CONTENTS
Tuesday 21 June 1994
Ministry of Health
Hon Ruth Grier, minister
Gilbert Sharpe, director, legal services
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:
Wessenger, Paul (Simcoe Centre ND) for Mr Lessard
Wilson, Gary, (Kingston and The Islands/Kingston et Les Îles ND) for Mr Wiseman
Wilson, Jim (Simcoe West/-Ouest PC) for Mr Carr
Also taking part / Autres participants et participantes:
O'Neil, Hugh P. (Quinte L)
Clerk / Greffière: Grannum, Tonia
Staff / Personnel: McLellan, Ray, research officer, Legislative Research Service
The committee met at 1603 in committee room 2.
MINISTRY OF HEALTH
The Vice-Chair (Mr Ted Arnott): We are doing the estimates of the Ministry of Health. I turn now to the Liberal caucus for questions to the minister.
Mr Hugh O'Neil (Quinte): First of all, it's a pleasure to be here today and nice to have the minister with us. We've had a little excitement over the last short while. I want to thank the minister for the cooperation and help that I received from her and her staff last week when we had a very large delegation up from the Quinte area and especially the Trenton Memorial Hospital.
I believe, as I have mentioned to her in the past, that all the rationalization going on throughout Ontario has caused some concern not only in my own riding but in other ridings. Having a new district health council handling the Hastings and Prince Edward area, with a new executive director, has placed some real problems on their backs trying to come up with a type of rationalization program and something that will keep everyone in the area happy and content. We're dealing in this case with the Belleville, the Trenton, the Picton hospitals, which Mr Johnson is concerned with, and also with the hospital in Bancroft where Mr Buchanan is.
I guess it will prove to be an ongoing discussion, but I hope that after our meeting last week with the minister and the question in the House and the delegation we had up from the Quinte area the minister understands that -- the process likely has to be gone through -- the people in that area are very concerned with the delays they've had over the last three or four years and the cost associated with hiring of different consultants and then going back.
It's my feeling that, although we say the work is going to be carried out by the district health council, the ministry staff are certainly doing some of the directing there. I'm always a little worried that they're doing maybe more directing than they need to and not leaving as many of these decisions up to the district health council. But trying again to be fair, it may be that they have a certain direction they want things to take.
It would sometimes make the process much easier if the ministry staff were to say from the outset to the district health council, "This is the direction we want to go; this is where we want to end up or close to that," and let the people in the district health council and the people in the area know what that direction is without delaying it as long as it has and going through the cost of consultants and everything else.
There have been additional meetings since last week. There was one last Wednesday evening in Belleville at Loyalist College where the presentations were made. That now has been put out to the public and the public are to get back to the district health council at some time within the next couple of months. Hopefully decisions can be arrived at by the hospital boards, by the different medical staffs and by the public in general that, if that decision is reached, we will have a quick decision by the minister and the ministry so we can get this thing on the road.
I've expressed some time in the past, pertaining to the Trenton hospital, I have some real safety concerns as to the position of that hospital: electrical, heating and some other issues that I think have been brought to the government's attention. Hopefully something will happen there.
I know there was a question today by our leader, Lyn McLeod, on cancer coverage. I wonder if the minister could comment. A lot of the work, the cancer operations that are done in our area, in the Belleville-Trenton area, are done at the Kingston hospital. I wonder if the minister could bring us up to date on what's happening lately in Kingston as far as trying to keep up with the workload and the examinations and things like that pertaining to cancer treatment are concerned.
Hon Ruth Grier (Minister of Health): There are two questions there. Let me respond to the first one and then perhaps -- I don't know whether there are some specific details about Kingston -- some of the ministry officials who are here can respond to that one.
I wanted to say to the member, whom I know has taken a very deep and close interest in the hospital restructuring and the work of the district health council in his area, that I fully understand how difficult it is for communities when changes are suggested in the institutions from which they have traditionally received excellent care. As somebody who has vacationed in eastern Ontario, I know from personal experience some of the excellence of care and the caring care that the hospitals in his area provide. I understand the community's fear of somehow losing that as change occurs.
But I think it's important for all of us to acknowledge and to help people to understand that the health care system is changing, and those changes have been under way for quite some time. We know the figures about the fact that there are reduced lengths of stay because of improved ways of doing things and new procedures and new technology. We know that people get better health care if they are helped to be up and about and ambulatory earlier than they used to be decades ago.
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We know that returning people to their own homes and familiar surroundings keeps them healthier, so in response to that hospitals have changed. The objectives of the change are to improve the system to make sure that people get the kind of health care that they want and that they get better health care. People always see it as somehow damaging the system when there are changes to hospitals, but in fact the overall objective is to improve the system and to improve system management and at the same time improve the quality of care.
We also have to, in difficult financial times, see what we can do to reduce duplication. If there are two hospitals in the same city providing the same services, as I've heard from physicians, they sometimes spend as much time parking their cars and getting to the bedside as they do at the actual bedside if they have patients in more than one hospital. We have to become more efficient and we also have to support the change from inpatient to outpatient care and provide from the savings in institutions the dollars to do that. We also have to be concerned about the people who work in the system.
I appreciate the sense that the member has expressed to me before, and again today, that there need to be some clear expectations from the ministry as to what the district health councils are to do. I'm very proud of the fact that in Ontario a lot of the restructuring planning, in fact all of it, is happening at the local level through collaborative planning. Again in collaboration with the Ontario Hospital Association, we have, through joint work with the joint policy and planning committee, enunciated very clear principles for hospital restructuring.
When the member says that the ministry knows what it wants to happen, we know the principles that we believe the district health councils have to follow. The outcome will vary depending on the date and depending on the communities, and those principles which were shared with hospitals earlier this year are very clear: that the client and the needs of the client and the needs of the community have got to be the focus of it all; that there has to be integration of service delivery, both between institutions and from institutions to community-based services; that we have to enhance the quality of care and examine very carefully what that quality of care should be; that there needs to be education and research as part of the plan, and an integration of both the clinical and the non-clinical data, because the collection of data and the analysis of data by the district health council and by the consultants of the district health council have got to be balanced by the view, the history, the culture of the community. I think it's that meshing that is best done at the local level by the district health councils. We have asked for rather extraordinary voluntary efforts by the district health councils to do that.
I certainly share the member's concern that when that work is done and when those consultations are over, there will be quick turnaround from the ministry. I can give to him my commitment that will happen.
I'm delighted that, as a result of the study that was released with respect to the Trenton and Belleville hospitals, there now have been initiated a number of meetings with citizens. I gather the turnout has been large, which is evidence of the interest that his constituents show in the process.
The preliminary results of the studies indicate that there are opportunities for restructuring. What precisely those will be and how they will play out will be dependent on what is heard at those meetings. I hope that both the district health council and the hospital and, I know, the member will share with the people of that area both the information that helps them to have confidence that they will end up with a better system and as many opportunities for participation as possible.
Mr O'Neil: I appreciate those comments. I talked to the people in Belleville and had a discussion on whether they have the same concerns or not. I haven't heard as much from them as I have from the Trenton people. But I think -- and this would be more for your ministry staff, along with yourself -- in the case of the Trenton hospital, that particular hospital has been working very hard for the last, I would say, eight or 10 years trying to follow the directives that were set out by our government and your government to cut back on the amount of time in stay and cutting back on the number of beds.
It has become, along with the other hospitals in our area, a very efficient hospital. They are maybe not given the consideration they deserve in cutting costs over a large number of years. On a comparison basis, I think they stand likely the highest in the province of Ontario.
I appreciate you saying that you will try to speed up, as soon as the study results come in from the district health council, the process so that we can get ahead with some of the capital costs and other things that need to be done in the riding.
Hon Mrs Grier: Let me make two points in response to that. Certainly in those areas where there is health and safety or problems that need to be addressed, we have developed, again in conjunction with the Ontario Hospital Association, guidelines that would enable the kind of essential capital work to continue, despite the fact that long-term planning and restructuring is occurring.
The other point I have to make is that while hospitals have over the last seven or eight years become more and more efficient, in many cases they have done that on their own voluntary efforts, but also in isolation from the rest of the system. As a hospital cuts the length of time that people stay there, we have to look at, are there developing in the community the services that are required to support people when they are released from hospital earlier than they might have been?
That's what the restructuring exercise is about, not just how efficient a hospital can get but how we can develop a whole system. That's what I mean when I say that people get better care as a result of restructuring than they would if the directive from the government was, as some parties would have it, merely "cut costs." What we're saying is we know the changes are occurring. We have to balance those changes by investing in other parts of the system, what kind of an overall plan we should have in order to enable that to happen.
Let me turn to the second part of the member's question, which was with respect to cancer care and particularly to Kingston. I'm not sure that I have specific data about Kingston, but I can certainly say to the member that the cancer strategy I released in April, the first time this province has had a cancer strategy, is all about creating improvements to services, particularly to support services.
I was pleased to be able to announce in addition an extra $15 million of investment in enhanced treatment services so that we could cut down on waiting lists and meet the needs that unfortunately are growing for cancer treatment. As part of that $15 million, there was $8 million for bone marrow transplants, $3 million for breast cancer screening and $4 million for additional treatment in Toronto, Ottawa and Kingston.
While I don't have with me the actual time frames when that will be invested and when we will see practical results from that, I can assure him that we understand the need and are very appreciative of the work being done in Kingston and have allocated some funding to that.
Mr O'Neil: Again, I don't want to sound too complimentary, but I will say too that --
Hon Mrs Grier: It's okay. You're allowed.
Mr O'Neil: It wasn't to you, Minister; it was to the Kingston hospitals.
Hon Mrs Grier: Oh, I see. Shucks.
Mr O'Neil: Partially, anyway. Just to say that each of us as members has people from within our areas where there's always a crisis situation or felt to be a crisis situation. When it comes to cancer, it is a crisis situation, where they have come. I will say that on any problems where we've had to do referrals from the area hospitals to the Kingston area, the staff there have always been very helpful and they're always very willing to help.
Another area I wanted to touch on, which has to do with our area -- I know that it deals with a different philosophy between governments -- has to do with the subject of nursing homes. I think as members, we are into nursing homes on a continual basis, whether it's visiting personal friends or attending birthdays or anniversaries or whatever it may be. I like to feel that in the Quinte area, we have excellent nursing homes that give excellent care to the residents who are there.
The nursing home people in general are quite upset with the direction this government is taking, where people in private business or private industry are more or less being told that over a number of years governments will control nursing homes and they will not be a private business. Is that not the direction things are going in?
Hon Mrs Grier: I think that's overstating the direction. Certainly our government has indicated our preference for not-for-profit delivery of health care, as the Canada Health Act calls for. As we integrate long-term care more and more into the health care system, as opposed to being a social service, it is critically important that we conform to the principles of the Canada Health Act and have that health care delivered, as our hospitals and other institutions are, on a not-for-profit basis. We have indicated that as we move to expand our long-term care system, both in the community-based services and in institutions, that expansion should occur in not-for-profit.
We have wrestled with the difficulties of making the transition from a system where there was a great deal of unevenness -- some people in nursing homes or homes for the aged paid $26 a day and some people paid up to $92 a day and there was not a consistent level of care or in fact a requirement for consistency in care, depending on the need.
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In the transition from that very fragmented and diverse system to a system based on people's needs and on some consistent evaluation of their requirements, we have invested a great deal in the private sector, in nursing homes, more, quite frankly, than I would like to have done, because of the pleas that we got from private sector nursing homes that during this period of transition they would be put at risk as business enterprises.
We have assisted in both funding that helps them with the maintenance of their properties through taxes and acknowledgement of mortgages and the costs that they have incurred over the years as well as maintaining the funding for personal care and services. I don't think, with all due respect, that the private nursing homes should have very many complaints against us, because the recognition of the need for assistance during the transition period has, as I say, I believe been very generous.
What we are going towards, though, is a system where the payments to the institutions are based on the needs of the clients. It used to be you were paid per bed, regardless of the needs of the person occupying that bed. Through the case-mix index and the evaluation that we began last year and continued into the future, we will get to the point where a home that has clients who need very little nursing care is paid by the taxpayers commensurate with the needs of the patients, and a home that has a lot more fragile and vulnerable people who need a great deal more nursing care is paid depending on the needs of those people. The extra funding that we've provided is to help homes make that transition.
Mr O'Neil: Again, I guess I'm a believer in somebody in private business running things rather than the government. It seems that once we get the government involved too heavily in the running of not only nursing homes, what you'll actually find over the years and as time goes on is that your cost will become higher than what it was when it was run by private industry.
It may be that there are examples both ways. Maybe there have been exorbitant profits made in some places, but I really do believe, Minister, that on the road you're heading down, as time goes on, in the future years you will find when you get government -- and I'm not going to say "government regulation," because there's no doubt there were some changes that needed to be done in some of the nursing homes and some changes that have been made over the last 10 or 15 years that have been good ones. You could end up with a system that is government-run and it's going to be a lot more expensive than when you have somebody who has to cut costs and makes a profit, and I'm not saying cutting costs in safety or treatment but in other areas. Sometimes government gets carried away.
That brings me to another subject. I know that when you're talking public versus private -- and we've had quite a discussion going on at the Belleville General Hospital on home care, where at one time home care was handled by one agency and now it's handled by three or four. Are you familiar with the subject at Belleville hospital?
Hon Mrs Grier: I was aware that the Belleville hospital delivered home care and was not entirely in favour of some of the proposals of our long-term care expansion and redirection.
Mr O'Neil: I understand they have written to you talking about the costs -- I forget whether it was $600,000 or $800,000 -- that had been saved by the hospital by putting it out to private agencies rather than having public agencies. Whether I want to get in that discussion or not, I just wondered whether you have received those letters and what your comments might be on those large savings they have made by putting it out to tender.
Hon Mrs Grier: Let me say, yes, I am certainly aware of their correspondence and of their concerns, but let me go back to your earlier question --
Mr O'Neil: I guess too that they've said they are refusing the request you have made to make it totally public rather than private agencies.
Hon Mrs Grier: Let me respond to that by replying generally and in response to your first question, which is that it's all very well for the private sector to say, "Let us do it," but we, the taxpayers, are paying for it. We are putting hundreds of millions of dollars into these private institutions and there's another balance of accountability.
We've had a great deal in the House these last couple of weeks about government funding going to non-profit, community-based agencies and the need for the government to be accountable. I think that holds true in spades when you're giving taxpayers' money to a private agency to provide a service. I suspect the member and certainly all parties would be the first to be critical if we just wrote the cheques and didn't have any accountability or standards or imposition of requirements.
Mr O'Neil: But in this case the Belleville hospital --
Hon Mrs Grier: I was talking about nursing homes. Now let me get to the hospital. The hospital has been running home care, but again this expansion of long-term care and the changes we are making come from a number of initiatives. The first is the recognition by the previous government and our government of the increasing need there was going to be for long-term care in the future.
The number of people in the population aged 65 and over is going to increase by 45% between 1992 and the year 2010. If we don't plan now for a system that helps keep people out of institutions and provides home care in a most cost-effective way, we won't be able to afford the cost of those services 20 years from now.
Mr O'Neil: The two things are good care and at a reasonable cost.
Hon Mrs Grier: But what we heard from seniors was: "We want to have a part to play in managing our own care. We don't want it done for us and we don't want the decisions about the kind of care to be made by agencies, institutions or the ministry."
Mr O'Neil: Like a hospital board?
Hon Mrs Grier: Like the hospital board. "We want locally based agencies that will be like Meals on Wheels, Red Cross, all of those agencies that we have known in the past where there are consumers on the board and which are dealing with an integrated and coordinated system of home care."
I understand fully the argument that the quality of care being provided now by some of the private providers is good, and I agree with that, but I think we also have to build a network of services that will take us into the future and respond to the needs of consumers.
However, the argument he has made and that Belleville has made is not unique to him and to Belleville. This whole process of expansion and reform of long-term care has been a listening and responding process by the ministry. We listened to those arguments and so in Bill 173, which I introduced into the House and which got second reading last week, we made a change in the requirement that not more than 10% of the services provided by multiservice agencies be to the for-profit sector. Bill 173 acknowledges that up to 20% of the services can be purchased. Whether that purchase is from a private sector provider or a not-for-profit provider will be the decision of the MSA.
I know that over the summer, when the standing committee on social development committee holds hearings on that legislation, this issue will be, I suspect, well addressed and well debated, and I look forward to those submissions.
Mr O'Neil: I guess that's where I would disagree with you. Whether it's given publicly or privately, I would look at the type of care that is given to make sure it is the best and I would also look at the cost. Sometimes public agencies out-cost what the private sector can do for it. I guess I am not against the private sector making a profit if their costs are within line or less and if they are giving the same or better service. I guess that's where our philosophies differ.
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Hon Mrs Grier: Let me respond to that, because I certainly don't believe that a profit ought to be made out of the illness of our citizens. When I hear people extol the values of private sector health care, I ask them to look south of the border and to see whether any profit or efficiencies that might be achieved by hospitals in the US are worth the suffering and the pain and the costs in human injustice that a private sector system can provide.
Mr O'Neil: I guess that's where we differ, Minister. I have no problem if they're giving a good service and it's very competitive. I don't want to socialize everything or I don't want to make everything public. I believe that there is a place -- and if you were to take your description of the health care system and apply it to industry and everything else, our province would be destroyed.
A couple of things: Again, the people in our area have worked very hard, the kidney dialysis community and also the people on the -- I guess you don't call them CAT scans any more, you call them --
Hon Mrs Grier: CT scanners, MRIs sometimes.
Mr O'Neil: We have a new CAT scan in Belleville, which I'm very pleased to have, and we have likely one of the most up-to-date dialysis centres in the city of Belleville also, which is really serving our people there. There are some concerns in the area, but there are also some very good things happening.
Thank you, Mr Chairman. I could go on for hours.
The Vice-Chair: But you don't have the time, Mr O'Neil. Thank you very much for your questions.
I now turn to the Conservative caucus. Mr Wilson.
Mr Jim Wilson (Simcoe West): I was going to ask how much Ticzon gets there to time us on these things. He's telling me I only have a short few minutes and he's probably right.
Hon Mrs Grier: You're referring to my legislative assistant, Mr Ticzon, just for the record?
Mr Jim Wilson: Yes. My question would be with respect to dialysis treatment. Minister, as you know, the social development committee is awaiting some further responses from your ministry on this crisis. I want to read to you a letter that I've received today from Dr David Mendelssohn, who is the staff nephrologist at the Toronto Hospital. He says:
"Dear Mr Wilson,
"I received today a copy of the letter of June 13, 1994, from Ruth Grier, Minister of Health, to Mr Charles Beer, MPP, Chair of the standing committee on social development. This letter details the minister's response to the two recommendations in the standing committee's report on dialysis treatment in Ontario.
"I am writing to tell you that I am shocked and saddened to see this non-committal response. The dialysis crisis which we have documented so carefully has grown in the past month or two to an unmanageable situation. The Toronto Hospital has now withdrawn from the city-wide emergency schedule, because it can no longer meet its commitments to its own patients. This withdrawal is for at least the month of July and probably for the entire summer. The two remaining hospitals, Wellesley and St Michael's, will try to meet the need, but it is anticipated that they will be swamped and will be quickly overwhelmed, leading to the complete disintegration of the emergency dialysis referral system.
"At the Toronto Hospital, the daily triaging of patients and postponement of treatments because of lack of availability of resources has impacted directly and negatively on patient care. Patients and families are very angry. Nurses are demoralized. Our teaching program is suffering because we are unable to accept interesting new cases, and instead of teaching about modern treatment with dialysis" -- keeping in mind, Minister, this is a teaching hospital -- "we are teaching about rationing and triaging. We are constantly forced to tell our students that this is what we would do if we had adequate resources, but this lousy compromise is what we do in Toronto in 1994. Eventually, an incorrect decision will be made and a patient will die because of postponement of dialysis. There is no legal defence for a physician if someone dies because resource constraints led to an incorrect triage decision. Personally, I am completely frustrated with the ongoing situation.
"You must also remember that if the funding announcement was made tomorrow, it would take two to three months before there can be any relief. It takes that long to hire and train nurses, especially in the summertime. The Toronto Dialysis Committee is now collecting information about which centres in Ontario are prepared to accept Toronto patients in transfer and we are making overtures to centres in northern New York state and to Detroit, Michigan, and Cleveland, Ohio.
"The nephrology community has remained relatively silent since the committee hearings concluded. Initially, we were promised by Mr Donald Walker that a funding announcement would be made shortly after the provincial budget in mid-May. Then, we were anticipating a major announcement to be made before June 17, which was the deadline imposed by the standing committee. Both of these deadlines have now passed and there is no funding announcement in sight.
"I can only conclude that the minister has chosen to disregard the input she has received from the Toronto nephrology community, and now also from the standing committee on social development.
"As always, if the nephrology community can help present our problems to anyone in government who is able to help, we are prepared to do so at any time.
"Thank you sincerely for your efforts on our behalf. I am disappointed that after all you have tried to do, I'm forced to write a letter such as this. It means all our efforts have been for naught."
Minister, I don't think you could ask for a stronger letter from a physician. It was unprompted by me; it just arrived in the fax machine about an hour ago, and it follows on a very serious situation that occurred today.
I had a frantic call from Dr Mendelssohn's colleague at Wellesley, Dr Janet Roscoe, yesterday evening. They're absolutely full in Toronto. Toronto Hospital's off the emergency roster now. There's no place to put dialysis patients. My patients in Alliston are being asked to stay there and try and find some other type of dialysis because there's no use coming to Toronto.
Last night, they were trying to transfer a patient to Kingston. Kingston can't take the patient. Luckily, just before question period or it would have been a subject of question period, this one patient, who's a 79-year-old man -- and I'll give you a copy of -- I think I have a letter.
Hon Mrs Grier: I've certainly seen the correspondence.
Mr Jim Wilson: You've seen the correspondence. They did find some arrangements late this afternoon to put him into --
Hon Mrs Grier: Arrangements were made to transfer him to Kingston, then a bed was found in Toronto. So the situation has been resolved.
Mr Jim Wilson: At St Michael's, that particular situation.
Hon Mrs Grier: At St Michael's.
Mr Jim Wilson: What if another patient comes on line in the next 24 hours, though? I mean, Toronto is full.
Hon Mrs Grier: Let me respond, because I certainly recognize Dr Mendelssohn's frustration. He is an outspoken advocate for his cause, and I appreciate that. We need that because this is an area of medicine where the increase in the number of cases is quite a shocking 10%, where our efforts at prevention are going to take some time to work through the system and where the reduction -- I'm not sure where there has been a reduction, but certainly where we do not get enough organ transplants to deal with the needs in the way that best serves the needs of patients, which is to make those who are eligible or able to have a transplant to get one, and that puts extra pressure on the dialysis system.
But as the member well knows, because it has been the subject of a great deal of discussion both at committee and in the House, we have just completed a three-year, $23-million expansion program for dialysis. I was pleased to be in Mississauga a few weeks ago to open a new haemodialysis service that keeps 18 patients able to do their own dialysis, which gives them a much better lifestyle than they would have if they were in an hospital bed.
The study that has been initiated and that the recommendations from the committee indicated ought to be integrated with other work being done by the Kidney Foundation is under way and is a study that the district health councils are doing in central Ontario to identify the needs and the different kinds of needs and how they can best be met for the next stage of expansion. We know this is a service that needs to be expanded.
I'm sorry that Dr Mendelssohn feels that the work that has been done in order to see whether or not there is a possibility of some interim solutions while we await the results of that study and the decisions on funding and expansion that I suspect will flow from that -- as I say, I'm sorry the doctor doesn't feel that those have been leading to a conclusion. My information and the ministry officials' sense is that we in fact have had some very productive consultations with the hospitals in the region as to what kind of interim solutions would be and that we are at the stage of working out some final details that will enable us to address those issues in the short term.
I want to say that I'm fully aware of the need. I was aware of the emergency situation a few days ago when there was not a bed and when some extraordinary efforts were made to find a place for a patient in Kingston. It's the kind of situation that I would entirely agree with the member is unacceptable. People have to be treated in their own community as far as possible, and I was delighted to then learn that a bed had been made available, but that will continue to happen in the short term.
Mr Jim Wilson: Minister, given that there's a crisis -- there may be nice, long-term solutions, but I want to get to the short-term solutions. There's a crisis right now in this province. What are you doing in the next 24 hours about this crisis?
Hon Mrs Grier: What I am doing is in the final stages of consultations with the hospitals as to what kind of interim solutions to meet the growing demand for haemodialysis services we can have as we continue planning systematically for the long term. This has not happened yesterday or the day before. These are discussions we have been having with the hospitals over the last several months and we still have some details --
Mr Jim Wilson: You've been having discussions. The bottom line is, you're going to have to reallocate financial resources in your ministry even more than you've done to address this. What is your response to that?
Hon Mrs Grier: My response is that we are actively undergoing those kinds of examinations and reallocations, and I share the member's hope that I will be able to give Dr Mendelssohn and the very many patients who need care an answer as soon as possible. I don't have one today and I won't have one within 24 hours.
Mr Jim Wilson: Let me tell you a little bit about your central east study. I'm absolutely fuming about this. I mean, the central east people, in your effort to make everyone feel so wonderful about dialysis -- and I'll tell you frankly, I just came from a seniors' seminar in my riding where there were 160 people and the only questions I got all morning were about dialysis, in the town of New Tecumseth and Alliston more specifically.
I am told that the 11 patients in the area have all been called. They're going to meet with consultants who have been hired by the central east people. They're going to meet Monday night in a feel-good round table session in the hospital boardroom in Stevenson Memorial Hospital in Alliston. Price Waterhouse has been hired to ask these consumers what they think about dialysis service in the province of Ontario.
Do you think that's a useful exercise with respect to the scarce dollars we have in health care today, when 4,000 people in my area have signed a petition and all the patients have been down or made representations either to the standing committee or to you directly? We already know what these patients think about services. They don't want to have to drive to Toronto or Orillia any more. They want services close to home, and I know you agree with that. The problem is you don't do anything about it. Price Waterhouse is spending I don't know how much money -- I'm about to find that out from one of the people on the committee -- getting them all together in an extremely insulting way to ask them on Monday night what they think about dialysis services in this province.
Hon Mrs Grier: I'm shocked that the member --
Mr Jim Wilson: You're shocked? I'm bloody well shocked.
Hon Mrs Grier: -- would consider that insulting. To suggest, if you were going to invest hundreds of millions of dollars of public money in services for dialysis patients, that you not ask the people who need the services, who are not uniform in their needs, their demands, their requirements, how best those services can be provided is to me the most paternalistic way of planning the health care system from a member who was part of a party that cut health care services.
Mr Jim Wilson: Minister, we have asked those patients. We had the social development committee study this issue ad nauseam.
Interjections.
The Vice-Chair: Order.
Mr Jim Wilson: There have been studies ad nauseam on this issue --
Hon Mrs Grier: And if you're going to shout at me --
The Vice-Chair: Order.
Interjections.
The Vice-Chair: Order, Mr Wilson. Order.
This committee is recessed for five minutes.
The committee recessed from 1643 to 1651.
The Vice-Chair: We are resuming questions to the Minister of Health in this estimates committee. I would just like to caution all members of the committee that the Chair will not tolerate grave disorder. I realize that members feel strongly about issues, but we cannot tolerate grave disorder. Mr Wilson.
Hon Mrs Grier: Mr Chair, can I merely respond, with all due respect to Mr Wilson, that prevention is the thrust of our health care system. High blood pressure does contribute to kidney disease, and I would hate to have 12 patients in Alliston needing care.
Mr Jim Wilson: Minister, I appreciate your overtures, but at this stage in my life I'm not really worried about my particular life. I'm a little more worried about the dialysis patients in my area and throughout the province. Perhaps I could ask you, in a calm way, if we couldn't get a few more specifics from you, although maybe all you can provide us with today is a time frame on some future funding announcements.
In fairness, the response that came back under your signature, as you know, stemming from recommendation 6 of the social development committee, which was that the Ministry of Health report to the standing committee within 30 days on its commitment to funding dialysis and related treatment in the current fiscal year, frankly the unspecific, pretty pappy response, Minister, that came back said there are discussions going on and all kinds of things that we already know, but nothing specific about actual funding to meet the patient demands in 1994-95 and beyond.
That's what Dr Mendelssohn is referring to in his letter, and I think that's what prompted his blood pressure to go up and obviously write that letter, given that this response I really don't think is worthy of a minister of the crown. Perhaps you could undertake to get back to us in the extreme near future about what the government is going to do about this crisis.
Hon Mrs Grier: I'd be happy to do that, Mr Chair.
Mr Jim Wilson: Could I ask, Minister, what avenue you will choose to convey your response, given that the Legislature may be adjourning this Thursday?
Hon Mrs Grier: I don't know whether that is a fact. As I watch the debate, I hope we are adjourning on Thursday. I'm not sure I can commit to get back before that, but I could certainly advise the Chair and I'm sure that the clerk could then share that response with all members of the committee.
The Vice-Chair: Mr Wilson, do you have any further questions of the minister at this time? You have an additional 10 minutes if you wish to exercise it.
Hon Mrs Grier: Don't the five come off his time?
Mr Jim Wilson: No, you were yelling at me.
Hon Mrs Grier: No. Hansard only got you yelling at me.
Mr Jim Wilson: I was just having a normal discussion. You should come from my area of the riding; that's the way we do business. If you don't answer questions, we get to the point.
The Vice-Chair: Let's not get into it again. You have 10 minutes, Mr Wilson.
Mr Jim Wilson: Minister, I understand from a couple of things that happened in the last 24 hours, particularly watching CityPulse News last night and CITY-TV -- there's an interesting transcript here where, in effect, the College of Physicians and Surgeons talks about a problem that it sees in interpretation of the Consent to Treatment Act.
Without reading the whole transcript, I guess it boils down to their contention that patients who are incapable but who cannot interact in a meaningful way because they are confused, demented or semiconscious, even if they're in a non-life-threatening situation yet they're unable to communicate -- there seems to be some confusion as to whether or not a rights adviser must be called in at that time.
To be a little more specific, then you said, and I'm paraphrasing, that CPSO was escalating people's anxieties by not giving a totally accurate picture. Of course, at the end of the interview the interviewer checked with the Ontario Advocacy Coalition and they said that the scenario presented to you by the CPSO was indeed correct.
The obvious problem here, when it comes to the good of the public, is that with this confusion out there or with this interpretation of the act, treatment could be delayed to those people who may need it and who get caught in, frankly, a rather bureaucratic and cumbersome process. I'd like you to comment on that particular scenario under that act.
Hon Mrs Grier: I'd very much like to do that because I was certainly very concerned by the interpretation that the College of Physicians and Surgeons put on what is very important legislation that this House has adopted, the Consent to Treatment Act. I might ask Gilbert Sharpe, the director of legal services, to amplify.
I just want to be very clear to the committee that the scenario that was described by the college at its news conference, which suggested in regard to somebody who was incapacitated that treatment could not be provided until a rights adviser had been obtained, was quite wrong. Because if the person is incapable of asking for a rights adviser, then no rights adviser would be sought and the family or the substitute decision-maker would make the decision.
This legislation is designed to strengthen the role of the family in giving consent and making decisions with respect to care. But if I could ask Mr Sharpe to come forward and introduce himself, I'm sure he could respond to the question.
Mr Jim Wilson: While he comes forward, I just want to read the actual scenario from the transcript. It says, "If, for example, you brought your elderly mother into an emergency department with a non-life-threatening illness, she's incoherent, the doctor decides she's incapable of consenting to treatment but he's not sure if she understands her rights, he cannot treat until a rights adviser is called in, even if you're standing there saying, `Yes, go ahead, treat her.'" I imagine the "you" is a family or friend or somebody else.
The Vice-Chair: Mr Sharpe, could you introduce yourself for the purposes of Hansard?
Mr Gilbert Sharpe: Yes, Gilbert Sharpe. I'm the legal services director in Health. That in fact was the version that was in the first reading of the bill, but that's not what we've ended up with. We've made significant changes after extensive consultation with many individuals and organizations, including all of the major health care groups.
The current and final provision of the bill on rights advice simply says that the individual, in a non-emergency situation, for a controlled act, which is a fairly intrusive thing that you're about to do to someone, should be told that they've indeed been found to be incapable of making a decision and that you'll be seeking consent from someone else and that if they choose to speak to a rights adviser, then one will be called in to talk to them to explain things to them as to what their options might be.
It's not mandatory or essential that a rights adviser would come in. It wasn't in the first reading version, but that was ultimately changed through the process.
Mr Jim Wilson: Could I just ask about a scenario and a couple of examples? How does a patient know that these rights advisers exist and know enough to call them? Given the explanation you've given, there's no mention of rights adviser, so how would a semiconscious patient know enough to even ask for a rights adviser?
Mr Sharpe: It would depend how out of it the patient was. If they were in a very bad way and really not terribly lucid, probably telling them that they're entitled to have a rights adviser come in and talk to them wouldn't be very effective or clear.
Mr Jim Wilson: At what point do you have to tell them?
Mr Sharpe: When the physician talks to the patient, attempts to explain to him what procedure is being contemplated and attempts to get consent, which of course is true of any of us, and it becomes clear to the physician that the patient doesn't have the ability to give an informed consent. The decision is made that they're not mentally capable to consent to the treatment that's being proposed.
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Mr Jim Wilson: Okay, but isn't the CPSO's contention right at this point that this is where it's unclear? The rights adviser then must be called because the patient is deemed to be incapable of understanding the conversation that's going on with the physician, and that delays treatment.
Mr Sharpe: You're right, and if that were the current state of the bill, that would be a delay in every case, but that's not the way it reads now. What it says is that the physician who has decided the patient's not capable has to tell him he's made that finding and ask him if he'd like a rights adviser to be brought in to explain what his options might be. Our expectation would be that in the vast majority of cases the patient would not want that, and then one would just proceed to the family who are there and they would give the consent and the procedure would take place.
In a situation where a patient disagrees with the finding that he's not capable of making his own decision, then there would be a delay and a rights adviser would come and explain that there's a means of challenging the finding. That provision is taken from something that was put into the Mental Health Act in 1986-87 in the last major round of amendments to that act.
It reflects the notion that if any of us were to have the ability to make our own informed choices about our health care removed from us by a doctor saying we're not sufficiently capable, then if we want to, we should have a means of challenging that, not through the courts, because there are terrible delays and costs involved, but at least through some mechanism where we can call into question the decision that we can't make decisions for ourselves. So that's the process.
Then the question became, how do patients know about that process? At one time the thought was that maybe every time a doctor makes that choice, there should be a rights adviser. After some discussion with the medical profession and others, the hospital association, it was decided that it should not trigger automatically but should be at the request of the patient.
Mr Jim Wilson: Thank you. Minister, given the confusion out there, because the CPSO has reviewed the copy of the legislation that was passed by the Legislature and there is a great deal of confusion, I guess my question is: (a) Are you firm on your planned proclamation date of this legislation or are you flexible on that to give more time for the public and health care professionals to understand the legislation? If you are firm, part (b) would be: What efforts are you making now to ensure that everybody understands this legislation as it was intended?
Hon Mrs Grier: I'm sure, as the member is aware, this piece of legislation, together with the Advocacy Act and the Substitute Decisions Act, is a package of legislation that works as a package, but they are also separate pieces of legislation. They had I think two rounds of public hearings, over 100 amendments, and a great deal of work has gone into preparing for implementation and proclamation, which will occur early in 1995.
I concur with the member that this is legislation that is very important to the public and that the public has been seeking for I think 15 years, so to explain and educate the public as to how to use it effectively and what it means is very much part of our implementation strategy.
The three acts and the three different ministries -- my own, the Ministry of Citizenship and the Ministry of the Attorney General -- have all been working in a very collaborative way to have an education program and information program so that before proclamation, which will occur but there will not be a delay in that, early in 1995, we make every effort to inform people about their rights and about, as I say, the ways in which the legislation is user-friendly. I really welcome the member's encouragement of us to do that, because we plan to.
Mr Jim Wilson: Minister, I just want to leave you with an inquiry that came to my attention this morning at my seniors' seminar. Perhaps one of your staff could write this down. It will save me the time to put it in letter form. Mr Duncan Rennie has given me his permission to bring this to you. I told him we were coming to the estimates committee today. His phone number is area code 705-435-2295. His address is 1 Greenbriar Road, Alliston, Ontario, L9R 1R5.
Mr Rennie is a leukaemia patient. He was involved in the interferon tests -- what do we call those things? -- drug tests, studies. Obviously, that study program is over. He now still requires interferon. It's not covered readily on the drug formulary. His doctor is Dr David Sutton at Toronto General Hospital, oncology. He filled out, apparently, a section 8, according to the patient, several months ago, and they've not heard anything from your ministry. I'm just wondering if somebody could check that and perhaps doublecheck with the patient.
Hon Mrs Grier: I'm surprised at that, because, as I responded in the House today in response to a question, certainly the urgency of some drugs is being considered as we deal with those requests and we've reduced the turnaround on at least one of them from 61 days to less than seven days. We've made a note of the situation and I'll undertake to have an investigation and get back to you.
The Vice-Chair: Thank you, Minister, and thank you, Mr Wilson, for your questions. I now turn to the NDP caucus. Do you have any further questions?
Mr Pat Hayes (Essex-Kent): We'll let the opposition ask questions.
The Vice-Chair: Mr O'Neil, you had one additional question, or do you want to defer?
Mr O'Neil: David would like to go for a few minutes and then I have a couple of things that I'd love to raise too.
Hon Mrs Grier: I thought we had some agreement on trying to adjourn --
The Vice-Chair: We only have about five minutes. If you could have your questions done in five minutes, we could --
Mr Jim Wilson: Are you sure that you have five minutes?
The Vice-Chair: They have five minutes.
Mr O'Neil: What time are we supposed to leave here?
The Vice-Chair: Our plan is, since a number of members, including the minister, wish to get to the House on Bill 119, we want to conclude estimates this afternoon at about --
Mr Jim Wilson: How much time did I get?
The Vice-Chair: You had your recommended allocation of time, Mr Wilson. Mr Ramsay.
Mr David Ramsay (Timiskaming): Minister, I just wanted to get a follow-up from a question I'd asked you in the House a couple of weeks ago in regard to the northern health travel program and the changes you're making in that program. As I said in my question, I agree with what you're attempting to do, but just with the problems we're running into, do you have any update as to the cleaning up of the list, making it more accurate as to the referral doctors so we can have a better response from the ministry when people put in their applications for the travel?
Hon Mrs Grier: It's certainly a question I have answered and certainly my colleagues on our side have raised with me, particularly the question of paediatric specialists. I think I acknowledged in the House that a specialist in orthopaedics, for example, might not be a specialist in paediatric orthopaedics. So my recognition is clear that it is the nearest specialist for the subspeciality, if that's what we're talking about.
I understand that we have in fact made some progress with respect to cleaning up the list and that the time has been reduced. If there are some specifics that I'm not aware of, I'd be happy to look into them, but I don't have anything more up to date than that.
Mr Ramsay: I'm glad to see in a way that the policy's changing. I guess what happens is, when somebody puts in the application for the grant, the computer, however it operates, just spits out to say no, there's an orthopaedic surgeon available in Kirkland Lake; therefore, that person should have gone there.
I guess I understand now that you seem to have an understanding of how it should work. I'm just wondering, how long is it going to take for the system actually to work that way, the way you do want it to work?
Hon Mrs Grier: This particular problem came to our attention I think just at the end of last month, so what the northern health -- I'm trying to think of the name of what we call our new -- we have a new office in northern Ontario, in Sudbury and out of Thunder Bay, working to work with the north and meet those needs. Certainly they undertook to call all the orthopaedic specialists and confirm which of them were treating children and which ones were not.
They estimated that that work would take approximately three weeks, which would take us to today, which is why I haven't got any up-to-date information and can merely repeat that, yes, we acknowledge the problem, work has begun on trying to sort out the subspecialties within that list and I hope that will make it better for people in the north. That has been our long-term objective, and I'm very pleased with the progress we have made.
The Vice-Chair: Mr O'Neil, you have about two minutes.
Mr O'Neil: Just briefly, Minister -- I'm just sorry there isn't more time -- one of the real crisis areas that I feel we're also experiencing in the province of Ontario, a crisis that has been there for a number of years, previous governments also, is the crisis in the mental health field. You know, we can call you, we can say we need a bed or an operating table for a heart attack or for cancer treatment or things like that, but a lot of the hidden injury that is out there today lies in the mental health area.
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I know in my area, as well as in other areas throughout the province, we have a problem getting proper medical staff to service the area. We have problems getting enough funding, enough homes to assist. I realize we're very short of time, but it's something I know you're dealing with and I'd just like to impress upon you that it is a real crisis in some areas getting the help that's needed for these people who are being left in their homes, left out on the street or not given the care they should be receiving. I don't know how we solve it, but it is a crisis.
The other thing in my area, and it was expressed the other day, is the number of doctors who are actually leaving the province and moving to the States. As I mentioned the other day in the Legislature, in our area alone the other day it was announced that three of our doctors in Trenton are leaving for the States. These are doctors with very large practices, and the other doctors, because of the volume of work they have or because of costs, are not able to take these patients. I don't know where these people are going to go, I really don't. It's a real concern.
Hon Mrs Grier: Let me respond to that by saying that, like mental health, is not a new problem for this province. Doctors have always moved when they saw it to their advantage to do so. I was pleased that in fact some statistics, I think last year, indicated that 85% of those who moved to the States returned after a period of time, because they found collecting their own bills and dealing with the kind of system that is there was not nearly as satisfactory to them in the practice of medicine as our system. But it is an ongoing issue and one that, working with the universities and the academic health science centres on, for the first time, human resource planning for the health care system, we believe we can make some progress in time.
Mr O'Neil: Where do these people go? I guess that's my question. Where are these patients going to go when the doctors who are there are not taking any more patients and we have the doctors who are leaving?
Hon Mrs Grier: What we have is unfortunately a system that doesn't allow us to say to doctors, "Thou shalt practice in Trenton, Belleville or northern Ontario." Doctors consider themselves small businesses and entrepreneurs and they go where they see that they can make an income.
I would hope that the practices of the doctors who are leaving would be put up for sale at a reasonable price and that privileges for new doctors would be afforded in the hospitals concerned, because those are often barriers over which we as a ministry have no control. But in the interests of their patients, I would assume that they would be encouraging people to come in. Then we have to leave it to communities to persuade doctors in areas like the greater Toronto area, where there are more doctors per capita than any objective evaluation would say are needed, that the quality of life they will have in Trenton and Belleville far exceeds what they may get in parts of downtown Toronto or the GTA. I fully believe that, but I don't have the power as minister to pick them up and put them where they're needed. As public servants paid by the public, I wish there was a way of doing that, but there isn't.
Let me speak briefly on mental health reform and refer you to Putting People First, the first mental health strategy and planning document the province has had. I'd be happy to send you a copy and hope that would address some of your concerns.
The Vice-Chair: The time allocated through the estimates process for the Ministry of Health has now expired. I want to thank the minister for her time in this committee, as well as all the members of the Legislature who participated in this process, for their questions. I also thank the Ministry of Health staff for assisting the minister in some of her responses.
At this time, we will have the votes on the Ministry of Health estimates.
Hon Mrs Grier: Mr Chair, we provided today the answers to a number of questions that had been asked before. There are some more to come. I assume that what I will do, as I said in response to an earlier question, is provide them to you and they can then be circulated. We will undertake to do that before the end of the week if we possibly can, knowing that members will be dispersed next week.
The Vice-Chair: The clerk will ensure that the members receive their written responses.
We move to voting.
Shall vote 1501 carry? All in favour? Opposed? Carried.
Shall vote 1502 carry? All in favour? Opposed? Carried.
Shall vote 1503 carry? All in favour? Opposed? Carried.
Shall vote 1504 carry? All in favour? Opposed? Carried.
Shall vote 1505 carry? All in favour? Opposed? Carried.
Shall the 1994-95 estimates of the Ministry of Health carry? All in favour? Opposed? Carried.
Shall I report the 1994-95 estimates of the Ministry of Health to the House? All in favour? Opposed? Carried.
Hon Mrs Grier: Thank you, Mr Chair. May I congratulate you on bringing this to a fine conclusion. I thank all the members for their help and questions.
The Vice-Chair: We will reconvene tomorrow at 3:30 on the Ministry of Transportation estimates for six hours.
The committee adjourned at 1716.