CONTENTS
Wednesday 8 June 1994
Ministry of Health
Hon Ruth Grier, minister
Jessica Hill, acting assistant deputy minister, mental health programs and services
Margaret Mottershead, deputy minister
STANDING COMMITTEE ON ESTIMATES
*Chair / Président: Jackson, Cameron (Burlington South/-Sud PC)
*Vice-Chair / Vice-Président: Arnott, Ted (Wellington PC)
Abel, Donald (Wentworth North/-Nord ND)
Carr, Gary (Oakville South/-Sud PC)
Duignan, Noel (Halton North/-Nord ND)
Elston, Murray J. (Bruce L)
*Fletcher, Derek (Guelph 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 Wiseman
Runciman, Robert W. (Leeds-Grenville PC) for Mr Carr
Sullivan, Barbara (Halton Centre L) for Mr Ramsay
Wilson, Gary, (Kingston and The Islands/Kingston et Les Iles ND) for Mr Hayes
Wilson, Jim (Simcoe West/-Ouest PC) for Mr Carr
Clerk / Greffière: Grannum, Tonia
Staff / Personnel: McLellan, Ray, research officer, Legislative Research Service
The committee met at 1534 in committee room 2.
MINISTRY OF HEALTH
The Chair (Mr Cameron Jackson): We've recon-vened for continuation of the Ministry of Health estimates. We have eight hours and 20 minutes remaining.
As I understand, we were able to complete the minister's opening statements yesterday, and by mutual agreement we're going to allow the third party to go first. The Health critic, Ms Sullivan, will go second, for her period of up to 30 minutes, and then the minister for her response. Mr Wilson, proceed.
Mr Jim Wilson (Simcoe West): Minister, Deputy and colleagues, may I begin by making an apology in advance, and that is, although I have a number of concerns I'd like to express and put on the record at this time, unfortunately -- or fortunately -- I have to go to London this afternoon and therefore, Minister, will not be here to hear at first hand your response. I do apologize, but I'll catch up prior to the next time we convene.
Over the course of the estimates debate, we will be pursuing numerous policy areas within the Ministry of Health. What has become apparent to myself, as the Ontario PC Health critic, and to members of my caucus is that there are some troublesome common themes in NDP health policy.
The first one that perhaps bothers us the most at this time is the inappropriate imposition of ideology in the reform of health care services.
The second is a general sense that there isn't an overall plan for health care in Ontario and that the government still has some areas that are not well managed. We'll be looking at issues of mismanagement during the course of these committee proceedings.
The third area that is of concern is the lack, again, of an overall vision to restructure the province's health sector in a comprehensive way. Included in the policy areas I intend to explore over the course of the nine hours allocated are the implementation of the Regulated Health Professions Act; on-call emergency services in small rural hospital emergency departments; long-term care reform; an overall view of emergency services; reform of the Ontario drug benefit program; mental health reform; OHIP eligibility; out-of-country coverage; the new health card, and health human resource planning.
The first area I want to make some remarks on is the on-call emergency services in small, rural hospital emergency departments. I had the opportunity this afternoon to ask the minister a question pertaining to this issue.
Physicians in small communities in remote areas have been unhappy with compensation under OHIP on a fee-for-service basis for the provision of emergency coverage. Physicians are less and less willing to accept the personal sacrifices of being on call at all times for emergency services. Remuneration under the fee-for-service system in low-patient-volume areas means limited fees for many physicians.
Some physicians have threatened to withdraw services. To date, most disputes have been resolved through alternative payment arrangements, including reallocation of hospital resources to supplement compensation to physicians.
According to a recent survey by the Ontario Hospital Association, 42 Ontario hospitals are currently making extra payments to physicians in order to guarantee access to hospital emergency services for the people of their communities. The OHA survey also found that an additional 14 hospitals have been forced to curtail emergency services, including reducing the hours of coverage.
In November 1993, the former deputy minister, Michael Decter, made a commitment to a comprehensive review of physician coverage of hospital emergency departments, involving the Ontario Medical Association and the OHA. Unfortunately, this issue remains unresolved, and I'll be pursuing that matter with the minister.
The OMA, in a May 25 letter to the Deputy Minister of Health, indicated its willingness to enter into formal negotiations with the MOH within the context of the 1991 framework agreement without any preconditions.
In May 1994, OHA held its annual conference for small hospitals. Not surprisingly, emergency department on-call physician service remuneration figured prominently on the agenda. Participants reaffirmed the direction of the November OHA resolution on this issue and underlined the immediacy of the crisis by requesting that a new, revitalized tripartite framework for negotiations be established by the Minister of Health and that this matter be resolved no later than July 31, 1994. The 56 communities that have been impacted by this issue also are pleading that this issue be resolved by July 31.
I'd like to know, as I asked the minister in the House today, what guarantees the minister can give to these communities that the government and the other parties involved will be able to resolve this issue by July 31. Second, given the failure of previous attempts to resolve this matter, again I would ask the minister to respond to the question, will she contemplate at least appointing an independent arbitrator, one acceptable to the government, the OMA and the 0HA, and have the arbitrator recommend solutions to this growing crisis?
I guess I need it clarified why the government does not at this time want to appoint an independent arbitrator. It seems to me that in your response today you made clear what the government's position is going into these talks, or as these talks have proceeded and not proceeded; they've been on and off over the past number of months. I don't see why the government's position, along with the other parties' positions, can't be put before an independent arbitrator and some solutions recommended.
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On this same issue, I have a local matter. Recently, we had a meeting, some physicians -- Dr Peter Wells and some representatives from the Collingwood General and Marine Hospital -- with the assistant deputy minister, Jodey Porter, and put before her a rural family practice residency program suggestion. I want to say for the record that Ms Porter was very considerate. Indeed I was impressed with her manner and approach to this issue and the courtesy she extended to the people of my riding. However, that was some several weeks ago and I've not had any follow-up from the ministry. Perhaps, Minister, you could endeavour to find out what, if any, progress has been made with that proposal put forward by the family practice physicians of the Collingwood General and Marine Hospital. I think the program, and certainly Ms Porter so indicated, fits into the direction the government wants to go in helping to resolve problems in underserviced areas, problems with respect to physician coverage in rural areas and the problem of attracting physicians to rural areas of this province. Given that it was a fairly amenable meeting, we are looking for a fairly quick response.
Second, the implementation of the Regulated Health Professions Act: Minister, as you know, I have had the opportunity to speak with you briefly about this issue. The current inquiry concerns rumours that are circulating that perhaps the government wants to open the RHPA up, particularly with respect to the concerns that have been expressed by dental hygienists and by dentists, and the position now being put forward by some members of the College of Dental Hygienists that being under the order of a dentist during the performance of their duties in public health might somehow impair the ability of dental hygienists to conduct their work in that sector.
I've not taken sides with this issue. I do know that some parties have asked that the whole matter be sent out to the advisory committee. I'd like to know what the government's intention is with respect to the RHPA and whether the government is contemplating opening it up for this profession or any other profession.
The whole matter of the quality assurance program has surfaced also at this time that the RHPA is being implemented. In a last-minute move during clause-by-clause debate on Bill 100, government members of the standing committee on social development introduced a motion that broadens the scope of regulatory colleges' quality assurance program. Section 22(2) of Bill 100, amending section 95 of schedule 2 of the RHPA, authorizes each of the quality assurance committees of the regulatory colleges -- the college is set up in the act to impose terms, conditions and limitations on a health practitioner's licence for up to six months.
I think most members are aware that Mike Harris, the leader of my party, has written to the minister asking that the matter be referred to the Health Professions Regulatory Advisory Council. Section 12 of the Regulated Health Professions Act specifies that matters be referred to the advisory council "unless, in the minister's opinion, the request is not made in good faith or is frivolous or vexatious." I understand that the Ontario Medical Association has made a similar request and that the request was first made in February of this year. I'd like to know what your intentions are with respect to this matter. Perhaps you could give us a status report also.
I also will have some questions relating to optometry and the RHPA, and, as I mentioned, dental hygiene in the RHPA, and would like to know what to date has been referred to the Health Professions Regulatory Advisory Council. I think it would be quite helpful if all members were brought up to date with respect to the matters that have been referred to that council.
Long-term care: A couple of days ago the second phase of long-term care legislation was introduced in the Legislature. A number of volunteer-based groups have raised very legitimate concerns with the implementation of the multiservice agencies, and some have raised concerns with the whole concept now of multiservice agencies. To be fair to the government, it would have been a little more helpful to all members if some of these conceptual concerns regarding MSAs had been raised during the discussion on Bill 101 originally.
Some of these volunteer-based groups have approached me and told me they view MSAs as the forced demise of volunteer-based community groups. They maintain that the loss of volunteers will translate into the loss of dedication to work in governance positions, a loss in the commitment to provide hands-on services, a loss of the historic values and commitments made by volunteers to these agencies, a reduction in donations and fund-raising ability, and a reduction in consumer choice.
Organizations such as the Catholic Health Association of Ontario believe that MSAs will eliminate consumer choice and ignore the history of competency in governance and management of Ontario's long-term care facilities and community-based organizations. They believe this legislation will undoubtedly put yet another nail in the coffin of the private home care sector.
I'm surprised how many non-profit groups and groups that you would not expect to be commenting too much on the issue have now come forward and expressed concerns similar to those I have expressed on behalf of my party with respect to the private sector and the direction the government is going in driving the private sector out of the delivery of home care services. The NDP has made no secret of its preference for non-profit home care services. They've also made it clear that the general thrust of the government is to not have the private sector involved to any great extent in the delivery of health and social services across the board.
On the subject of private sector involvement in health care services, my party has been vocal in opposition to the government's repeated attacks on private sector involvement in the delivery of health care services. We believe public administration of the health care system should not necessarily translate into public ownership of facilities. My caucus colleagues and I have been consistent proponents of the view that the private sector is a major contributor to the province's health care system, enhancing both the quality and availability of services for all Ontarians. We defended the critical role of the private sector in the delivery of health care services during the debate surrounding Bill 101, the Long-Term Care Statute Law Amendment Act.
The NDP government, basing its decisions on ideology instead of pragmatism, has shown favour for the not-for-profit long-term care service sector, thereby ignoring the essential role the private sector plays in meeting the needs of consumers. This makes no sense to the PC Party of Ontario, nor does it make much sense to many of the service providers or to many of the consumers.
The most recent example of the inappropriate imposition of ideology has been in relation to in-home health care services. What is most disturbing about this decision is the government's obvious disregard for the serious and disruptive spinoff effects this policy move will have on consumers. There are several practical problems with strict adherence to this preference, including the dislocation of workers, the creation of significant gaps in services and the limitation of consumer choice.
Private home care providers were shocked to hear originally from a senior adviser in the Premier's office back in November 1992 that the government intended to cut their market share of home care services from the current 45% to 10% in two years. This decision was made without the benefit of a single study to determine the socioeconomic or cost-benefit impact of this policy decision. Minister, you've admitted and your predecessor's readily admitted that there are no studies available in the Ministry of Health to prove that driving the private sector out of the delivery of services is somehow better for the people of Ontario.
Recently, you admitted, in response to a reporter's question and to a question I asked in the House following your press conference announcing the second stage of long-term care reform, that the 10% limitation now will be a legislated 20% limit for each multiservice agency on the amount of private home care services that it may purchase.
As Health critic, these issues greatly concern me, and I hope this committee process will allow us to discuss some of the implications of this ill-conceived, ideologically driven policy of the government.
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It's been the policy for many years in this province that there be a balance between the role of the private sector and the public sector in the delivery of health care services. It was about 1986, I suppose, when that balance started to shift and the previous Liberal government expressed a preference towards the public or not-for-profit sector and moving away from the private sector, but regardless of that announcement by the previous government, we still found that the private sector was involved in about 45% of the delivery of community-based home care services.
When the government pays the same amount of money to not-for-profit agencies and commercial agencies, I don't see how, at the end of the day, from the government's point of view, the payor's point of view, there can be any benefit one way or the other. It's all fine and dandy to go around talking about how people shouldn't make a profit on the backs of the sick or on the backs of children, but if we look at what's happened in the area of child care and we look at what the auditor of this province has said about that scam, we realize that a lot of money has been spent trying to drive private sector day care operators out of business and not creating new spaces or reducing the waiting list for subsidies.
We will continue to pursue this throughout the dying months, perhaps, of your government, and it's not something we are pleased with at all. Common sense indicates that there seems to be no rhyme or reason for this other than an ideological preference.
Quite sharply, you could say, in response to my question the other day in the House, Minister, you accused me of having as much ideology, if not more, than the government. I don't think ours is ideology, though, as much as a belief in the fact that consumers should drive the system and a belief that a consumer-driven marketplace will decide who will deliver the services to them and that there isn't a role for government in making arbitrary decisions and distorting that consumer choice.
I could see a role for government if somehow one sector was being paid more or was costing the government more, but we've not seen any studies to indicate that the private sector is indeed costing the government more or being paid more for the services it delivers. In fact I think the rule of thumb out there over the years has been that having the private sector involved in the delivery of many government services helps to keep competition in the system and helps to keep prices down also in the public sector, and it's been generally good for this province.
Obviously, I want to talk during this time about the Ontario drug benefit program. Minister, we are still awaiting the release of details that will shed some light on your government's overhaul of the ODB. While the seven principles of reform and six areas for consultation outlined in the government's paper suggest the general format of the government's hopes for a new drug plan, precise details are still missing. The only matter we've obtained any certainty about is the fact that the government does not intend to introduce a copayment for persons 65 years and older, as was contemplated at one time by the government.
Last summer, a week before the Ontario Federation of Labour convention here in Toronto, the government announced it wouldn't move ahead on a copayment. That leaves, in my look at things, a great deal of pressure on the actual drugs that are allowed to be listed and remain listed on the formulary.
Having just had a seniors' seminar in my riding last week, the majority of questions surrounded the Advocacy Act, the Consent to Treatment Act and Powers of Attorney Act. I shouldn't have been surprised but was somewhat surprised about what experts individual seniors are on the ODB. They were able to get up and tell me exactly what drugs had been delisted and give me the history, in many cases. There were over 100 seniors at this seminar, and probably half in the room took the opportunity to express concerns about drugs they can no longer get.
I think the issue has been contained to the extent that they're currently able to get some substitute drugs. But if the government keeps randomly delisting drugs, we're going to hear from seniors in this province, because one of these days something is going to be delisted that impacts very severely on that population.
If you ask seniors the following question, "Would you like us to continue just delisting drugs?" in their words they say we're delisting with no rhyme or reason. They don't know why they can't get one but can get another. "Do you want us to keep delisting drugs or would you want us to have as many drugs available on the formulary and you pay a small fee" -- a yearly fee or whatever model you come up with -- "towards the cost of keeping those drugs on the formulary and providing them to seniors and those on social assistance?" Overwhelmingly, audiences -- and I've posed the question many times over the past two years -- say: "No, I'd rather have access to the whole range of drugs. I trust my physician and my care givers, and we'd like to have access to the whole range of drugs available in this world, to the best humanly possible, and yes, we are willing, as long as it's means-tested some way, to pay a copayment." The government, in contemplating copayments, must have had similar feedback from the seniors community.
Hon Ruth Grier (Minister of Health): I wish we had.
Mr Jim Wilson: I find it depends on how you pose the question, because seniors really do know what's going on. I think they feel they're being attacked in a number of areas, and that's probably why we're getting a negative response to copayments at this point, because there are other things, like out-of-country health services, that I want to talk about also. But if we level with people and say we've got an affordability problem and go to the public and ask them to help solve that problem, I'm confident we can come up with some solutions.
Just to put you on notice, I'll also be asking some specific questions about the special drugs program and the government's future intentions in that area.
With respect to OHIP and out-of-country payments, I remain very concerned with the recent changes to the Ontario health insurance plan. As of June 30, 1994, the province will only pay $100 per day for individuals who need emergency hospital treatment when travelling outside of Canada. The current rate is $400 per day, which reflects approximately the amount that hospitals in Ontario charge per day for a patient's stay in hospital.
It's my firm belief that the slashing of out-of-country coverage violates the Canada Health Act and specifically the portability clause. This violation is made clear in subclause 11(1)(b)(ii), which states, "where the insured health services are provided out of Canada, payment is made on the basis of the amount that would have been paid by the province for similar services rendered in the province...."
Minister, I have a couple of questions about that. So far, your only defence in moving to reduce your out-of-country payments has been, "Well, other provinces did it and they didn't get in trouble from the federal government, which has the responsibility for enforcing the Canada Health Act, so I guess it was okay." I think you should take a more responsible approach to that. Just because other provinces are in breach of the law doesn't mean Ontario should be trying to get away with it too.
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Secondly, there's the claim by the government that somehow you'll save $20 million on this. What seniors and I find offensive about that is that it almost implies that people -- because you were paying over the last year and a half a capped amount anyway, a fixed amount of $400 per day for out-of-country reimbursement, which approximated what the cost was in Ontario -- seniors are somehow going to Florida or Texas and purposely having their heart attacks down there. It seems to me that if you're going to have a heart attack, you're going to have it wherever you are and whenever God decides it's time. Whether you have that heart attack in Ontario and the province therefore has to pay, for argument's sake, the $400 a day under OHIP or you have that down in Florida and the province has to pay $400 a day, the province still pays. To say that you're going to save money, I just don't see how you're going to do it.
What's going to happen obviously is that people are not going to go south as frequently or in as great numbers as in the past and they're going to get sick, as they would have gotten sick anyway, I suppose, in Ontario. At the end of the day, you're not going to save $20 million. I'd really like to know what studies you have or what proof you have that you can save money, those significant dollars, from this initiative.
Secondly, I continue to argue, as do many senior advocates, that it may very well be the case that some seniors save us dollars. If you're severely arthritic or have other ailments, maybe the best place for you is to spend a couple of months in a warmer climate rather than being pent up in your home here in Canada and suffering and visiting the emergency room at night etc. It's not all bad that seniors travel south, some for legitimate health reasons. I really never have had the government admit that indeed some seniors do travel for legitimate health reasons. That admission would be helpful, Minister.
You must know people in my area, as I do, who aren't terribly wealthy but go down south for exactly that reason, because they just feel better. They use their savings and spend time in a warmer climate and probably save us money, although I don't have any hard evidence -- I have anecdotal evidence -- that they would save us money.
Health cards: All members of the committee are well aware of the mismanagement that's gone on in Ontario's health card system over the years. It's an issue on which I, on behalf of my party, have consistently, and with a great deal of determination, tried to get the government to make the right decision. I don't think, with the fairly recent announcement that you're going to put photos on a magnetic strip card, that you've come up with the right answer. For the first few months of this year I purposely stopped raising health card fraud matters to give the government some breathing room, hoping that you would adopt a smart card system, because at the end of the day you've only served one purpose with the announcement of your intention to introduce photo ID, and that is that you've met your obligations under the OMA-government agreement, but you've done nothing to enhance data management, data collection and health care analysis of the data.
I've had some wonderful discussions recently with people from ICES, the Institute for Clinical Evaluative Sciences, who, without mentioning any names, explained to me the frustration in trying to find the data they feel should be readily available in our health card system, that having a magnetic strip card, although it may be the cheaper option at this time, is not the technology we should be embracing because it won't in any way improve our data.
I'm sure you agree, Minister, that the real saving that will come in the future to our health care system is not to continue on a slash-and-burn approach but to obtain good data and to undertake proper analysis of that data, which ICES is trying to do. However, the good people at ICES will have to live many, many years beyond a normal lifespan to cover all of the treatments and procedures that are used in this province in our health care system and to properly analyse and report back as to the direction we should be going in treating both disease and preventing disease and illness in our society.
Again, I would like an explanation, Minister, on why you moved towards a simple magnetic strip card again, what the government's intention is with respect to better data collection and management and analysis, and how you're going to achieve those better ends with technology that was put in place in other sectors of our economy long before I was born and technology that is so outdated that really only the Ontario government's embracing it any more. It's a shame, because if you had made the decision to go to, and bite the bullet on the cost of, a smart-card system or a better data system, then over the long run I believe those systems would have paid for themselves.
Secondly, I think all parties have been approached by the banking consortium that had approached the government in the past offering to pay for much of the cost of implementing and starting up and putting in place the hardware for a smart-card-based health card system. I want to know -- I've never been able to get an answer from the ministry -- why the ministry rejected the help from the private sector in that area, specifically the proposals put forward by a banking consortium, which was made up of the major banks in our province. To me, their approach made eminent sense and I don't know why the government rejected it and embraced technology, as I said, that's so old as to be useless.
These are just some of the areas that I hope we have the opportunity to explore in greater depth during the time that's allocated for this committee. I hope, Minister, you'll also be able to tell us how you intend to proceed with Bill 119, your smoking legislation. I'm getting a little tired of the actions that are occurring in the Legislature almost on a daily basis with petitions being read by government members accusing my party of holding up this piece of legislation; that's ridiculous. You know with the new rules imposed by your government, we can't possibly hold up a piece of legislation. In fact, it's quite a falsehood to put out there that we are holding up legislation. If you want to deal with this bill, you can ram it through with your majority like you've done with every other piece of legislation. You've obviously decided that same-sex legislation is more important. You brought it forward even though you had something as important as Bill 119 on the agenda.
You'll have your chance to respond to that, Minister. I know you have a different opinion. I appreciate all members' time today and look forward to the responses from the government.
Mrs Barbara Sullivan (Halton Centre): I'd like to begin my remarks by quoting excerpts from a paper that has been written recently by the chairs of the family medicine schools in Ontario. I'll let Hansard know when the quote ends, but I thought it was a particularly valuable piece of work. They say:
"The creation of our national health system is one of the landmarks of Canadian nation-building, much like the building of the railways from coast to coast in the last century. Building a national health care system broke new ground in the creation of our national identity.
"Until recently, medicare was such an untouchable national institution that public discussion about the need to reform certain aspects of it was nearly impossible.
"It's not surprising that medicare was a major issue in the election," that is, the federal election. "Media reports focused on four areas:
"Possible changes that threaten reduced access to the health care system;
"The possibility of reduced services available to consumers;
"The cost of health care as a contributor to national debt; and
"The possibility of user fees.
"Health care is a major industry. It provides services to Canadians through a variety of provincial plans, and employs hundreds of thousands of people. Does today's system, however, meet the needs of the population? Does it meet the principles enshrined in the original medicare legislation: accessibility, universality, comprehensiveness, portability, and public administration? Is it effective and efficient? Is it affordable? Are the originally enunciated principles out of date? Do we need to add new ones?"
That's the end of the quote, for Hansard.
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The recent ICES atlas, Patterns of Health Care in Ontario, concluded in its final chapter that "the three keynotes for modern health care are effectiveness, efficiency and equity."
I'd like to draw also from the ICES report for another conclusion with respect to accountability issues in health care, and, once again for Hansard, a quote starts:
"For the present, however, there is no single and rapid solution to the current problem. Short-term responses to the affordability crisis are therefore likely to be piecemeal and increasingly dependent on an improved information flow among stakeholders....Clearly, for Ontario's health system to do better with less, or at least to hold the line against erosion in the quality and accessibility of care, there will also need to be an enormous ongoing investment of energy and goodwill. The success of such an investment may depend on new local and provincial structures bringing together key stakeholders in the health care system. Many groups and agencies have important roles in providing and managing health care, but coordination is crucial if there is to be clearer accountability for system performance."
Those two reports and their approaches have been presented by other bodies and I believe that the statements underline several issues of vital importance in today's health care debate, not the least of which are effectiveness, efficiency, equity, affordability and accountability, which are new measures against which our health care system must be judged.
No one believes that health care delivery should be returned to the place it was close to 30 years ago -- between 25 and 30 years ago, I suppose -- when medicare was first devised. Changing demographics, new scientific knowledge, new technologies, new goals, new expectations and new affordability pressures bring change and a drive for change in our medicare system.
It's my view that the issue of affordability will not go away, and in fact will not go away for many years, and must be a significant component of any system reform. Further, there should be a public dialogue about the affordability issues as discussion of change takes place.
Any change that occurs must be directed, it must be coordinated, it must be effected with the goodwill and energy that ICES speaks of. It must be consistent in its approach, it must be accepted by and accountable to the three components which the deans of family medicine described: the purchaser, the provider and the consumer.
In speaking to the estimates, I want to underline that in my view, cost containment itself is not reform, and whether it's masked in words such as caps or deinstitutionalization or rollbacks or downsizing or restructuring or rationalization or cutbacks or recapture or delisting or copayments or user fees or reallocation or rationing -- we've heard all of those words -- the impact is still the same.
ICES has pointed out that Ontario, as with other provinces, has a hospital system in transition and raises the question -- once again, another quote for Hansard: "The issue is whether the transition can continue without damage to the quality or accessibility of care."
I don't think that we should underestimate the ability of the people to understand that change must occur. It's been my experience that consumers and health care providers alike value the health care system in Ontario and are willing to adjust expectations to ensure the viability of this system. However, what I'm told by those same people is that what is occurring and what they are frightened of is a dismantling of the medicare system. They see the minister making impulsive decisions to solve immediate problems without the understanding of the long-range implications of those decisions.
In my own community, professionals and patients tell me that care is already compromised because patients cannot get care in the right place at the right time by the right professional. We have the lowest number of long-term care beds per population in the province. We have some of the most enlightened hospital leadership, and I think that the minister and the deputy minister would recognize that, in my area, but we have inadequate home care services for those patients who don't need to be in hospital but do need professional health care.
We have lengthy waiting lists for treatment, whether in hospital or on an out-patient basis. We have volunteer services that rightly feel threatened by new long-term care proposals, and what we see generally is a crisis in confidence in the health care system and a morale crisis among our health care professionals. In my view, none of those circumstances bode well for reform and none of those affected see these issues, frankly, as reform issues.
Let me give you another example of the frustration that's felt in some quarters by both the health care professionals and the patients and their families. The government has announced that it intends to contain the costs of the Ontario drug benefit program and that new single-source drugs will not be added to the formulary unless there's an offset, and any addition to the formulary must be cost-neutral.
What's occurred, however, is that cost neutrality is measured only within the confines of the drug benefit program itself. The pharmaco-economic model that the government has chosen to adopt means that the manufacturer must reduce the cost on other listed drugs or take one off the formulary. There's no opportunity to make the case for a full economic appraisal of the benefit of their product on a system-wide basis because the criteria have been compartmentalized into a silo economic evaluation, and there's also no opportunity to include a measure of quality-of-life improvement or enhanced health status.
In my constituency, I have a company called Genentech which has developed a biopharmaceutical product, a DNA enzyme called pulmozyme, for the treatment of cystic fibrosis patients, and is a breakthrough treatment. For cystic fibrosis patients, the product liquefies sputum, works in vivo and reduces the environment for infection, which leads to both increased hospital stays and shortened life.
Patients who are now coming off clinical trials and have met the criteria which have been set by the CF specialists are anxious to maintain the therapy because they have seen significant improvement in their health status and in their quality of life. They want to maintain that improved health status that's been brought about by this new enzyme. The enzyme was approved by the federal health protection branch and the FDA at the same time and framework trials have shown efficacy for a significant portion, but not all, of the CF population. Application has been made through the Drug Quality and Therapeutics Committee for its listing and availability by CF clinicians through Ontario's 10 cystic fibrosis clinics.
Other provinces have approved this drug, and yet Ontario has sent pulmozyme to the DQTC rather than to the special drugs program for fast-tracking and assessment. That leaves CF patients in Ontario without the most up-to-date therapy that could and may well should be provided to them. The minister received a letter on April 22 requesting a meeting with providers and recipients of the drug, and there's still been no acknowledgement of the letter or a meeting date set.
The issue here of the offset data which were required is one that I think is problematic. The offset data were provided and offsets, however, from reductions in numbers of hospitalizations, numbers of hospital days, IVs, physician fees and oral antibiotic treatments could be identified. Furthermore, a significant improvement in lung function was traced over an 18-month period, along with a 30% reduction in infection rates.
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Again I underline, this is a breakthrough therapy, a biotechnical product and not an ordinary chemical approach, and is the first dedicated CF drug introduced in 30 years. If the offset rule is maintained as it stands, this drug will not have an appropriate and full economic appraisal and therefore will not be available to CF patients because the economic offsets required cannot be met through comparators with existing listed drugs. There are no measurements also of quality of life or improved health status in this particular process. Cost containment, through the offset criteria which have been defined, will therefore mean that what may well be an opportunity for an enhanced quality of life, an increased health benefit, is not taken into account. It seems to me that simple rules don't always account for health benefit.
I think there are other examples where the simple cost-containment rules may well lead to increased costs. New rules relating to home oxygen availability may well mean that 3,000 patients across Ontario who hitherto have qualified for home oxygen will no longer qualify. In fact, we're told that those who had previously been identified as eligible for respiratory services will be removed from that service. The predictable is likely to happen: health deterioration and subsequent increased costs as a result of necessary increased hospitalization and professional costs.
If there is an appropriate assessment of the medical value and necessity of those services that is public and understandable to the professional and the consumer, then there's an appropriate scenario for change. But if those rule changes are made simply to contain costs, then within one silo of the cost, that being the assistive devices program, the government bears a real burden in its lack of accountability to patients and providers.
An area which I want to explore at greater length during the course of the estimates inquiry is that related to the $41-million cutback, which is year to year from this year's estimates over last year's actual, in spending devoted to mental health services. This, in rough calculations, is something over a 6% cut.
I know that the estimates are estimates-based and show a cut of 6.1% but, given that those services which were provided in the past were already strained and needed by a particularly vulnerable portion of our population, for whom the need for increased rather than reduced services has been identified over a long period of time, I believe that this decision demands a thorough explanation and defence. I'm asking the minister and her officials to devote some time to this particular issue during the estimates consideration, and we will want to put substantial questions about what we see as a major redirection of emphasis. I don't know who's here today from the ministry, but perhaps we can start off with some explanation of that particular cut in this afternoon's discussion.
The minister has spoken at great length of initiatives that she's taking to control fraud in the health care system by spending $110 million over the next five years on a new identification card. Minister, I know you know that I cannot imagine a worse-defined strategy or public spending policy than this initiative. The prediction of savings cannot be substantiated by any study or experience and I believe is a flamboyant guesstimate at best. Anyone with expertise in the information technology field simply rolls their eyes in disgust, but the taxpayer will pay in the end.
I make no apologies or defence for what has occurred under past governments. An apportioning of blame must surely be put behind us. Isn't it time to do what every assessment of this issue has told us to do: forget the slogans and get down to the real business? Isn't it time to use modern technology and our skilled human resources to bring an information system that can maintain a secure patient record, that can help us with the administration and management of health care, that can help us to evaluate those services that are provided and that the most effective are used, that can help us plan to guarantee that we have the right facilities and people in place to deal with our health care needs?
Isn't it time that we offered our health care professionals and facilities a mechanism for simple verification of eligibility and a cost-effective and timely way to submit accounts and be paid for services provided? And isn't it time that we co-opted and involved and accepted as partners people from the private sector who have expertise and capital that can be used to help us answer our public requirements?
We beg the minister to abandon what is widely seen as a foolish initiative and begin the real work on an integrated health information system. Parts of it have been started -- the drug network is one around which I have discussed some of the positive impacts with pharmacists -- and I believe there are many other major initiatives that should take place, but they should be planned from the beginning and a strategic direction worked out from the beginning, rather than adding piecemeal change later on, which in the end becomes far more costly.
I want to raise the issue of predictability and stability in Ministry of Health decision-making, which is a matter of continuing concern through the entire health care industry. The minister well knows, because I know she's heard articulate arguments about the difficulties that have been faced by hospitals that learned of abrupt changes in budget and funding decisions. The changes that they might have had the flexibility to make with appropriate planning, and therefore with the buy-in of stakeholders, were compromised by new demands from the ministry and new levels of funding transfers. That's one negative aspect of ad hoc or changed direction, an abrupt change in direction and decision-making.
There are other areas that matter as well. The Regulated Health Professions Act has taken years to reach a legislative, regulatory phase, and about a year from now all the regulations under the RHPA for the 22 existing acts will finally be in place. Everyone will breathe a sigh of relief when that occurs. The Health Professions Regulatory Advisory Council has been seen as a fundamental part of a process to ensure the review and assessment of additions of new self-regulating health professions or in changes to the mandates of existing professions.
We were therefore disturbed to learn that the HPRAC process is to be short-circuited through the direct decision of the Minister of Health regarding potential amendments to the Dental Hygiene Act. This process change adds to concerns about integrity of the process and further adds to concerns about predictability and stability in the system. The issue of predictability, I point out, goes beyond funding and moves into expectations with respect to policy decisions as well. I brought one example of that here with respect to legislative amendments to the Dental Hygiene Act. Many others could come to mind and will probably be brought forward during the course of these estimates.
The minister well knows that I'm strongly opposed to her announcement regarding the reduction of out-of-country coverage for emergency treatment and that my objection is that this is a direct contravention of the portability provision of the Canada Health Act. My concern is that if the government is willing to compromise in such a blatant way one of the fundamental premises and principles of the Canada Health Act, what is its next compromise and what is the next principle that will be taken away?
If the Canada Health Act needs change, then let's bring those change issues to the attention of the Ontario public and ask them what new principles should be added to the Canada Health Act or what principles should be changed and in what way. Ontario has an obligation to put those issues on the federal agenda. But to make an arbitrary change which is a very clear and direct contravention of one of the major and singularly important provisions of the Canada Health Act, in my view, is absolutely the wrong way to go and underlines some of the deep concerns that are felt by individuals and health care providers and professionals about whether indeed medicare is about to come apart at the seams.
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As I conclude my remarks, and they have been shorter than the full half-hour, I see some real hope for improvement through the government's cancer strategy, and I once again reiterate that I'm concerned that the network or coordinating committee is a temporary vehicle.
In her remarks to the committee at the beginning of the session, the minister mentioned that the Princess Margaret-Toronto Hospital joint venture initiative is a positive one in bringing together the formal cancer system with the informal cancer system and the expertise and experience of those institutions. That's an initiative which I too celebrate, and I know it's one which came out of the energy, the initiative and the leadership of those two hospitals.
In the future, after the initial PMH-TGH bugs have been exposed and hopefully some of them eliminated, I personally expect and hope that some of the other hospitals such as Mount Sinai, Sick Children's and Women's College will be added to that joint venture approach to cancer care.
With the academic component of the University of Toronto, I believe that initiative will bring significant coordination and collaborative work to cancer care and cancer control in the Metro Toronto area and particularly in downtown Toronto at the U-5 hospitals.
But I want to point out that this initiative began with the institutions themselves. The direction was not imposed nor even led by the Ministry of Health. No false deadlines were set. No declarations or demands were made from outside. As well, the tough issues, including the funding issues, the human resources issues, the determination of how the full continuum of care can be met, the research goals prioritized, still require considered examination within those institutions. Neither the PMH nor the Toronto Hospital have an easy row to hoe over the next few months as they face those issues square on.
This is but one example of initiatives occurring around the province that should be celebrated. Actions taken locally to solve common concerns in these difficult financial times are ones that require praise and acknowledgement. Many of these actions have not been as a result of ministry intervention but by those in the field who want to maintain the best level of service to their patients at the local level. They've had the courage to try to lift themselves above constraining forces, many of which are imposed by government, and they've exhibited a commitment to our health care system that I believe is admirable. In this, as in many things, they've shown that if government keeps its mind on end goals, other components of the health care system can concentrate on their roles and also be truly accountable for the continuation and growth of the medicare system.
The Chair: Minister, would you like to proceed with your 25 minutes?
Hon Mrs Grier: I'd like to ask for some direction as to how you wish to proceed. Mr Wilson in his comments had made reference to a number of fairly specific issues which I would like to respond to. I don't know whether it's possible to reserve some time to respond when he is able to be here at our next meeting and let me respond rather generally now to Mrs Sullivan's comments, or whether your rules require me to respond to both of them at the same sitting.
The Chair: What we'd recommend is that you respond in accordance with the presentation, and we'll ensure that Mr Wilson has instant Hansard so he's up to speed for the next meeting. If there are responses which require a fuller or more detailed response, if they were treated in a similar fashion to an order paper question and staff could provide those in writing, we'd find that extremely helpful. If they could be circulated through the clerk, they'll be distributed to the members of the committee and that'll help facilitate further discussion. I think the questions were raised to precipitate further questioning during the course of the estimates. If we can proceed on that understanding, that's generally the procedure we work with.
Hon Mrs Grier: I appreciate that, Mr Chair. You're absolutely right that the issues that were flagged were the ones that, we certainly agree, deserve some full debate during our time before this committee. Whether we respond in writing or whether the ministry officials who are present are able to give the answers during the debate, we certainly plan to do that.
Let me start by responding generally to Mrs Sullivan's remarks. I think this kind of exercise often explains or clarifies the difference in perception, because certainly the quotations from the deans of family practice and from ICES that Mrs Sullivan has quoted at length I would agree with. I would of course affirm that we believe the ministry is proceeding in the directions that have been recommended.
As I said in my opening remarks to this committee yesterday, I think I very clearly set out that we have a goal, we have an understanding of the kind of health care system we wish to maintain and to change in this province. We believe the actions we have taken and the framework within which they have been taken have very clearly put us on the road to a new direction that enables us to assure the people of this province that they will have in the years to come a health care system that is affordable, effective and efficient.
I recognize in this exercise that for every example I would cite as demonstrating the truth of that approach, my critics would of course probably view the same action as evidence of our lack of progress towards that same goal. But it is somewhat comforting to begin by recognizing that we at least share the same objective, which is, if I may say so, the fact that the way we proceeded during the 1980s is no longer sustainable and that the kind of double-digit increases in health care spending that exemplified the actions of governments at all levels -- and I'm not pointing partisan fingers -- in all provinces and of all political stripes, have come to an end.
It is better management, it is better accountability, it is the development of the tools to enable us to do that that I think we are all quite legitimately struggling to construct, to define and then to put in place. In Ontario we are doing that in a way that combines the best of both the local, decentralized approach and the need for the province as the funder to lay out very clearly what our goals and expectations are.
In my opening remarks I quoted from Dennis Timbrell, and let me quote it again: "On the national scene only Ontario and Manitoba still put faith in local governments' operation of health care. Other provinces have taken central control and abolished local boards. They have absolute central control. There is no evidence this improves the quality of health care or cost-effectiveness." I would agree.
When Mrs Sullivan describes some of my actions as impulsive or flamboyant, not words that I frequently hear attributed to my approach, I don't know whether to be pleased or unhappy. But I think any actions I have taken have been consistent with my belief that a decentralized approach to the planning that involves as many people as possible is the way to go and that a framework that clearly identifies the ultimate objectives encourages that.
While she would characterize the actions of Princess Margaret and the Toronto Hospital in coming together to provide integrated cancer care as solely driven by the actions of those hospitals -- and yes, indeed the hospitals took the initiative and moved quickly on that -- I would of course counter by saying that our long discussions around cancer care and the need for a framework and the need for a network and the need for a more integrated system encouraged, facilitated and perhaps led to the decisions that are being taken by those hospitals.
What matters is: Were they the right decisions? Do they contribute to a more effective and efficient and affordable and accountable system? Are they in the best interests of all the people the health care system is designed to serve? That, ultimately, has to be the test of everything we do.
Mrs Sullivan also spent some time -- I suppose I should say the member for Halton Centre; isn't that my correct terminology here, as in the House? -- putting some emphasis on the Ontario drug benefit plan. I am not, as she is, an expert on some of the economic aspects of specific drugs or equipped to comment on those, but let me say to her that I would agree we have not got a mechanism to do the kind of pharmaco-economic analysis of drugs that we need to do.
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But any decisions about the delisting or the listing of drugs are not made without good data. They are made by the Drug Quality and Therapeutics Committee, which is an objective group of experts drawn from different backgrounds to determine what is in the best interests of the Ontario drug benefit plan to be listed.
To expand beyond that into a greater understanding of the effects on the entire system of those drugs, and whether or not they are available, I would agree with her, is a road that we have go down. Particularly as the system changes to shorter stays in hospital, to a greater emphasis on home care, we have to be able to do that analysis. ICES, in Patterns of Health in Ontario: The Practice Atlas, clearly made the point that we need to look at the way in which prescription drugs are prescribed and to get a better handle on that.
When my critic from the third party talks about going back to a system where every drug that was available on the market was paid for by the province under the Ontario drug benefit plan, I say to him that I don't think that's in the best interests of the health of the people the Ontario drug benefit plan is designed to serve. Any drug that has been delisted from the plan by the ministry has been delisted only on the advice of the DQTC and because it is, in their opinion, not going to impact on the ultimate outcome, the health care and the wellbeing of the client, to do that delisting. Again I say that that has to be the ultimate test.
Yes, we need better data and we need a better understanding, which we are developing and which will come over time, of the total effects on the system of the prescribing of drugs or the non-prescribing of drugs.
The member for Halton Centre also talked about the changes in the mental health system. We do have officials here whom I would like to ask to comment on that specifically. Whether we spend some time on that today or get to that on another occasion, I would agree that that is certainly one area where we need to spend some time and which I would rather have officials respond to, than do it in this time frame.
I'm a little surprised in the comment that hospitals have had abrupt changes in their budgets and in the levels of transfer payments and were required to respond without any background or consultation to those, because nothing could be farther from the case. The discussions with respect to reallocation within the hospital budgets were part of the discussions with the Ontario Hospital Association and the result of an extensive period of developing a formula, clustering hospitals with their peers in order to determine which ones were effective and where there might be some reallocation.
I think the surprise for hospitals this year was our ability to announce that there would not be any change in the transfer payments, that we would maintain the zero increase as opposed to a decrease, which I think was a welcome surprise, as opposed to anything else.
Both members referred to the Regulated Health Professions Act, and again I'm sure we'll get into more discussion on that in the interchange later. But let me refer specifically to the question of dental hygienists, which was raised by both of them, and point out that the question of the scope of practice of dental hygienists was something that was certainly debated during the passage of the legislation, and that the act, as passed, in section 5, which I think is the contentious one, clearly sets out what the scope of practice of dental hygienists might be.
There is a concern on the part of the hygienists that they do not have as broad a scope of practice as they would like to have, and I think the issue is, how do we resolve that? They would like to see us move an amendment to the legislation. I have indicated to them that, at this point and in this session of the Legislature, in fact maybe even in the next session of the Legislature, that is not something we see ourselves being able to do.
Let me say that as we all learn how to implement and live with RHPA, I think we will find that there may well be some tinkering with the legislation that over time needs to be done. I think we need to have some period of time to work with the legislation before we begin to make specific amendments around specific pieces of it, because we may well want to look at a larger package of amendments at some time in the future. But I know the concern of the dental hygienists and am happy to be able to tell the committee that, as an interim measure, the College of Dental Hygienists of Ontario and the Royal College of Dental Surgeons of Ontario have come to an agreement which allows dentists to issue a general, rather than a case-by-case, specific order for most procedures. I certainly hope that agreement will allay some of the concerns of the dental hygienists and enable them to carry out their practice as they have wished to do and as they have in many cases been doing in the past.
I was trying to deal with most of the issues raised by Mrs Sullivan and then turn to the issues raised by Mr Wilson, and I think it was the out-of-country, the general approach to OHIP, that you had touched on and that he had touched on too. I have to say to both of them that as we try to constrain the costs and reverse the trends in increasing costs that I have referred to and that were there for the 10 years before our government came to power and before the economy deteriorated underneath us, we had to look very carefully at things we had paid for in the past and that, in our opinion, we could no longer continue to pay for. Many of those were the kind of open-ended programs that had resulted in excessive payments to hospitals in out-of-country.
I don't agree with Mrs Sullivan that, as a result of the changes in payments from $400 to $100 a day for treatment in foreign hospitals, very many people who travel will be dissuaded from doing so. The decision to look to make some savings in that area as opposed to other areas was a deliberate one, knowing that people who travel have insurance anyway, because the $400 frequently didn't meet the costs of hospitals in the United States, in fact very seldom did.
What we are asking those people who travel to do is to pay a little bit more on the insurance that they purchase and were already purchasing so we can continue to maintain and indeed to expand the quality of the services that are available here in Ontario, both for those people who remain in Ontario for the most part of every year and also for those people who now travel and who need to have those services maintained for them when they return, or, as in many cases, if they are seniors, when they reach the stage when they are no longer travelling regularly and need to take full advantage of the services here in Ontario. Difficult though some of those decisions are, they were ones we made in the best interests of the system as a whole.
Let me turn to some of the issues that Mr Wilson had raised and say to him in absentia, but on the record, that when he opened his comments by accusing us of being driven by ideology, as I said to him in the House yesterday and as I said at the opening of this stage of my comments, ideology is all in the eye of the beholder. Whether it is the ideology of this government that the Canada Health Act is the framework within which we maintain and support the health care system, which is a not-for-profit delivery of health care services, or whether it is the ideology of his party, which is that if it can be done by the private sector, that's preferable, we're the government.
The revolution he is advocating indicates that people would be required to pay a health tax, and that too is a suggestion we reject. That kind of introduction of a fee or a user payment for health care is, in my opinion, the beginning of undermining a system that Canadians feel very strongly about and desire to keep as universal, accessible, affordable and effective as possible.
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The Chair: Could I get clarification on that? Does that mean the employer health tax is inside or outside of the Canada Health Act?
Hon Mrs Grier: The employer health tax is entirely consistent with the Canada Health Act, which says you will pay for the health care system by way of public taxation, and the employer health tax is one form of taxation which contributes towards the payment of the $17-billion budget of this province for the health care system. It doesn't go a very far distance in meeting that $17-billion commitment. It is our sales taxes, our income taxes, our corporate taxes that make up the bulk of the spending on health care.
Mr Wilson spent some time on on-call in emergency and asked me to guarantee a solution to that problem by the end of July. That is not a commitment that I can make or that anyone can make because, as I have said on so many occasions, it is a problem that is caused by actions by physicians, by hospitals, and cannot be resolved simply by them or by the ministry. It has to be within the discussion framework of all of us.
I am delighted the OMA has agreed to resume discussions. They have agreed to come back to that table. They said they would come back with no preconditions, but they have in fact put on a precondition, which is that the discussions must only be within the framework of our 1991 agreement with the Ontario Medical Association.
I have to say, and I will be saying to them, that it is the 1993 agreement, which places limits on the cap on total physician billing, that has to be the framework within which those discussions take place, because we do not have additional money to put into fee-for-service physicians or into alternative payment plans for physicians. As we get into the discussions, we have to look at what we are now paying to physicians within that $3.8-billion budget and see how we can reallocate it in order to provide emergency coverage.
The 1991 agreement only contemplated bilateral discussions or negotiations, including the dispute resolution mechanism, which would bind the government to potentially increase compensation and add new money to the envelope that was already agreed to in 1993. That would have to be at the expense of other professionals or as a result of a decrease in services, and that again we are not able to contemplate.
The Ontario Medical Association has the ability through the central tariff committee to make schedule changes -- and it could do that any time -- that would enable physicians to be compensated for their emergency room coverage at a rate that would make it worth their while to be there. In fact, there have been changes recommended by the central tariff committee on a number of procedures to reduce their relative weight in relation to other procedures. They could also use the same mechanism to address the issue of compensation for rural emergency coverage.
Having said that, however, we are more than happy to work to develop the terms of reference, including a time frame, and call the parties together to come to a resolution.
I suspect we'll have some more discussions on long-term care -- that was one of the issues Mr Wilson raised -- and on the question of multiservice agencies. Certainly some of my colleagues may want to get into that. Again, I remind him and the committee of our commitment to the provision of services in a non-profit way.
The fact that there have been so many for-profit agencies developed throughout the long-term care system I think is a reflection of the fact that hitherto long-term care has not been considered an integral part of the health care system. It has been part of community and social services. It evolved as a result of actions by communities saying, "We need these services," by, in some cases, not-for-profit small groups coming together to provide those services, and in some cases agencies responding in the marketplace to meet those needs.
What we are doing through our long-term care reform is clearly indicating our recognition of the need for long-term care to be part of the health care system and therefore provide it in a not-for-profit manner. That is also very clearly the preference of the consumers, the clients, especially the seniors of this province, and our policy responds to that.
I'm always concerned when I hear the allegation that the way we are intending to expand and reform long-term care will dissuade volunteers from being part of the system, because nothing could be further from the truth. The planning, the decisions, the recommendations as to how long-term care is going to be delivered in each district, is not being done by the ministry. It's being done by district health councils, which are themselves volunteers bodies, volunteer boards that have taken on a very real responsibility and are being asked to take on more by this ministry, which they are gratefully agreeing to do because they agree it is better that they have the decision-making role and that the recommendations to the minister come from them as opposed to being centrally driven.
I am enormously impressed by the magnitude of the volunteer effort that is going into that planning around the province and that is rallying to the district health councils and to their efforts to speak to not just long-term care but also mental health reform, the cancer strategy and so many of the other initiatives that are changing health care within this province.
The role of volunteers on the boards and in the provision of services through the multiservice agencies is integral to being sensitive to the needs of consumers and to making sure the delivery system is driven by consumers, and their role on the board will of course be as volunteers.
Both critics have talked about health cards, one saying, "I think it's time we had a new health card, but we ought to get into a smart card and a more extensive card," and my critic from the official opposition saying she didn't think this was a good initiative for us to get into.
I view the move to a new health card as very much part of the need to have better data, because we don't have good data now -- ICES was correct in identifying that -- and we will only have it when we have a better handle on the registration system and when we are in a position to take advantage of new technology as it becomes readily available and usable by way of smart cards.
The difficulty with moving at this juncture to a smart card that would encompass a great deal of information on the card is that we don't have the technology out there in all the providers' offices to take advantage of that technology if it were on the card. One of the reasons we are proposing a five-year renewal cycle on the cards is precisely so we have the flexibility to take advantage of new technology when we have the ability to read that new technology in the hands of all the providers of care. There's no point in making an enormous investment in having a computer chip on the health card if not all the providers of health care have the technology to read it, and we are not in a position at this point to make that available around the province.
I believe the advice of the private sector in how to implement the health card and how to make it secure and what the best system would be has been invaluable, as we have done extensive work and preparation for the announcement I made with respect to a new health card, and I can assure the members of the committee that that work is continuing as we prepare to introduce the new health card, and to be clearer on the methods of implementation and the timetable for that, which I hope to be later this year.
I'm shocked to find Mr Wilson mention that it is in the government's hands to bring Bill 119 to a conclusion. I wish it were so. At each weekly leaders' meeting, our House leader raises with the third party: "Can we call 119 this week and get the discussions in committee of the whole completed so we can move to third reading?" and is constantly told: "No, we need a great deal more time to debate it."
We have not wanted to move to time allocation on this bill. It is a bill that has had broad public support throughout the province and I think has support from all three parties. It is being held up by two members who have a particular concern for their constituents, which is their legitimate right, on the basis of the loss of jobs, but who have had from me constant reassurance that the packaging provisions in the legislation, based on the amendments from the member for Carleton and his intervention at the committee level, are not going to result in this province moving unilaterally to plain packaging and therefore to the loss of jobs in the constituencies concerned, I hope will enable them to not delay this legislation any further, because it is certainly my intention that we should have it in a state to be proclaimed by the end of this session, and I hope that my critic in the third party will contribute to that.
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Let me stop there, Mr Chair, and thank my colleagues for having raised so clearly so many points that they wish to discuss in the time remaining. I'm sure we'll come back to many of them in greater detail than I've been able to comment. As I've said, we have somebody here now who can go into in more detail the savings on mental health if that would be the desire of Mrs Sullivan in the next time allocation.
Mrs Sullivan: I wanted to clarify the minister's understanding of my statement with respect to the health cards. I am an extraordinarily strong proponent of an information system that will provide data for care management, administrative and planning and research purposes. What I think that the decision of the minister, with respect to the introduction of a photo ID with one new piece of information being an expiry date, has done is to create and add simple madness into what should be a fully integrated and comprehensive information network system that can be introduced over a period of time with private sector participation in the capital funding and provide significant benefit to the health care system. I see no added benefit to the health care system with this kind of interim measure that the minister describes precisely as an interim measure.
The Chair: I would like to resolve a couple of procedural matters for the committee at this time.
Mr Ted Arnott (Wellington): Would it be appropriate to ask a question of the minister, based on what I've heard since I came in? Is that possible?
The Chair: It is, rather, by time allocation, but I'm in the hands of the committee, and I'm seeking its direction with respect to the first question I generally ask at this time, which is, shall we stack the votes? If there's general agreement, we will do that.
The second question is if we wish to proceed in a time-allocated fashion or do we wish to introduce a subject and questioning can occur through the direction of the Chair.
Mr Larry O'Connor (Durham-York): I think the Chair is usually quite reasonable as far as if there is a question that somebody wants to tag on to someone else's question, there's usually a little bit of liberty in the committee so that we can have that happen. So in a time-allocated fashion, I think that we could probably do that and achieve an orderly procedure here.
The Chair: Okay. This is actually a matter for the committee, Minister.
Hon Mrs Grier: Can I have a question, or is that not appropriate?
The Chair: If it's for clarification, absolutely.
Hon Mrs Grier: I'd just like a clarification as to whether, in your time allocation, it was your usual procedure to deal with one subject and complete all questions on that topic, for example, mental health, so that officials could be here for that discussion and know that the subject had been dealt with when that round had been completed.
The Chair: That's my next point, Minister. At this point, the answer is that that's possible, but because you go to time allocation, you sometimes run out of time when people have been asked to be here. The Chair is open to any requests from members to have any specific agency, board or commission affiliated under the aegis of the Ministry of Health to be present. Any matter within the estimates is of course an item that can be dealt with before the estimates committee. So if there are specific ministry officials or, as I say, agencies, boards or commissions whose presence you wish to request, please let the Chair know. The sooner we can hear that, the sooner we can make those arrangements. To the degree that we can best coordinate the attendance of those staff, we will endeavour to do that.
I had one request from Ms Sullivan with respect to the administration of mental health services in Ontario. Ministry staff whom I communicated that to have made arrangements for this afternoon, but that doesn't mean we would finish our questions on mental health at this point.
Mr O'Connor: I wondered if it might be possible that we hear from officials from ICES, as Mr Wilson had brought it up and that might be something that could lead to some very fruitful discussion.
The Chair: Very well. I appreciate that request. We can receive some of those requests as we proceed. We're a bit of a corporal's guard today and we'll be flexible in that regard.
If that's the case, we've had prior agreement to the best utilization of the next 45-or-so minutes before we're called to the House for a vote. We have, by mutual agreement, allocated the balance of this afternoon's time to Ms Sullivan as leading the questions. So the Chair just wishes to set out the balance of the agenda for the afternoon.
Mrs Sullivan: With respect to the mental health issues, I think this is an important matter because of the significant change in the funding. I don't know that we will want to spend the entire time this afternoon on mental health issues when Mr Wilson isn't here.
The Chair: Ms Sullivan, first of all, I'd like to indicate that the Chair's rule, and it's based in parliamentary rule, is that we don't make a lot of discussion around the attendance and non-attendance of individuals, because it happens to all of us from time to time.
Secondly, it's your 45 minutes, Ms Sullivan, and you can order it up any way you choose. We're in your hands, once we recognize you, in terms of the questioning that you wish. Any number of ministry staff are available to you for your questioning, as is the minister, for the next 45 minutes. No decision has been made to dismiss any group or individuals from the ministry, to say we will no longer wish to deal with them. Once we stack the votes, it's implicit that all matters are available for discussion until the final votes are taken. The opposite of stacking the vote is dealing with all matters and votes. We have five votes by panel and on occasion we've been known to do it that way. Then you cannot go back, because then we vote and sign off a section and we don't return to that section. So all matters are open for discussion for the seven hours or whatever is remaining. Is that helpful?
Mrs Sullivan: Yes.
The Chair: I would like to recognize Ms Sullivan. Please proceed. Could any staff members who are called please identify themselves for Hansard and state their name and their position within the ministry. That would be helpful for Hansard.
Mrs Sullivan: As I start, I think it's important to recognize that members of the Legislature and members of the public have high expectations of awaited reform in the delivery of mental health services. It becomes a matter of concern when a 7% chop is seen in a budget.
This estimates period is a useful time to bring the issues forward and have a pretty thorough update on what's occurring in mental health reform, on what new services are being put into place and on where changed emphasis is occurring, because, frankly, we don't have any other vehicle through the legislative process. There are no bills coming forward. There's no other activity legislatively that places mental health services onto a public agenda. In fact, I guess the only time since I've been elected that mental health services have been on a public agenda has been peripherally through the Consent to Treatment Act and the Advocacy Act, where the Psychiatric Patient Advocate Office was involved in that discussion. In fact, that's a question we want to have answered: Are they going to be transferred to the Advocacy Commission or not? But I think it will useful to have a fair exploration and almost, if you like, a briefing now on the mental health issues and the direction the ministry is taking.
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Hon Mrs Grier: Perhaps I could ask Jessica Hill, who's the acting assistant deputy minister, mental health, to come forward. Let me say that I really welcome the opportunity to have this kind of discussion, because I agree, Mrs Sullivan, that we don't have a forum in the Legislature.
Frankly, our mental health reform has been proceeding apace and very well received, based on the Graham report and the other directions that were clear we now have a clear policy framework to guide a consumer-focused reform, a framework that will ensure that all mental health services work together to improve access to services and shift services to the community.
Perhaps I could also share with the committee that at 6 o'clock tonight I will be hosting an event for Nobel prize winner Dr Michael Smith, who won the Nobel prize for his work on schizophrenia. We're very proud that he has donated his prize to the Clarke Institute of Psychiatry for the development of a chair on schizophrenia. The ads were in the press today. I think that's a tribute to some of the research being done in this province, a lot of it within the provincial psychiatric hospitals, the kind of work that we're very proud of, want to see continue and consider to be a very important part of our mental health system.
If I could ask Miss Hill to perhaps respond to your request for a progress report on where we're at, that would, I'm sure, lead us into the financial elements of it.
The Vice-Chair (Mr Ted Arnott): Thank you, Minister. Welcome to the estimates committee, Miss Hill.
Ms Jessica Hill: Thank you. Jessica Hill, acting assistant deputy minister for mental health programs and services group.
To begin with, mental health reform began with putting forward a policy document entitled Putting People First, which definitely built on the Graham report and the planning that was undertaken by the district health councils.
Perhaps the most significant addition in the Putting People First document was the identification of key services and supports that we feel need to be in place at a local, regional and provincial level. The key services that were identified were case management, crisis response, support services to housing and consumer initiatives.
In the last year, I would say the ministry has been actively working on implementation planning with a wide range of working groups that have involved stakeholders throughout the community on each working group. There are many working groups, but a quick list would be as follows.
Community services and supports: That working group developed a set of policy and planning guidelines which will help district health councils develop the appropriate approach to the services I described.
Another working group looked at the labour strategy that is needed to create an integrated mental health system, which is a very complex undertaking, since we have several forms of employer-employee relationships within our mental health system, which has clearly been one of the factors that have prevented it becoming a system, but a group of individual services.
Another working group, called the multi-year plan work group, has been working towards the development of a multi-year plan for mental health reform, since the initiative was always perceived to be one that would take 10 years, as a time frame, for planning and shifting.
Another set of working groups looked at health promotion, ethno-racial mental health needs and women's mental health needs.
We've also developed a working group looking at the relationship between planning for housing services and planning for support services.
Many of these working groups are finishing up now. We have sent out recently an implementation vision and the first part of our multi-year plan for consultation to over 1,200 recipients across the province. We are planning to release our full multi-year plan in the fall. It will include an information strategy, a fiscal strategy and a labour strategy, as well as all our work group reports.
It may be seen that we've been involved in a lot of planning and we haven't actually put much service in place, but with the policy framework it became clear that implementation planning was as important an activity that we begin with to guide district health councils as they look at the challenge of both restructuring services, redesigning services and reallocating resources from institutions to community. These tools will be extremely welcomed by our district health council partners.
We also held a forum with mental health consumers, families and providers and district health councils about a month ago, where we focused on our next steps. This was a provincial forum and it was one of the most, I think, exciting events and was well received because it focused largely on how to make the partnerships work. Now, when there are obviously not new funds to invest in large service expansion, the question of how we do our business and how we more effectively provide services to consumer survivors and family members is going to have to be a considerable focus of our efforts. So this was really directed at all types of service providers, as well as family members and consumers.
I have to say that one of the most exciting responses was to recognize that people are aware that in this time of fiscal constraint, the challenges to implement mental health reform have a great deal to do with changing our relationships to each other, and that there is a belief that a great deal can be done.
So I think that's probably some of the concrete activities we've been involved in. The other one I would mention is, we did invest some new resources into support services to housing, and I can certainly at another occasion provide you with the details of which services we invested in to enhance our support services to housing this year. As well, I can provide you with a specific report on all the activities under mental health reform that have been taking place over the last year.
Mrs Sullivan: I'd appreciate those reports. I think that would be useful. Could you talk for a few minutes about directions with respect to actual operation of psychiatric services, including hospitals?
Ms Hill: Yes. One of the activities we've been undertaking with the psychiatric hospitals is looking at the fiscal constraints that we are working within and the multi-year expenditure target we've been working with. From last year's fiscal year through this year and into the next year, there have been a number of efforts at looking at efficiencies, looking at opportunities to restructure the support services -- not the clinical services, but the support services -- to the facilities. We were able to meet our expenditure target last year of $5 million, and the planning we've been undertaking has been to focus on further opportunities for operational savings.
The other thing that has taken place is that there are a number of communities where there are restructuring activities under way where the provincial psychiatric hospitals are participating in the restructuring discussions regarding psychiatric services in those communities. London and St Thomas is the one that of course is probably the largest restructuring within our own system, looking at rationalizing between London and St Thomas, but there are also activities taking place in both Brockville and Thunder Bay where our psychiatric hospitals are participating in restructuring discussions, either around acute care services and who is the most appropriate provider in that community to provide the service, or to do with overall rationalization of hospital services. So those are two other restructuring activities.
Our belief is that we are working towards our targets from a perspective of looking, for the most part, at restructuring of those support services and opportunities for efficiencies, but we're also looking at restructuring of programs that either move to more community supports with fewer inpatient beds or amalgamations of wards, that kind of response, but always from the perspective of, how does it fit with the mental health reform and who are the other appropriate partners for the discussion? So those are the explorations we're undertaking right now.
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Mrs Sullivan: Just to move back to the provincial psychiatric hospitals, has there been consideration of moving those hospitals from the aegis of the province and into a community-based -- maybe this is a policy question for the minister. Have you been considering that kind of approach with respect to governance of the provincial psychiatric hospitals?
Hon Mrs Grier: We have certainly not at this point been considering that. There has been a suggestion, I think, as part of the restructuring in Thunder Bay that that might be one way of dealing with it there, but it has not been a decision we've contemplated. We've been working with the district health councils and with the hospitals on mental health reform without contemplating any change in their status or responsibilities at this stage.
Mrs Sullivan: Another issue that I see as highly problematic, and I've of course had this kind of constituency problem, is the linkage between children's mental health services and those provided in the adult system. I believe it's a serious problem that the person who is coming out of the children's mental health services -- first of all, if they can get them adequately in the beginning. I have one of my constituents who finally found secure psychiatric services at the Syl Apps Youth Centre in a kind of correctional environment, and they do other things wonderfully well there, but it drives me mad when I see some of the difficulties patients and families face with respect to finding a place as a young person and then, when an age limit hits, all of a sudden having no place again. I just wonder what the ministry's approach to dealing with that kind of issue is.
Ms Hill: We did recognize within mental health reform that we need to definitely pay attention to the relationship issues or the conflicts between the Ministry of Community and Social Services policies and our own policies with respect to children's mental health.
We are beginning a children's mental health working group specifically addressing this question of the relationships between the policies and the programs and where we can resolve some of the problems that have been identified as long-standing within the field. The Ministry of Community and Social Services is leading that work group and we are participating in it from our group, because we believe that we definitely have to build a consistent response with our adult mental health system and the ministry's role with respect to children's mental health. That is beginning in the next month or so.
Mrs Sullivan: Is there a formal process, say, with respect to linking with the children-at-risk policy directions that are coming forward, or is it that formal in terms of setting up a long-term ongoing mechanism?
Ms Hill: Well, I think in the first instance it's an attempt to look at the current policies that are not working well and are in fact in conflict and trying to resolve those. I think probably out of that we will be looking at questions of ongoing relationships: how we build on the ongoing mechanisms to ensure we're not working at cross purposes. We are also working on a similar initiative with the Ministry of Community and Social Services around the dual diagnosis population, and we recognize, certainly with that group, that we do need to build some ongoing working relationships and ongoing mechanisms to ensure, especially if we're not the lead ministry, that we're cognitive of the piece that's not part of our ongoing work. We are both aware, certainly with that initiative, that if you don't have an ongoing mechanism, it's very easy to move away from the needs of that population. I suspect with children's mental health a similar kind of discussion and opportunity will have to be pursued.
Mrs Sullivan: The dual diagnosis issue is one that's also problematic. Many people from my area are served at Oaklands, both developmentally disabled but many of them are dually diagnosed, and one of the difficulties the residents and their families see is a hell-bent-for-leather deinstitutionalization emphasis when in fact what has been built up is a community of people sharing similar problems and who have lived together for years and years and see Oaklands, by example, as their home. I wonder what the Ministry of Health's position is with respect to those kinds of issues.
Ms Hill: The dual diagnosis initiative has resulted in the funding of, I believe, four pilots, and I can provide some more detailed information for you about where those pilots are, focusing specifically on how to strengthen the relationship between health care providers with knowledge of mental illness and mental health problems, behavioural issues, with the field that serves the developmentally handicapped. By building those relationships you can put in place a very effective response to those who are dually diagnosed.
If my memory serves me correctly, the communities where those projects are are in Ottawa, Toronto, and there are two others; I can't remember which, but I will provide you with a note through the committee on that. The results of those initiatives have been very exciting and those communities feel it has been a very, very worthwhile initiative. It's the best use of both sets of resources.
We also have within our psychiatric hospitals dually diagnosed programs, and they are really aiming to ensure that those with the most severe problems are provided with adequate in-patient assessment and stabilization and often medication adjustment so that they can then return to the community with adequate supports and in a sense in a better position to live in the community. Those programs we see as being part of our role within the psychiatric hospital system. Again, we're talking about the most severe population in this instance.
The other role that those units play is an educational role with the Ministry of Community and Social Services program area to ensure that there is continual education of those people in the developmentally handicapped service provider field about issues of severe mental illness and how this population needs to be cared for a little differently and cooperatively. Those initiatives are under way, and we are discussing with the Ministry of Community and Social Services that after these pilots are completed and we get the results of the evaluation which has been ongoing, and if the early results prove to be true for all the pilots, somehow we need to ensure that there's a mechanism for supporting this collaboration between the fields on a province-wide basis.
Generally speaking, I think what both systems are recognizing is that very few people who enter the system now come with one set of needs, they come with complex sets of needs, and we have to be more effective at integrating our service responses and learning from each other.
Mrs Sullivan: The next question is also a question for the minister. What decision is being made with respect to the Psychiatric Patient Advocate Office? Is it going to be transferred to the Advocacy Commission?
Hon Mrs Grier: I'd ask my deputy, Ms Mottershead, to respond to that.
Mrs Margaret Mottershead: We have a memorandum of understanding with the PPAO, and it was signed over two years ago, that has within it the notion of the transfer to the Advocacy Commission. The memorandum of understanding recognized the planning process that was going on at the time for the establishment of the commission, and the need to have an integrated program was also seen as desirable at that time. Therefore, the language in the memorandum of understanding is very explicit that this will be considered.
There have been discussions going on over the last several months. We've had a number of issues raised by the patients in some of our own psychiatric facilities. We've had discussions with the PPAO executive director and the committee that is an advisory committee to the PPAO. Everyone has a slightly different understanding and need, so we're really trying to sort through those issues before making a final determination. But there is a basis and a starting point which is included in the memorandum of understanding, and that is that a transfer would be desirable but consultation would be contemplated before that happened.
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Mrs Sullivan: My understanding is that the patients would prefer to maintain the existing situation.
Mrs Mottershead: Certainly one of the spokespersons for the patient group is very much of the view that they would rather have a separate organization to deal with their own specific needs. We are well aware of those issues and have received a lot of correspondence.
Mrs Sullivan: As we all have. Basically, you're saying: "Wait for our response. We haven't decided yet."
Mrs Mottershead: We're talking about it.
Mrs Sullivan: Okay. One of the things we know, particularly in this economically strained environment, is that joblessness and the stress associated with that contribute to mental health problems. I heard about a very interesting study taken in Britain when Margaret Thatcher was introducing downsizing and cutbacks in government. The day the pink slips arrived was the day there was an enormous blip in cardiac arrests and in appointments with psychiatric institutions and facilities and professionals being made. It's fascinating; I'd love to get my hands on it just to see what the impact is.
But public health officials in communities, usually through the public health units and so on, have been attempting to deal with those issues; community agencies have been attempting to deal with some of those issues. My sense is that a lot of the activity is the spinning of wheels. People are trying to do their very best to deal with the questions and to ensure that there are supports in place, but have problems doing so; individuals have difficulty finding where the supports are. I wonder if you'd just talk for a few minutes about how you see the almost preventive mental health services being put into place and what the emphasis is on that aspect of mental health.
Ms Hill: At this stage we are definitely in the planning phase around health promotion and mental health. The other thing I'd say about that is that the health promotion report, that we've only seen drafts of at this stage, focuses very much on community mental health activities, looking at strategies to discourage violence against women, looking at strategies to discourage racist behaviour and attitudes, looking at suicide prevention, those kinds of strategies and initiatives.
I don't think we're far down the line in terms of being concrete about what should be the strategies we put into place. Definitely, the pressures on the system range probably more along the acute mental health side, the support to people with a severe mental illness. I would have to say that is our initial priority.
However, I know that in the discussions we've had about the multi-year and reallocation, we recognize that as we look at reallocating resources to case management services, crisis response, supports to housing, we also need to ensure that we are providing some initial enhancements or resources to health promotion, to women's mental health and to ethnoracial mental health specifically. There are real concerns that we address those issues as well, and some of the ways in which we may approach service design for the severely mentally ill or acutely mentally ill may not be exactly what ethnoracial communities would like to see in place, or women's mental health programs. That will probably affect how we will share the dollar, but I think we see it equally important that we begin to seed as much as we can as we move through the 10 years.
Hon Mrs Grier: Let me just add to that response, because the member raised the very real issue of determinants of health, which I referred to in my opening remarks, and we all know that economic security contributes to good health. I accept her contention that at the time of layoffs there is undue stress, both physical and mental. That's why our whole emphasis has been on the creation, through Jobs Ontario and other economic activities, of a healthy economy as the foundation for a healthy society.
As I look to the prevention of mental illness, it seems to me that a lot of the activities that are required are in all ministries and in all spheres of activity as well as through our mental health program. I often use the example of my own constituency office where for years I spent a lot of time dealing with tenants who were wrestling with the uncertainty and, if they were seniors, with the incredible worry of, would their rent go up an enormous amount at the end of the year or would they suddenly get a notice to quit because the apartment building had been sold?
While nobody would think our rent control legislation was mental health legislation, the effects are there because we don't now have seniors living their lives in a state of uncertainty about whether they will have their home for the foreseeable future, just as, dealing with justice issues, employment equity also contributes to people's security. As we know, through the work of the Premier's councils, that healthy, supportive families and communities are a very strong determinant of health, legislation that facilitates the development of those healthy families and communities is all a contribution to good mental health.
Mrs Sullivan: Can I go into specific budget items, the social contract savings with respect to psychiatric services of well over $12 million? That's on page 123 of the estimates book.
Ms Hill: I'm not sure what the question is.
Mrs Sullivan: One of the savings under the social contract, $12,200,000, is identified as a social contract savings for psychiatric services. I'd like to know what the impact of the social contract was in service delivery, in availability of patient services, because in this case we are dealing with the acute and heavy-demand care load, how the Rae days were met and what effect that had on patient services and care, and how many, if any, service providers were declared critical.
Ms Hill: I'm going to have to get back to you with the specifics of what happened last year and what the approach is for this coming year. There are different specific targets for days between the two years. Last year we did manage our services: There were not reductions in clinical services. That was achieved through tremendous challenges around scheduling and some backfilling for critical services, but next year we are looking at, as I said, efficiencies and opportunities to try to achieve these dollar targets without threatening our clinical services. There may be some program restructuring to do that, but we're certainly attempting, as much as possible, to do that through the efficiencies.
Mrs Mottershead: Can I add to that for clarification that what happens as you go through these estimates is that the salaries and wages and standard accounts are assigned to each program. In fact, when you're managing a ministry, the salary budgets can be aggregated; therefore there is some room so that, if there are particular pressures in certain areas, you might assign a higher target in another area so that it alleviates a major problem.
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What actually happened in psychiatric services last year is that because of their critical function and essential services, a lot of the work did have to be backed up, with people taking turns in terms of filling in for social contract days, or actually having to hire people who are on standby or on call for some of those clinical service parts. Therefore, the whole target really wasn't achieved as planned, as a direct result of that.
The target you see there is an assigned target based on the percentage of days required by both the particular OPSEU bargaining unit and the other quasi-bargaining units, and that's the target. That's an estimate. We will certainly try and manage this as part of our discussions with each individual hospital on its specific plans to meet this and the other savings Jessica has mentioned.
Mrs Sullivan: What were the actual savings last year in psychiatric services? Would you know that?
Mrs Mottershead: I don't have that information broken down per se, but I can get it for you, no question. I don't have it here; it is available in the ministry.
Mrs Sullivan: It would be interesting, first of all, to compare the two, but also, can you provide more information on what kinds of program restructuring you'd be anticipating to meet those social contract targets?
Ms Hill: It wouldn't be just to meet the social contract savings; it would be to meet the overall targets. What we've asked the hospitals to do is look at scenarios for savings within their facilities of a 5% or a 10% cut. It's a planning exercise to see what the impact would be -- it could be 5%, it could be 4%, it could be 6% -- but to begin the discussion.
The results of those discussions are not firm yet. We were pleased to see that a great deal can be achieved without touching clinical programs. In some instances the proposals looked at, with some one-time support, shifting to case management teams, which have been initiated in Brockville very effectively and in, I believe, both Cornwall and Ottawa. The desire is to create more of those teams.
In some instances, it is looking at the psychogeriatric population within our facilities to determine whether there are opportunities. This is not something new. This process of streamlining the service for the psychogeriatric population and ensuring that we play more of a tertiary, consultative role to the long-term care system and the care and management of care for people who require a different kind of facility has been going on for a number of years in our hospitals and is part of their operating and strategic plans. It's really taking those strategic plans and the operating plans and saying, "Are there things that we could move more quickly to achieve?" as opposed to deciding there's going to be a radical departure from those documents.
No decisions have been made. We're very much in the discussion, information-gathering phase to determine what the opportunities and the consequences and impacts are so that we are making very concrete recommendations.
Mrs Sullivan: We'd appreciate being kept up to date on those issues.
The other issue, of the psychogeriatric patient in the nursing home, is one that's becoming increasingly difficult in that the acuity of the problems has increased inordinately. I don't know what the measures are, but certainly the evidence is that the patients are older, sicker and more disturbed. The formulae with respect to the classification system aren't necessarily meeting the needs and the linkages with psychiatric services elsewhere aren't necessarily in place. I wonder if you could just comment on that a bit further.
Ms Hill: One of our working groups is a long-term care mental health working group that is focused specifically on the psychogeriatric population. One of the things they found is that there are many people in nursing homes who look identical to the people in our psychiatric facilities. Then again, there may be some people in the nursing homes who have difficulty maintaining their tenure there because of incidents or episodes.
The things a psychiatric hospital offers that have been identified to us as a major need on the long-term care side are some secure, locked space for people who are suffering from Alzheimer and have a tendency to wander; the second is walking space, pacing space, which our hospitals offer; a third is trained expertise in terms of being able to care for the patients who may have severe behavioural problems.
What we're trying to do is say, "You may not need to be in our facilities to have all of those supports to your programs." That definitely has been a very positive relationship, where the psychiatric hospital has played a very strong outreach team approach. Often a person, like the diagnosed population, needs to be assessed, stabilized, maybe some medication modified and some opportunity to be in a psychiatric facility for a short term, as opposed to using the psychiatric hospital as a place to live for years on end. What we're trying to do is restructure that relationship so that the psychiatric services are providing the right support.
Clearly, the psychogeriatric work group report, or the long-term care mental health work group report, speaks both to that population and how we might better use the resources to support the long-term care system, but the other is to ensure that those older people with a mental health problem are identified more effectively by the health care system generally and are responded to effectively in terms of depression, that kind of thing.
Really, many of the things we're doing or talking about are ensuring that what we're doing is a correct support and that the right kind of expertise is provided to another part of the system, as opposed to just saying we have to have all these people in our facilities.
Hon Mrs Grier: Let me build on that. Mrs Sullivan has identified the need for long-term care reform, and as I talk to district health councils about their planning, I'm tremendously encouraged by the congruence of their mental health planning exercise in their long-term care and the linkages that are happening there in the different districts, as well as what's occurring in a number of nursing homes, which is the development of facilities, whether it be for Alzheimer or other illnesses, within the nursing home.
I was in a wonderful facility in Whitby, Fairview Lodge, run by the municipality, where the Alzheimer unit had developed a secure outdoor area where members could walk and was really providing psychogeriatric services there, obviously with linkages to the professional system and Whitby Psychiatric Hospital. It's those kinds of connections that are emerging.
The other critical element of long-term care reform that will make a difference here is a more appropriate assessment of people's needs, because as both you and Ms Hill identified, there are inappropriate placements at this point, for whatever reason.
So I'm not sure I see shifting, necessarily, the people who are now in institutions, but as we get to a way of being able to do more appropriate assessments before people are placed, we will then find we can put people and have them live both where they can get the kind of help and support they need for their particular condition and in the most appropriate placement for them, given that condition.
Mrs Sullivan: I don't want to get too much into long-term care issues today because I think we'll have ample opportunity in the debate on the new bill to discuss those issues. But certainly in my community, where we don't have long-term care beds, we have the lowest availability in the province, and those facilities that are available have to link with Hamilton -- we're in Oakville and Burlington -- and we have very, very big problems with respect to an increasing, frequently dually diagnosed, psychogeriatric population with very severe problems -- a very difficult time coping with those people.
Too frequently as these issues are addressed there's a focus that assumes that the supports and the expertise of the major centres are going to be available everywhere in Ontario, and it isn't the case.
We have a vote, so there's one last question I want to raise here, and I'm sure the other parties will have some questions to raise on this issue. With the rationalization of St Thomas Psychiatric Hospital and London Psychiatric Hospital, you're predicting $15 million worth of savings. Why would that not have been put into the system? Are you anticipating, therefore, that in another year that money would go back into the system in another way?
Hon Mrs Grier: Certainly we identified some years ago the ability to make $45 million in savings, I think it was, mostly from administration and rationalization within the psychiatric hospitals. Of that, we have at this point committed to a reinvestment of up to $5 million in community-based services. The actual programs that will be developed as a result of that I think are all part of the exercise in planning that Ms Hill has identified that is currently under way.
The Vice-Chair: Thank you, Minister, for your response, and thank you, Ms Sullivan, for your questions. As we have a vote very shortly, we will adjourn the committee at this time. We have just over six hours remaining in our Health estimates. The committee will resume sitting on Tuesday, June 14.
The committee adjourned at 1751.