there will be a huge stacking of days off, and in the end the taxpayers of Ontario are the losers in this.

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I would ask you to explain what will happen on March 31, 1996, with respect to the stacking of these days off, what the bill will be, what the cost will be at that time to the taxpayers of Ontario; to dispel for me, if you can, the fact that I truly believe, after having examined this, that these are deferred savings, that no matter who the government is in 1996, a huge bill is going to come in and the taxpayers of Ontario are in for a shock at that time.

Hon Mrs Grier: I think the deputy began to explain that. I'll be happy to ask him to do it again, but the conclusion we arrive at as a result of examining this is quite different from the one the member comes to.

Mr Decter: Let me try again. First of all, I only wish I had succeeded in negotiating a social contract. As it turned out, the negotiations didn't succeed and the social contract was in fact legislated some time after my involvement ceased, just to be clear on that portion of your question.

On the issue of what will happen April 1, 1996, I don't have a crystal ball or any magic to forecast that. I will tell you that the impacts on individual employers in the health sector vary a great deal. I won't name institutions because I don't think that would be fair to the managers who have spoken to me in confidence about their situation.

In one hospital of significant scale, the CEO indicated to me that between the wage freeze and the freeze in grid movement, his hospital was in the position that it needed no layoffs and no days off without pay. For another major hospital, the impact of those same two measures was something on the order of half a million dollars of a $9-million target.

To give you some idea, depending on what assumptions people had made, what provisions they'd made for various uncertainties and how they run their policies, and in fact the age structure of their staff -- if you've got quite an aging staff and you have some retirements out the top end, which is the experience the ministry is seeing now, and you either don't need to fill those positions --

Interjection.

Mr Decter: Not in my case, but we are having a lot of people take advantage of the factor 80 provisions.

We have a hiring freeze on, so as we restructure that work, we're going to end up over the three years of the social contract with our payroll coming off due to those factors. For the stacking or deferral that you speak of, there's uncertainty around it; frankly, that's why the provision is permissive, not mandatory. We have said to employers on one side, including ambulance operators, "There will be a reduction in the funds you receive," and on the other side, the government has in legislation done a number of things to offset that reduction.

It's very difficult at this point, and that's why we're out on a survey and we're working with individual operators to know how all of that works. This is new for them as well. Some of them have reacted, I think overreacted, on the front end because of uncertainty. They have in some cases taken reductions directly out of their employees' paycheques, something that's not legal under the act, and we've had that brought to our attention. In other cases, I think they've set in motion reductions in service that are much larger than what they'll need to accommodate the social contract.

What I would say is that I cannot give you a precise answer because it's going to depend on how all of those things work together. But offsetting any accrual of liability for unpaid days under the special leave or the critical function provision are these other factors of the freeze; the freeze in grid movement; exiting, which generally takes place out the high end of the pay scale; entrance, which tends to take place in the low end of the pay scale. I think it will take time.

The other question is, will the ambulance operators come into local agreements as of April 1, 1994, which would be our wish, which would reduce their social contract obligations by some 20%? There are a number of uncertainties in this piece.

Of all the areas we're facing, this is the one that's had the most attention from us because it's the one that, because of the nature of ambulance service, poses the most difficult problem. A hospital certainly does have people in emergency and critical functions, but a much smaller percentage of its staff would be in a critical function. For example, in our psychiatric hospitals we were able to go to weekend levels of staffing on the two Fridays; that was a significant reduction in cost for us without a significant impact, if you like, on the service. We had a weekend level of service rather than a weekday level of service.

I know that's an answer that's far less precise than one would want to give. I think in a few months, when we have some good case studies, we will be able to be more precise about it.

We have seen the ambulance system achieve some significant savings in the past two years through restructuring and efficiencies, and we're hoping to see some of that aided by the provisions of the social contract through the next period. But I don't think it's as easy as saying this is a simple deferral of 12 unpaid days to end up as a balloon in 1996.

I guess I should also point out, because the question's been asked about the regulation --

The Vice-Chair (Mr Ted Arnott): Deputy Minister, could you conclude your response.

Mr Decter: I'll conclude. I'd just point out that the regulation is permissive in saying employers "may"; so is the legislation on special leave. I think if the regulation had tried to be mandatory, it would have been found to be ultra vires the statute. Frank is here to reinforce that, in case I'm trying to practise law without a licence here.

Mr Jim Wilson: We'll talk about ambulance licences in the next round; you mentioned the term "licence."

The Vice-Chair: Thank you, Mr Wilson. We now turn to the New Democratic caucus, and I recognize Mr Bisson.

Mr Gilles Bisson (Cochrane South): I'd like to first of all congratulate the minister for taking on the task of being Minister of Health, probably one of the more difficult ministries to manage in light of where we find ourselves fiscally, not only here in Ontario but across the country.

We're looking, obviously, with great passion at what's happening in other provinces and how they're dealing with expenditure problems and revenue problems, looking at the kinds of things they're doing in their provinces. One of the difficulties we have in the province we happen to govern is that people look at Ontario in isolation from other places sometimes when they compare what's happening, but it's the same as you'd probably see in Manitoba or Quebec or Nova Scotia etc.

I say that because it seems to me that in all the discussions I've had across the province of Ontario, as I'm sure you've had, minister, as have the members of the opposition, I think there's a keen recognition that government needs to do everything it can to manage the health care system better. Nobody argues, from opposition side or from government side, that we should do away with our health care system. We all want to play our part in making sure that we preserve health care for Ontarians and Canadians overall. Where we probably differ is how to deal with the management of the system; how to make sure there are dollars at the end to pay for health care, to make sure that Aunt Mary or Uncle Joe, if they're sick, can get into the hospital and get taken care of.

Particularly with everything that's gone over in the last year through expenditure control, through the social contract, through various initiatives that were started by the previous minister as well, overall it's been not too bad a job done. I'd like to point that out, because often the minister is criticized, for reasons people will understand, but there's not keen appreciation of the job. I tip my hat to you.

I want to raise that because there's an issue going on back home, in the community of Timmins. We're in the process right now of completing the building of a brand-new district hospital that will serve all the community of Timmins, to Hearst to Kirkland Lake to everywhere else in northeastern Ontario.

It's a magnificent building, as I'm sure you're aware. Just to give you an idea, I was talking to an installer who was installing our CAT scan system there recently. He said he had been in most hospitals throughout North America and found this to be one of the best-built hospitals of all when it came to the way they put it together, that there was a lot of thought put into it. I think we need to tip our hats to the local people who worked on it as well as the people at the ministry.

But for all of that, there are always problems. One of the things I've found is that often problems are somewhat based on reality but sometimes much exaggerated. What I'm looking for from you here today is some reassurance on a couple of issues -- and you may have to call some of your staff forward for that -- around the opening of the new Timmins and district hospital. I'm concerned about the question of CAT scans and also the budget for the new hospital that will be opened. Maybe I can start with the CAT scan issue.

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You would know that they will install a CAT scan in that new hospital in order to serve northeastern Ontario and other areas within the province in terms of the imaging needs of our community and others. One of the things that's being said right now by some of the people in the medical community in Timmins is that the bad old Ministry of Health is not going to allow the hospital to open that CAT scan wing because of financial constraint. I'm wondering if you can put to rest those fears and let people know in the good city of Timmins and other places out there that indeed the CAT scan unit will be operating, that it will be operating for the benefit of not only those people in my community but other communities around the province.

Hon Mrs Grier: I certainly am aware of the Timmins hospital and the fact that it is nearing completion and is an amalgamation of Porcupine General, which is in South Porcupine, and St Mary's. I want to congratulate that community for its support and its initiative in working together over time to build a new hospital. I know it's taken a while to get it to that point, and having visited Timmins and been introduced by the member to a number of people involved in the health system there, I know how anxiously the hospital is awaited.

The specific question of the CAT scan you haven't raised with me before, which amazes me, and therefore I'm not sure I can respond to that with any degree of detail at this point. The normal process is that a hospital, as it submits its operating plan, includes in that the operating of the CAT scan; it is required, if it is an existing hospital, to identify the savings, which are very real, that it can have as a result of installing a new CAT scan. With respect to a new hospital that is putting one in for the first time, I would anticipate that as we review with the hospital its operating budget, discussion as to the operating costs of the CAT scanner will be part of that discussion. But I'll be happy to try to examine that and give you privately, seeing we're out of estimates time, some additional information on that.

Mr Bisson: In fairness, the reason it wasn't raised is because I was faxed today an article from one of the local papers -- I didn't provide you with a copy of it and I should -- where a particular individual in the community was asserting that a number of services would not be provided in the new hospital. I know the issue because I've been following it very closely -- I've been dealing with people in your ministry; I deal with people on the board -- so I do know what the answers to my questions are, but I guess I'm looking for a bit of assurance that indeed that CAT scan unit is in place, that it is being installed and would be operating.

Hon Mrs Grier: I'm not able to give you that assurance today. Certainly to me, if the money was raised in the community, as I suspect it was, to help provide a CAT scanner, then looking at the budget and making sure it can be operating makes some sense.

I did want to respond to your opening comments about the issues faced in this province and other provinces, because I had the opportunity since our last meeting in estimates to meet for the first time my colleagues across the country at a federal-provincial meeting of ministers of health. I think it's worth putting on the record that it's a very non-partisan group. We all come from different political backgrounds, but the issues that are being faced in every province are very similar, and the goal of both containing the growth in expenditures while at the same time changing the system to make it less focused on institutions and more dealing with prevention and planning for the future is a common one throughout all governments.

What is not common is the way in which the savings and the cost constraints are achieved. We all saw yesterday, I think, the Alberta announcement that salaries would be rolled back by 5%. They hope it will happen voluntarily --

Mr Bisson: Is it termed "draconian" in Alberta?

Hon Mrs Grier: I wish them good luck, but certainly they've made no doubt that that is what is going to happen, whereas in other jurisdictions we've tried to do it through negotiation.

The Vice-Chair: I now recognize Mr Hayes with a question.

Mr Pat Hayes (Essex-Kent): Just for some information: President Clinton, for example, with his plan for the health care system in the US, calls it making history, that his plan is very historical, but of course we made that history quite a few years ago, thanks to people like Tommy Douglas --

Interjection.

Mr Hayes: It was he who certainly pushed it, yes, in Saskatchewan.

What I'd like to ask you, Madam Minister, is, can you tell us why there's really such a strong interest in the system that we have here in this country, and also, while you're at it, maybe you can tell us why there is such a radical difference in the coverage and the cost of medical care in the US versus Canada and Ontario?

Hon Mrs Grier: I'd be glad to comment on that. There has been an enormous amount of interest in our system as a result of the move that President Clinton has been making. We've had US television companies up here looking at everything from our anti-tobacco strategy to our insurance system. I had the opportunity to be on an open-line show across the US and to field questions from California to Florida to Buffalo, which was a new experience. They wanted to know why we didn't have contingency lawsuits and how we could have a good health system without contingency lawsuits, which was, I thought, an interesting approach to the whole question.

What it brings home is that we have such a first-rate system. We tend at sessions like this and in question period to focus on the problems, but when you look at what we've got, every poll says, I think, that 96% of the people in Ontario believe we have an excellent to a good system, which has been created over the years by all of us and which we are struggling to maintain in the face of enormous and escalating costs, and in the face, of course, of a whole change in the basis upon which the system was brought in, which was a 50-50 sharing between the federal and the provincial governments.

Some years after Tommy Douglas introduced the plan in Saskatchewan, he made the comment that the first challenge was providing access to the system for people regardless of their income, so that nobody would be denied health care because they couldn't afford it. He then said the second challenge was to make sure that we reform the system, that it provides the best possible care in the best possible way. It's taken us 40 years to really come to grips with that second step: reform. The US is only now beginning the first step: making sure nobody is denied health care because they can't afford it.

What is interesting when you look at the two systems -- there was a study in the New England Journal of Medicine earlier this year that pointed out that US hospitals spend on average 40% more on each patient than those in Canada. It was a five-year study and it found that Canadian hospitals use high-tech medical equipment much more efficiently and spend far less on administration. They said that by adopting Canadian practices, US hospitals could save as much as $40 billion a year. We tend to sometimes lose sight of the fact that our costs are lower, and as a result of having a single insurer in each province, as opposed to the plethora that there are in the US, our administration costs are much lower. The proportion spent on public and private insurance administration in Canada is 1.2% of our health spending; in the US, it's 4.9%. The percentage spent on hospital billing administration is 9% in Canada and 20% in the US.

What to me is most important is that our health status indicators show that our people are healthier, despite not spending as much as in the US. For example, our infant death rates per 1,000 births are 7.2 compared to 10 in the US; our life expectancy at birth in 1990 was 77 years in Canada and 75.9 in the US; one-year-olds who are immunized is 85% in Canada and 48% in the US.

What we're trying to do is to preserve what is already an excellent system and make it better, and we're being looked at with some envy by people south of the border who have yet to get to the point we're at.

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The Vice-Chair: Thank you, Minister. That concludes the 15 minutes allocated to the government caucus.

Mr Hayes: Are you sure there's not a minute left?

The Vice-Chair: One minute.

Mr Hayes: I'd heard that New Brunswick is actually prepared to privatize its payment and collection system in the province. Have you any idea how that would affect --

Hon Mrs Grier: I saw that story, and all I know is the newspaper story, but perhaps the deputy can explain the details behind that.

Mr Decter: I don't think all the details are sorted out. The New Brunswick government is contracting its claims processing to Blue Cross and shifting some staff involved in that area.

Mr Bisson: Is that also termed "draconian" in New Brunswick?

Hon Mrs Grier: No, "privatization."

Mr Decter: There's almost nothing one can make as a change in health care that someone doesn't describe as draconian.

The Vice-Chair: I now turn to the Liberal caucus.

Mrs Sullivan: Actually, I had lunch with Frank McKenna on Thursday and we discussed what's occurring in New Brunswick and the initiatives they're taking in terms of starting a process that will involve the private sector not only in the health card billing-claims process, but also in providing the kind of system that frankly we lack in a desperate way in Ontario, and that is the database system that can be used for health management and planning.

I am very impressed with what Frank McKenna is doing in New Brunswick, and I am discouraged that Ontario is not at the same speed ahead as New Brunswick in terms of the development of a database management system for health planning purposes. We should be there now and we are not there now.

Mr Bisson: Is it privatized? Are you suggesting it be privatized?

The Vice-Chair: Order.

Mrs Sullivan: There's nothing wrong with the private sector being involved in the technological development associated with a database management system. It seems to me that under this government, the previous government and the government before that, we have been looking at health care as a method of economic development and this is one area that should be pursued. I am very disappointed that it has not been pursued to the position it should be at now.

Hon Mrs Grier: Can I clarify that I think we're mixing some apples and oranges here. Of course there is nothing wrong with attempting to market our expertise and what we've developed as a result of our first-class system and our publicly funded system here, and that is something that I hope, through our health economic development strategy, we will do in a more effective way than has been done in the past.

What my colleagues were raising was the contracting out of services that are currently being provided by the public service, and I think that's a totally different issue.

Mrs Sullivan: It's one that I support, however, when there can be efficiencies that will leave more money for health services delivery, and surely that's what we're looking at.

I wanted to discuss another issue, and I think that while it may be awkward to raise it, people are interested in it. When the deputy came before the estimates committee on a previous occasion with the previous minister, first of all, there was a discussion of the reorganization of the Ministry of Health. We have seen some of that reorganization occur to meet some of the priorities that the government has put into place and to change approaches that were perhaps not as effective as they could have been.

We have, in the course of that reorganization and subsequently, seen significant change in the personnel of the ministry, and we hear of another one today, as we understand that Dr MacMillan will be leaving the Ministry of Health. We know that Mr Drazin left just recently, that senior people in the legal division left last fall, and indeed that a deputy minister who, if I may say so, has gained a lot of respect during his period of time here, is leaving, as we know, for personal reasons.

I'm asking the minister what steps are being taken to adjust the ministry organization plan, what kinds of human resources structures or initiatives are being put in place to ensure that the senior people with experience and skill are being recognized, and what are you going to do to correct a view that the Ministry of Health is falling apart?

Hon Mrs Grier: It's certainly not a view that I hold or that my predecessor holds. It may have been when we took office in 1990, but I am absolutely confident that as a result of the reorganization and the strong leadership skills and management that has been put in place, the Ministry of Health is in a position, and is better equipped than ever before, to implement an agenda that is very innovative, creative and proactive, and that has been clearly spelled out by my predecessor, as we enunciated, for the first time, goals and strategies for the ministry.

As the deputy responded in response to a question from someone else, as a result of the factor 80, as an example, there have been some people who have been with the ministry for some time who have chosen to take advantage of that opportunity, because as I think is well known, our government believes that we can achieve our agenda in an effective way with perhaps fewer public servants and by looking at streamlining and delayering within some ministries and throughout the public service. But we are only doing that in a way that contributes to the better management of the system and to the achievement of our goals, and in a way that allows those people who feel there might be some advantage or who for personal reasons wish to seek a change in career to do it in a way that provides them with some security and dignity.

Nobody feels for a moment that there are not successors within the public service who can carry on, and while I know our current deputy has a reputation that goes far beyond the boundaries of this province, with his knowledge and background in health care, I am confident that when the Premier makes an appointment, the management of the ministry will be in good hands.

Mr Decter: If I could just make a supplementary.

Hon Mrs Grier: You disagree with me?

Mr Decter: No, I am certainly not going to disagree, and I appreciate the member's kind words. I would echo the minister on two dimensions. I promised the ministry I would not do another reorganization. I think those can be very trying for morale in the ministry. I inherited a reorganization that was under way when I arrived and saw it through.

I think the basic structure of the ministry is sound. We will, however, from time to time, find that a program located in one division might more appropriately be in another. A good example of that is the assistive devices program which was located in the health management group because it was essentially paying claims. When you look at who its client group is, it became clear that we should move it to the long-term care division because we do want to address the problems that the Chair raised earlier when he wasn't the Chair, and so we will, over a period of time, do that. We have consolidated some of the management functions of the drug program secretariat with the drug reform secretariat in preparation for implementing a number of reforms.

We've had some changes in management personnel through restructuring. We've also had a number of people who've taken the factor 80 retirement. What I would say that gives me great comfort and confidence is that we have a large group of very talented people not yet in the senior management group who are capable of moving up in the organization and taking on additional responsibility. We also have some people who are in the senior management group who have done very well on tough assignments. Donna Segal's leadership of the negotiations with the OMA this summer and Theresa Firestone's work in the drug program area I think are just two examples of many people in the ministry.

It is a difficult time. The changes in the health system are not easy ones for the provider groups and the ministry absorbs, at a staff level, a great deal of anxiety and in some cases anger at change.

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However, I guess the final thing I'd say is I think there is a really capable core of people in the ministry and that although you are seeing some departures, I think the ministry will be able to handle and successfully implement the priorities that have been set for it in a fairly difficult environment.

I have to say on my own front that deputy minister of health is not a long-service position these days, although it is about three years since I was retained to help with negotiations. In that time I've had three federal counterparts as deputy of Health, three BC counterparts, and I think I'm by now the third-longest-serving, or fourth-longest-serving, depending on one phone call that I don't know about in another province, of the 13 deputy ministers of health across the country.

So it is a time of some change and I think that takes a toll, but there is good succession behind the management team in the ministry and I think you'll see evidence of that over the next number of years.

Mrs Sullivan: Thank you. I want to move to the question of how the ministry is organized to deal with challenges of the future. We recall that Dr Orser presented a report, I suppose now three or four years ago, with respect to decentralizing the funding and delivery of health services to a regional base. I see that Dr Naylor, head of the Institute for Clinical Evaluative Sciences, has just recently spoken at the May annual meeting with recommendations which are comparable although slightly different from the Orser recommendations of a few years ago and would have decentralized planning, decentralized funding through a regional envelope, the regions being responsible by example for the payment of physicians and determination of the level of physician care or what services would be provided by local hospitals to meet regional needs and so on.

I want to explore now as to whether those ideas are on the agenda, if the government has made a decision with respect to whether services should be decentralized. We have seen some decentralization efforts in long-term care delivery. I'm thinking more of the acute and primary care issues, but a funding envelope that would cover all of those areas. And if that is the priority and direction of the government, what other necessary steps will be taken within the next short period of time within the mandate of this government to implement a decentralized system?

Hon Mrs Grier: Let me start by describing the system as it is now in place and the decentralization that has occurred. Primarily, that decentralization has been with respect to the planning and the strengthening of the district health councils and the assigning to the DHCs a very primary role in a number of the reforms that are under way.

Long-term care, the member will know, was essentially assigned to the DHCs to set up the long-term care committee to make recommendations with respect to allocation. As we look at mental health reform, that too is going to be essentially a role that the district health councils will play, and there have been a number of other instances where we have strengthened their capacity to both do the planning and move towards recommendations with respect to the allocation of funding.

We have worked with the district health councils and established a joint task force between the district health councils and the ministry to look at some of the issues the member raises, but more particularly the future role of the district health councils. They've been in place for 20 years, but it really is only in the last six or seven years that they have assumed a leadership role within the health care system and been acknowledged to have that role.

So the joint task force, who were members of the DHCs and the ministry, looked at issues of accountability, performance, quality assurance and how we could move forward along those lines, not into the devolution and funding envelopes that you describe but leading in a direction that gives much more responsibility to the district health councils.

The other thing that is happening and that is happening at the same time is, in a number of areas, the realization, almost, of comprehensive health organizations which go a long way towards being the envelope funding that you've described and which we believe need to be experimented with but have to happen as a result of communities seeing that this is in fact the way in which they want to manage health care in their area. Where those are emerging most strongly is in the north: Fort Frances, Rainy River and in the vicinity of Sault Ste Marie, or it's now something Algoma. It's got a new name; it changed -- Wawa? I thought it had another collective name. Anyway, those are areas where CHOs seem to be achieving the greatest acceptance and where I believe we will see models in place that will enable us to evaluate what in fact that means.

The other thing that is happening and again is driven very much by needs identified in different districts covered by DHCs is of course hospital restructuring. As that occurs and as communities begin to look at a rationalization of their hospitals, and Windsor is the furthest along of any community in doing this, they recognize that if they are truly to plan a health care system and not merely a hospital system, then they have to begin to look at all of the other spending on health care that is occurring in their districts. That leads to a much more integrated and comprehensive look at their systems and to the development of a plan that identifies the needs and the gaps in the existing services along the whole range of health care, from community-based services to institutions.

So, while in answer to your question I can say, no, at this point I do not see us moving holus-bolus across the province to the kind of decentralization that you're asking about, there are within the initiatives that are ongoing a number of examples that encourage and give authority to communities to plan their own health care systems, because that is the basis of the reforming of the system that we envisage, which is allowing communities to identify their needs and the ways in which they want those needs to be met.

Mrs Sullivan: Just for the record, could I correct: I think I called Earl Orser Dr Orser, and he's not Dr Orser.

Hon Mrs Grier: Since you reminded me, let me just pick up on his very helpful report which was done some years ago and which is now being looked at in greater detail by a coordinating committee looking at southwestern Ontario in the light of the developments that have occurred since Mr Orser began his work, those developments being the enhancement of the role of DHCs as well as some considerable progress in hospital restructuring.

The Vice-Chair: Thank you, Minister. Mr Bradley, you had a question.

Mr James J. Bradley (St Catharines): I asked you in the House a question about services for Alzheimer's patients. There are three things I'll fire at you since there's so little time.

Hon Mrs Grier: Before you even start, I know that a briefing note suddenly appeared as a result of your question, but I haven't got it with me. So maybe whoever had it could produce it again and then I could give you more details than I could yesterday.

Mr Bradley: I'll tell you the three things so you'll know. One is the Niagara Peninsula Children's Centre. Are you going to speed up the funding for that since the Niagara Peninsula members toured that on Friday? We believe that it should proceed at a more rapid pace than it is at this time. Larry O'Connor was visiting on your behalf.

The second thing is Alzheimer's patients, with two kinds of services: There are not enough beds, and everyone is phoning the MPPs to see if they can bump somebody else out of line and get their mother or father into it, which we naturally are unable to do and it would be unfair to do. So what we need are more beds in the Niagara region. The second part of that is that we need more respite care because while the funding I think has been frozen or may have been adequate in the past, the problem is that the number of Alzheimer's patients is increasing.

Third, I raised one day, probably more with the Minister of Community and Social Services than you, a situation of the young McLaughlin girl who has multiple disabilities, a little baby with multiple disabilities, and there is not enough home care for that person. That may come under Comsoc rather than you because I think in the House you directed that to the Minister of Community and Social Services. I'd be interested in any of your comments on the progress for people in those categories.

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Hon Mrs Grier: On your last one, I'm afraid I haven't got any details with me at this point. I certainly am aware of the needs of the Niagara -- I never remember the name -- Peninsula Children's Centre. That has been raised by you, by my colleagues in the Niagara Peninsula and Mr O'Connor, who of course toured the facility I think on Friday and has spoken to me about it.

I am very much aware of that and I hope -- I think I said this the last time you asked -- to have an announcement with respect to the future funding in the very near future. All I can say now is that "now" is nearer than it was when you last asked me about it.

With respect to Alzheimer's and the intermittent care, the Niagara region already is piloting an intermittent care program which provides one week of relief for every six weeks -- this started in 1992 -- in six of the municipal homes. Also, the Niagara region has been providing in-home respite and home day care. So while there may not be sufficient, there is in that region a program that not all regions already have. I know, as I said in the House, the difficulties with Alzheimer's patients and I acknowledge that there are not at this point enough facilities, but working towards meeting that need is part of what the long-term care program is going to be about and I hope we can do that.

Mr Bradley: In the meantime, it's very difficult -- I don't think I'm telling you anything you don't know when I say that it is extremely difficult for people and it's largely children and/or spouses who are looking after the Alzheimer's patients. In the early days of the disease it's a little easier, though still a challenge, and in the latter days when it's progressed it is a fact that the mental stability of the people looking after the patients is affected by the fact that they are just a real challenge to deal with and it takes people with specialized abilities to do so and specialized facilities to do so.

I know you have great sympathy for these people and they're at their wits' end as to what to do with them. Many of them are at the stage now where the only option seems to be a nursing home.

Hon Mrs Grier: But even a nursing home requires special facilities and I think that's what I was talking about in the House. I understand there's over 3,000 long-term care beds divided among 28 facilities in the Niagara region. I don't know how many of those are identified for Alzheimer's but that might be something that should be raised with the long-term care committee that is currently preparing the long-term care plan as part of our reform for that region.

I will be glad to take it up with them and see whether specific needs of Alzheimer's patients and their families are being factored into their plan, because that would be where I think it would best start.

The Vice-Chair: The time for the Liberal caucus has expired and I move to the Conservative caucus.

Mr Jim Wilson: Minister, because of the time constraints I can't pursue in any great detail the remainder of my questions with respect to ambulance services. I would like, though, for you to report to this committee the status of the emergency medical services review, the Swimmer report that was released in December 1991; what is the current status of the report's recommendations is my specific question.

Hon Mrs Grier: Can I just respond to that? I can do it very quickly and do it right now. As part of our discussions with respect to the social contract, a commitment was made that we would establish a multi-sectoral committee to look at the Swimmer report. Our view had been that many of the recommendations in the report made sense and we began to implement some of them, but the governance issues of putting in place one system would add considerable costs to the system and the administration of it.

As part of our discussions with the employees, who are very much concerned about this, we've said that if that can be done in a way that does not add cost to the system, we would be more than happy to examine it. This committee has been set up with a fairly tight time frame to do that and I understand has had its first meeting just this week.

Mr Jim Wilson: I appreciate your response. As you know, my caucus's position with respect to the Swimmer report has been that we will accept whatever recommendations come forward that are the best deal for the taxpayers of Ontario. It was an issue we pursued vigorously with your predecessor, Ms Lankin, and I think we eventually got her around to that way of thinking. I am pleased with your remarks in respect to getting the best deal possible for the taxpayers.

There are a number of concerns out there with respect to the deinsuring of medically necessary and currently medically insured services under OHIP. One of them, among many, is laser treatments for the removal of port wine stains. I want to show committee members a picture of a young lady who was born with a rather large port wine stain to the facial area and to read briefly part of the letter that was sent to you, minister, in a letter dated September 9 and copied to myself and my colleague, Mr Don Cousens.

It reads: "I am writing to you at this time concerning laser treatments for port wine stain not to be covered under our Ontario health plan. With this in mind, I need your help. I understand that this is being considered for port wine stain, with it falling under cosmetic. Port wine stain is not cosmetic, it is medical, and should not fall under cosmetic."

She goes on to describe some of the comments she receives from people who come into contact with her little girl. The questions she encounters every day are: "What is wrong with her? Did you burn her? Did you leave her in the sun?" or, in the winter, "Is she frostbitten?"

She goes on to say, "I've been in the hospital and someone started screaming, `What is wrong with her?'" She says in her letter that patients are always telling their kids not to come near her child because they do not know what is wrong with her. She states that her child is too young to realize what people are saying about her or why they are staring, "but when she does, it is going to be very devastating for her. Please help me in avoiding this situation." She goes on to describe the pictures.

I think the important part of the letter is that the mother indicates that with the ongoing treatments the child is receiving -- the latter part of the portfolio shows remarkable progress in removal of the port wine stain; you can see in the later pictures that the little girl is quite a bit older and that the stain is probably 50% or 60% lighter than it was -- eventually this stain will be removed almost totally.

Minister, before I ask you the question, I also have a letter that was forwarded to me by my colleague Bill Murdoch from a constituent in his riding. It's a young lady who's 18 years of age. She says:

"I would like to bring to your attention a large concern of mine. The Hospital for Sick Kids in Toronto is currently giving laser treatments to children with birthmarks (port wine stains), to gradually lighten until removing these marks. The procedure takes very little time and, according to my doctor, requires a trivial amount of money. However, this program is to be shut down by our government because of cost-cutting. I'm in midtreatment of this procedure and am finding the results very pleasing. Unfortunately, midtreatment is likely where I will remain.

"What the government does not understand is how this treatment benefits children who would never have to face the cruelty and isolation of being slightly different in our society. It is simple surgery, no more meaningful than having a wart removed or a tooth pulled, but it is a procedure that will save a child needless emotional pain. I know from experience that children and some adults can be exceedingly heartless and would like to ask you to do something for this program of small yet massive importance to children such as I. Why should a child feel judged when something can easily be done to prevent that?"

Secondly, it's been pointed out to me by my colleague Mrs Marland that in cases where the port wine stain may encompass a large surface area of the body, indeed those cells grow faster than other skin cells, and physical deterioration does occur.

Are you going to delist the removal of port wine stains?

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Hon Mrs Grier: Let me make it very clear. No, port wine stains for children are not something I'm considering delisting. When a list of potential delistings of procedures that were seen as being cosmetic as opposed to directly health-related was released earlier this year, there was enormous concern raised about that, and as a result of our negotiations with the Ontario Medical Association, a process was put in place for trying to look at what procedures should be delisted.

As part of that, the Ontario Medical Association, which wants very much to be involved in all of these discussions, agreed to suggest, from its point of view, some procedures it thought should be delisted, and the ministry to propose, from our point of view, some that we felt ought no longer to be covered by the insurance plan. Those discussions are ongoing and there will be some public participation in those discussions, and I'm very pleased about that. It's the first time these kinds of decisions have ever been made with the public having an opportunity to participate and to play some role in deciding what they believe our collective insurance system should pay for. But certainly as part of proposals that the ministry has put forward, the delisting of the treatment of port wine stains for children is not one of them.

Mr Jim Wilson: For children. Then up to what age is the laser treatment allowed?

Hon Mrs Grier: No firm conclusions have been reached --

Mr Jim Wilson: Well, it sounds like a fairly firm conclusion.

Hon Mrs Grier: -- and no decisions have been made. I'm merely indicating to you that with respect to the list of procedures that could be considered that the ministry has put forward, the delisting of this with respect to children is not one of them.

Mrs Margaret Marland (Mississauga South): Minister, I want to ask you about a matter over which our caucus -- and I'm sure it's the same with all the caucuses -- has received hundreds of letters from across the province, dealing with the subject of in vitro fertilization. You and I are the only people sitting in this room today who have been elected going back to 1985, and both you and I can remember your passion in opposition, as the New Democratic Party, about the subject of equal access to health care in this province. We are concerned about the discussion that perhaps in vitro fertilization and fertility clinic programs as a whole may be delisted and may not be accessible through OHIP insurance for the couples in this province who need that particular treatment.

I think it's very important to realize that when we talk about infertility we're talking about a medical condition. It's the same as any other medical condition. It's a problem. It's very, very serious for young couples who wish to have children and are not able to without that help. In the meantime, if there is a risk of that service being deinsured and these couples continue to fund services of other categories through their taxes, it's a tremendous double standard here and a horrible irony. Through their taxes, of course, they're funding other health services, from abortion through maternity services all the way to sterilization.

I'm very concerned about the fact that you're even considering delisting this particular service. In fact, what you would be doing, if you were to go through with it, is creating the very thing you have argued passionately against, which is a two-tiered medical system: The couples who can afford it will have access to it; the couples who can't afford it will not have access to it. You're certainly gung-ho on abortion services in this province, across the entire province, and I cannot see how you could possibly ever defend funding abortion services and not funding infertility clinics with whatever is needed, in vitro fertilization as part of that treatment.

I want to ask you directly, will you assure these families that you will not discriminate against them in the future and that you will continue to have in vitro fertilization as an insured service in Ontario?

Hon Mrs Grier: Let me say to the member that I certainly know the strength of the views of people who believe that this is a process that they want to take advantage of. I would point out to her that Ontario is the only province where it is now an insured service. I don't know whether she has discussed this with, for example, Premier Filmon or Premier Kline and other provinces where it is not seen as being an essential service.

I have to say to you that I have some concerns about the process, and I await with interest the report of the Royal Commission on New Reproductive Technology, which I understand will be out next month, because the treatment of infertility occurs in a number of different ways, in vitro fertilization being one. There have been some recent studies that indicate that perhaps the chances of conceiving with that kind of treatment as opposed to some more conventional treatments are not that greatly different and that the side-effects are things that have yet to be evaluated.

In coming to a conclusion as to whether or not this is a medically necessary procedure and one that should be covered by our insurance plan, I want to have some more discussion and am not in a position to give you a categorical confirmation today.

Mrs Marland: Is there any relationship between the fact that the deputy comes from other provinces where this is not an insured service? I wonder.

Hon Mrs Grier: I think that's really a most unacceptable comment, Mr Chair, and I'm sure it's not one that the member genuinely wants to make.

Mrs Marland: Would you agree that infertility is a medical condition, minister?

Hon Mrs Grier: I am not a doctor and do not practise medicine, nor do I intend to. I accept advice and I listen with care to advice from all sides on all issues and come to some conclusion.

Mrs Marland: Therefore, you can't talk about side-effects of a procedure you know nothing about, which is what you just said.

Hon Mrs Grier: I was merely relating the fact that there are very significantly different points of view around this particular procedure.

Mr Donald Abel (Wentworth North): You're way out of line, Margaret.

Mrs Marland: And it's okay to fund abortion clinics?

Mr Abel: Are you against abortion clinics?

Mrs Marland: I'm asking if it's okay to fund one side of reproduction and not another.

The Vice-Chair: Mrs Marland, could you address your question to the minister.

Mrs Marland: I'm handing it back to our Health critic.

Mr Jim Wilson: There's a great deal of concern around the province regarding the government's approach to psychiatric services. Community Mental Health Services in Collingwood, in my riding, has written to your ministry and expressed its deep concerns about your government's psychiatric sessional fee reduction, which is part of your expenditure control exercise.

I want to quote from a letter dated September 15 from Mr Eric Sutton, manager of Community Mental Health Services in Collingwood. The letter was addressed to Ms Jessica Hill at the community mental health branch of your ministry. Mr Sutton writes:

"Not only does the announcement of cuts retroactive to April 1, 1993, put us in a difficult financial situation this year, but the possibility of inadequate psychiatric support is a threat to the viability of our operation. Already, we have had a resignation from the consulting psychiatrist to our psychogeriatric program, Dr Stephen Kiraly, over this program.

"We are a small team, five mental health professionals working with the support of a psychiatrist clinical director and two other consulting psychiatrists. Although we are a small team, we process 800 referrals from the community each year. Of the approximately 175 people active on our case loads, 60% of them suffer from schizophrenic-like illness, an organic brain disorder or a major affective disorder. We contend with these kinds of numbers and acuity level only because we have solid psychiatrist availability and consultation opportunities. We can be much more than a counselling service and meet the needs of the community because of this level of psychiatric support.

"In this time of mental health reform planning, when more money is supposed to be going from institutions to the community, this cut of 25% in psychiatrist availability is a move in the opposite direction. This plan may well threaten the ability of many programs to help the seriously mentally ill. I would urge you to reconsider."

What Mr Sutton has said, it seems to me, flies in the face of your mental health reform strategy as outlined in the document entitled Putting People First, which says in part, "As far as possible, enabling people with mental health problems to remain in the community, using hospitalization only when clinically necessary."

The 25% reduction in psychiatric sessional fees, which in fact will be a 50% reduction in year one because of the retroactivity, I think will serve to undermine your goal of deinstitutionalization in the mental health care sector. Could I have your comments on that with specific reference to the Collingwood situation?

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Hon Mrs Grier: I can't address the specific reference to Collingwood because I'm afraid I don't have the details on that. I acknowledge that in fact we did reduce the sessional fees, but I take issue with the member characterizing that as concern about our mental health reform policies, because of all of the initiatives we've taken and the actions we have started, I think the level of acceptance and approbation of our mental health reform policy has been the greatest. We now have a clear policy framework to guide reform, and the member is right: it is consumer-oriented and community-focused. The organizations that provide the kind of counselling and support, the families of people who are diagnosed with schizophrenia, the community-based counselling, the survivor organizations, are all very accepting and very supportive of the direction that we are going.

The reduction in sessional fees was part of our budget constraint program. I would point out to him that most of those fees are paid to hospitals and to people who practice out of hospitals; who practice sometimes with community groups but who are essentially not the kind of community-based services which the Graham report and the Canadian Mental Health Association and all of the grass-roots community organizations over the years have called for. We have a provincial advisory committee on mental health reform which has been chaired by Glenn Thompson, a former deputy minister and official of the Canadian Mental Health Association who has been working with my ministry in moving to implement the reforms as a special adviser.

While I met some months ago certainly with representatives of the psychiatrists who were concerned about the reductions in the sessional fees and what it meant to their income, with respect to the implementation of the reform, as I say, my sense is that it has been well received, welcomed, and the district health councils and the psychiatric hospitals are working towards integrating their long-term plans so that we can at last have a comprehensive community-based mental health system in the province.

Mr Jim Wilson: But with respect to the reform, I think I would agree that the theory of the mental health reform has been well received by district health councils and stakeholders. None the less, with the onslaught of cuts in the sessional fees, the expenditure control plan and the social contract, we're seeing a reduction of services at the community level. Mr Sutton points out in his letter that they've already lost one professional who was part of the team there and it's a reduction of services to the people. So on one hand you talk about deinstitutionalization, you talk about reform, but the reality out there is that there's actually less service for people in their own communities.

Hon Mrs Grier: Again I would disagree that that fact the reality. I was able to indicate to a meeting of some OPSEU workers from psychiatric hospitals a couple of weeks ago that as part of our reinvestment of some of the savings from the institutions, we will have an additional $5 million to allocate to many of the community-based programs. I believe the beginning of implementation of mental health reform is reflecting the needs that are actually being identified in communities and through the long-term plans that have been done.

Mr Jim Wilson: I want to read from a letter that was faxed within the last day to the leader of the Ontario PC Party, Mike Harris, from Patricia George, who's founder of the Heart and Lung Patients Support Services of Ontario. Mrs George is very anxious for you to hear at first hand her concerns regarding your handling of the cuts to the Ontario drug benefit program.

"I am writing to you on behalf of all of the senior citizens of Ontario. They are very disgusted with Health minister Ruth Grier and all who are involved with the seniors' drugs being cut, especially when it comes to heart and lung medication. Our phones are ringing from all across Ontario asking us to help them to pay for their medication that they have to have. Most of these seniors are 60 and over and they just cannot make ends meet. Some of this medication that they take ranges from $100 to $300. Besides paying for their medication, they have rent and food. It is beginning to look like they either pay for their medication and do without food and a roof over their head, or they buy food and pay their rent and do not take their medication and if they are lucky, will end up in the hospital, with the government having to pay.

"I would like for you to address this concern to Ms Ruth Grier and ask her, does she not have a heart when it comes to seniors? How can anyone treat them like this? What in the hell is this country we call Canada coming to when we can always help other countries, but we cannot even help our own people? Every time you turn around it is the seniors who are getting the shaft. This is not right and we, the above organization, will fight and fight for these people."

She mentions that she sent you a letter along the same lines dated September 15, and has not yet received a response.

"When are we going to have a Health minister that is going to show they care and show respect for the seniors and not dig a hole for them to crawl into?"

She goes on, again pleading with Mike Harris to bring this to your attention. Minister, do you have any comments with respect to Ms George's letter?

Hon Mrs Grier: I certainly hope that Mr Harris in his reply will point out the actions this government has taken with respect to assistance to seniors, whether it be in health care, whether it be in housing, whether it be in a range of other activities, and will point out that, for example, long-term care, which we've been discussing here, is moving to action, something that other governments have only talked about for lo, these many years.

I'm sure Mr Harris will also point out to her that Ontario is the only province where drugs are currently available with no charge to anybody over 65, regardless of their income. As the member will know, in looking at how we can reform our drug program and extend that eligibility to perhaps people with catastrophic illnesses or families of the working poor, we have considered whether one way to do that is to impose some kind of user fee on those who can afford it and who may have hitherto not had to contribute to the cost of those drugs.

That is something that is under consideration, something on which broad public consultation ended at the end of September. The response has been, as the member might expect, with those who currently benefit from our program indicating that they don't see any need to change and those who have not been so fortunate and have in fact enormous costs of drugs, partially because of the federal government's actions in supporting Bill C-91, which increased the cost of generic drugs to seniors all across this country and not only in Ontario, some people saying, "We wish we had access to your drug program."

The changes that we have made with respect to changes in the formulary are based on the expert advice of the Drug Quality and Therapeutics Committee, which looks at the medications from the point of view of what is the most cost-effective and does not recommend the removal from the list of any drug for which an alternative is not available or for which they do not believe a very cost-effective alternative can be obtained, either through changes in diet or over the counter.

So the concerns that your constituent has written about are in anticipation of changes to the drug system that are yet to be made and lack recognition of the very real reforms and progress that have been made in this province in providing security and secure health care to seniors.

The Vice-Chair: Thank you, Minister. We now turn to the New Democrat caucus. Ms Haeck.

Ms Christel Haeck (St Catharines-Brock): Madam Minister, I appreciate your coming before us. I have written a letter to you as well as to previous ministers of Health with regard to a psychiatric service problem in our area.

St Catharines falls under the umbrella of the Hamilton Psychiatric Hospital. Geographically we make up about 30% of their catchment area, but we receive only about 11% of service in return. I have talked to our district health council, so I have some sense of what the problem is. The concern I have is that we really do lack a range of follow-up services for psychiatric patients who have been released from Hamilton Psychiatric.

1750

There is one group that at this time is being funded by the United Way, which is the CMHA facility, actually very close to where I live. They are right now under a severe threat of being cut back because, as many other institutions are, the United Way is seriously looking at how it is funding a range of agencies. This particular agency would like to, as many other sort of drop-in centres -- what they would like to establish are funded through the community mental health branch.

This may be just an anomaly, but it is one that exists, that they are having great difficulty in making their case heard for at least getting some recognition of the problem and hopefully at some point some funding. So I'd like to again advocate on their behalf to see about getting their drop-in centre so some of our ex-psychiatric patients can in fact get the kind of care they need.

Hon Mrs Grier: Miss Haeck has done an admirable job of drawing to my attention the fact that the peninsula, because it is often lumped in for statistical purposes with the Hamilton-Wentworth region, is underserviced and lacks facilities. I want to assure her and her constituents that, yes, that picture has been drawn for me, I understand it, and as we review the plans the district health councils will be drawing up in terms of mental health services, I will certainly keep it in mind.

There is more money for community mental health, as I indicated in response to a question from, I think, Mr Wilson. Part of the savings that we have identified from within the psychiatric institutions will be reinvested in community support programs. I'll be happy to look into the specific one that you raise and see what its status is.

Ms Haeck: I thank you, Minister, because, living downtown and having worked downtown for many years in St Catharines, we do see a lot of the ex-psychiatric patients. It's something that they truly need to have available to them.

Mr Bisson: I was going through some documents I had asked for from legislative research on something going on at Sunnybrook Health Science Centre in terms of cost-of-care statements. I don't know if you're aware of that.

Hon Mrs Grier: As to what?

Mr Bisson: Cost-of-care statements. We had a discussion about a year ago with a number of people in our community about the issue of health care and trying to contain costs. One of the big things to come out of it -- surprise, surprise -- is that many people, although they understand we spend a lot of money in health care, don't understand how much it really costs per individual going to a hospital emergency department etc.

Sunnybrook has for a while, through the health science centre, been doing cost-of-care statements, and I'm wondering if the minister could respond as to what the possibility is to take a look at what they've been doing there. Is that really something that's feasible to extend to the rest of the province so people understand how much health care actually is?

Hon Mrs Grier: This is something which shortly after I became minister I expressed a very real interest in, and I was excited to find that Sunnybrook had been doing a pilot project to have a look at that. I think it is an opportunity for us to assist people to understand more about the system and about what the costs that are incurred are. I will certainly, as we look at revamping the health card system and how we can make sure that we verify expenditures, look at this as an opportunity to do that. I see it as an opportunity both for us to have a better control on the system, perhaps, but also to enable patients to understand what happens.

I continually cite the case of a doctor I was told about who frequently visited a senior citizens' building, went down the corridor knocking on apartment doors and saying, "Hello, Mr Jones. How are you feeling today? Hello, Miss Smith. I hope you're well," and then, they suspected, billed OHIP for a house call.

If those particular people got a statement of cost and realized that at the end of a quarter or the end of a year, "There were 12 house calls? I don't remember that," and begin to hold that particular physician to account, that's one of the ways that we can make sure we have a more effectively managed system. So I'm very interested in pursuing that and I can assure you that I will.

Mr Bisson: Just something following up: The only thing I would add to that is that one of the things that struck me with what they're doing at health science centres is they're giving a cost-of-care statement but they're not including physicians' billing in that. Given that a lot of money we spend is on actual doctors' care, I'm just wondering why that's not in the statement.

Hon Mrs Grier: This is a project that Sunnybrook centre is doing, so it's the cost of care to them. The doctors' fees would come in through part of the OHIP system, and so Sunnybrook would not have that. As we look at the system in a more comprehensive way, then I want to see what kind of technology we need to be able to do a total cost of care.

Mr Bisson: I'm just wondering if the Chair needs a motion in order to consider the estimates concluded.

The Vice-Chair: I do.

Mr Bisson: I would make a motion that we consider the estimates of the Ministry of Health as being concluded at this point.

The Vice-Chair: All in favour?

Mr Abel: I'll second that.

Mr Jim Wilson: Mr Chairman, do we get discussion on that motion?

The Vice-Chair: We have about five minutes left to go. Mr Wilson.

Mr Jim Wilson: My understanding is that both the Liberal Party and the Conservative Party are still owed time in this process and that we're not constrained by 6 o'clock.

Mr Larry O'Connor (Durham-York): Can I speak to that?

The Vice-Chair: Just a second. It's my understanding that we were to conclude at 6 o'clock.

Mr Jim Wilson: On whose agreement, Mr Chair?

The Vice-Chair: Mr O'Connor.

Mr O'Connor: Maybe if I could shed a little bit of light on this. I did have a discussion with the other Chair before he had to leave us and was assured that both opposition parties would get their full time allotment. In fact, to enable them to get their full time allotment, the government caucus limited itself so that they would have their share of time. So at this time everyone's received their share of time other than the government caucus, which hasn't received its share of time but in the wish of trying to proceed in an orderly fashion has conceded that time over at this point.

Hon Mrs Grier: That was my understanding, Mr Chair, from Mr Jackson. I very much appreciate my colleagues making that sacrifice.

The Vice-Chair: Perhaps this might provide some additional clarification: It was my understanding that the Liberals were to receive 55 minutes approximately, which they did; the Conservatives 55 minutes, which they did; the New Democrats 30 minutes this afternoon, which they did.

Mrs Sullivan: There was certainly understanding that the New Democrats had agreed to move back from time. I think the misunderstanding arose in that the opposition parties thought that we had another 25 minutes left each. So when the totals were shown to us on the paper they were probably a total that didn't include an extra 25 minutes, because I was prepared for another round of questioning of about 25 minutes. But if the time is not short 50 minutes, then we'd better vote.

The Vice-Chair: Yes. The time has expired and the opposition caucuses have had the requisite amount of time.

Hon Mrs Grier: Could I ask you to vote on my estimates before we leave?

The Vice-Chair: This now completes the time allocated by agreement to complete the Ministry of Health estimates for 1993-94. Shall vote 1601 --

Mrs Marland: Can we have a recorded vote?

The Vice-Chair: A recorded vote? Shall vote 1601 carry? All in favour?

Ayes

Abel, Bisson, Haeck, Hayes, O'Connor, Wessenger.

The Vice-Chair: Opposed?

Mr Jim Wilson: Sorry. Which number again?

The Vice-Chair: Vote 1601. Opposed?

Mr Abel: Are you sure you want a recorded vote on this?

The Vice-Chair: We're having a recorded vote.

Mrs Marland: Mr Chairman, I'm not subbed into the committee, so I can't make that request.

Interjections.

Mrs Marland: Well, look: I'm being very honest.

The Vice-Chair: We're in the midst of vote, Mrs Marland. Opposed?

Mrs Sullivan: Point of order, Mr Chair: The member has indicated that she is not subbed in on the committee and she has asked for a recorded vote that in fact she was not eligible to request when those of us who are on the committee -- I don't know if I can speak for my colleague, but I do not require a recorded vote on every section. But the member --

The Vice-Chair: On this vote we're having a recorded vote.

Mrs Sullivan: Okay.

The Vice-Chair: We're in the midst of a recorded vote on this vote. Vote 1601, opposed?

Nays

Wilson (Simcoe West).

The Vice-Chair: Carried.

Shall vote 1602 carry? Carried.

Shall vote 1603 carry? Carried.

Shall vote 1604 carry? Carried.

Shall the 1993-94 estimates of the Ministry of Health be approved? All in favour? Opposed? Carried.

Shall the Ministry of Health estimates be reported to the House? Carried.

This meeting stands adjourned until tomorrow when we will consider the Ministry of Labour estimates at 3:30.

Hon Mrs Grier: Thank you, Mr Chair, and thank you, committee members.

The committee adjourned at 1800.