HAMILTON-WENTWORTH DISTRICT HEALTH COUNCIL
HALIBURTON, KAWARTHA AND PINE RIDGE DISTRICT HEALTH COUNCIL
CONTENTS
Wednesday 7 August 1991
Agency review: District Health Councils
Hamilton-Wentworth District Health Council
Haliburton, Kawartha and Pine Ridge District Health Council
Ministry of Health
Continued in camera
STANDING COMMITTEE ON GOVERNMENT AGENCIES
Chair: Runciman, Robert W. (Leeds-Grenville PC)
Vice-Chair: McLean, Allan K. (Simcoe East PC)
Bradley, James J. (St. Catharines L)
Frankford, Robert (Scarborough East NDP)
Grandmaître, Bernard (Ottawa East L)
Haslam, Karen (Perth NDP)
Hayes, Pat (Essex-Kent NDP)
McGuinty, Dalton (Ottawa South L)
Stockwell, Chris (Etobicoke West PC)
Waters, Daniel (Muskoka-Georgian Bay NDP)
Wiseman, Jim (Durham West NDP)
Substitutions:
MacKinnon, Ellen (Lambton NDP) for Ms Haslam
Villeneuve, Noble (S-D-G & East Grenville PC) for Mr Stockwell
Ward, Brad (Brantford NDP) for Mr Waters
Clerk: Arnott, Douglas
Staff: Pond, David, Research Officer, Legislative Research Service
The committee met in camera at 1000 in committee room 1.
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AGENCY REVIEW
Resuming consideration of the operations of certain agencies, boards and commissions.
DISTRICT HEALTH COUNCILS
The Chair: Come to order, please.
HAMILTON-WENTWORTH DISTRICT HEALTH COUNCIL
The Chair: The witnesses are from the Hamilton-Wentworth District Health Council. Please identify yourselves and your responsibilities with the health council.
Mrs Nagawker: I am Nancy Nagawker, the new, incoming chairman of the district health council, appointed on June 1. I apologize for the sound of my voice, but there was nothing much I could do with it after this morning. Dr Susan Watt is a member on council and has been on the consumer portion for two years. Linda Dayler is the assistant executive director of the DHC. We also brought with us a new planning staff member, Marion Emo.
The Chair: Do you have an opening statement you would like to make? Please proceed.
Mrs Nagawker: We are very pleased to be here today to talk with you about the Hamilton-Wentworth District Health Council. Our presentation is divided into three parts. The first is a very brief overview of the district health councils in general; the second is a specific review of the Hamilton-Wentworth DHC; and, finally, providing a summary of achievements, challenges and goals for the future.
We understand that your briefing package will contain some information that will overlap with our presentation, so to keep within the time frame we will take the liberty of moving through the introduction rather quickly and highlighting only as we go. Also, we have had a quick change in the course of presentation today because of my obvious throat/voice problems. We have coerced Susan into doing the presentation this morning for us. She will be doing most of the presentation, as is somewhat obvious, to save you from listening to me for most of the morning. I will let Susan assume the presentation now.
Dr Watt: There are 28 DHCs in Ontario that are assigned to six provincial areas. There are five DHCs which include health science facilities. Hamilton is one of those health science facilities. The others are Toronto, Ottawa-Carleton, London and Kingston.
The DHCO, the District Health Councils of Ontario, is a newly formed association of district health councils established to strengthen the capacity of DHCs to undertake comprehensive planning and to become active partners in regional and provincial planning.
The Hamilton-Wentworth District Health Council is located in the central-west health planning area, which consists not only of the regional municipality of Hamilton-Wentworth but also Haldimand-Norfolk, Niagara, Brant, Waterloo and Wellington-Dufferin. We are located at the tip of Lake Ontario, not too far from where you are sitting.
The members of district health councils, as you may be aware, are appointed by order in council and they represent either consumers or providers in the community. Each council has a small core of professional staff and within this framework each DHC has considerable leeway to structure both its organization and programs to the health care needs and issues of its own community.
The primary functions of the district health councils are to identify health care needs, to monitor the health care system, to plan and co-ordinate health services, to promote social development and to advise the Minister of Health.
Today, health care issues have a prominent position in the public eye and it is increasingly important, we believe, that we manage our health care system effectively. Some of the issues that we as a council believe to be important are escalating costs, the growth in high-technology utilization, equal access to service, changes in federal funding formulas and the reforming of long-term care. The challenges which these issues hold for DHCs and their communities include things like determining the most appropriate location for care, questions of decreasing the use of institutional resources, determining the most appropriate distribution of services, the balancing of consumer rights and consumer responsibilities and the inclusion of more citizen participation in decision-making in a meaningful and productive way.
The challenges before us lead us to consider new roles for the DHC as promoted by the Ministry of Health. Our council, like other district health councils, has begun to explore the ways and develop the means to accommodate new roles, and this has led us to highlight some of the new activities which we believe will develop in these directions.
As a result of a comprehensive consultation process, our council has revised its mission statement to emphasize the fact that it is a community advisory body which works in collaboration with other planning bodies and is committed to an equitable partnership among providers and users of service. The consultation process included a strategic planning process and includes, in an ongoing way, retreats, workshops and consultations with providers and consumers within the health care system as well as in the social service sector.
Much of the work done at council is carried out by volunteers. The importance of the volunteers in the organization of district health councils really cannot be underestimated by this committee. The involvement of volunteers in the health planning process enriches both the quality of the plan itself and the community understanding of the complexity of the health care system. Enhanced community knowledge and understanding, we believe, are absolutely essential if we as a community are to manage our health care system in a responsible way. Volunteer involvement, however, takes time and training and support, both from the organization and the volunteer, because volunteers do not come fully dressed in traditional bureaucratic expertise.
In our current structure, we have six standing committees, as are listed. We have chosen to highlight for you, for purposes of example, two of those committees, the community health planning and the joint action committees.
The mandate of the community health planning committee is to provide a forum to develop a co-ordinated approach to community health planning. A wide range of representatives from health and social service agencies participate in this process. Two examples of the health issues that have been dealt with recently by this committee are AIDS and the ethical policy manual, which you may have seen, that was developed out of the Hamilton-Wentworth region, and also strategic planning in palliative care for our area. Emerging community health issues for this committee include women's wellness and the health of the homeless.
The joint action committee is a forum for discussion and for information-sharing among Hamilton area hospitals and institutions and serves as a vehicle, when it is appropriate, for joint action among those organizations. The Hamilton-Wentworth District Health Council has consistently been able to bring the hospitals together to discuss their plans, review their proposals and co-ordinate services and programs within the institutional sector.
The main focus of this committee and its subcommittees over the last 10 years has been the regionalization and rationalization of health services, an area where Hamilton-Wentworth has been a leader in the province in ensuring that health services are comprehensive but are not duplicated. This collaborative planning has been established as standard practice in Hamilton-Wentworth and has resulted in major projects for which we are known, such as the central bed registry and the agreement on the purchase of a magnetic resonance imager for the Hamilton area, which was a consortium agreement among our hospitals.
We would like to give you a bit of context to understand how and why we do what we do and particularly how we plan in our region. We deal with six area municipalities and heavily involve our local government in planning. We are a very diverse community culturally, which presents very special challenges in health planning. We are a designated francophone community.
The age structure of our community tells us that by 2006, from the best projections we get from our health science centre, 68% of our elderly population will be over the age of 85 years and therefore fall into that group of frail elderly we worry most about in trying to plan appropriate services.
Our region also has a changing employment base and a restructuring of its economic foundation. That should not be news to you if you look at where jobs are being lost in communities around this province and you look at the industrial base that serves Hamilton-Wentworth coupled with its farming base. So we are looking at a number of restructurings of the economic base in the area we serve.
One in four persons in our community is in receipt of some kind of social assistance, which includes welfare or family benefits, unemployment insurance or disability allowance. We also have concerns about the critical state of child poverty in our community and the long-range implications for the wellbeing of these individuals.
We want to present to you a picture of the complex interrelationship in our community as it pertains to health planning. This circle depicts the entire universe -- we always start in Hamilton within the universe -- and the outer circle represents all the factors that influence and affect planning in our community.
Hamilton-Wentworth supports three hospital corporations encompassing five active treatment hospitals, as well as a provincial psychiatric hospital and a designated chronic care hospital for persons over the age of 65. As we have mentioned, the DHC, in collaboration with these hospitals, was one of the first in the province to rationalize health care services, the result being the elimination, we believe, of the duplication of costly services. For example, one of our hospitals is designated an adult trauma centre, another is a neonatal intensive care and high-risk pregnancy centre and another handles renal dialysis. It is also important to know that some of the hospitals are also designated as regional or provincial centres for specific services. For example, the regional or central-west program trauma centre is indeed the Hamilton General Hospital. So the Hamilton-Wentworth District Health Council has been involved with the hospitals in the development of plans not only for our local area but also for its regional service plans.
Some of the hospital issues that the district health council has initiated and will play a lead role in in 1991-92 include a review of emergency services in Hamilton-Wentworth, a chronic care review and a strategic planning process for palliative care in our region.
Hamilton-Wentworth has a rich network of community-based services. We have a well-established social planning council, an agency that plans and co-ordinates children's services and an active multicultural community. Throughout the years, the DHC has played a role, and a very active role, in the promotion and development of community-based health care services. Some of the accomplishments include a multicultural health care needs study, a partnership with the region and McMaster University in sponsoring workshops on healthy communities and establishing a regional sustainable development task force. We, as I have indicated, will be working on women's health care issues in the coming year, and we are just completing a mental health multi-year plan and an addiction services study and plan for the region.
We believe we are indeed fortunate in having an excellent working relationship with our regional government and with the Ministry of Community and Social Services. They have invited our participation in many of their health and social service endeavours and they have actively participated in many of our projects and planning processes. We are particularly proud of our joint three-year seniors' study. The study focused on finding solutions to seniors' needs and integrating health and social services in addressing the needs of seniors. The DHC, in co-operation with the region, has recently completed an assessment of the needs of the disabled in our community.
McMaster Faculty of Health Sciences assumes a leadership role in providing education, research and new knowledge through the entry of clinical services. Since the beginning, the DHC and the health services committee have enjoyed what I would characterize as a supportive and productive relationship, enhancing each other's ability to perform their respective jobs.
Progressive health care planning and services cannot be divorced from research or new knowledge. The DHC is the broker often between the Faculty of Health Sciences and the Hamilton-Wentworth community. The DHC fosters and promotes public accountability within the Health Sciences Centre. Premier's Council money could lead to other exciting endeavours by creating a forum to bring partners together where we have a role in helping community agencies to become involved with research undertaken by academics within health sciences or other areas of the university.
The Health Sciences Centre and the DHC collaborate on the development of complex multifaceted regional programs which involve a number of health care professionals and institutions. This process of regionalization is achieved by the appointment of a co-ordinator by the DHC and Faculty of Health Sciences to manage specific programs in the network. Some examples of that would include our regional co-ordinator of emergency services, regional co-ordinator of geriatric services, of palliative care, of trauma -- the list goes on for all regional services.
In future the DHC will continue to develop linkages with the Health Sciences Centre through its partnership with the faculty and the Halton District Health Council. A five-year project recently funded by the Ministry of Health supports research into interventions with individuals with chronic conditions, and those are both health and social conditions.
Working together with the Health Sciences Centre enhances our capacity as a district health council to plan realistically, based on the needs of the community.
The DHC is the only organization amidst this myriad of planning bodies that has, as its major mandate, health planning. We play a pivotal role in linking hospitals, communities, government, health sciences and consumers. From our vantage point we see issues in their early stages and are equipped to respond, or at least to identify those who should respond, to these issues. We are a catalyst, facilitator and advocate in local health planning.
Community health planning is a complex task. In a large urban centre with many competing priorities, pressures and interests it becomes as much an art as it is a science. Our presentation would not be complete if we did not identify some of the obstacles we face.
First, to the public at large, the DHC remains largely unknown. Even those who know us are frequently unclear about our role, mandate and authority. We are delighted the DHCO has accepted as a major priority improving communication between DHCs and key stakeholders in the system. We as a council are committed to enhancing our community's knowledge about us.
Second, sometimes our relationship with the MOH is problematic. There are discrepancies in priorities between district health councils and ministries of health, and that is to be expected. This is natural, given the milieu in which we operate.
There is often a problem with time lines. The ministry expects the district health councils to identify and review issues and proposals within an often unreasonably short time frame. While councils are committed to providing reliable and factual advice with community input which reflects the needs of the community, the ministry must acknowledge that this process takes time. We have not had data collection automation until recently, so it has often been a problem to secure information which the ministry has requested. Time lines for voluntary organizations have to be longer than when you can point your finger at a bureaucracy and say, thou shalt before thou leaves today. You cannot say that to a group of volunteers.
Mrs Nagawker: Or yesterday.
Dr Watt: Or yesterday. Yes, usually it is "yesterday" when we have a problem with it. "Today" we can often accommodate.
Conversely, the community needs to understand that policy and program development can also take time. Communities and families do not understand that they have to wait for policy development to catch up with needs. For example, right now we are working as a broker with the community and the ministry about the redevelopment of chronic care beds.
Furthermore, there are still inconsistencies in the use the ministry makes of district health councils. This has improved in the past year, but on occasion our planning role still is bypassed or not given enough time to work properly. It is not so much that we are not asked, but it can happen that we are asked for comment yesterday. This adds further to the community's confusion about the role of the district health council.
Recently the role of the DHC has received much discussion, and while we applaud this debate, we wish to actively participate in it. We hope that sooner rather than later there will be a clear restatement of our purposes, our enhanced roles and our accountability.
As we look to the future with optimism, we are particularly pleased in Hamilton-Wentworth with the Premier's Council on Health Strategy's report. We support the direction and the commitment to healthy communities and look forward to our participation in working with our community to achieve these goals. We believe the DHC has both the expertise and the enthusiasm to be a key proponent of achieving these objectives.
What we have presented is a description of how we presently achieve our shared objectives, yours and ours.
Finally, we would like to share with you a draft version of our goals, which we believe will enable us to continue to provide sound health planning advice to the minister, to participate with our community in-house planning, and to actually be part of creating healthy communities that we all want to live in.
Our goals include the identification of health needs, leadership in the development of planning to meet those needs, co-operative planning with social services, community management of health and social services, partnerships between the public and the providers in planning and co-ordinating health services, and enhancement of public awareness related to health issues and resources in Hamilton-Wentworth.
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Mr McLean: How many requests in a year would you get to react to a government request? You indicated in your remarks that you would get it to do today or, you said, yesterday. How many requests would you get from the minister to act on a certain item?
Mrs Nagawker: That is an interesting question.
Mr McLean: You brought it up.
Mrs Nagawker: I know.
Dr Watt: There are really two categories of requests. There would be those that come out with a long perspective: "Would you look at the needs of disabled in your community? You've got three years; give us a proposal for budget." Those would be the standard kinds of planning requests.
Then there would be more immediate things like, "Give us an evaluation of this particular program that we're proposing go into your region, and we'd like it a week ago last Sunday, please." We average --
Interjection.
Dr Watt: Of that kind of request? Once a month?
Mrs Nagawker: We have a short consultation maybe once a month.
Mr McLean: That is fine. I have another question. You seem to have a close liaison with the university. Why is your association with them so major, it appears to be? Is it the medical side of Hamilton university?
Mrs Nagawker: It is not only the health sciences faculty, by the way. We have liaison with other faculties within the university, but our major liaison would be with health sciences, which carries programs other than medicine. It carries now physiotherapy, occupational therapy, nursing and medicine.
If one lives within a region with a health sciences centre in it, it would be naïve to think that the centre did not have a major impact on the health of the community, because of the services or the expertise it brings to that community. So in bringing on manpower, new physicians, new experts, new researchers, they have an impact on that community and we must know where that impact is.
Mr McLean: What would a district health council do that did not have any university in its area?
Mrs Nagawker: Probably a little less work than we do, but to be not facetious about it, it would not have to worry about the level of the expertise coming in, or the researchers, or new programs being developed or proposed as frequently. It does not have, probably, nearly as high-tech development of programs or the volume of programs available. I do not know if you want to add anything.
Dr Watt: It would also have problems. For example, what happens when you have to send people out of your region for all this high technology? What kind of planning are you going to do for long-distance ambulance transport services or helicopter transport services for critically ill patients who are going to be ferried to health science centres, as we have, the problem of what we do with people who come from out of region and we have to plan for their care both in hospital and out? So it is a tradeoff between them. They are different planning issues. Perhaps the volume is the difference in the nature of it.
Mr McLean: I just have two short questions. When does your health council meet, daytime or evening?
Mrs Nagawker: Three to five, approximately, in the afternoon; late afternoon, early evening.
Mr McLean: Do you have a problem getting your volunteers out, the ordinary layperson?
Mrs Nagawker: No.
Mr McLean: The other question I have is, how many paid staff do you have?
Mrs Nagawker: We have an executive director, an assistant executive director, two planners and three secretaries.
Mr McLean: Would the directors' salaries be the same pretty well across the province?
Mrs Nagawker: Yes, I would think so.
Mr McLean: How much does your executive director make?
Mrs Nagawker: In the region of $75,000.
Mr McGuinty: You referred to a program I understand you have implemented which acts to either eliminate or substantially reduce duplication of services offered by different hospitals. I have four major hospitals in my riding and one smaller hospital and they seem to be conducting an ongoing campaign to provide different kinds of services, a number of which duplicate.
There are some surgeons who seem to me to spend more time at press conferences than they do in the operating room, in order to -- and I do not blame them for this -- raise the profile of a particular department that falls within the hospital they happen to be working out of. So I am interested in hearing a bit more about your programs to reduce duplication.
Mrs Nagawker: Early on in the history of the development of councils in Hamilton, it started with a hospital council. So the history had already been well established in the past. They recognized pretty quickly that there was only a certain amount of money going to come to the area and how, number one, were they going to attract and develop the programs?
If we wanted that program in the area, we had to settle on a method, a process of determining which centre was going to have it. At that time they pretty much hammered out a practice of making a proposal that was jointly agreed upon prior to the proposal coming out. In other words, the hospital group meets at joint action, etc, and they hammer out between themselves who is going to present what program and what hospital will be looking after what areas.
Much of that work had been done early on in the past. It has become established practice now for us to carry out more than a new practice that we are concerning ourselves with. A new physician would not come to Hamilton not knowing that he may have to negotiate and it is a process of negotiation within those hospitals.
Mr McGuinty: Do you have any authority to coerce hospitals if, let's say, you had competing demands for services that would in essence be a duplication? How do you deal with that?
Mrs Nagawker: Actually, in truth I think if we were to look at it seriously, I do not know if anyone has any authority to coerce. The ministry's authority lies within the funding arrangements. The best authority it has is just not to fund, or it withholds funding to hospitals. But in truth, hospitals are independent facilities with community boards and they make their decisions on what they will do with their funding. Does anyone else want to add anything to that?
Dr Watt: What we can do is we can cajole. We do a lot of that. We take a lot of carrots around in our community. We make people sit in the same room and we have joint action and we do not let them get away with planning without getting that out into the open early in the game so that it is not a fait accompli when it comes to council. It also, as I indicated, has become the process that new programs come to council for public debate. Once it is out in the community, we use community pressure to make them look at this again and talk about where they are going to provide the services.
Mrs Nagawker: Just to add to that, besides which, if it is a program that we have determined that we want for that community and that we do not want to lose the opportunity of getting it, then we have to negotiate with them and say, "We can't afford to lose this program to this community, so settle down and get on with organizing negotiating."
Mr McGuinty: Given that you have limited funding, I gather at times you have to make decisions whether you are going to give priority to equipment or to human resources. I met with a group of cancer patients recently and they told me that what they would like to see is more basic care, such as being turned in their beds, more bed baths, for instance, rather than some sophisticated piece of equipment. What criteria do you use in determining where you are going to fund in terms of equipment or care, human contact?
Mrs Nagawker: The new funding proposals we see are program related and so they would have a package of funding within them that would include operating human resources, supplies and equipment. The programs we see now are really more packaged than to say, "If we buy this piece of equipment, we can't fund the human resources." I do not know if I am being clear about that.
On the other hand, if you look at funding where it is the hospital basic care that is being given, those are not the issues that would be brought to us. That is an internal issue for that agency to deal with. We would have to turn it back to them. If we are advised of a particular issue within an agency, we turn it back to it and ask either for clarification or for correction if that is the issue. Most of the funding proposals now come as a package with all of the parts in it.
Dr Watt: It should also be clear that we have nothing to do with hospital global budgets and the funding of existing programs. We see new program proposals, not existing programs. That is a different issue.
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Mr Frankford: Could you say something about the relationship with the health unit or would your area cover more than one health unit?
Dr Watt: We deal with one, Hamilton-Wentworth, in our area. We are responsible for taking a look at its annual budget, the proposal for its budget. We have an ongoing, pretty close relationship with the Ministry of Health and with the planning staff in that area. We see their programs and their budget on an annual basis and frequently more often if there is a public health issue that we are working on. We seek the advice of our MOH on a very regular basis.
In the appointment of the MOH, the executive director of the district health council was part of that search committee and we often use interlocking search committees at senior levels, both within health science and other areas to give the DHC some influence and involvement in other areas. We are involved extensively with that. We use some of their information for planning as well as using health priorities analysis unit which is housed there, but is a university research agency. We use all of those resources on a regular basis.
Mr Frankford: You said you approve their budget.
Dr Watt: We were asked for advice on their budget. We do not approve their budget because it goes to the region.
Mrs Nagawker: They present their full budget to the full council. It is a fairly extensive review with questions as to what programs are in their mandatory group of programs and which are their priority within that group, and we give our view on those.
Dr Watt: These are the enhancements to it. District health councils are charged with new or changing patterns of health care, not ongoing baseline health care systems, so we would look at enhanced programs under local planning authority and quite in detail. It goes to a subcommittee, it is torn apart, it is argued and it does that before it goes to regional government.
Mr Frankford: Do you get any tensions there? Are there disagreements about what the health unit thinks should be done and what --
Mrs Nagawker: I can give you an example. The francophone member of council indicated they thought that the strength of the public health nurse intervention in a French-language immersion school was not what it should have been. So the presenters were sent back to fill in that material for that person and for council. They came back with a different proposal as to what they would do to try and obtain public health nurses who are francophone, French-speaking, etc. There can be tensions and there can be some things that we want to see either highlighted or developed in greater scope.
Dr Watt: We may also ask for them to do future planning. For example, as the result of our study on the disabled, we have gone back and said, "When you're looking at your new initiatives for next year, we want you to pay some attention to these things." If they do not pay the kind of attention we want them to pay to it, then we can follow up when we see their plan and ask for some accountability on that.
Mr Frankford: Briefly, what about your ability to affect medical practice in the community, what doctors are providing out of their own offices?
Mrs Nagawker: The medical profession as you know is a self-regulating profession and it has its own group of standards, if you will, that they must practice by. I am not sure that anyone other than their own profession at the moment has influence on what they actually do, other than the medical-legal issues involved. As far as their interface with the agencies and with the health of the community is concerned, it is a negotiation issue. If they wish to do something within the community that is different than normally, they would bring that to health council or put it through one of the agencies through which they function or practice. They are private entrepreneurs in their offices.
Mr Frankford: They are working in a public system. Would one not think that perhaps they are the greatest resource or one of the major resources, let's say, of information about disease in the community?
Dr Watt: No, they are only a source of information about people with diseases who come into their offices, and that is not necessarily a reflection of some of the major problems in the community.
Mr Frankford: Although if they have registered populations like the significant number of health service organizations you have in Hamilton.
Mrs Nagawker: Yes, that is not the individual practitioner out in the community in his private office. I suppose the only way in which they have been more recently influenced will be through the government negotiations with the Ontario Medical Association around the financing of physicians' services in the province. That will have a big influence on what they do, I suspect.
Dr Watt: Although the information systems are getting better, they are still inadequate to be able to track exactly from utilization what is going on. Utilization is one issue; disease is quite another. In HSOs they are not necessarily geographically bound. I am involved with a research unit with an HSO that is located outside Hamilton-Wentworth and almost 40% of the patients in that HSO live in Hamilton-Wentworth. They, however, work outside of Hamilton-Wentworth and belong to an HSO that is closer to work. It may tell you more about that. The ministry also is developing some pretty good kinds of information systems, but they are not yet useful to us as a local planning authority. We have some hope they may become useful to us.
Mr Grandmaître: Your role is an advisory one to the Minister or the Ministry of Health, responsible for long-term planning. What has been your involvement or your participation in the Social Assistance Review Committee report?
Mrs Nagawker: I am sorry; in which report?
Mr Grandmaître: The Thomson report or the SARC report; long-term care. What has been your involvement or your participation? The Social Assistance Review Committee.
Mrs Nagawker: I understand what you are saying now relating to that report. It was from social services, was it not? The council did review the report and passed on its comments, but that is all. It was limited just to a very quick review and comments submitted.
Mr Grandmaître: In other words, you did not participate in the long-term --
Mrs Nagawker: No.
Dr Watt: The response to the consultation went through our local Social Planning and Research Council of Hamilton and District, and we participated in that we responded to them initially and got our input in that way.
Mr Grandmaître: Since 1989, the then minister extended the role or the responsibility of the DHCs across the province. What have been the differences since 1989? What have you seen, what results or what accomplishments? What has it done? Are there any improvements since 1989 as far as advising and your communications with the Minister or the Ministry of Health are concerned? Has it improved? Do you think you really have more power, or it is only on paper?
Mrs Nagawker: I do not think its intention is to give more power. Its intention was to enhance the role of the district health council in four specific ways. In most of those locations, district health councils have been spending the last year, approximately, trying to determine exactly what their role and responsibilities would be within the enhanced roles as described by the ministry. Probably within the province the most significant area would be the partnership issue between public, consumers, interest groups; certainly enhanced collaboration with the Ministry of Community and Social Services, although DHC in Hamilton-Wentworth has had a fairly long history of collaboration with Comsoc in nearly every area.
Our subcommittees have membership from Comsoc on them, and mostly community agencies, so within our particular agency we have seen some progressive change. I think most of it for the province, though, will be in that collaborative relationship. Power is not the issue as yet. Any other comments?
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Dr Watt: In some ways the enhanced role has validated what Hamilton-Wentworth had been doing for a long time. We were able to go far more public in that collaboration, but we have been involved with it from the beginning. It was one of the things that I am sure made us a thorn in the side of many of the MOH staff. But also we thought we were quite progressive in the way we were heading, and certainly needed, in our community.
Mr Grandmaître: Some councils feel they are being ignored by the ministry or the minister. District councils are supposed to advise the ministry as to the priority and special needs for your area. I should ask you very plainly, how many times have your recommendations been turned down by the Ministry of Health?
Mrs Nagawker: Our role is to advise. Nowhere is it written that the Ministry of Health has --
Mr Grandmaître: But you do have a list of priorities as far as programs are concerned?
Mrs Nagawker: Yes, we do. I would re-emphasize and reinforce that the role is to advise. We have not been turned down very often, but what would happen is that there is not any response at all.
Mr Grandmaître: No response?
Mrs Nagawker: We do not know whether it is a turndown, a delay or whether it just has not gotten anywhere. In the last four years of my history alone with DHC, I have four letters of appointment from four different ministers of Health. I think it is pretty hard for a new Minister of Health to be able to catch up with and make some decisions around a lot of these programs. They are very complex, especially for a complex situation such as ours.
I would not suggest there is a deliberate delay or a deliberate ignoring of the needs. I just think that, within the context of changing government and changes in the bureaucracy, it is probably very difficult to do anything else. That is not making excuses for them, because I do not think there is an excuse for not having a return of information requested or for information sent as advice. But we are living in the real world and that is the reality of the situation. I do not think it is so much that we were turned down; it is just the delay in responding: A new minister, a new government, the Ministry of Health has reshuffled its bureaucratic structure, there are new people responding to new places and faces and they all have to be able to get familiar with all the issues within that region.
I think that is a problem, but I do not think it is the other way around. Their mandate is not to respond to us, although we would like it that way, obviously. The community would like it. The local community wants it that way. They see it as taxpayers. They want the response and we say the tension arises in not having that response as timely as the request that has come in.
Dr Watt: We have also decided that we are going to proceed to plan, whether or not Queen's Park requests that. Because they are waiting for something, that does not mean we have to. We set priorities in our community. That is what we are charged with doing.
Mr Grandmaître: That is right.
Dr Watt: During some of the turmoil, it does not mean we have to have the turmoil in our organization. Again, I reiterate we expect that to happen. We are not dependent on that. It does not have to filter down the system. I think the ministry officials would tell you that Hamilton-Wentworth never allows itself to be ignored. We may not like the answer, but we are never ignored by the ministry.
Mr Grandmaître: And your relationship with your three hospitals and regional council has been good?
Mrs Nagawker: Excellent, yes, truly. That does not mean it has always been quiescent. We have some reasonably fire-breathing discussions, but we come out with an agreeable negotiation and that is the important thing. It is not that we all talk the same or say the same or believe the same, but we must agree on the most effective use of resources and that is the important thing.
The other thing is that we want to be a little more proactive so we are ready and can anticipate some of the things that may come from the ministry. That is always a better position to be in. We have our ducks in a row and we are ready for the question when it comes in. That is another one of our objectives, to try to do that. Sometimes it is a little difficult and we are fast-pedalling to keep up.
Dr Watt: In a health science centre it is easier to do that because of the resources of the university. The university is a leading-edge university in a number of areas. We use all those areas so that we can anticipate. We get the same reports the ministry gets too and we read the journal articles. It really is very helpful.
Mrs MacKinnon: Thank you very much for your presentation. I have one short question first. I have never heard of a central bed registry. Is this pretty well across the board or is it just a case perhaps of your doing it and not somebody else?
Mrs Nagawker: No. We have had it for a number of years now. In Hamilton-Wentworth we had the first central bed registry. The Toronto region now probably has one after the major kerfuffle around a lady from Midland who was transported down to somewhere in this area that did not have a central bed registry and nobody knew where to place her. The bed registry allows us to know where the open beds are, in what circumstances --
Mrs MacKinnon: So is that more or less provincial?
Mrs Nagawker: It is going to be adopted provincially, but it started locally in Hamilton-Wentworth.
Mrs MacKinnon: Thanks. When I heard you say it I had not heard of it before. That is why I asked about it.
I heard you refer to seeing the budget for the health unit in Hamilton-Wentworth. This is quite a bone of contention in my riding because health units are volunteers.
Mrs Nagawker: No.
Mrs MacKinnon: Excuse me; DHCs are volunteers; health units are hired people. How do you feel about the election of people to health councils as opposed to the appointment procedure that is going on now, being elected just like I was?
Mrs Nagawker: The council, along with regional government and the faculty, promoted a study we did on behalf of geriatrics and co-ordination of services for the elderly, actually, which described a mechanism of a planning body that would be in place which would have perhaps one third consumers, one third providers and one third elected officials. We have made a foray, if you will, into that sort of discussion about the what-ifs of that sort of package. I must tell you that a good portion of our council would very seriously look at elected officials in providing a council. That in their eyes would be more accountable to the public because it was elected. But not all of it would be elected. It would have to be a balanced mix of people within that planning body. But we have only had very, very preliminary discussions and what-ifs about it. Whether it ever gets anywhere I do not know.
Dr Watt: The flip side of the argument being that if all of the DHC were elected, then health planning would become purely a political issue. There needs to be the expertise brought by volunteers, both the providers and consumer volunteers. This is an ongoing budget item. We do not believe necessarily that it should be just who can garner the votes for it. We really are concerned about what the US has called the orphan diseases, the less-than-popular disease-of-the-month club. There is real pressure put on from disease-of-the-month clubs to get whatever somebody wants. Interest groups provide a lot of political pressure, and if one is elected one cannot help but respond to political pressure. That is the nature of the game.
The nice part of being appointed but part of the general public is that I as a consumer can say exactly what I think. I am accountable because it is publicly reported, but it is not dependent on being elected the next time. I can say things like, "Is this a disease of the month?" and, "Whose vested interests are really being served here, guys?" and ask some of those tough planning questions that have to be asked in health care. A number of us also share the perception Nancy has told you about that some kind of balance is needed, that either/or probably does not serve the best interests of health planning and that some kind of different balance may work a bit better.
We have regional government representatives on our district health council. They have an important input to it and are publicly accountable, and we hold our MPPs pretty publicly accountable in Hamilton-Wentworth too.
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Mrs Nagawker: Just to sum that up, we see ourselves really as an honest broker and we can be at arm's length from the ministry, from government, from the providers and from vested interests in the consumer groups or whatever, so I think that is an important aspect as well.
Mrs MacKinnon: I just have one more question. How do you ensure that there is a cross-section of your community represented on the councils? I am sure you get people who come forward and volunteer their services. I have a very, very rural community. Unfortunately we do not have very much, if any, rural representation on that district health council, and that disturbs me. I also live in an area where there is a lot of industry. What about the people who carry the brown lunch bags and the lunch buckets? How do you get representation from them? Let's face it, I will bet a lot of my people could not go to an afternoon meeting from 3 o'clock to 5. Only bankers could do that.
Dr Watt: No, you have to live in a shift community.
Mrs MacKinnon: Yes, we have shifts too but I think some of them would get upset getting there. With 12-hour shifts you cannot.
Mrs Nagawker: That is one of the unique, I guess, advantages and disadvantages. You have both sides of the sword. Each community has its own characteristics. In ours, part of our membership is aided and abetted by the fact that there are shifts. They can get to some daytime meetings. If not, we have just done a survey again -- we do not have the results of it -- asking what is the best time of day, day of the month, week or whatever to have the meetings, to have committee meetings and task force meetings. So surveying to try to get consensus around time and even location is one thing.
The other thing is that we do put a public call out in the newspaper. We advertise for people who are interested. When vacancies come up, we look at a long list of people from whom we could select who would fill certain sectors -- a geographic location in the community, an interest in the community or labour or consumer groups -- and so we try to deliberately balance where we can.
We have been very fortunate so far and have a large selection of people. We have a lot of people interested from the variety of communities we have. We do not seem to be short of people wanting to have input to the health council.
Mrs MacKinnon: Your method seems to be word-of-mouth plus the media.
Mrs Nagawker: Yes. We advertise in the local papers.
Dr Watt: And we actively seek out people in consumer groups, for example, so if we are going to deal with the disabled we make sure our consumer groups and the disabled are there. There are 290 volunteers currently active with the district health council, so we are doing something right. Committees meet at night too.
Interjection.
Dr Watt: The question asked by the gentleman was, "What time does council meet?" Most of our committees would meet later in the day or in the evening. Some meet during the day: joint action, for example. That is possible because those are institutional executives meeting. We try to balance it off. Committees usually meet once a month. Task forces sometimes will meet in a flurry of activity and finish their task and go on, so they could meet in concentrated ways.
Mr Villeneuve: Ladies, thank you very much for being here from the Hamilton-Wentworth District Health Council. Do you hire private professional consultants to do some of the research work you need?
Mrs Nagawker: Yes. From time to time on special studies we have to.
Mr Villeneuve: I come from the area covered by the District Health Council of Eastern Ontario. There is frustration there in trying to get people involved and keeping their interest. As a health council that is working quite well, you must have some frustrations from time to time, and we are trying to address the major obstacles and problems you have. Could you outline what your major frustrations are as you operate as a district health council?
Mrs Nagawker: In general? We have one major frustration at the moment, and that is getting our appointments for council confirmed. That is number one, and that is a major issue because we only have 19 members, and when you are short of members -- and we are short three people at the moment -- then it makes a lot of work for those who are still there.
Mr Villeneuve: What has been your time lapse for appointment confirmation?
Mrs Nagawker: Six months. There are certain reasons for that, but that is one major frustration. The second frustration probably is perhaps the lack of response to task force reports that have been sent in.
Mr Villeneuve: From the Ministry of Health?
Mrs Nagawker: Yes.
Mr Villeneuve: You do not have too many problems with the people you work with, the hospitals and McMaster or whatever?
Mrs Nagawker: No, actually. No, the local scene does not provide frustrations for us in terms of relationships and communication and collaboration. It provides frustration because we are suffering the same way as anyone else with the squeezing down of funding and changing bases and lots of things like that, but everybody in the province is suffering from that.
Mr Villeneuve: Your budget as a district health council has always been sufficient. You have outlined the staff that you have, plus the consultant work you farm out. Have you run into budgetary problems?
Mrs Nagawker: We have always come in on budget. That is not to say we have always had all the money we would like to do with everything. No one does, and so you live in a certain reality with that.
The major frustration we have had up to about a year ago was the fact that we did not have office automation and the ability to collect data and have timely reports, as we wanted to produce them, and we are still working through that, because today information is absolutely important to be able to run, data collection. The last person we just hired, only just this year, was a planner with specific expertise towards data collection. That has been a major frustration, the information system within the office, and I think probably a major frustration across the province is the information systems within DHCs, because they are not very mature and not very sophisticated, strangely enough, given the sophistication and the level of health care in the province.
Mr Villeneuve: Would the Ministry of Health not be in a position to assist you there in sharing possibly the data it has, or does it come from you?
Mrs Nagawker: We get data shared from the ministry, and it has huge banks of resource information, but it is not specific sometimes to the small area you are involved with.
Long-term care reform is another area which is providing us with a fair amount of frustration at the moment, because it is on again with the first government and off again with the next government and on again with the next. So while your services within your community sit as inadequate, you are waiting and waiting and waiting for catch-up in terms of information and decision-making in long-term care. That is another major frustration.
If you gave me enough time, I could probably -- I do not want to indicate to you that it is all frustration; it is not. It is an interesting experience and I would not want to miss it, and as many complaints as you might have about it, I think it is still a super system.
Mr Villeneuve: I noticed in your goals that communication was mentioned once or twice, and we certainly appreciate what is going on, but we wanted kind of first hand what are your imminent problems as you have seen them and as you foresee them.
Mr Bradley: What do you do with hospitals that attempt to do an end run around the health council?
Mrs Nagawker: We have not had too many end runs. We very seldom get an end run any more.
Mr Bradley: What has been the success of people with end runs?
Mrs Nagawker: Not successful.
Mr Bradley: That is probably why you would not have them, and that makes sense.
Mrs Nagawker: I must say, though, that the ministry has been really excellent in helping us out there too. They actually do make them turn around and use the facilities, so it has been with ministry support that that has occurred, but it also has occurred because of internal community pressure. Either we are going to use the health council as a vehicle for that purpose and we use it to our advantage, or we are not, and you make a decision in your community that that is what you are going to do and you stick by it.
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Dr Watt: We have also stopped the minister from making end runs around the DHC.
Mrs Nagawker: Yes, true.
Dr Watt: It works both ways. Every once in a while a minister will decide to announce, without any consultation, that something is going to happen in our region, and in the absence of consultation, we have certainly publicly stopped that kind of end run as well. So it is a two-way street.
Mrs Nagawker: I do not know about stopping it.
Dr Watt: Well, we have slowed it down considerably.
Mrs Nagawker: A minister can decide to do whatever he wants.
Dr Watt: The minister can do whatever the minister wishes. We have slowed it down.
Mrs Nagawker: I guess each does it at their own peril, I would gather, us included.
Dr Watt: Yes, us included.
Mr Bradley: You have a number -- a number, of course, could be any number -- of CAT scanners in your jurisdiction. My understanding is that the ministry has changed its policy now -- I could be wrong -- from dealing with district health councils to dealing with individual hospitals. It used to be that the hospitals went to you people and said, "Here is our plan or proposal why we think we should have a CAT scanner located at our hospital." It is my understanding that now there is a new policy out that says it is everybody for herself getting the CAT scanners and individual hospitals will now make their bid to the Ministry of Health. Is that your understanding, and if it is your understanding, will that not just be a three-ring circus?
Mrs Nagawker: As we progress through history, we have seen new technology come along, and when a new technology comes in, that is the time when we need to look very hard and long at the utilization of it, the costs of it, where it should be, where it should not be.
CAT scanning has now become very commonplace. In fact, probably in a few short years we will not have what you normally know as the X-rays. It is called diagnostic imaging now, it is not even an X-ray department, so we are moving from the traditional X-ray. We have moved through CAT scanning where CAT scanning now has become a standard.
As each one of these new technologies becomes a standard, then there is no purpose in it coming back to health councils. Correct me if I am wrong, but this would be my feeling about it.
The next version and the next generation is the magnetic resonance imager. The MRI did come through council, and that is appropriate, but it might be five years down the road that the vision of the future and then MRIs might become commonplace in terms of diagnostic imaging. So I think my answer to that is, as each new technology comes in it is appropriate for it to be very well examined and scrutinized. Once it becomes a standard, there is no longer a need for that level of scrutiny.
Mr Bradley: I do not want to put words in your mouth; you will correct me, again, if I am doing so. But the district health council then, I hear you saying, really should not be determining which hospital or if any hospital is going to get a CAT scanner.
Mrs Nagawker: No, and I would not be specific to the CAT scanner, because if it is a new issue in that community, then it is a new issue in that community and it should come to that district health council. But once it has entered into that community and once that technology becomes the standard, then I do not see it coming back to us.
Mr McLean: But does the council not determine where that CAT scanner goes, make the recommendation?
Mrs Nagawker: As far as I am concerned, the first time around, but I do not know that we necessarily have to thereafter. Mr McEwen might have some different information than I have on that.
Mr Bradley: It is unfair in a way, because I am talking about a different health council, but I am trying to draw on your experience. I represent an area that is adjacent to your area, the Niagara region, which has one CAT scan machine now. While the dogs and cats are getting it in York, we have one CAT scan machine with a five-month backup in the Niagara region unless we can sneak into Hamilton and get one.
The issue there is that the district health council made its recommendation and said, "Yes, this is the highest priority, and yes, we think it should go in a particular place," and now the Ministry of Health apparently says: "That's all off now, where it was going and who's got priority. We're now going to hear from individual hospitals." I am just wondering whether it is better to hear from the health council or from individual hospitals.
Mrs Nagawker: My answer is that if you are still at the level in your community of requiring district health council input around the negotiations of where it should go, then that is appropriate, because it is introduction in new territory or introduction of a new piece of equipment. But I do not think it would be reasonable for us in Hamilton to look at CAT scans. We are into the next generation of diagnostic imaging, which is MRI.
Mr Bradley: We will catch up to you in a few years, I am sure, to where you are now.
Mrs Nagawker: Yes. If I were in your region and facing that, I would probably say, "No, I think that's probably still an issue, for this time round, to come to health council if it cannot be settled."
Mr Bradley: The other alternative now is that while people are over at Tops shopping, they are over also in Buffalo and Niagara Falls shopping for their CAT scan or their magnetic imaging machine, one of the two, at a cost to Ontario and a cost to themselves, and inconvenience to everybody else, but that is what you do if you have money or wherewithal. You simply head to Buffalo to get what you need in terms of medical services, which some people think may be good planning. I question that.
Mrs Nagawker: If I were in that district, I would probably want that material to come to health council for the opportunity to make some arm's-length decisions.
Mr Bradley: Actually, I share that with you. My view is that the district health council can play that impartial role. As a local MPP, and before as a member of the cabinet, even though people would come to me from individual institutions and individual areas to try to get something, my view always was that it should go through the district health council. That takes the onus off making -- first of all, it takes away from a major political decision with a capital P. Second, there is always a danger in evaluating people on their ability to deliver machines for services because that can also backfire when the services are not delivered as well.
I really like the concept of the district health council from that point of view. I consider them to be objective and to be able to say everything should not go to one hospital. There may be a very good reason. The district health council always comes up with very good medical and other reasons, non-political reasons, why it should go in a specific hospital.
That really for the politicians -- and it is not your job to take them off the hook -- does take them off the hook in the best sense of the word. They do not have to make a political decision because the appropriate medical decision has been made after the input from everybody on the district health council.
Dr Watt: Again, this is one of the differences when you are in a health science centre. Our five facilities are all teaching centres, so you would not be able to keep, for example, your accreditation as a teaching centre these days in the absence of appropriate imaging equipment. Our district health council has to be aware of those kinds of rules and regulations as well in advising. We may be into supporting a CAT scan for a fifth facility, and everybody in Niagara looks at us and says, "You guys are overfacilitied for X, Y and Z," but the decision becomes that we have to maintain teaching hospital standards in all five hospitals.
The question may be how we liaise with Niagara and form a better regional plan for the use of these facilities. That is the kind of central-west planning we have been engaged in as the major teaching centre.
Mr McLean: Do you have a regional hospital, one designated regional hospital?
Dr Watt: No, it is done by program, it is rationalized out by program. So we have a trauma unit, a neonatal unit -- you name it, we have it.
Mr McLean: The five hospitals that you mentioned, would they all have a dialysis machine?
Dr Watt: No, absolutely not. St Joseph's, which is one of our teaching hospitals, is the regional dialysis centre.
Ms Dayler: You have a list, which was handed out to you by Doug, that has all the regional programs on it.
Mr McLean: Who determined which hospital got that machine? Is that in there too?
Mrs Nagawker: That was determined with the district health council input, getting those hospitals together to ask: "What are your priorities? Where do you see yourself functioning? What is your role and responsibilities within this community?" That was carved out some time ago.
Mr McLean: My final question is, do you have hospitals in your council area that are looking for additions or new facilities?
Mrs Nagawker: Yes.
Mr McLean: Do you have a global amount that the ministry has recommended that you could put in, so much for each one? Have you made a recommendation to the ministry?
Mrs Nagawker: Yes, on long-term care, replacement of existing beds.
Mr McLean: How many millions is district health council recommending, how many million dollars to be spent in that region?
Mrs Nagawker: Budgets for redevelopment probably are in the range of $40 million to $50 million in two facilities.
Mr McLean: That is just what you are recommending be done, and no approvals yet?
Mrs Nagawker: No, but that is redevelopment of old facilities -- pre-war.
The Chair: Thanks very much. We appreciate your appearing here today. It has been helpful and informative. We regret that our scheduling may have upset a few schedules within the district health council, I understand, but we have to live with the time allocated to us. That is why this particular week of the month was decided upon. Again, on behalf of the committee, I thank you for appearing here today. We very much appreciate your testimony.
Dr Watt: Good luck with your work. Keep in touch.
The Chair: We will break for lunch and reconvene at 2 o'clock.
The committee recessed at 1201.
AFTERNOON SITTING
The committee resumed at 1409.
HALIBURTON, KAWARTHA AND PINE RIDGE DISTRICT HEALTH COUNCIL
The Chair: We will come to order. We already have the witnesses from the Haliburton, Kawartha and Pine Ridge District Health Council at the front table. Perhaps for the purposes of Hansard you could introduce yourselves and your roles within the health council, please.
Mrs Galloway: I am Carol Galloway and I am a member of the executive board of the health council.
Dr Swales: I am David Swales. I am chairperson of the council.
Mr Elliott: I am Marshall Elliott, the executive director of the district health council.
The Chair: Dr Swales, do you have an opening statement you would like to make? Please proceed.
Dr Swales: On behalf of the Haliburton, Kawartha and Pine Ridge District Health Council I welcome the opportunity to provide you with an overview of our council and our activities. We welcome any questions or concerns you might express to us. You have already met Carol Galloway, who is also a member of the executive committee.
You were all given a detailed package on this district health council previously. This included a functional review of the health council which was done recently by the Price Waterhouse company. This was an in-depth analysis of our entire operation. I believe that documentation fairly reflects our council. However, I would like to elaborate on additional areas of our council and other activities, which I hope will give you greater depth and feeling as to the issues we face.
Initially I would to just say who we are and what we do. Our council is made up of 16 residents who bring a balanced perspective to planning issues in our district. Many of these issues are fed to the council from the 150 members of our various committees. We are all non-paid volunteers who are concerned about health issues within our community. The council and committee members represent an occupational and geographic diversity, particularly since our health council is the largest geographic unit in southern Ontario for health councils. We include the four counties plus the city of Peterborough. Our council thus is not provider-driven; it is a balanced perspective from consumers and providers.
The council involves at-risk groups throughout its planning process and integrates their views into our proposals as well as soliciting feedback on ministry initiatives. This involves meetings in legion halls and church basements and the like to provide a non-intimidating environment for these people. We have found that it is not appropriate for us to summon consumers to our council chambers to ask their advice; we would rather go out and meet with them on their own territory. We find we get better participation and probably a more accurate reflection of their concerns.
The council acts as an honest broker and a bridge builder within our district. This involves the providers, consumers and the municipal government groups. I will elaborate on that a little later. The council fosters co-ownership of government policy and direction by working out differences of opinion and finding common ground at the local level. If the people do not understand what is happening there is little understanding, acceptance and teamwork. The council not only formulates advice to the minister but initiates local implementation of ministry initiatives so that the reports do not sit on the shelves to be forgotten.
A cardinal rule in our council is impartiality. This involves both professional, geographic and other conflicts. These are just not acceptable. This is particularly critical in our area, where we have such a geographic diversity.
The council is not a buffer for the government. I can assure you that neither I nor the other 150 volunteers would tolerate that role. We are community advocates with a commitment to improve the state of health of the citizens in our community. Likewise as chairman I can assure you that before I sign off advice to the minister from our council I want to know that the process has been fair, honest, open and truly reflects the community as a whole.
Probably the single most significant characteristic of our council is its ability to set in motion dozens and dozens of volunteers to tackle the tough issues, because they simply do care.
Last, from the standpoint of fiscal responsibility, we feel we are truly responsible in that area. In the last figures we have available for Ministry of Health spending they spent $210 million in our four counties for our slightly over 250,000 in population. Our council's budget was roughly $250,000 at that time, so approximately $1 per resident of the health budget is spent in planning and co-ordinating a budget of $200 million-plus. When you realize the range of issues and activities that are pursued by the 150 volunteers, giving their time freely, it is a very effective and productive use of our funds to maintain a secretary and a small office. What other large central company or corporation would spend one tenth of 1% on planning and co-ordination, particularly when you consider the pluralism and complexity of health and human services in Ontario?
In today's package you received there are four handouts, one of which is a tabloid which was drawn up following our directional plan for Haliburton county. This was a primary care study dealing with the health, social and housing needs of the county. This would be a typical rural area of Ontario with a population of just over 15,000 people in the entire county. This tabloid was distributed with the local newspapers to allow the residents of Haliburton to know what our findings were. On the front page you will see there are notices of five open houses or public meetings which were held in April so that the council could get feedback on the report. Not only did we want input as we started the planning process; we were committed to telling the people the results in an ongoing effort to create consensus.
Additionally, on the last page you can see there is a tear-off for comments and views to be mailed to the council if individuals could not make any of the open houses. I should add that this was the second round of open houses. During the development of this report we had numerous focus groups, open houses, public meetings and the submission of briefs by various groups, both providers and consumers. This was encouraged right from the very start of the review in 1989, so this was very much a bottom-up process, not a top-down process.
I draw this example to your attention because it reflects some of the principles I elaborated on earlier, including our district health council's history of collaboration with others to avoid the duplication of costs and to promote a co-ordinated system. This was not only for the Ministry of Health but also involved the Ministry of Community and Social Services, so this was a joint venture between the two ministries, which have not been noted in the past for their co-operative efforts.
The second handout, in the grey, is called Chautauqua, which is the native term for a meeting-place. This is the December 1990 issue of a newsletter that the council distributes within our region that touches on some important social issues: family violence, environmental concerns and the need for all of us to take a greater role in our own health and wellbeing. As a follow-up of this initiative we are co-sponsoring a community seminar on October 4, 1991 in Peterborough on family violence. This has had an important impact in drawing together various players in the community who have an interest in this area to help collaborate on finding solutions to the very significant problems that exist in this area.
Third, we have a short status report on our multi-year planning dealing with the Graham report on mental health. This is it here. This is an example of the council's openness not just with the steering committee members but with the consumers of mental health services to secure and maintain their involvement in this very important planning process. Over 200 posters describing this study and asking for consumer input have been distributed to locations throughout our district to ensure community input. In fact this is working; we are getting feedback from people who are seeing these notices, in physicians' offices particularly.
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The fourth example, in the beige paper, is an initiative for agencies, organizations and individuals to become involved in a study on primary care. The significance here is our attempt to gather initial ideas, issues and response at the very start of this planning process to review the nature of primary health care needs in our district. Good planning entails involving stakeholders and consumers at the design stage, not just asking them to comment on the findings of the report once it has been completed.
This is a very important distinction: The council wants the input and ideas as we begin problem-solving. The council, as I mentioned before, is not a top-down organization; it is really a reflection of what the citizens of our community wish. It is process-oriented and we encourage constructive criticism at any stage of our planning process and we are flexible to the changing conditions.
In the more traditional areas of health care delivery we have vigorously pursued the rationalization of institutional services, particularly in Peterborough. At present we are just beginning a rationalization review of the critical care needs of the two hospitals in Peterborough. The council is concerned that the future services be as effective and efficient as possible, without any duplication of beds or resources.
This study in Peterborough follows on a very positive and productive history of rationalization between our two city hospitals. In fact, we are, I believe, much further ahead than most two-hospital communities in Ontario in this endeavour. This is an area of continuing concern, but we are certainly making a lot of progress.
In a broader context, we are collaborating in the rationalization of emergency health services in setting up a regional trauma network for the region to improve the efficiency and cost-effectiveness of emergency health services in all of central east Ontario.
There are a number of other initiatives as we carry on, and I mentioned the rationalization of services in Peterborough between the two institutions. We are in the throes of trying to achieve the same results with the Coburg and Port Hope hospitals, which are situated 10 miles apart and have recently developed long-range strategic plans, both of which were done independently of one another. The health council felt this really was not acceptable, and they have now returned to the drawing board and are talking to one another to try to develop common areas where they can share resources. So we have had a very positive impact there. We are not as far ahead between those two hospitals as we are in Peterborough, but we are starting to make progress there.
Recently the Peterborough Civic Hospital, for budgetary reasons, opted to withdraw the diabetic day care clinic. There was no alternative resource for these people. There was a lot of concern expressed by the people with diabetes and to the Canadian Diabetes Association, so we have taken the initiative of getting both the hospital and public health, the Victorian Order of Nurses, and the diabetes association together to try to plan for an alternative approach to this particular problem. In this situation we are acting, as I have mentioned before, really as the broker in trying to bring disparate groups together to try to work out something which will be reasonable for our district and provide the service which is now ceasing to exist.
My two colleagues and I would be very happy to try to answer any questions you might have.
Mr B. Ward: You made a comment that you seemed to have excellent co-operation between the two hospitals. My feeling is that that is probably unique throughout the province. How did you achieve that, because the feeling I have is that hospital boards have a tendency to protect their own turf and are reluctant to share resources, or even to share ideas. Could you comment on that, please.
Dr Swales: It has not been an easy or a quick process, and you are quite right on the problems that exist. In this particular case, a lot of it in fact has been physician-driven. Physicians now have very much leaned on the two boards to allow a common medical staff to be formed between the two hospitals to allow co-ordination of planning on clinical services. The boards have gone along with this. I think they may have been reluctant initially, but there is a joint medical staff now and one common medical advisory committee between the two hospitals.
Preceding that, there have been initiatives by the health council on the rationalization of services, such as obstetrical services being confined to one hospital, paediatrics to one hospital, psychiatry to one hospital, orthopaedics to the other hospital, to try to achieve a balance to maintain the concept that both hospitals are still acute care hospitals -- one is not being designated a chronic care hospital; it will remain an acute care hospital, but specialize in specific areas where it will try to develop expertise.
I think the fact has been accepted by the hospitals that we were not creating a primary and a secondary hospital in the community, that both hospitals were still acute care, of equal importance, but dealing with different areas, and that has been accepted and it is working.
Mr B. Ward: I would like to congratulate you.
Dr Swales: We are pleased with that. It has been over a number of years that this process has been going on; it is not an easy process.
Mr McLean: Your association with the Oshawa General Hospital: At one time, was it not the best, and now, with the study they have asked you to participate in, I am wondering if there was a power play between the two councils to have the Oshawa hospital designated regional that would take in part of your area.
Dr Swales: This is a very sensitive issue, certainly within our four counties. You are right that part of it was a turf war. The inclusion of our four counties in the catchment area of the Oshawa General Hospital and its strategic plan really was done without consultation with our four counties. It was just assumed that this would be the situation. There is a lot of resistance to that in our four counties. I am putting it gently. Quite frankly, there are some services in Oshawa General which are stronger than they are in the Peterborough Civic Hospital, which would be our regional centre, but there are some services in Peterborough which are stronger than they are in Oshawa. It seemed ludicrous to us then to be referring patients to a centre we did not feel had as strong a service.
Mr McLean: Do you have a computerized axial tomography scanner in Peterborough?
Dr Swales: Yes, we do. In fact the volume that we do on our CAT scanner is about 50% greater than it is on the Oshawa scanner.
Mr McLean: Could you indicate to the committee what your major problem is with your council? Is it getting volunteers to participate, or what is the major concern that you have?
Dr Swales: It is not difficult getting volunteers now. With the new mandate, the profile of the health councils rose. This was a problem previously. We advertised annually for applicants for membership, and if I take the city of Peterborough, we would get one or two applicants a year. This past summer when we advertised, we got 16, so now we have the luxury of too many applicants in effect. For the city of Peterborough that is the case.
In Northumberland county we still have a shortage of applicants. We obviously have not done as good a job there as we should yet in raising the profile. Obtaining the volunteers has not been a particular problem for us.
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Mr McLean: The overall emphasis on health care, additional facilities, new facilities: Do you have a projection that is going to the ministry of so many million dollars for a new facility or additions to existing facilities within your recommendations you are making to the ministry? What figure would that be, roughly?
Dr Swales: Nothing has gone in recently, because the ministry has not asked. In fact they have indicated they do not wish to receive applications for new and expanded services, so we have not been sending that in.
Mr McLean: When did they indicate to you that they did not wish to receive any?
Dr Swales: That would be 1988-89. That is at least two years. We have not sent them in for two years. We still do the process locally so that we know what the hospitals feel they need.
Mr McLean: But I thought you were to advise them on what you felt should take place within your area of representation and recommend to them what you felt should be done. I am surprised to hear they have said they do not want any recommendations.
Dr Swales: It is a delicate point. Initially, the first year, we sent it anyway. Even though we were told they did not wish it, we sent it anyway. We did not the last year, so we have not for a year.
Mr McLean: I thought that was your function; not for them to dictate that.
Dr Swales: Yes. I do not know if any of my colleagues want to elaborate on that.
Mrs Galloway: I really do not have anything else to add.
Mr Elliott: As my chairman did say, it is a delicate point. Also as Dave said, we do prepare a list. We feel in a sense that we have both the brokerage role and the responsibility within our district to ensure that we know, as a district health council, what either the present needs or the emerging needs are of the eight hospitals in our district. It should be understood that the hospitals are in agreement that we prepare a list, but we do not forward it to the ministry. We have the list and the hospitals feel very comfortable with the council maintaining a list, on a year-to-year basis, of new and expanded hospital-based programs.
Mr McLean: I really have a problem with this, because some time ago our minister went around this province indicating that this hospital was going to get funding, $30 million, and that this one was going to get $50 million. Today, nothing has happened to all those commitments, and here they are telling you they do not want you to give them any input.
Dr Swales: Our existing submissions still have not been funded. Our top priorities in the various hospitals still are outstanding. They have not changed. There has been no change in our sequence. If we were to send in our list today, it would be the same list that went in in 1989.
Mr Frankford: Am I right that there is a Women's Health Care Centre in Peterborough?
Dr Swales: Yes, that is correct.
Mr Frankford: Can you give us some description of the role of the district health council in its development and planning?
Dr Swales: The health council had probably very little role initially in that. That was a ministry initiative and we really were not asked to comment on the pros and cons of the centre. That really bypassed the health council process.
Mr Frankford: Is its existence part of your planning when you are planning for the whole community and women's needs?
Dr Swales: Yes, it would be. Certainly, we have I think a good rapport with the women's health centre. The director is on a number of our committees. She is actually the chairman of our current primary care study.
Mr Frankford: Can you give us some idea of how the existence of the centre is impacting on your planning?
Mr Elliott: To a degree, prior to the existence of the centre, there was not a resource in our district or in the immediate community of Peterborough which would have the knowledge, the base, the resource. There were other groups we could liaise with. Historically, it would be groups like the Young Women's Christian Association, the rape crisis one, or Trent University through one of its faculties.
Now we have this group, which is funded. They have resources and they have capabilities to assist the council in our planning, to bring forth certain issues, not necessarily women's issues, but to bring forth some advocacy points of view: anti-poverty, antiviolence. In a sense, I guess our district health council probably sees the women's health centre, besides the more social-medical activities it is involved in, as a principal resource on issues of poverty, anti-poverty, to a degree literacy, and also certainly violence.
Mr Frankford: Is it providing facilities for pregnancy, and also for termination of pregnancy?
Mr Elliott: Are we speaking from a planning function, sir?
Mr Frankford: I am just asking what it is doing.
Dr Swales: It is off-site. It is down on the main street of Peterborough. It initially started in the civic hospital, but it has been moved off-site. It is probably more appropriate to be in a downtown location for walk-in clients.
Mr McGuinty: Dr Swales, we heard from another group this morning, the Hamilton-Wentworth District Health Council. As a matter of interest I see that its expenses for 1989-90 were about $277,000. That is connected with service for a population base of 424,000. I am just wondering how I can relate that to your population base of 250,000. Your expenses were pretty well on a par.
Mr Elliott: For that year you just quoted, the most recent year, there were probably two or three things in our district that would distinctly put us apart from the Hamilton-Wentworth experience. We went through a major office expansion, so in that budget there is the capital dollars, the furnishing and the enhanced rent. There is also an upgrade of computers, going from two older 286s to five, I believe, new 386s. I think that offsets what the difference would be on a per capita basis, because it occurred in that one year.
Mr McGuinty: Dr Swales, you indicated you have done some things recently to attract volunteers, to raise the profile of the health council in the community. Are there still only 10 board members at this stage?
Dr Swales: Yes, we have a number of applicants that have been in over a year, but we have not heard from the ministry whether they are being accepted or rejected.
Mr McGuinty: So you have been at 10 for almost a year now?
Dr Swales: Yes.
Mr McGuinty: By looking at the list here, at the notes we have been given as committee members, I do not see any municipal representatives. Do you have some applications in from municipal representatives?
Dr Swales: We had a meeting. Marshall and I sat with the wardens of the four counties and the representative of the mayor of Peterborough in March to discuss this. Our problem is that if we go by the 40%-40%-20% distribution, with 20% municipal representation, that would mean two or three municipal representatives. Because we have no regional government in our area, we have five distinct municipalities, with the four counties and the city of Peterborough all being distinct entities with no cost relationship, and we have two health units. We had suggested that one representative from each health unit, the city representative on each health unit, would be an appropriate way to do this.
They were unhappy with that. They felt there would not be adequate feedback to their individual councils. They are pressing for five members, one for each of the municipal jurisdictions. We submitted a proposal to the ministry suggesting that if they wished to do that, then to create a reasonable balance, if they increased the total membership to 19, we would have 5, and then 7 providers and 7 consumers. It would not be quite the 40%-40%-20%, but it would not be too far off, and that would satisfy the municipal concerns. They were happy with that suggestion. That was submitted this spring to the ministry and we do not have a response yet to know whether that has been accepted or rejected.
Mr McGuinty: I am just wondering if that might make for inherent parochialism, the parochialism that is going to be inherent from having a representative from each of the various communities. Do you not see that as making it perhaps a bit more unworkable, rather than more workable?
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Dr Swales: This is a real concern. We have had elected officials on in the past. They have not been appointees of the municipalities. We have selected them. They have applied and we have selected them. Quite honestly, we probably have dragged our feet in this area for that very reason, that we have made it very clear to all members when they join that they are not representing a geographic district. I am the only physician on the council. I am not representing the physicians at all; I am there representing the district. That is made very clear, and if members do not wish to agree to that before appointment, then their names will not be submitted. No question, it would create a change in philosophy, and one we would not be particularly happy with.
Mr McGuinty: I was impressed with the fact that you take your hearings out on the road, into the various communities. Perhaps somewhat connected with that, one of the criticisms that has been levelled against health councils is that they are not accountable to the people they serve and are not elected to public office for a certain term. Has that criticism ever been levelled against you, and even if it has not, if it was, how would you respond?
Dr Swales: We have not had it directed to us locally, but certainly we are well aware that this has been a criticism on the provincial level. I think it touches on the same problem we just discussed. Our concern is that if you had elected representatives, then you would be responsible to a particular constituency. Presumably, one would make promises to gain election, and to remain elected you would have to show that you had in fact obtained beds for your local hospital, or some other high-profile issue. Long-range planning issues are not particularly glamorous for re-election, I am sure, antismoking campaigns and this sort of thing. It would very much change the thrust of the council.
We now feel we can deal without conflict with issues which may not be particularly glamorous but which we think, in the long term, will improve the health of the community. We do not have to do anything that is going to catch the elector's eye. As well, we have, with all our subcommittees, 150 volunteers. I think this would create a different atmosphere for those volunteers, knowing that we were paid members of a council. I do not think people would feel as free to volunteer their time. They know we are volunteering our time, so I think they are much more willing to help and contribute. You do not see many volunteer committees with school boards. I think we would run into the same problem.
Mrs MacKinnon: Thank you very much for coming with your presentation. I can hardly visualize having four counties under one district health unit, but obviously you are doing it. Do you have a central bed registry?
Mrs Galloway: No, we do not.
Mrs MacKinnon: My question to you, really, is how do you feel about the election of members to a health council as opposed to appointments such as you are doing now? From your former answers I am beginning to wonder. I think you said there is one of your counties from which you do not even have representation.
Dr Swales: No, that is not correct. I just said we have had more difficulty getting volunteers in one county, but we have representation from that particular county.
Mrs MacKinnon: Well, how do you feel about electing members or people who choose to run for a health council?
Mrs Galloway: Probably the chairman's answer to the former question is the same answer to that question. If you are being elected for a particular reason, you likely have a vested interest for why you want to be elected.
Mrs MacKinnon: I do not mean elected from the particular sitting county council. I do not mean that.
Mrs Galloway: No, I understand that. The thing that impressed me so much when I applied to the council -- and I am a neophyte, which is one of the reasons I am perhaps hanging back with my answers and letting the people who have been on the council do most of the answering here -- was how much it was driven home to me that regardless of what my background was and what sort of work I do, that was not the reason I could be part of that council. I had to have a more generic overview of the four counties and of the health provision and social services provision in those counties, regardless of my own particular point of view. It seems to me if you were asking people to run as elected members of the district health council, you would jeopardize that slightly more than the way it is now.
Mrs MacKinnon: Anybody who wanted to put his name down would have to get out and campaign. Hopefully they would get to know -- you might have representation in your particular case, then, from every county.
Mrs Galloway: We do have representation, Mrs MacKinnon, from every county. In fact, when we were reviewing the peoples' names recently who were interested in applying to the council, we were very specific about seeing who had applied from each of the four counties. The advertisements go into each of the four counties' newspapers and so on. As Dr Swales says, it is a question of getting a profile, perhaps a little more in the south part of the area, and it is a huge region.
Mrs MacKinnon: If you have 150 volunteers, you do awfully well, I think. Therefore, what do you do to assure yourselves of a cross-section of your four counties or regions? I notice you have something here I guess you must send out. Would this go to every mailbox?
Mrs Galloway: Probably Marshall Elliott could tell you exactly where they had gone, but usually it depends on the specificity of the document you have in mind. I actually asked that question myself the other day, where do we send each of these things, depending upon the group to which it might refer. If it was mental health, it might go to doctors' offices and it might go to various agencies that deal with mental health issues. It would depend on the particular reason for the publication. For example, the flyer Building a Healthy Community for the Future was specific to Haliburton county because a major study had been done in that county. That was distributed to households.
Mrs MacKinnon: Because this one appears to have been just strictly for your board.
Mr Elliott: I wonder if I could maybe comment on that, Mrs MacKinnon. That is one of our early upfront starts for our primary care study. In that particular study we were looking at commuters in and out of our district. One of our major concerns is, are people moving into our district for lifestyle reasons or real-estate, cost-of-living reasons, from the Ajax-Toronto area?
That particular questionnaire was distributed in physicians' offices. It was distributed at the GO trains outside of our district. It has gone already to the Havelock-Toronto-Peterborough Rail Association. It is going to schools and libraries in the southern part of our district and also in the western part of our district, where these people are moving in, to find out particularly what their concerns are in terms of accessing health and social services. The assumption we are making is that they have moved from a community; ie, Toronto. They are probably still maintaining medical, physician, a lot of social services, until a crisis happens, and then when are they going to get their service? So it was given wide distribution, trying to hit places where we would find people on the move.
Mrs MacKinnon: I do not want to take up all the time, but I heard you say that you do not have a diabetic -- does this not come under the health unit as opposed to the district health council?
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Dr Swales: In the city of Peterborough this had been operated for years through the Peterborough Civic Hospital, with a diabetic day care centre for instruction of new diabetics. This is not for long-standing; this is for new diabetics, to train them on diet and so on. The hospital, in looking for ways to cut costs, decided to cut this program. It was a board decision. It was not supported by the medical staff at the hospital, who opposed it. As a result, there really was no facility, other than the primary care physicians instructing the patients on diet and so on when they are initially discovered to be diabetic. This may be quite satisfactory at times, but other times it may not be. This was not felt to be satisfactory at all. We are looking at involving the health unit, the Victorian Order of Nurses and other groups to do this as an outpatient service somewhere else in the community.
Ironically, the health unit was doing this service in Cobourg and Port Hope and it has now been transferred to the hospitals. They have just had funding to do it in the hospitals, so it does not make sense. We are trying to sort it out as best we can to try to get a satisfactory solution for the poor individuals who have diabetes who cannot get that or shortly will not be able to get that information.
Mr Grandmaître: I would like to follow up on Mr McLean's type of question. One thing that I would like to get straight is that in 1989 you were told not to provide the ministry with -- let's call it a wish list. Did I hear you right?
Dr Swales: That is correct.
Mr Grandmaître: Does that mean that since 1989 your hospitals or your agencies, the agencies under your umbrella, have been dealing directly with the ministry?
Dr Swales: No. It means that they have not initiated any new or expanded programs in that time, have not had the option to do so.
Mr Grandmaître: So whatever was in place in 1989 is still in place. It is being fine-tuned every year.
Dr Swales: That is correct.
Mr Grandmaître: No new programs have been established since 1989?
Mr Elliott: In terms, sir, of a general route of funding for new and expanded hospital-based programs, there are specialty areas -- like rehab, emergency health services, some perinatal areas and so forth -- where funding is available on a provincial basis, sort of divided within a region. The ministry gives us notice. We give our hospitals notice. This is typically the hospital sector, as opposed to the community sector. We will give the community hospitals notice that there is a pot of money for rehab or emergency health or whatever, and then it is a competitive process. Dr Swales was speaking of the earlier process of new and expanded hospital-based programs, which you referred to as a wish list. That process is non-existent as of 1988-89.
Mr Grandmaître: I see. Good. I just wanted to set the record straight.
Mr Hayes: My question is really in the same line as Mr Grandmaître's, and also Mr McLean had raised it earlier. I just want to get a clarification here because I think that the way you answered Mr McLean, people would leave here with the impression that the Ministry of Health does not want your input. It kind of came out that way and I would really like a clarification on that, because there is something wrong if this is the case. You talked about how they do not want you to come up with any new programs. I guess if you wanted to check the Hansard, it came out that way. Mr McLean said, "They said we don't want your input," and I believe you said, "That's right." I would like you to clarify that.
Dr Swales: In that specific area, if you talk about a wish list, as Marshall said, there have been government initiatives in some areas, such as sexual assault and abuse, where the funding has been available and money has gone to the hospitals, so those are new programs for the particular hospital. By and large, those have been initiated by the ministry. Those have not come from the hospitals. The hospitals have their own wish list. For example, at Peterborough Civic the coronary care unit, the intensive care unit, has been the number one request since 1988. That has not changed since 1988. There has been no request for a new wish list and we were told not to send them in.
Mr Hayes: This is now?
Dr Swales: Yes. So those have been new and expanded programs which are initiated locally. There is a distinction. I should not say there are no new programs, there are some, but they have come from the ministry initially, such as sexual assault and so on.
Mr Hayes: Is the ministry actually saying, "We have some priorities here and we want to get through with these"? It is not just strictly, "We're going to ignore yours," maybe, but they are not as much a priority as the ministry feels its programs are. Would that be correct?
Dr Swales: That is probably fair to say.
Mr Hayes: Just one more quick question. The previous group talked about the problems with the ministry making appointments and time lags. Is there a problem there too, and also any task forces you have problems with that are not being addressed as quickly as you would like them? Are these some areas where there have been problems?
Dr Swales: Certainly the appointment process has been a sore spot and we have outstanding requests going back over a year now which we are still waiting to hear about, so this is why our numbers are down. Certainly for volunteers it puts an extra pressure on the remainder, because we have 10 instead of the expected 16, so we in effect practically have to double up on duties.
As far as task reports and those sorts of things are concerned, I would have a criticism of the ministry in its requests for feedback. Granted these are usually more minor issues, but oftentimes these will come down with a two-week turnaround time. From our perspective, that means that, if we are lucky, the executive committee will get to review it, but certainly the full council will not see it, so it is not really a true community feedback. It may in fact be just feedback from the permanent secretariat of the health council. So I find that disturbing, because if the intent is to get community feedback, that is not happening oftentimes because of the short turnaround time. With volunteers you need a fair bit of time because you cannot call meetings on the spur of the moment. They have to tie in with their schedules and so on.
The Vice-Chair: How many times has your council met with the ministry in the last three years?
Dr Swales: We certainly have frequent meetings with the ministry, with reps. That is not a problem, meeting with them. They are certainly very good at meeting with us.
The Vice-Chair: Have you met with any of the ministers in the last three years?
Dr Swales: Yes. Mrs Caplan came to visit us. That would be the last in three years.
The Vice-Chair: Other than that, it has been staff?
Dr Swales: Yes.
Mr Wiseman: I would like to pursue your statement of revenue and expenditures. I see your actual for 1990 was $281,247 and your actual for 1991 as of March 31 was $364,828. That is an increase of roughly $83,000, and the two areas where I see most of the increases are under salaries and benefits and furnishings and equipment. Could you describe for me what makes up the increase in those two numbers?
Mr Elliott: I think you have already identified it. It is salaries and benefits in one area and the other one is the office expansion I referred to earlier. We went from 1,800 square feet to I think it was 2,500 square feet. There is the rental aspect, and there was also the renovation, the equipment and so forth that went into that. The salary one is an equity adjustment that went across all district health councils -- I think it was effective something like December last -- which affects that statement. So it was an equity adjustment.
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Mr Wiseman: That one is around $49,000. Was that to hire more staff?
Mr Elliott: There was an increase of a part-time clerical person to full-time and there was equity adjustment to the four permanent staff salaries.
Dr Swales: It was a 0.6 to a 1.0 typist, but otherwise the staff did not increase.
Mr Wiseman: What created the demand to increase the staff? What are you doing now that you were not doing before?
Mr Elliott: There is no increase in staff in that, it was just a clerical person from 0.6 to 1.0, which is two days a week. It is to catch up with all the work the committee structure is doing. As Dr Swales said earlier, since both our functional review and the enhanced role for DHCs, we have been very involved, not just in the traditional health area but in other areas like housing, social services, environmental issues and so forth. The amount of agendas we do, the minutes we do, the contactings we have to do to get people together to meet at the legion hall somewhere and get dessert ordered in or coffee; we needed the extra help in that area.
In terms of our office expansion, that was to accommodate a second meeting room, because our committee room, our boardroom -- we needed a second meeting room to accommodate the people we deal with, the volunteers and so forth.
Mr B. Ward: Just a couple of clarification questions. You mentioned that the appointments have been held up for over a year. My Brant and Brantford health council recently received a letter from the minister stating that the applications for appointments have been sent to the committee to make the final recommendation, I guess, on who should be sitting. Did you not get a copy of that letter, as far as you are concerned? No?
Dr Swales: I did not see it, no.
Mr B. Ward: The priorities that you set back in 1988-89 and then you submitted in 1990 and then I guess were told, "Don't bother," have those priorities changed or were they the same? I think you said they were the same.
Dr Swales: Most of them are the same in the hospital. I think there was one hospital that changed its sequence. They did not change the listing, they just changed the order, that was all.
Mr B. Ward: So you do not have any money to deal with them. "There's no sense in wasting the paper and sending them again, we've already got them on file," is more or less probably what happened?
Dr Swales: Yes.
The Chair: Mr McLean?
Mr Bradley: Are you finally getting on?
Mr McLean: I am finally getting on, yes.
Other than doctors, nurses, administrators for homes for the aged and those types of facilities, how many other people are there on the council's executive who are not involved in input in the profession of administrators for nursing homes and nurses and in the health profession? How many are on your board who are not in the health profession?
Dr Swales: On the executive committee or on the board?
Mr McLean: The executive committee.
Dr Swales: There is sister and Barb. There are two out of five.
Mr McLean: I thought the sister was a director of nursing home or -- she is not?
Mr Elliott: She was formerly a director of a home for the aged and has been retired -- not in terms of age, but retired from that job -- for I believe about five years.
Mr McLean: Home for the aged?
Mr Elliott: Yes.
Mr McLean: I was just curious how many people were on the executive council who were not involved in that direct health care line of work.
The Chair: I guess this is an inappropriate question, really, doctor. Looking at the makeup of your board in respect to the board that we heard this morning, which is essentially an urban board, there seem to be a number of providers and physicians in respect to appointments to the board, although I take a look at the makeup of the 10 appointees that we were provided with and nine out of the 10 are related in some way, shape or form to the health care field. I guess initially when I took a look at the Hamilton-Wentworth board, I was wondering about the impact that a Dr Swales has on the deliberations of the council, professionally a provider. I am wondering how the average lay person would -- perhaps this is an inappropriate question to direct to you. It may be more appropriate to direct to a consumer representative on the council, but I am wondering if you have any observations in respect of that, that perhaps you, as someone who is formally educated in the field and works in the field, have undue sway over the deliberations of the council.
Dr Swales: No, I think it is a fair question. I certainly did not initially at all, because I found even as a provider there were a lot of areas in the health and social service area that I really was not familiar with. There are so many providers in the field that it is a real maze and I could say it was probably a year and a half before I felt comfortable at the meetings because I felt I did not have enough background to really comment very meaningfully on the issues.
Currently I contribute my fair share, I think. It is more difficult for consumers. I think I started up a step because I was in the field. It is a tough issue for consumers to get hold of all the complexities of this system, which is extremely complex.
I think the balance between providers and consumers is a very useful one and I think that is ideal. If the board were solely providers, then we would not be challenged by consumers and we would stick to our old programs and ideas. Conversely, if it was solely consumers, then I think they would become very dependent on the permanent secretariat and it would tend to be more driven by the permanent employees of the council rather than the volunteers. I think we have a good balance now that we have the planning expertise of our permanent staff, you have the experience of providers, plus you have the consumers, who obviously need to be heard more than they have been in the past. So I think it is a good balance.
The Chair: So you are happy with the mix you have on the council now? You do not believe there are any --
Dr Swales: We do not have the municipal reps at the moment, and as we have discussed, I think that depends very much on the individual. You can certainly get some excellent individuals from there who will look beyond their own narrow constituency, but there is a risk with the municipal reps that they might not. Other than that, I am happy with the mix, that there is a balance with three elements who all bring a different perspective to it. I do not think any one of the three should be dominant. I think they should all counterbalance each other and challenge each other. That is what makes the meetings interesting, that we will be challenged.
Mr McLean: Supplementary to that, Mr Chair, why would it be a greater risk with a municipal politician being on the board than a health provider from any one of the professions being on the board? Would they not be there looking at it in a broad perspective the same as you do?
Dr Swales: There would be one subtle difference with the selection of providers. We screen those, and being in a smaller community, we know which providers are -- at least I certainly know among my colleagues which ones would have the interests of the community at heart and which would have solely the profession at heart, so we would not encourage the latter group to apply to the council. In the situation of municipal reps, they would be appointed by the municipality. We would not have any say in who would come on board, so we could not screen them. We do screen the providers now, so we get providers who do have a broad perspective.
Mr McLean: I thought politicians were supposed to look after that.
Mr Frankford: Following on a bit to this, you said you thought that if it was an elected or a political position, people would be trying to score political points by promoting some popular cause. Have you come across in other boards or in your board people who get on the board to promote one single issue?
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Dr Swales: Certainly that has been a problem on hospital boards in Ontario, on general hospital boards, where you get probably the vestiges of some of the pro- and anti-abortion groups. So that is a risk, and that would be an example of a public board where that has happened.
Mr Frankford: But you have not had people applying --
Dr Swales: Not on our council. It has not been a problem. I would like to think it is because of our selection process. I hope it is. Maybe we have been lucky; I do not know.
Mr Wiseman: I am still trying to come to grips with costs. I know that in your area there is an antitax group that is starting to grow. So I see an increase in costs and I ask myself, how do we measure in terms of an increased budget the effect that has in terms of delivering the services that are needed and whether or not we are getting value for our money in terms of assessing that? Is there any way that you could put a handle on that for me, that gives me some kind of measurement about what you do that may make the delivery of health care more efficient in your area?
Dr Swales: I might just make a comment at the outset, and the others will answer. Because we are such a wide area geographically, if we are involving consumers they have to have their expenses paid to come down, particularly involving the rural poor who are an important element in our area. They do not have the funds to travel down to Peterborough. So we have probably higher costs from that point of view than an urban DHC would have, where you just have your subway fare and that is it. Here it is much more difficult than that. So we have higher costs probably because of that to start with.
Mrs Galloway: It seems to me too that the end result is where the cost gets rid of itself as being a problem. It may look high up front.
What happens with the planning process through the district health council -- at least certainly this one, and it is the only one with which I am very familiar at all -- because it starts at a community level and brings all the players together, the providers, the consumers, just getting to know other providers within the four counties and what each of us does best, then if there is a particular issue -- for example, we are doing a respite care study in the four counties at the moment and specific to our own county that I happen to live in and represent on council -- what we have found out about each other is who does what best.
So when there is a respite care program the outcome should be that we are doing it the most effectively and the most efficiently and therefore the best for the consumers as well as the most cost-effective. Without the interference, if I can put it that way, of the district health council promoting this planning, each of us who has an interest in respite care would be off doing our own respite programming and beating the drum for finances for our particular area or issue instead of having an overview of it and, it seems to me, in the long run creating a more effective system. That is where the funding will show itself as having been effective.
Dr Swales: I have one more example, and we touched upon this before. It is the rationalization of the institutional services in Peterborough, where we really are ahead of, as I say, most communities in Ontario with two hospitals. This has reduced a lot of duplication, and I think we are getting a much bigger bang for our dollar now in the two institutions than we were previously. This certainly was initiated by the district health council.
Initially, certainly in the late 1970s, if I was at a county medical society the term "district health council" was really considered a dirty word and just another level of bureaucracy. In the last couple of years I have had physicians come up to me and say, "Push harder to get the hospitals to talk to each other to rationalize services." So this is very much behind us now and in fact we look at the district health council as the leader in getting the two hospitals to rationalize their services. We are hopeful we will achieve the same thing on the lakeshore with Cobourg and Port Hope.
I cannot give you dollar figures but I am sure we have saved a lot of dollars in that area because of duplication of services.
Mr Wiseman: One other question has always sort of bothered me. From where I came from before, there was a lot of money being spent to meet the year-end deadline in terms of spending. Have you given any thought to whether it would be beneficial to you or to other areas of being able to roll your budgets year over year, multibudgeting, planning and so on? Have you ever given any thought to that?
Mr Elliott: No, I have not given any thought to it myself personally. I can see merit, though.
Dr Swales: Certainly for hospital budgets it would make sense. I know this has been a real problem in hospitals.
Mr Wiseman: Yes, a sudden rush to spend the dollars to make sure --
Dr Swales: There is no question that happens. I think that would be an excellent proposal.
Mr McLean: You have indicated that you have worked together and saved a lot of dollars. How would you expect to have the government spend money when you cannot make a proposal to it?
Dr Swales: That is a tricky question.
Mrs Galloway: I have the same question sometimes myself, to be perfectly honest, as Marshall will know, but it seems to me that at least with what the council does in its role as planner and advocate, the planning is there, the documentation is there, and the footwork has been done. It is a question now of where we go as a council to initiate. It is dollar-driven. There is no doubt about that.
The Chair: I may have lost on that last one. We were talking about rationalization and you are talking about being dollar-driven. Maybe I am confusing apples and oranges here where Dr Swales was talking about --
Mrs Galloway: It is the outcome we are talking about here. We were asked why we cannot make proposals. At the same time, what we are doing is creating the planning and the atmosphere in which there is an overview so that there are no mistakes made and that there is advocacy from the part of the council. But the reason, as I understand it, that a halt has been put on putting forth proposals is there just is not the financing at this point to do it. That is what I mean by the finance-driven part of it.
At least the planning is done and it will not be a question of scurrying to see whether what is happening is right. We have a plan of action to follow when there is financing to do the work.
The Chair: One of the concerns when health councils were formed back in the 1970s was the scarcity of dollars. It is an ever-increasing concern. I am just wondering if you look at other areas other than rationalization where you can see more effective use of dollars in the health care sector. We know it represents about one third of the provincial budget now, and there are increasing concerns about being able to maintain the quality of health care in the province.
I am wondering if you as an individual health council take a look at some of those broader questions there and ways and means in which, in your particular area, you could achieve some savings while not diminishing the quality of care.
Mrs Galloway: Again, I guess the only thing that any of us is doing in that area at the moment is trying to bring the various boards and agencies -- there are so many boards and agencies, each of which seems to be duplicating services -- together to see who does what best and maximize what each of them can do best so that it reduces that duplication. I am not sure that, honestly, we have done anything more than that.
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Dr Swales: In the longer term, you will not see an immediate result on this, but in the health promotion area we have been very active in trying to involve at-risk groups to take greater charge of their own lifestyles. We will not see a saving on that, unfortunately, long before a decade or more, such as the smoking and diet and so on. That is a longer term investment on which I think we will see results down the road.
Mr Elliott: I have a comment on one very immediate return in that area and that has to do with Parks Canada, which is a federal branch of the government in Ottawa, and the concern with the Trent-Severn waterway where the boat accident rate from drinking and boating is exceptionally high. Unfortunately it is still exceptionally high today, but our office was approached a number of years ago by Parks Canada and by the Ontario Provincial Police to see if we could do anything in terms of co-ordinating something.
It has resulted in a program by the name of Captain Drydock throughout the Trent-Severn system which goes from the Trenton area up to Georgian Bay. It is an effort to increase boaters' awareness that the risk of driving their boat and drinking is just as serious as drinking and driving, so I think in that sense there could have been some very immediate returns in the number of accidents and boating collisions and so forth. But we were able to capitalize on that opportunity with the federal government and the provincial government to do something which is very visible and very awareness-oriented.
The Chair: Mr Hayes has brought to my attention that we are about seven minutes over our schedule, so Mr Frankford, I am sorry, we will have to defer your question.
Thank you very much for appearing before us today. We appreciate your testimony. It has been very helpful. As provincial representatives, we thank you for volunteering your time and energies to the cause in the province of Ontario. We very much appreciate it.
MINISTRY OF HEALTH
The Chair: Our next witnesses are from the Ministry of Health. Can we encourage you to take a seat? We have Charlie Bigenwald, who is the executive director for policy, planning and evalution, who is getting a coffee I think at the moment. Welcome to the committee. Michael McEwen is the director of the health planning branch of the ministry. Do you have any comments you would like to make at the outset before we get into questions?
Mr Bigenwald: If it would be helpful for the committee, we had planned a brief presentation which takes a quick overview of the evolution of district health councils and where they stand right now as a group. Then we would be glad to answer whatever questions we could.
I will just say a few words about the now ancient history of district health councils and then I will ask Mike to bring us up to date on what is going on currently.
The legislative mandate for district health councils comes from the Ministry of Health Act. It is a small little phrase in the act that gives the minister the authority to appoint advisory groups to her or to him on health matters. As you know by now, all of the members are appointed by order in council as advisers to the minister under that section of the act.
The first district health council was appointed back in about 1973. There was a fair amount of activity going on at that time. Some of you may recall the Mustard report, which took a look at, among other things, health planning in the province and made recommendations that there be district-level bodies developed to advise the government on planning.
Currently, there are 28 district health councils. The last two were formed in the Parry Sound-Muskoka area. Under consideration right now, I believe there are three or four other district health councils, as well as a recommendation before the minister for setting up a steering committee or an advisory committee in another area of the province.
Each district health council serves a population area, and that population varies substantially across the province from a low of about 72,000 people all the way up to the Metropolitan Toronto District Health Council, which serves an area of over 2,000,000 people. In general, the district health councils right now cover areas of the province that represent over 90% of the population.
Originally, district health councils were given four specific roles. I think the terms of reference were listed in the background material. But in general, they were set up to identify district health needs and consider alternative methods for meeting those needs; to plan a comprehensive health care services program and establish short-term priorities; to co-ordinate health activities and ensure a balanced, effective and economic service which meets the needs of the people; and to work towards co-operation in the social development activities in the district.
If I could just editorialize a bit on that, as the district health councils evolve, I think initially the role of most district health councils was largely one of taking a look at specific parts of the health care system. For example, they would go out and look at an acute care study, or if the community identified as a problem services to children or perhaps drug addiction, they would initiate a study and come into the ministry with recommendations.
From those early studies and from the early years, back in the early and mid-1970s up through the 1980s, things became substantially more sophisticated, you might say, and more time-intensive. Districts continued to identify the needs they had, but I think you heard in the presentation this morning and this afternoon that successive ministers of Health asked for more and more advice on specific areas. You would have a minister say: "Mental health is a priority. I'd like all district health councils to do a mental health study." There have been a series of those over the years.
More recently, something that Mike will be getting into in a bit more detail, we have been pressing district health councils to do what we call systems planning: rather than looking at, piece by piece, acute care beds, long-term care beds, children's services and whatever, to begin to look at it in a broader sense and say, "How can we better meet the needs of the district, looking at how the hospitals relate to the public health units and to the community health services, what the links are, and how can we improve the service delivery?" With that, I will stop and ask Mike to take you through a few other areas.
Mr McEwen: The district health council membership: As you saw today, the strength of the district health councils is their volunteer membership. The council members not only attend monthly meetings, they also attend their subcommittee meetings. They are usually expected to chair at least one subcommittee. Those subcommittees involve somewhere between 1,500 and 2,000 other volunteers who are dealing with specific issues in the community, in task forces and subcommittees or in council.
One of the key elements in the work of council is the notion of the public consultation in its communities through a variety of mechanisms. It also serves as a forum for, if you will, this discussion of policy and an element of public education with respect to health care in Ontario and where it is going.
The membership, as we have heard several times now, is by order in council. The key responsibility of a council member is not to be representative of a particular group or interest, but rather to represent the community as a whole. Councils spend a good deal of time in orientation of new members, and most members of council will tell you that it takes about two years to get a grasp on the issues and begin to feel comfortable with the breadth of issues being raised.
Councils routinely get enormous packages of information which outline a variety of issues. The record I saw was one package for a district health council meeting that was 465 pages long, doublesided.
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The councils are intended to be reflective of their community: an urban-rural balance, male-female, francophone, native, multicultural and the geographic distribution within council. Some effort is placed by councils in being able to meet those kinds of requirements, and it is certainly a part of the ministry review of recommendations for council membership. The aspect of the 40%-40%-20% has been mentioned several times, so I will not go into that in any detail.
Councils are asked to provide several different types of advice. There are the locally initiated issues, such as health promotion, mental health and the Independent Health Facilities Act. Health councils play a major role in that new legislation. They have been asked to do, as Charlie mentioned, mental health plans following the Graham guidelines. They are involved in emergency and primary care services and continue to be involved in long-term care.
As part of the expanded role of district health councils and part of their drift away from new program additions to the outer edges of the system, councils have been asked to take a lead role in something called health system reviews. As part of the $850-million, 4,000-bed announcement, the Premier's Council recommendation is that those all be re-examined and only those that are absolutely necessary built, because to build them all would eliminate any ability to move from institution to community.
We asked councils and communities to look at the institutional needs in their community, using those dollars which had been designated but looking at other alternatives to additional beds, moving much more towards the notion that beds do not represent health care, and particularly, that the ministry did not want to continue to support the planning of hospitals in isolation of each other and in isolation of the rest of the health care system. The health system reviews are actually looking at issues like who is the population, not only its age and sex, but what kinds of diseases they are suffering from, what the appropriate range of services to be provided is, and where the most appropriate place to provide those services is, and not always relying on the facility or the institution to provide those services.
The other issues generated by the ministry range from such specialized issues as dialysis as a regional service through to the provision of French-language services and such local issues as health promotion.
The emphasis for councils has evolved from prioritizing program expansion or new program proposals to an emphasis on planning for the health system, the notion of the new and expanded programs being: not encouraging those types of submissions since 1988 -- that was in keeping with the whole shift from an ever-expanding hospital and health care system and the funding of hospital deficits -- through to the management of the system, a much heavier emphasis on rationalization and co-ordination of services and looking to build something that looked and worked more like a system, rather than a group of independent players doing their own thing. That is one of the key elements of the notion of a health system review and the role of council in that process.
There is also a growing emphasis on regional and district envelopes. Your current operating expenditure is what you have to work with for health care, and you need to be looking at providing it in the most efficient and effective manner, and an emphasis on the most effective use of existing resources.
Future direction of councils: You have heard a little bit about the expanded role of district health councils. One of the key areas that is moving forward is the integration of health and social services. Virtually every district health council has a strong working relationship with its local representatives, its sister ministry in Community and Social Services, a growing relationship with the Ministry of Housing and in its role in the human services.
Strengthening of area-wide planning: groups of district health councils getting together to plan for those types of services which are required, whether they are small populations being served or specialized programs. Councils have been continuing to be concerned with the human resources implications of health services. This is of particular emphasis in northern Ontario.
And, of course, there is the allocation and reallocation of funds for the system. An example of that is the health system review.
The Chair: Could I just interject here? How much longer do you think you are going to be? We are under some time constraints and I know the members would like to pursue some areas with you.
Mr McEwen: If you like, I will conclude my remarks. The rest of the presentation is before you.
The Chair: Thank you very much. I appreciate that.
Mr Grandmaître: On the integration, this morning the Hamilton-Wentworth people appeared before us and I asked them a question, "Did you take part in, or what was your involvement in, the SARC report?" and they said none. Now we are talking about the integration of health and social services. Can you tell me how come these people were not involved in the making of the SARC report? How come they were not involved? I believe some services should be integrated.
Mr McEwen: I am afraid I cannot give you a sound answer to that.
Mr Grandmaître: It seems if you are going to integrate or amalgamate services, people who are part of the amalgamation or fusion of these services should be part, maybe not of the final decision-making process, but at least of the writing of the report or the recommendations to the different ministries.
Mr Bigenwald: The historic relationship of district health councils, by legislation, was that the councils report to the Minister of Health. Over the years, consistent with the original terms of reference, the district health councils typically developed a working relationship with their colleagues from the Ministry of Community and Social Services to solve specific issues. If there was, for example, a difficulty, a needed service for children, which has always been an issue that bridged both sides, typically that issue would be solved right at the local level, between that level.
The broader discussion of the integration of the two ministries, and particularly what eventually leads to the joint division between the two ministries for the long-term care reform, is of more recent vintage. I think it is fair to say that up until the last couple of years, district health councils did not have a specific advisory role to the Ministry of Community and Social Services. That is a roundabout way of saying they would not have been asked directly for input into the evolution of the SARC report at that time.
Mr Grandmaître: Back in 1989, when SARC was instituted and the role of the DHCs was improved, I still cannot understand how come these people were not part of the process. When you look at the role of DHCs, they are antennas. They are out there to feed you information as to the needs of the community and how people feel in their district areas, yet they were not part of it. I find this very strange.
This morning, again, when we were talking to the Hamilton-Wentworth people, they were talking about communication. It is not only in your ministry. I think it is right across the previous and the present government; I have to qualify this. Communication is always important and these people were complaining somewhat about the kinds of communication or the lack of communication they were having between the ministry, the minister and district health councils.
Another thing, if I may add, is that these people were saying we had two changes in ministers, and maybe three or four in the last two and a half years. Also personnel: They had to deal with different people every four, five or six months. How many changes took place in your area of management in the last six or 12 months? I am talking about human resources.
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Mr McEwen: My particular area of the ministry has undergone four reorganizations in four years.
Mr Bradley: You must be due for another one.
Mr Grandmaître: It is like municipal official plans; they get reviewed every five years.
Another thing, the Haliburton people were saying they were told back in 1989: "Don't send us your wish list. We don't have the money. It's no use." Did every district health council receive this directive back in 1989?
Mr McEwen: The whole issue of new and expanded hospital-based programs became a very difficult planning process that worked against a number of priorities. It encouraged hospitals to work by themselves and to pursue individual initiatives. Some of the criticisms of that process were that some of the submissions covered programs that had already been implemented without approval. There were other means of trying to deal with deficits.
When the ministry began to look at a better level of management of the system, the idea of new and expanded programs as individual submissions -- I believe your terminology of "wish list" is very accurate -- shifted to an emphasis on not funding deficits, management of the system, reallocation of funding within the system, reduction in duplication and bringing the system under some form of control. There was funding for growth and there was funding for life-support programs, those kinds of things, but the idea of having wish lists generated all across the province became very counterproductive.
Mr Grandmaître: Does that mean that when the minister stands in the House and says, "Thirty million dollars here, $30 million there, $25 million over there," it means it is a rehash of old programs?
Mr McEwen: No. We are getting into some technicalities about specific program funding issues that are not my day-to-day area of responsibility, but I will do my best to answer the question.
On the funding for growth and funding for life-support programs, the announcements around cardiac, cancer, neonatal intensive care, dialysis and a number of those initiatives, cardiac and cancer, for example, are considered to be provincial programs and are planned for provincially. Depending on the type of announcement and whatever, no, they are not rehashes of old programs, but --
Mr Grandmaître: I am sorry to interrupt. When you talk about provincial programs, did they not initiate, let us say a year or two years ago, from feedback from the DHCs?
Mr McEwen: I am not sure of your question.
Mr Grandmaître: The minister did not wake up one morning and decide, "Let's do this." Usually a ministry will take maybe six months, maybe 12 months to work on a program.
The Chair: Unless you have John White dreaming.
Mr Bradley: Lots of people do not know who John White is.
The Chair: I know. That is a dated joke, is it not?
Mr Grandmaître: Yes, it is. What I am getting at is that it takes a long time not only for governments but the private industry to plan these things. You do not wake up one morning and say, "Hey, we are going to do this." So now the feeling I am getting is that DHCs were not given more power; they were given less power as far as I am concerned. Back in 1989 they were told, "Don't send us a wish list," and now the minister stands up and says, "We're going to do this and we're going to do that," and they are called provincial programs.
I have great difficulty distinguishing between a provincial program and programs that were initiated, or thoughts of a program that were initiated, 18 months or 24 months ago by DHCs. They are supposed to advise the minister or the ministry. They are called provincial programs so: "We don't need the input of DHCs. We're going to call it a provincial program." Do you see what I am getting at? Maybe I am totally wrong.
Mr McEwen: I certainly do not want to leave you with that impression. There are certain programs. The ministry, for example, in cancer takes its advice from the Ontario Cancer Treatment and Research Foundation and the district health councils would like to me more involved in that process. I would like to use Haliburton, Kawartha and Pine Ridge for a moment as an example of district health council input in terms of the 18 chronic care beds that were announced for Haliburton.
The ministry asked the DHC to undertake a review process, and the review process was probably one of the best we have undertaken in the province in terms of the quality and nature of the data gathered. They did surveys not only of everyone who was in a bed, but also of all the people on a waiting list, and it was virtually, given a small number of people, a 100% sample. They came back with a report that stated that indeed the beds were required. The ministry is now dealing with that report, but it was a major initiative and done extremely well.
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Mr Frankford: In the expanded role of DHCs, one of them is to be involved in the allocation of funds, I believe. It seems to me that even if DHCs are not developing wish lists, one could see ways in which they could encourage programs which would save funds. If preventive programs work, this should save some costs. Would there be a role for the DHC to have some say in spending those saved dollars?
Mr McEwen: The difficult thing with saved dollars at the moment, particularly in the institutional sector, is that with certain types of bed reductions it is to balance the budget and some of those kinds of issues. There certainly is the notion in long-term care and chronic care beds that there will be some reallocation. There are some areas of the province that are over-bedded in acute care and the possibility exists for some reallocation of funds in those types of areas, but that would be over a reasonably long period of time.
I feel that yes, there is a role for district health councils in the reallocation of resources, and that requires that a council have undertaken a relatively rigorous planning exercise for the community and have a good handle on what the spectrum of services are that are required.
Mr Frankford: That is not something that is happening at the moment?
Mr McEwen: It is in a number of communities, particularly in areas where we have encouraged the notion of a health system review. That is happening.
Mr Frankford: There is a reference in the submission of the Haliburton council to independent health facilities as a way in which costs may be saved by a less hospital-based approach. That is one example which was raised. I would suggest there could be saved funds there. The council seems to think it might have a role in reallocating.
Mr McLean: Would you give me the chain of command, how it works in the ministry. You have your district health council. Do they report to the policy planning evaluation committee, and does it in turn report to the health planning branch? What is the chain of command there?
Mr McEwen: The chain of command is that the district health council is advisory to the minister and it sends its advice under covering letter to the minister. Then it comes down from the minister's office to the ministry, to my branch actually, to co-ordinate.
One of the common complaints of councils is that it takes so damn long to get a response from the Ministry of Health. It is important to recognize that much of the work of councils centres around fairly major studies that can contain from 75 on up recommendations that touch on the Ministry of Health, the Ministry of Community and Social Services, sometimes the Ministry of Housing, sometimes the Ministry of Culture and Communications, sometimes the Ministry of Tourism and Recreation, sometimes the Ministry of Education, and sometimes affect their own municipalities in the area.
Where it is fairly straightforward, it takes a while to get all that together. When councils raise major policy issues, issues around things like palliative care and ambulatory care centres, and initiatives where there is no clear policy in the ministry as yet, those become rather difficult to respond to and are meant to be. Sometimes the recommendation is included knowing full well that it is meant to tickle someone.
Mr McLean: So the health planning branch is kind of the go-between.
Mr McEwen: We act as a co-ordinating function between various ministry divisions and the district health councils.
Mr McLean: Would you say that is the branch where there seems to be the problem?
Mr McEwen: That is my branch.
The Chair: Totally objective answer.
Mr McEwen: We attempt to be part of the solution. I am sure that many would see us as at least part of the problem.
Mr McLean: I have a question that I hope you will be able to answer in the health planning branch.
For a long time I have been a firm believer that we have hospitals full of chronic care patients, whole floors of chronic care patients. Why is there not some movement to get those people into a home for the aged or into a setting where there is a homey atmosphere and at about half the price we are paying in chronic care. Why is somebody not doing something about it?
Mr McEwen: The two ministries are, and that is the whole purpose of the long-term care redirection, the notion that Ontario institutionalizes its elderly like no one else in the world. The ultimate objective is to look at other forms of communal living as an alternative to putting someone on a hospital floor, at a home environment and idea that growing old is something that does not have to be done.
Mr McLean: Are there any reports or studies being done to determine if that is feasible, and how many people in the province would they be looking at? I see nothing. I always hear that reports and studies are being done, and really nothing is being done from what I see. Is there something that I can see to know that there is a movement to get more people into a homey setting instead of sitting up looking at another roof?
Mr McEwen: It was really in the summer that Mrs Akande made the announcement, and I am pretty sure the report was released at that same time, so there is some documentation on the issue.
Mr McLean: What is the name of the report?
Mr McEwen: It is Redirection of Long-Term Care Services.
Mr B. Ward: We heard from the previous presenters that they have managed to gain co-operation between two major hospitals in one city, and the feeling was that this led, if not to actual cost savings, at least to cost containment because of co-operation, elimination of duplication etc. Is that something that your branch would be encouraging health councils throughout Ontario to look at, to get co-operation among various hospitals to attempt to ensure that any health tax expenditure is effective and not going towards duplication of services, which may happen in some cases?
Mr McEwen: Certainly, that is one of the major thrusts of councils, the bringing together of the major institutions, particularly in places like two-hospital towns and multi-institutional centres, to deal with those very issues. In earlier times, it was easier for hospitals not to do that, but with the policy of not funding deficits and hospitals seeing themselves in a position where they need to co-operate and rationalize services, and with councils working towards that goal with the hospitals and the hospitals beginning to see real advantage in it, I think we will see much better results in that area.
Mr McLean: Is it fair to say that the ministry and the minister are supportive of preparing planning documents -- I guess that is what it would take -- to examine the roles of each hospital in the community and project what that role will be in the future? Is it fair to say that the ministry is supportive of that type of effort?
Mr McEwen: Yes, and that thought needs to be expanded in terms of not an individual facility but the various facilities that would exist in a county or district health council area, looking at themselves as part of a system, as opposed to being individual facilities with an individual role.
Mr B. Ward: Part of the community, in effect, rather than in isolation?
Mr McEwen: Yes.
Mr Bigenwald: In fact, at any given time, there are probably a dozen of those kinds of studies going on across the province.
Mr B. Ward: Are they flowed through the health councils or are they flowed through the ministry?
Mr Bigenwald: They are often actually initiated and done by the councils, or if not initiated by the councils, they would go through the councils.
The Chair: I would like to follow up briefly on what Mr Ward raised in terms of rationalization in respect to my own riding. I know in the city of Brockville, they have been arguing for about 30 years about rationalization of the two hospitals. They finally came to some agreement -- it must be approaching two years ago now -- and they are still awaiting some word from the Ministry of Health, the minister's office, in respect to proceeding to the next phase, and unable to get any kind of response whatsoever from the Ministry of Health. It is a damned frustrating exercise, I want to say.
I have had people, the chairman of the board of the St Vincent de Paul Hospital and the Brockville General Hospital and others involved, say: "Look, we have people who are extremely enthusiastic about this exercise we're finally getting co-operation in the community, and we are not getting any response from the Ministry of Health. It's damned frustrating." I do not see any good answers for those concerns forthcoming. No response?
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Mr McEwen: I worked with that particular committee for its first stages and I am very well aware of the effort that went into that. The ministry started health system reviews on a community-by-community basis, and what we ended up with was a variety of reports dealing with a variety of issues and the scope tended to be different from community to community.
What we were asked to do was to put together a framework which would be explicit about what the ministry expected from these exercises and much clearer on what the parameters were. That process seems like for ever to the communities that have participated, but from a planning perspective it was a pretty short time frame to put something together that would be able to cover an exercise that one would refer to as a health system review, which had the possibility of covering everything from primary care through to rehabilitation.
That is currently under review by very senior parts of the ministry and the minister has yet to have an opportunity to see it. That has been the holdup. A number of communities are going to say, "Good God, we waited all this time for this?" But I think it will be helpful.
The Chair: So you think there is a light at the end of the tunnel?
Mr McEwen: Yes. God, I hope so.
The Chair: I have another question in respect to mental health and again it deals with my own riding in respect to deinstitutionalization, which, for whatever reason, has been a very popular sort of thing to do in the past couple of decades and it is creating a lot of problems in my own community.
I was wondering what role the health councils have in respect of funds allocated for community resources when you are shoving people out of mental health facilities across this province, and many citizens view those measures as inappropriate in respect to the fact that some of these people are not ready for community life. That is an observation anyway, whether it is accurate or not. When they are shoved out into the community, there are simply not the resources to deal with them, to handle them. You see people even in the city of Toronto sleeping in bus stops and what have you. I am just wondering if health councils have a role to play or do play a role in respect of that.
Mr McEwen: Councils were asked to use the Graham report as the basis for developing mental health plans for each of the districts and a good deal of time and effort has gone into that. At the end of this year there should be mental health plans for each district; that provides the framework for building mental health services for the community.
A community such as yours, which actually has a provincial psychiatric hospital, has particular concerns. I am trusting that the district health council has taken that particular issue into account in its planning.
Mr Bigenwald: Historically, I guess ever since the early 1970s when that deinstitutionalization began, it has really been the district health councils that have done the planning and the pulling together of community resources for those, I think, now over 500 community mental health programs. Up until recently, there used to be a call for proposals yearly, or about every 18 months, and it would be the district health councils that would develop those proposals with community partners, rank those proposals and send them to the ministry, which led to the funding and the development of the programs that now do exist.
The Chair: One final question, Mr Bradley.
Mr Bradley: Yes, it is regarding CAT scanners and the policy of CAT scanners. I have drawn a conclusion from a series of articles in the St Catharines Standard by its health reporter, John Nicol, who has done some investigative reporting in this direction, that you have changed your policy as a ministry, that you are no longer dealing with district health councils when allocating CAT scanners and that you are now dealing with individual hospitals.
In other words, your ministry has now invited individual hospitals to deal directly with the ministry in making a bid for CAT scanners, which is alleged to be a change in policy, and certainly for those in the Niagara region who are lining up for five months for elective work done by the CAT scanner, it is not very pleasing news. My understanding is that the district health council has almost thrown its hands up in exasperation when it thought it had moved to a certain point in time.
My question is, first of all, is it accurate to say that you have changed your policy, that individual hospitals now make their bid directly to the ministry for the allocation of permission to install a CAT scan machine?
Mr McEwen: No. The ministry's former policy, as I recall -- and I hope I have this correct -- was that originally you had to have special approval and the ministry would give a grant of $150,000 and the hospital had to be able to fund the rest of the CAT scanner within its operating expenditure, but it required special permission.
The ministry is currently reviewing its policy and there is no policy statement that has yet been prepared to reflect what many people feel is a change in the status of the CAT scanner, as opposed to a piece of equipment like MRI, which is still experimental or under review and this sort of thing. I called, when I heard your question this morning, and the paper is not written.
Mr Bradley: Does this mean that all requests for permission to install a CAT scanner are on hold, that the ministry will not approve any until such time as a new policy is developed?
Mr McEwen: I would not want to make a definitive statement like that, but I think the notion of the development of a policy will be important in that process.
Mr Bradley: Actually, the kinds of questions I would pursue further to this, Mr Chairman, would more appropriately be pursued with the Minister of Health as opposed to the witnesses we have today. However, I did want to raise it in the context of district health councils, because it was my impression that they were to play a significant role to avoid the situation where individual, favoured hospitals would make their individual bids to the ministry.
Again, it is a bit of an end run, I guess, around district health councils. We all know the problems. You have to deal with it all the time when people try to do an end run around district health councils. I know your general policy has been not to ignore completely, but certainly to try to work through the district health council and unless there is political interference by a minister, which you have to put up with, that you would deal directly with the health council.
That was my concern, that it seems under the new policy direction that is evolving that district health councils will have a diminished role to play in the allocation of CAT scanners or MRIs, I think they are called, magnetic resonance imagers. Is that not correct?
Mr McEwen: I do not believe there is any intention to remove the notion of CAT scanners and where they would be placed from district health council review.
Mr Bradley: I will cut my questions off on that now, because I think it is more appropriately pursued either with the minister or in estimates. I just wanted to put it in the context of district health councils.
The Chair: As the agenda indicates, we are going into a closed session to discuss this question and provide some guidance to our research officer.
The committee continued in camera at 1609.