CONTENTS
Wednesday 16 June 1993
Subcommittee report
Appointments review
Susan Copeland
Lyn Guenther
Rahul Manchanda
STANDING COMMITTEE ON GOVERNMENT AGENCIES
*Chair / Présidente: Marland, Margaret (Mississauga South/-Sud PC)
*Vice-Chair / Vice-Président: McLean, Allan K. (Simcoe East/-Est PC)
*Bradley, James J. (St Catharines L)
Carter, Jenny (Peterborough ND)
*Cleary, John C. (Cornwall L)
*Curling, Alvin (Scarborough North/-Nord L)
*Frankford, Robert (Scarborough East/-Est ND)
*Harrington, Margaret H. (Niagara Falls ND)
*Mammoliti, George (Yorkview ND)
*Marchese, Rosario (Fort York ND)
*Waters, Daniel (Muskoka-Georgian Bay/Muskoka-Baie-Georgienne ND)
*Witmer, Elizabeth (Waterloo North/-Nord PC)
*In attendance / présents
Substitutions present/ Membres remplaçants présents:
Rizzo, Tony (Oakwood ND) for Ms Carter
Clerk / Greffière: Mellor, Lynn
Staff / Personnel: Pond, David, research officer, Legislative Research Service
The committee met at 1005 in room 228.
SUBCOMMITTEE REPORT
The Chair (Mrs Margaret Marland): Good morning. The first order of business is to approve the subcommittee report on committee business.
Mr David Pond: Just a brief warning: As members know, the subcommittee usually gives me about 13 days' notice before it chooses appointees. Mr Waters knows exactly what I'm going to say. This time, through no fault of the subcommittee at all, we're only getting seven days' notice. I'm just warning you, there's no way we can prepare the usual full package for next Wednesday. You'll get something from us for each appointee but not the full package. It just won't be physically possible.
The Chair: So which subcommittee report --
Clerk of the Committee (Ms Lynn Mellor): This is the one.
The Chair: All right, if somebody would like to move it.
Mr Daniel Waters (Muskoka-Georgian Bay): I'll move it.
The Chair: Thank you, Mr Waters. All in favour? Thank you.
APPOINTMENTS REVIEW
Consideration of intended appointments.
SUSAN COPELAND
The Chair: I would like to welcome Susan Copeland. Would you like to come forward and be comfortable. Ms Copeland, if you wish to address the committee briefly with some opening comments, you may, or we may just start in rotation with the members of the committee asking you questions.
Mrs Susan Copeland: You may start with asking questions.
The Chair: All right, thank you.
Mr John C. Cleary (Cornwall): Welcome to the committee, Susan. I guess one of the things that I hear a lot about is the backlog for the appeal process. Would you like to comment on that?
Mrs Copeland: The appeal process at the Workers' Compensation Board?
Mr Cleary: Yes, the backlog.
Mrs Copeland: I don't know that I can comment on their backlog. I do understand that they do have so many days after they hear a hearing to come up with a decision from the hearings process. Are you talking about a backlog in hearings or a backlog in adjudication?
Mr Cleary: I am talking about a few incidents that I've been dealing with where a member has been appealing his claim -- this has been going on for a number of years -- and they tell me once he finalizes the papers, then it could be up to two years before he's heard.
Mrs Copeland: To my knowledge, I don't know that is the norm with the board. My experience has been that the backlog has not been that lengthy.
Mr Cleary: The other thing that I guess I'd like to talk to you about -- and we're hearing more and more about it all the time -- is stress, in many ways. Would you like to comment on that, because I imagine that you're going to be having lots of dealings.
Mrs Copeland: With regard to stress in the workplace, I believe it would have to be case by case, and it would have to be work-related in order to be compensable. That's my opinion.
Mr Cleary: Those are my questions.
The Chair: Are there any questions from --
Mr Allan K. McLean (Simcoe East): Ms Witmer is just about ready.
The Chair: We could change the rotation, if you'd like, and go to the government members first and come back.
Mrs Elizabeth Witmer (Waterloo North): If you wouldn't mind. I am almost ready, but I just want to review this for a second.
The Chair: That's fine. With pleasure.
Mr George Mammoliti (Yorkview): Welcome, Susan. I note that you've had some experience in workers' compensation claims in the past. There are a couple of questions that I wish to ask. One would be what experience you think you can bring to the board and how useful that experience will be in terms of -- well, we'll talk about the positive experience right now. What can you bring to the board that will improve it? That's the way I want to ask it.
Mrs Copeland: As you can tell by my work experience, I have been the representative of an employer and have gone before WCAT. I feel that I have represented both employer and workers, so I feel that I have both sides. Although I have been with an employer, we have represented both at WCAT. I think I have a broad perspective and knowledge. I don't know that I can improve the board, but I certainly feel that I can participate in its already very recognizable --
Mr Mammoliti: In speaking to them, one of the biggest concerns that employers have is that when an individual perhaps appeals a claim of some sort, whether it's a pension or whether it's a decision that was made, one of the biggest things that employers are concerned about is doctors and the types of doctors' letters and the credibility of a lot of doctors. Would you agree with some of those employers that perhaps there are some doctors who don't necessarily give adequate information, which would lead to perhaps false pensions or false claims? Would you agree with a lot of those employers?
Mrs Copeland: I don't know that I would agree or disagree. I don't know that I could comment on the qualifications of any physician in Ontario. What I do believe is that employers require medical information and should pursue obtaining the information they require. I don't think to judge a physician --
Mr Mammoliti: That's fine. The last question is on the office of the worker adviser. I've had some particular problems with the worker adviser office in that when we refer certain constituents to the worker adviser office, it refers them right back. The backlog is so huge that it's actually hurting claimants and their right to be heard, even at the board level.
Do you think there's some relevance between your position and perhaps improving even the worker adviser's office somehow, or no? Do you think it's out of your hands?
Mrs Copeland: I'm not that familiar. I have knowledge of the worker adviser's office and what it does. I'm really not familiar with their backlog in hearing workers. I really can't comment on how WCAT could improve their workings, how this board could improve on that agency.
Mr Waters: Good morning, Mrs Copeland. I guess I'm a firm believer in trying to avoid WCAT. I see the WCAT as the very last step in a long, long process sometimes that isn't needed.
You've had an extensive background, I feel, working with compensation from a lot of different angles, and I'd like to hear your opinion as to whether or not we should be looking at resolving a lot of these. We're talking about the fact that there's a backlog at WCAT, so should we not be resolving them, or are a lot of them resolvable before WCAT? I wouldn't mind your opinions on that.
Mrs Copeland: I think that a lot of cases are resolvable at the Workers' Compensation Board level. There are various levels of review before it even gets to a hearing at the board, so WCAT is the external agency which reviews those decisions after the board has had its levels of review. My opinion is that WCAT serves a very good purpose in giving an outside-the-board-itself review of the decisions.
Mr Waters: I'm going to go offtrack, because with all your experience, I think WCAT is a beast unto itself that, as we've said, is the opportunity of last resort, I guess, and final decision. But I do have some concerns about WCB, and I'll give you a case.
A young woman in my riding, 15 years of age at the time, working in a small rural country store, was working with the meat grinder. They took the grinder off her arm in Toronto. She rode for over two hours with that grinder on her arm. Her compensation level for life was set at the rate of pay that she was receiving as a 15-year-old student in a small country store.
I know I hear a lot about costs of compensation, but not only did this meat grinder destroy her potential earning ability, her ability to go and do what she would have wanted to do at the university level to become a skilled person, but it also destroyed her social life. I believe that compensation should take those things into consideration and at this point doesn't. I'd like your opinion on that. Should this type of thing be considered?
Mrs Copeland: Well, that's a case I can't really comment on without knowing all the specifics. However, I do believe that outside of financial compensation, the board certainly, for severe and critical injuries, or all injuries but specifically a case like that, is very much willing to rehabilitate and provide any future loss of career along with the financial --
Mr Waters: But in this case you're looking at a kid of 15. What would her career have been? You're looking at a loss of potential, but how do you even know what the potential was? If that was to come before WCAT -- and if I have my way, one of these days it will --
Mr James J. Bradley (St Catharines): It had better be within the next two years.
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Mr Waters: Good morning. It's nice to see you.
I guess I'm concerned about -- as a number of employers want to see, they claim -- some fairness in the system. I think that there's been a lack of fairness also to a large number of injured people, and I guess what I'm after is a system that is fair, just and efficient. If there were some efficiencies, what would you suggest as efficiencies within the board to make it work better so that you wouldn't have the backlog?
Mrs Copeland: That's a big question. Within the board?
Mr Waters: That's where it all starts and you end up with a backlog because of the inefficiencies or the inability of the board to deal with its problems, historically. Now, I know that there are some changes going through at the board at this time that are very promising under the new director or under the new chair, but I wouldn't mind hearing, because of your experience with the board, if you think there's something we're missing.
Mrs Copeland: Certainly there can be improvements in all areas of any organization, and specifically the board. It deals with a lot of controversy. I have dealt with the board for many years. I have been frustrated with them and I've also been very happy with them, and it depends on how hard an employer or a worker works with the board. I think they have a lot to offer. I do believe that they certainly have areas that they can improve on in efficiency and their timeliness, and I don't presume to or I can't presume to solve their problems or come up with solutions at this time.
The Chair: Thank you, Mrs Copeland, Mr Waters. Mrs Witmer?
Mrs Witmer: Thank you very much. Mrs Copeland, I notice that you applied on your own initiative and I guess I would just ask you why you feel you would like to serve in this capacity on this particular tribunal.
Mrs Copeland: I'm having a change of career this year and I'm looking for an alternative. I have been involved in the workers' compensation area since about 1980 and I feel that I have a good knowledge base of the process. I have had dealings with WCAT, and I very much like its agency and its organization. I feel I can bring a lot of knowledge to that organization.
Mrs Witmer: You indicated now that you've had dealings with the WCAT and obviously you felt that it has functioned effectively. I think you said something positive. How and why do you think it is functioning effectively?
Mrs Copeland: I believe with the tripartite panel that it serves both the worker community and the employer community. It has written decisions, they're published, and I feel that both communities can draw on the experience and the past decisions and it's a very fair and equitable manner of dealing with humans.
Mrs Witmer: So you feel that it is functioning as effectively as it can. Would you have any changes that you would recommend?
Mrs Copeland: Being an outsider at this point, I don't recommend, I'm not in a position to recommend changes. I may in the future if I have the opportunity to be there.
Mrs Witmer: Okay. I'd like to go back. I know that Mr Cleary did discuss and ask some questions of you concerning the stress and the fact as to whether or not chronic stress should be compensable. As you probably know, this is a very contentious issue, as is almost every other issue related to the WCB. As Labour critic I can tell you that I think both employers and employees throughout the province do feel there is a need to make some very drastic changes to WCB in order that it will more effectively meet the needs of the employee and the employer communities.
Getting back to the chronic stress and the fact as to whether or not it should be compensable, what's your immediate reaction regarding stress? Should we be compensating for chronic stress? What is your definition of chronic stress? What do you perceive should be compensable?
Mrs Copeland: I really feel that's a very difficult question with stress today, because there are many definitions of stress. There's acute stress and traumatic stress and chronic stress, and once again, I believe it should be on a case-by-case basis. It all depends on where the stress came from, the causation, if it's work-related. I believe that we should be hearing stress cases and dealing with them on a case-by-case basis. At this point, I'm not prepared to give you a blanket, "All stress should be compensable," or "All stress should not be compensable." I do believe it's individual.
Mrs Witmer: Would you consider such a thing as a demotion stress?
Mrs Copeland: It could, and it could not. It would all depend, once again, on the causation factors of that individual case.
Mrs Witmer: Because obviously, that's an issue that the WCB is going to have to continue to wrestle with. As you know, the cost of funding the WCB is growing at an alarming rate. We have an $11-billion unfunded liability. Obviously, if we add stress and we start compensating everybody for everything, the system is going to get to the point where there won't be any money left to pay people in the future. We already know there's $11 billion promised that we don't have funds for. Obviously, it's something the WCAT is going to probably get involved in, depending on what the definition is going to be. Do you have any other comments on that particular policy of compensating for chronic stress?
Mrs Copeland: I really don't think I could add to my previous comment.
The Chair: Thank you, Mrs Copeland, for appearing before the committee this morning.
LYN GUENTHER
The Chair: I'd like to welcome Dr Lyn Guenther. Good morning, Dr Guenther. You're welcome to address the committee briefly with some opening comments if you wish, or we may just start into rotation of questions.
Dr Lyn Guenther: Good morning. I'm a dermatologist from London. For the past two years, I've been chair of the division of dermatology at Western, and I am also in private practice in London.
Mr Robert Frankford (Scarborough East): Good morning and welcome. I think this is an extremely important committee, because it really can determine patterns of prescription drug use which are costing hundreds of millions of dollars right now, and I believe there's considerable scope for more rational and appropriate use of drugs. Do you agree?
Dr Guenther: I don't think there's much question about what you've said. I definitely agree with you.
Mr Frankford: The mandate of the committee is really quite broad. It's to advise the minister on the operation of the drug benefit program and drug-related matters, recommend educational, scientific information for distribution to health professionals and the general public and facilitate communication between the ministry and the professional organizations.
Certainly, in my political life now I'm aware of the impact that its decisions often make, particularly around the withdrawal of drugs. I trust they're always defensible on clinical grounds, but in the realities of political life, people come in quite often when they find their drug has been withdrawn and say, "What is all this and who is this faceless committee or this ministry that doesn't care about my health and is doing this to me?"
I think that the communication is extremely important, both to the practitioners and to the public. Do you have any thoughts about that?
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Dr Guenther: Ideally, it would be nice to provide everything to everybody, but unfortunately we do not live in those times. There's only a certain amount of money in the pot and we therefore have to look at the most effective and best way of using our resources that we have. I think it's a difficult decision. I was not part of the decisions because I have not been part of the committee as far as what was delisted from my patients.
Yes, there's an outcry when you haven't received things. It's always difficult, when people have received things, to take them away, no matter what they are. If you're used to receiving something, it's a very difficult problem for them and they don't take kindly to things being delisted. But I think, from my understanding, there are drugs that perhaps need to be delisted, perhaps need to be added too. I think it's a mandate of the committee to decide what most optimal, efficacious therapies should be included.
Mr Frankford: It seems to me that ideally the profession is so well informed that it's using the most rational range of resources. Perhaps as an example, I'm sure you're aware of the Medical Letter, but it seems to me that it's not universally subscribed to. I think that if resources like the Medical Letter, which comes out of the US, were used routinely by physicians -- and perhaps the committee could either encourage this or perhaps even be developing its own regular newsletters or other information sources -- we would all be much better off.
Dr Guenther: I think there certainly is some need for optimizing both physicians' methods of prescribing and patients' compliance, and not doctor-shopping, not always taking their medications, taking medications that could interact with other medications and not informing their physicians what they are on. I think there certainly is a definite need for optimizing treatment and care of patients in that regard.
Mr Frankford: It seems to me there could be many advantages to stopping having a hard copy formulary and turning it into a computer electronic formulary. For one, it could be updated all the time instead of waiting for six months, which is not always six months, and secondly, one could start to do some interesting things around interactions.
Dr Guenther: I totally agree. The way of the future really is computers. As you're probably aware, most physicians, effective this July, will be having computers in their offices just from the OHIP billing point of view. There will be a penalty imposed if they submit it on hard copy rather than computer copy. I think that, certainly from a physician's point of view, in my practice would be beneficial. If there was some way of tracking what patients were on, you could look up and see what they were on, because frequently they don't know and you can't always get hold of the family doctor to find out what they're on.
The Chair: Dr Frankford, two other of your colleagues wish to speak, and you're halfway through the time. Mr Mammoliti.
Mr Mammoliti: Let's talk about drug addicts for a second, the illicit drug addicts, not the prescription drug addicts. I want to talk a little bit about methadone treatment that is currently under the Ontario drug program. What do you think about the methadone treatment? Should we continue such treatment? It's not a cure; it's therapeutic, from what I can gather. Should we continue that methadone treatment or should we be looking in another direction?
Dr Guenther: I actually don't have a comment on that. In my practice, being dermatology, I have no experience with the methadone treatment and I therefore can't comment.
Mr Mammoliti: So there's no point in me asking whether or not we should legalize drugs and give out prescription drugs as some other countries do. I'll yield to somebody else, Madam Chair.
Ms Margaret H. Harrington (Niagara Falls): I have a couple of questions. First, through our constituency offices, we have had occasion to ask doctors to write letters with regard to a special case for a drug which is not on the formulary. Is that called section 8?
Dr Guenther: That's correct.
Ms Harrington: I have found, in one particular case anyway, that the doctor was very reluctant to do that. He said it would take too much time and effort for him to take part in that and actually write the letter. I wanted to ask you to comment on that.
I'll go ahead and also make my comment about the future of our system. First of all, I believe there are too many drugs on it. We have to have effective management of the whole system, a more rational system, and part of that will entail that people have health care more in their own hands. Because individuals are so different, I might be one who says, "Less is better for me," always taking, say, a prescription and trying to use the least possible, that type of thing; another person might say, "More is better," and take that angle.
What I'm getting to is that an education program is very important for people, to try to use some knowledge from physicians as well as from other sources to try and make some of those decisions themselves. When a drug is taken off the formulary, the rationale for that should be made public so that the consumers themselves would understand more about health care and about drugs and be able to be part of a rational system, because it is their tax dollars, and if there is waste, it is hurting everyone.
I'd like you to comment on those two questions. The first was about section 8 and the doctor's reluctance.
Dr Guenther: I think all of us in busy practice are always burdened by letters for this and that. When you are requesting a drug for a patient, and I've requested drugs for section 8, you write your letter, you put the appropriate data; there's a list of various things that should be included. I think you have to act as your patient's advocate; however, the system has to be friendly enough and easy enough to use from the physician's point of view so that it's not taking one or two hours to get a drug for a patient; you're also having to make several long distance calls, at the physician's expense, to get a drug for a patient. So I think the system has to be such that it's simple, doesn't take a lot of the physician's time.
Ms Harrington: So you think changes could be made right there.
Dr Guenther: I think there is potential for some changes. Right now, I'm not on the committee. I am not privy to their method of accessing medication.
Ms Harrington: My other question was about the education of why drugs are off the formulary or on.
Dr Guenther: Education certainly is something that can be improved. One thing you mentioned was that a patient might feel they only need a few days of a drug, and perhaps antibiotics would be a prime example. A patient might feel better after a couple of days of taking an antibiotic and then feel they no longer had to take the antibiotic because they're cured; however, they'll relapse a week later and might be resistant to that antibiotic, and if they had taken the medication for the full prescribed course, 7 to 10 days, then they would not have had that problem.
So I think there's education to the patient. I know when I prescribe antibiotics, if it's for a specific infection, then I will say, "Even though you feel better, make sure you take the full course; otherwise you could relapse." I think there's also potential for the pharmacist to be involved with patient education in addition to physicians, the committee nurses.
Ms Harrington: I think the committee has a very important role in the future of health care.
The Chair: There isn't anyone here at the moment from the official opposition, so we'll go to you, Mr McLean, and move back to Mr Cleary.
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Mr McLean: I want to welcome you to the committee and thank you for offering your services. I see you're a very busy lady.
My question has to do with the formulary and generic drugs. I'd like to know for my own personal purposes about some of the generic drugs that are taken off the list and substituted. How does that system work?
Dr Guenther: As I mentioned, right now I'm not on the committee, so I'm not involved with making the decisions. My understanding is that the drugs are evaluated in regard to their bioavailability and their efficacy and that the active drugs have to have the same maximum concentration. I guess the differences can be about 80% to 125% of the parent patented drug. So they have to show that they're efficacious and also safe and can therefore be interchanged.
Some of the "inert" ingredients could be different. That could potentially lead to small problems. I can only speak from a dermalogic point of view, where if you have a cream with perhaps a preservative which is inert, some patients are allergic to it. But with that minor exception, if the drug is equivalent, then it is equivalent with regard to the bioavailability of the active ingredient.
Mr McLean: Some time ago the minister made an announcement with regard to the nine pilot projects aimed at improving the quality of prescription drug treatment. What role do you see playing in that as a member of the committee?
Dr Guenther: My understanding of the committee is that the committee acts as an advisory, independent, expert body to the minister, so if the minister requests the committee to take on various commitments, then the committee would be looking at those issues.
Mr McLean: In some cases I have seen, doctors have written prescriptions for 100 pills and the pharmacist has said, "I can't give you them all at once; I'll give you 25 at a time," thereby getting a fee for each repeat that's filled. Does your committee oversee any of that type of practice?
Dr Guenther: I am not on the committee right now and I have not had its welcome package with all of its mandates, so I cannot comment on that.
Mr McLean: But in your own practice, would you observe that is a common practice in some areas?
Dr Guenther: It's not that common. Generally, what I have found is that if you prescribe medication for a patient, occasionally the pharmacist doesn't have enough in stock and can't get it from Drug Trading, which is sort of the warehouse for the medication. If they don't have it in stock and the patient needs it right away, they'll give them what they have in their pharmacy, but then generally they will fill the rest of the bulk of the prescription. I don't think it's a general practice, certainly not that I've seen in my practice, that pharmacists are trying to jack up their prescriptions.
Mr McLean: There are now becoming warehouses for drugs. There's a large one opening in Toronto, I have observed from the news, where you can send in and get your prescription filled. What are your views on that? How are you going to keep control of the amount of drugs someone will be able to get by sending it in and getting it back in the mail? Could you get overprescribed, or what about somebody looking for extra?
Dr Guenther: This is news to me, this mail-in prescription order you are referring to. In order to get medication you have to have a signed prescription by a physician or a dentist; therefore, if the physician says you should only have X quantity, you can't photocopy your thing and send it to several different pharmacists. You have to have the original signed and sent in.
There also is a computer network system which is being developed to look at people, especially those who are recipients of the Ontario drug benefit program. I think that would certainly help eliminate some of the duplication of services.
Mrs Witmer: It's a pleasure to have you here. It's always nice to see somebody from Western, my own alma mater, and certainly I am impressed with your qualifications.
I'd like to take a look at the changes being contemplated to the Ontario drug benefit plan. One of the things that's now happened, I guess as of yesterday, is that the dispensing fee of $6.47 for prescribed drugs is going to continue in place. Do you have any comments? The government has decided this will indeed occur. Now the pharmacists are saying that's too low. What comments do you have?
Dr Guenther: I don't have the information to make a valid comment about how much it actually costs the pharmacist to stock the drug and whether even $6.40 is a valid figure to begin with. I think you have to take a number of different factors into consideration: the pharmacists' expenses, carrying costs, the costs of the medication, and whether that is a valid fee. I can't comment because I don't know how that was arrived at in the first place.
Mrs Witmer: One of the other areas the government is suggesting some changes will be made in will be the possibility that there are going to be user fees introduced for prescription drugs. As you probably know, the United Senior Citizens of Ontario certainly are very critical of this measure and the fact that they may be asked to contribute towards the cost of their prescriptions. Do you have any comments on that method of reducing the cost?
Dr Guenther: Certainly we have to look at ways of decreasing the cost of drugs, because the cost has been escalating, and I don't think we can afford the increases we've had to date. I understand that is one of the issues they're looking at. Again, if you've been used to receiving something free, and you've waited till age 65, you've finally made your age 65 and then they take away what you've been looking for, that's difficult, no matter what issues you discuss around it, no matter what explanation you give. It's a benefit they waited to get and you're now taking it away. But I think it's something that has to be looked at, because there isn't enough money in the pot to continue at this rate.
Mrs Witmer: Thank you very much. I wish you well in your career. It appears you're very successful.
Mr Cleary: Welcome, doctor. I guess the role of the DQTC has been changed by the NDP and its recommendations are less important than unilateral decisions by government. What drugs over the counter and drugs of nutritional products should be included in the formulary?
Dr Guenther: Was that a question you were asking?
Mr Cleary: Yes, nutritional drugs, products, that should be included in the formulary.
Dr Guenther: Do I think they should be included?
Mr Cleary: Yes.
Dr Guenther: I think that's a decision that the committee will have to decide.
Mr Cleary: Should government make these unilateral decisions?
Dr Guenther: I think the time people object to government making unilateral decisions is when unilateral decisions are made without advice from an independent group particularly. If they go ahead on their own initiative without listening to a number of different sectors that are involved by their decision, that's when you have the outcries.
Mr Cleary: Are you familiar with the government's recent announcement about possible changes to the Ontario drug plan?
Dr Guenther: I have some awareness.
Mr Cleary: Are you in favour of what's possibly coming?
Dr Guenther: Not being on the committee, one of the things I understand is that there's going to be a relook at the over-the-counter medications that are currently listed. However, when you consider delisting them, you also have to look to see if delisting them is going to be more expensive to the plan. You might, for example, delist benzoyl peroxide for acne and then prescribe something more expensive because it's now on the plan whereas the drug benzoyl peroxide is no longer on the plan. I think you have to take into account not only the efficacy of the medication but also what the alternative would be if it were delisted.
Mr Cleary: Do you have any comments on how many drugs might be delisted?
Dr Guenther: I don't have a number.
Mr Cleary: You never heard a number?
Dr Guenther: I've heard things thrown around. I don't know; do you have the number?
Mr Cleary: Only what I hear. A hint has been around that there'd be a couple of hundred. I don't know whether that's true or not.
Dr Guenther: Not being on the committee, I have no idea.
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The Chair: Mr Curling, do you have any questions?
Mr Alvin Curling (Scarborough North): Doctor, I just arrived. I don't have a question for you, but as I was glancing at this Drug Quality and Therapeutics Committee on which you serve, the concern lately, of course, is where we talk about quality. There are all types of drugs on the market. Normally one hears that if you want to find drugs, just open anybody's cupboard. All those prescription drugs that are sitting there, thousands and thousands of them not used or outdated.
Do you have any concerns about that? With the kind of concerns that you have, what type of thing do you think the government should be doing in controlling these kinds of drugs that are prescribed so easily out there? I know one is quality. If there were quality stuff, people will be taking them. It seems to me that they are being given -- some would say that even when they don't take it, they improve. Do you have any comments on that aspect of things?
Dr Guenther: I think there is a concern about drugs not being taken appropriately, about people hoarding drugs, and there also is the problem that if you do have a cupboard full of different medications and you feel ill and you don't know which one to take when you feel ill, so there is a potential for actually making your patient sick, or people becoming sick, because they're taking something that was stacked up in their closet. Some medications also can have problems if you use them past the outdated date that's listed on the bottle or on the package. Also there's potential for drug interactions and a potential for drug overdose by having closets full of different medications.
One of the problems you run into is that if you prescribe a small quantity to people, you have this dispensing fee that was mentioned. If you prescribe a small quantity to get around that potential problem, then you might be jacking up the price because you're having to dispense it several times. I think in certain cases there might be a role for a small trial quantity and then giving a larger quantity once the patient has shown he can take the medication.
Mr Curling: Quality and quantity, I presume, almost go hand in hand, in a way.
Dr Guenther: Well, not necessarily.
Mr Curling: Quality and quantity would be a concern of the government because it would lead to cost eventually. If it's good quality, I presume it to be effective, and as they're educated about the drug, people would be able to understand that this would enhance their recovery from any medical problems that they've been having.
I don't want to put you on the spot with your colleagues, but do you think there's a bit of abuse on behalf of doctors in the sense of the amount of prescribed drugs that are being given out?
Dr Guenther: You can say, is it an abuse of a physician? Certainly, it takes the physicians time to write the prescription out, so they're not really getting anything by doing that, except perhaps, I guess you might say, the patient came in demanding a medication and then they gave them a prescription to keep them quiet, but hopefully that doesn't happen frequently.
Mr Curling: I have no more questions, but I want to thank you for coming in. Your qualifications stand you in good stead in the sense that I hope the advice you give to the government would help the province on the whole in saving funds and in saving lives.
The Chair: Thank you, Mr Curling. You actually have three and a half minutes left, and Ms Harrington has a question.
Mr Curling: I'm such a kind, generous, considerate person. Maybe she can remember next time.
Ms Harrington: I wanted to bring to your attention a leaflet that is from the CAW, the Canadian Auto Workers, in St Catharines to their seniors. What it says is that for some seniors, this is a loaded gun; that is, having too many pills. They're actually having workshops for a maximum of 15 people at a time talking about the wise use of medication. I'm wondering if you would be able to promote something like this more widely. Would you be in favour of doing that and helping to do that?
Dr Guenther: I think their initiative is excellent. Yes, certainly it would be nice to see more people taking an active role and I think it's great that the unions are taking that. Whether I personally would be the one going around promoting this thing, I'm in favour of it, but I can't say that personally I would be going around doing that.
Ms Harrington: Okay. I'm not exactly sure if that's within the mandate of the committee, but certainly as part of the medical system and leadership in this province, I would think that you could lend a voice one way or the other.
Dr Guenther: Certainly, I would be in support, from a personal point of view, of that initiative and I would encourage other people to take initiatives in a similar fashion. It's excellent.
Mr Mammoliti: Very quickly, to touch on something that my friend Mr McLean talked about in reference to mail order drug companies, recently there's been some controversy about a company called Meditrust. You're not familiar with it?
Dr Guenther: I'm not familiar with Meditrust.
Mr Mammoliti: I know for a fact that receiving and getting prescription drugs from this company saves you a lot of money, a quarter of the price that it would cost you to go to a regular pharmacy. Don't you think the province should be looking at these types of savings for things like the Ontario drug benefit program? I can already estimate savings of millions of dollars if we were to look at something like this, recognizing of course that there would be some problems with the mail order type of system.
Dispensement fees have always been a problem. Pharmacists can literally charge you basically whatever they want for a drug. This would be a saving that people would, I think, appreciate. That would be within your mandate, wouldn't it, to look at something like this for the potential savings to government?
Dr Guenther: I can't comment whether that's within the mandate, having not received the official briefing.
The Chair: Mr Mammoliti, we're just about out of time.
Mr Mammoliti: But zeroing in on this, it's very important.
The Chair: No, I think a courtesy was extended to your caucus to come back in rotation, a courtesy extended by the official opposition. I'd like to thank you, Dr Guenther, for appearing before the committee this morning.
RAHUL MANCHANDA
The Chair: I'd like to welcome Dr Manchanda to the committee. Perhaps you wish to make a brief opening comment, or we will just start in rotation with the committee members to talk to you about your appointment this morning.
Dr Rahul Manchanda: My name is Rahul Manchanda. I was born and brought up in India. I've been practising psychiatry for just over 20 years, six years of which was in India, six in the United Kingdom, and I have been in Canada for just over eight years now.
Mr McLean: Welcome, sir. Are you familiar with the Review Board for Psychiatric Facilities?
Dr Manchanda: Yes, sir. I worked for four years in St Thomas Psychiatric Hospital between 1984 and 1988 and had the opportunity of appearing before the review board on several occasions.
Mr McLean: What about the other facilities, such as Whitby and Penetanguishene?
Dr Manchanda: No, I've only worked in two hospitals in Canada, St Thomas Psychiatric Hospital, and in University Hospital for the past four and a half years.
Mr McLean: I observe that a lot of the appeals by patients of involuntary committals, when they appeal, there's about 80%, in the cases, that are revoked. How often would those appeals be heard with those individuals? Can you appeal once a year, or how often can you appeal, if you're in there but want to get out of the facility, to the appeal board?
Dr Manchanda: The patient can be brought into the hospital against his will on what is called the application for psychiatric assessment. This is a certificate that brings the patient in for a maximum of 72 hours, during which time the psychiatrist is asked to assess the patient to then decide whether the patient should be a voluntary or an involuntary patient. If the psychiatrist then decides to put the patient, against his will, as an involuntary patient, he puts the patient on what is called a form 3, which is valid for two weeks. The patient is told of his rights to appeal to the review board at this time, and the patient has a right to appeal to the review board. The review board meets within seven days of such an application.
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Subsequent recertifications can be made, which are valid for one month, two months and three months, and during each of these recertifications, the patient is informed of his rights to appeal to the regional review board. Should the patient not decide to appeal to the review board during any of these, at the time of the fourth recertification, the patient automatically goes in front of the regional review board, which means that even though a patient may not exercise his right to go to the review board, at the time of the fourth certification, which is approximately six months of continuous certification, the patient will go before the regional review board and it will decide on the certificate.
Mr McLean: What right does the individual have to refuse treatment?
Dr Manchanda: A competent psychiatric patient over the age of 16 years can refuse psychiatric treatment. This has nothing to do with his involuntary status. He could be kept in hospital, but if he's competent to consent or refuse treatment, then if he decides not to take treatment, he cannot be treated.
In deciding on the competence of a patient to consent for treatment, what the psychiatrist takes into consideration is whether or not the patient understands the nature of his illness, whether or not the patient realizes the benefits of taking treatment, whether or not he realizes the risks of taking treatment, the fact that he could deteriorate if he does not take treatment, the fact that he can improve if he does take treatment, and the risks that the patient has in case he decides to take treatment in terms of side-effects and so on, and that everybody may not respond to it.
There's quite an elaborate process involved in deciding whether a patient is competent to consent for treatment or not. This is something that is assessed on a day-to-day basis and does not have a duration placed upon it.
Mr McLean: Can you tell me under what circumstances the electroconvulsive treatment can be used?
Dr Manchanda: The most common indication for using electroconvulsive treatment is a major depressive disorder, especially when the patient is also delusional and has marked suicidal ideation. However, in order to give electroconvulsive treatment, we have to obtain the patient's consent to do so. If the patient is mentally incompetent to consent, you can ask for substitute consent from the next of kin as defined within the act.
Mr McLean: Does the patient have the right to legal counsel when they go to each appeal?
Dr Manchanda: Oh, yes, of course.
Mr McLean: Who supplies that legal counsel?
Dr Manchanda: What happens is that when a patient is certified, one of the copies of the certificate is sent to the local legal aid office. A representative from the legal aid then comes to see the patient, usually, in my experience, within 24 hours.
Mr McLean: The other question that I have is with regard to release of patients upon a recommendation of the review board. In your experience from the facility that you worked in, what percentage of them have committed a crime to be readmitted again?
Dr Manchanda: I must mention that I do not work in forensic psychiatry. Therefore, my experience is mainly to do with the regional review board within the Mental Health Act and not within the Criminal Code, so I do not have experience in that area.
Mr McLean: What are your thoughts on the ability of a psychiatrist to identify potentially dangerous persons?
Dr Manchanda: This is a very difficult area. This is a controversial area, because there is no real test to decide on dangerousness. Research has shown that patients who have committed an offence in the past or have been dangerous or violent in the past have a greater risk of being violent in the future. Patients who have been violent during the course of a mental illness again have a risk of becoming violent during a relapse of the condition. Finally, this may not be very scientific, but the gut feeling of an individual, not just of a psychiatrist, is an extremely important indicator of the dangerousness of a person.
Mr McLean: A final question: What are your thoughts with regard to the Mental Health Act? Do you feel there are some changes that could be made to make it better?
Dr Manchanda: The Mental Health Act has evolved over the last 20 years. If you look at it from a patient's point of view, it protects the patient's rights throughout the course of hospitalization and psychiatric treatment. So it is really good from that point of view in terms of protecting his rights and liberties.
If you look at it from a psychiatrist's point of view, the first impression or feeling might be that there is too much procedure involved in it, but the fact of the matter is that anybody who needs treatment can get treatment under the act, and I think that is the important thing. It would be nice if the patient consents to treatment and comes into the hospital voluntarily, but the fact of the matter is that we are in a climate where this is not going to happen. The Mental Health Act is here to stay, and it is for us to make the best use of the Mental Health Act to protect the patient's rights and yet, at the same time, treat the patients who do need treatment.
Mr McLean: How much time have I got left, Madam Chairperson? About two minutes?
The Chair: You've got two and a half.
Mr McLean: Thank you. The patient's rights: We have now the freedom of information act. We have the position where a patient can write -- and we have one who writes 50 letters a week, expects replies, makes information requests. He expects replies from all the ministries and individuals and is costing society a pile of money for his requests. Should there be some limitation to that patient's right to be able to do that?
Dr Manchanda: Well, sir, I don't know. How do you draw limits on patients' rights and people's rights? I guess economics is a strong factor, but I don't think that can limit a patient's rights and liberties under the Charter of Rights.
Mr McLean: It's interesting, because the individual, the patient, wrote to the Ministry of Government Services, found out how long it would take to cut through the bars. He got all that information but he got it all through the freedom of information act. So I'm wondering how far patients' rights can go to get this information.
Dr Manchanda: I guess it's a pendulum, sir: It will swing to the other side and finally it will have to come back.
Ms Harrington: In this job in dealing with our constituents we always seem to meet the most interesting of our constituents at times. I'd like to tell you about a situation. It's going into the area that you have already discussed. I had a woman whom I know quite well in the city of Niagara Falls come to speak to me about her 26-year-old son, who is a schizophrenic and dangerous to himself and others. It's very difficult for her to get him the adequate treatment.
Now, I'm certainly not an expert, so I can't speak to all the details, but using that as an example, my question is, is the process that you are now involved in adequate with the three-person panel, with, as you said, one person who is the layperson with this gut feeling -- I would agree with you that sometimes that is important, to have another person there using their instinct -- and balancing between the rights of the individual to some kind of control of their life, but also the rights and the safety of society? You've explained the process and I believe you're doing everything you can to make it work, but can you, in the future, see any changes that would make the system better?
Dr Manchanda: That's a very valid and important comment that you've made. There are occasions when my heart goes out to my patients' families, because at the end of the day they are the ones who are dealing with the individual patient.
I think one of the things that can be looked at in the future in terms of the Mental Health Act and does not exist is the provision of treatment after a patient is discharged from the hospital. One of the things that is happening is that there is a greater move towards deinstitutionalization. We are looking at a lot of community treatment of psychiatric patients. I think it is very important not to confuse homelessness with deinstitutionalization. It is important that these patients are treated when they're out in the community. But the fact of the matter is that there is a certain group of patients who do extremely well on treatment, do not wish to take treatment, and who, when they are discharged into the community, do not follow up on adequate treatment.
I think the answer to that is -- and again, not to put everybody in that category, but patients who respond well to treatment during hospitalization, if in some way they can be asked to continue with treatment as outpatients so that if they do not take their treatment they can be brought back into the hospital before the situation gets so bad that the family and the community are suffering because of it, it would do a lot, not just for the patient but for the community and, I think above all, towards the overall costs of hospitalizations and review boards and hearings and everything else.
It has been shown that in places where you've reduced the number of beds and you have sent people out in the community, short stays result in more frequent hospitalizations, whereas if you have a lot of beds available, then the patients tend to stay longer. So where do you draw the balance? Do you draw the balance in terms of a more comprehensive treatment for psychiatric patients, not just within the hospital but also in the community, and hopefully get the Mental Health Act to support that provision?
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Ms Harrington: My question was actually the process of deciding whether a patient should be voluntary or involuntary or making that person take treatment. Should that process be changed? Do you feel there are ways of improving that?
Dr Manchanda: No, I don't think so, because if you look at it, in 80% of the cases the certificate is confirmed by the review board anyway. The majority of the patients who are considered that they should be staying in hospital, the review board agrees with it. So these are the patients who are staying in hospital and are taking treatment. There will always be a subgroup of patients who will go between the cracks, and I'm not sure if there is anything within the present Mental Health Act which is going to be an answer to that without compromising patients' rights and liberties.
Ms Harrington: That's a very delicate balance.
Dr Manchanda: It is indeed.
Ms Harrington: You're saying that you can't go too far in one direction. You have to have that problem, that some will fall between the cracks because of their rights.
Dr Manchanda: Yes, ma'am.
The Chair: Mr Waters and then Mr Marchese, and there are five minutes left.
Mr Waters: I will try to be as brief as possible. Correct me if I'm wrong: You do not deal with the criminally insane.
Dr Manchanda: I do not, sir.
Mr Waters: Therefore, the person Mr McLean was talking about who is held at Oak Ridge under what, when this person was actually being held, was a Lieutenant Governor's warrant, is not the person you deal with.
Dr Manchanda: No, and neither does this regional review board.
Mr Waters: Okay. That was one thing I wanted to make sure of.
Both Mr McLean and I represent the community where not only Oak Ridge is for the criminally insane but indeed the Penetanguishene Mental Health Centre as well as Georgianwood. What we find, though, is that we get a lot of people like the schizophrenics who come out, and because they have lived there for so long, they go into our community instead of going home. What I guess maybe we find more than other communities is needs. They have needs in the community for things like psychiatrists and psychologists to work on an outpatient basis within the community.
We also find that these people, probably through no fault of their own -- I know I take medication every day and sometimes I forget, but their medication is much more crucial. If they forget and they slip a bit -- they might forget a pill today, and then tomorrow or the next day it's two or three -- they end up back in. I was wondering if you think there's any better system on the outpatient aspect that we could do.
Dr Manchanda: I had just mentioned about extending the certification process and need for treatment on an outpatient basis. I think that will take care of that, but I do agree with the other comments you've made.
Mr Rosario Marchese (Fort York): Dr Manchanda, I have two questions, if we can squeeze them in. One, how do we balance out the effects of treatment versus the effects of lack of treatment? I see that the treatment at times, in terms of the prescription of drugs, has adverse effects on people. How do we balance those two?
Dr Manchanda: I've often remarked this to my medical students and residents: 50% of the time I'm trying to convince the patient to take the medications and the other 50% of the time I'm telling the patient not to take medications.
In all psychiatric treatment trials there are certain things that are absolutely clear. One is that about 30% of patients do not respond to currently available medications. The second is that all currently available medications are more effective than placebos. So there are 30% of patients who will respond to placebos or who will respond to nothing or who will respond to medications. But the fact of the matter is that by and large medications are better than placebos.
Medications do have side-effects and I think over the course of the 20 years that I've been prescribing I've seen drugs with a lot of side-effects versus those with very minimal side-effects, and I guess that's the process we are in in trying to have drugs which are at least as effective, if not better, but have fewer side effects. And that's the balance that we have to achieve.
Mr Marchese: I wanted to ask you a question on the abuses of power by psychiatrists, but I'm going to pursue this point a little bit because I've known a number of people who have been prescribed many drugs, sedatives, Valium and the like, and have taken them for years because of problems of being isolated in some communities where they don't have enough recreational activities or friends who they can talk to in a similar area. The doctors' answer to some of that is to prescribe things like Valium and other drugs. I don't really know what they are. My sense is that over a long period of time it's damaged people.
So I understand that some psychiatrists and doctors have a good sense of balance, but, also, I'm afraid that some do not and they simply prescribe without having that overall sense of the overall effects on people's bodies and minds, and that is why I ask that question because it continues to be a worry for me.
Dr Manchanda: I think the responsibility lies equally on the patient as well as on the doctor. I think it is important to weigh the benefits of a medication versus the potential for abuse. We have a system where you can have one person refusing to give a drug and the patient just goes out to another place and gets the medication. We see that with antibiotics all the time. You have a person who says: "This is a viral infection. You do not need antibiotics." The patient gets away from the doctor, goes into a walk-in clinic, gets an antibiotic and that's it.
I think that is going beyond the mandate of this committee but I think I would like to mention that patients are often told that the medications have a limited effect and that is what it has to be used for. I cannot just put all the blame on the profession because I think patients have a role to play in it too, but I think what really needs to be done and is being done to a large extent is education in the matter.
A lot of the times the patients are told that they should only be taking the medications for a certain period of time, and the surprising thing is that there are many patients who will not take the medications even though you ask them to take them, and there are others that you are telling them not to take and yet they continue to want a prescription. There's a kind of a consumerism in this where the patient feels that he has to get what he wants. I don't have the answer to that; I don't know if anybody else does.
Mr Cleary: Something that's been on my mind for a number of years and I just would like your advice on it, an experience that I had back a number of years ago of a friend and I guess he was reaching out for help. I had made some phone calls on his behalf, trying to get him admitted, and I had run into a big roadblock. He wouldn't do it on his own and the end result wasn't very good and it took me a considerable length of time to get over it. But I'd just like your advice on how you would go about it when you saw someone in the community who needed help.
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Dr Manchanda: My experience is that myself and my colleagues included are very cautious in matters like this. Given the medico-legal climate, there is a greater attempt to bring the person into the hospital if there is a need to, as opposed to getting the patient not to come into the hospital. But the fact of the matter is that there is no foolproof test of whether a person is going to hurt himself or not. One acts in best faith and with good judgement, but it is possible that at times mistakes are made. I don't think, in my experience, it is due to pure negligence, but there are always some patients who will present to you very differently than they have presented to some other people in the community.
Mr Cleary: What should an ordinary citizen like myself do if I see someone like that?
Dr Manchanda: A person can go to the family doctor, who is the primary physician. A person can call the police if a person is threatening or has threatened, is attempting or has attempted to hurt himself or others. The family can go to a justice of the peace and present enough evidence and the justice of the peace can then put a patient on a form 2 and send the patient for a psychiatric assessment, which is then carried out in a hospital setting. There are all these situations.
If a patient has been seen by a doctor within seven days prior to that day and if enough evidence is presented to the doctor to say that the clinical condition has deteriorated, that particular doctor can still certify the patient and send him. There's a lot of a network there to get the person into the hospital in a situation like this. Quite often patients and families will call the hospital for advice on this matter as to what they should do. This is what I would advise them.
Mr Cleary: I had called a hospital but there was no mechanism there to get this individual admitted.
Dr Manchanda: Was there a department of psychiatry there? Because it has to be a schedule 1 facility.
Mr Cleary: Yes, there was. This is back a number of years ago. Maybe things have changed now.
Mr Mammoliti: He has to be of harm to himself or to the community before he can be admitted.
Mr Cleary: That's right, he was of harm to himself.
Just to follow up a little bit from my colleague Mr McLean, are there any changes that you'd like to see to the Mental Health Act that would improve it somewhat?
Dr Manchanda: The only thing I mentioned was that I think the extension of treatment beyond hospitalization will do a lot towards maintaining patients in the community and preventing frequent rehospitalizations.
Mr Curling: Dr Manchanda, it's an important role you're going to play, I know. I'm going to take some of the positions that my colleagues have taken, some of their experiences.
But before I do that, it's quite tempting, whenever we see a policeman, to try to extract from him all the information about what parking tickets we've got and how we get out of them -- or we see a doctor and get all the free advice out of him -- instead of paying. Here's an opportunity now where I'd like to get some free advice out of you as a politician on serving on this board.
If there's any issue that comes before me as a member of Parliament -- when families come before me about a schizophrenic son or daughter or member of the family, they seem to be completely frustrated with the system in order to get treatment in a way or having this one individual institutionalized. Government plays a role in deinstitutionalization, institutionalization and what have you without any backup at times, resources outside there.
I'd like to ask two questions on this. One is, do you see any improvement that could be done in regard to the Mental Health Act in assisting the family more? I know the patient is important and I know the doctor who is treating is also very important. But the family somehow, although you said there are resources there -- and I hear you mentioned adequate resources there for them to do this -- I don't feel so, or I am frustrated. I lack the knowledge and information and they also lack the information. Is there any way you see an improvement in the way we educate those people or bring about resources that can assist them to help their families in that very dramatic time?
Dr Manchanda: As the act stands, it does not give any such powers to the family, so really there's nothing that can be done about that. But in terms of educating the family about the provisions of the act and how best it can be implemented, that is something that is possible with combined efforts of either the medical community or the regional review boards having some kind of an educational role within families of schizophrenics or other situations. In my capacity as a psychiatrist, I have often talked to families of schizophrenic patients and explained to them the limitations set within the law, and I suppose one just has to work within it.
Mr Curling: But you're just one doctor and I'm talking about the board here. Is there a strategy that you think should be put in place? Somehow they feel that the law has failed them.
Dr Manchanda: I think there is a strategy in place in that the family members are invited to the board for a hearing and present their view as to what the patient was like before hospitalization, and I've seen that happen many a time.
Mr Curling: I'm just going to say this to you, and maybe sitting on the board may reveal to you more, that they feel it's not adequate; somehow it doesn't assist them. I'm not making a judgement in that; I'm passing on information to you.
The other question I had is that it is also felt there is not enough infrastructure out there when we deinstitutionalize mental patients outside there. We saw that in the early 1980s when the government decided to do that. I personally had to deal with that when I was the Minister of Housing, to house these people -- as you said, they're homeless people. Some are being put on the street and, as you said, maybe they did not take their medication and found themselves floating there.
Is it a concern to you that when we do put those individuals out of the institution, because you feel there's an independence and they don't need to be there once they take their medicine, do you feel there is enough support out there to assist them through that process as they become familiarized again with society? I'm talking about housing and the other areas of counselling adequate there to keep them supported when coming back into the community.
Dr Manchanda: I'm sure we could do with more support, but it's not for me to decide whether that is available or not available.
Mr Curling: But I want you to decide that when you get on the board. I want you to say to them that it's not adequate while we see this need. The board will say, "It's no use putting these people out there if there is no support there." I don't need a comment from you now, but I think it's a great concern out there that people are out on the street because they're not taking medication. Your decision to release someone out there will depend on the support they have outside there in the community.
Dr Manchanda: Indeed that is true.
The Chair: Thank you, Mr Curling, and thank you, Dr Manchanda, for being before us this morning.
Dr Manchanda: Thank you very much for the opportunity.
The Chair: Would the committee like to move the appointments, please. The first is Susan Copeland to the Workers' Compensation Appeals Tribunal. Mr Mammoliti moves that.
The Chair: All in favour? That's unanimous.
The appointment of Dr Lyn Guenther to the Drug Quality and Therapeutics Committee, moved by Dr Frankford. All in favour? Opposed, if any? Mr Mammoliti, you have to vote one way or the other.
Mr Mammoliti: I'm in favour.
Ms Harrington: Everyone has to vote.
The Chair: Yes, or leave the table. It's in our standing orders and we don't have a choice, so I'll take that vote again. All in favour of Dr Guenther's appointment? Okay. Opposed, if any? Well --
Mr Curling: I voted for.
The Chair: All right.
Ms Harrington: Could it be recorded?
The Chair: Thank you. The appointment of Dr Manchanda to the Review Board for Psychiatric Facilities, moved by Mr Marchese. All in favour? That vote is unanimous. Thank you, members of the committee. If someone would move adjournment, please, we'll move into the subcommittee.
Mr Waters: I move adjournment.
The Chair: Thank you.
The committee adjourned at 1131.