Assemblée législative de l'Ontario

The House resumed at 8 o’clock, p.m.

ESTIMATES, MINISTRY OF HEALTH (CONTINUED)

On vote 2802:

Mr. Chairman: On item 1, the hon. member for Welland South.

Mr. A. J. Roy (Ottawa East): Is it my turn?

Mr. R. Haggerty (Welland South): No, sit down, you rabbit.

Hon. E. A. Winkler (Chairman, Management Board of Cabinet): Oh, you’re priceless!

Mr. Haggerty: One of these days I’m going to get a sledge hammer to get his attention.

Mr. Chairman, before the recess, I asked the minister a question about the uranium mines and milling operations around Elliot Lake and about the radioactive waste that has been dumped into the rivers and lakes in that particular area. I want to know what the minister is doing to try to bring it under control. As I understand it, there have been some problems with it in the past. Would the minister like to give us a little more information on the level of contamination?

Hon. F. S. Miller (Minister of Health): Perhaps I misunderstood the beginning of the question. Did it refer to the mines or the environs of the mines?

Mr. Haggerty: The radioactive waste that’s being dumped into the lakes and rivers.

Hon. Mr. Miller: I really feel, with great respect, Mr. Chairman that question is a question for the Minister of the Environment (Mr. W. Newman). I’ve been told by my staff that we’ve been monitoring the situation from a health hazard point of view, and that is our duty.

Mr. Haggerty: Well, that’s what I want to know. What health hazard is involved there?

Hon. Mr. Miller: Well, I thought I had said before supper that our ministry was satisfied that there was not a health hazard existing at this point in time. But it’s being monitored at all times.

Mr. Haggerty: Can you give me some of the levels of contamination then? If you’re monitoring, you must have some information.

Mr. F. Young (Yorkview): He’s got the report.

Hon. Mr. Miller: Well, I am told the monitoring report will be available Nov. 1, which is tomorrow. I will be back for estimates on Tuesday, I understand, but whatever day it is I’m back on the floor, I’d be pleased to provide figures at that time if the hon. member will permit me to wait until that point.

Mr. Haggerty: Well, since I’ve waited this long, I can wait another couple of days.

Mr. Chairman: Shall item 1 carry? Carried. Shall item 2 carry? Carried.

Vote 2802 agreed to.

On vote 2803:

Mr. Chairman: Item 1, health insurance.

Mr. Roy: Yes, Mr. Chairman, I would like to make some comments about this item and to discuss it with the minister. I made some comments in my opening remarks and in the general discussion of his ministry’s estimates we discussed what steps could be taken in this area to curtail costs.

The minister has been going around the province in the last while speaking about his concern about the question of costs.

In his speech that I quoted yesterday -- I think it was a speech made on Oct 1 -- he mentioned that one of the ways to curtail costs in terms of health insurance relates to the number of physicians. We’ve also discussed the fact that the open market system of supply and demand unfortunately does not apply to a universal health plan, in that if you add more doctors to the system you can readily see the costs increasing, and you don’t really get a competitive atmosphere in that field.

We have talked about the number of physicians, and I think the minister is in agreement with me about the question of foreign doctors coming into the province. I think we’re also in general agreement about expanding our medical schools and keeping this doctor-per-patient ratio somewhere in the area of one to 600.

The big problem, of course, is the matter of distribution. Before I leave the question of the number of doctors, I would like to ask the minister what he is doing about this question of distribution across the province.

I understand there is a plan that has been operating for some time where you pay a flat minimum rate to physicians to go to a particular area. I would like to know from the minister, firstly, what do you pay them? What is the basic guarantee that you give a physician to go to an outlying area?

Secondly, are you satisfied with that programme? I suspect that you are not, and that there has to be another system whereby you encourage people to go to outlying areas. Thirdly, there is the problem we discussed the other day, the question of the OMA saying that the government has no say at all in where a doctor is going to set up his practice. I’d just like to have answers to these questions, Mr. Chairman, and I can proceed with some of the other points on the question of health insurance.

Hon. Mr. Miller: Mr. Chairman, I had the feeling that perhaps this discussion really wasn’t a health insurance discussion.

Mr. Roy: What is it?

Hon. Mr. Miller: Perhaps we are back on the first vote again. I think I can talk about dollars, but I think the question of the distribution was properly dealt with in an earlier vote.

Mr. Roy: That may well be. Okay, let’s talk money.

Hon. Mr. Miller: Yes, we have a salary guarantee of $33,000 a year in the northern part of Ontario for physicians practising in designated areas, and a salary guarantee of $28,000 a year for those practising in southern Ontario. As you know, the line of that is across North Bay and that general meridian, if you want to put it that way.

Mr. J. E. Stokes (Thunder Bay): You finally agreed that you are --

Hon. Mr. Miller: When it comes to getting any money I’m obviously south of the French River. I’m still in northern Ontario by my standards.

Mr. J. M. Turner (Peterborough): You are not ashamed of the rest of us, are you?

Mr. Stokes: You finally found a home.

Mr. Roy: Could we get those figures on salaries for northern Ontario?

Hon. Mr. Miller: Thirty-three thousand dollars.

Mr. Roy: And for other areas.

Hon. Mr. Miller: Twenty-eight thousand. There is a grant structure which I believe is phased in over a few years, and I would be pleased either to give it to the member for him to keep or try to decipher it here. It may be safer, if you are really interested in the results, if I gave them to you to keep, because they are printed and you can have them.

Mr. Roy: That’s most generous of you.

Mrs. M. Campbell (St. George): It is Halloween.

Mr. Roy: You can send it.

Hon. Mr. Miller: This was the trick rather than the treat. You can have it.

Mr. Roy: Are you satisfied that the plan is working adequately?

Hon. Mr. Miller: Yes, as a matter of fact I am very satisfied that the plan has done a great deal to relieve the 175 areas that we’ve designated. They are not all in northern Ontario. When the plan began it was assumed there would be no designated areas except in northern Ontario. We quickly learned that places near Windsor, for example, would claim -- all of a sudden a member has opened his eyes.

Mr. R. F. Ruston (Essex-Kent): They were open.

Mr. Stokes: Yes, people had to go 30 miles for medical care.

Hon. Mr. Miller: Yes, well the fact remains that there were areas in southern Ontario that were deemed to be underserviced and so we had the plan split for northern and southern Ontario.

One talks about relative success rather than total success, but what I mentioned last night is that while we have between 40 and 50 designated and still unserviced areas, from a medical point of view, we had more physicians committed to go to these areas that we really had to have, already in the medical schools of Ontario, already under a contract agreeing that they would put their time in there. So, yes, I think it has been a success, and I have to say that when I talk to other health ministers in other provinces they are looking at our scheme with real interest because they too face these problems.

Mr. Roy: I understand when you talk about success it is certainly a relative thing. The consensus that I get when I talk to people across this province and to many members of the profession, is that you have certain inequalities. We’ve heard the member from that area talk about the services in the city of Kingston, but the minute you get outside the city of Kingston, somewhere between Kingston and Ottawa, there are many, many centres where the ratio just jumps right up. I think Kingston has one of the lowest ratios of --

Mr. Chairman: You are talking about health services. We discussed that in vote 2001. We are on health insurance at the present time.

Mr. Roy: I am just making a prophecy about --

Mr. Chairman: If you would like to relate it to health insurance, then carry on.

Mr. Roy: Yes I will. If you just hang on a second you will get to follow the trend of my argument here.

Mr. Turner: He wants to make a speech, Mr. Chairman.

Mr. Chairman: Don’t ask me to hang on too long.

Mr. Roy: Look, I’ve hung on here all day waiting for other people to make speeches, so just hang on.

Mr. Turner: So he is going to take his chance now.

Mr. Roy: In any event, Mr. Chairman, the point I was trying to make is, are you considering at all, through the health insurance scheme, having a different fee for service in different areas of the province? Has that been given any consideration as an incentive to get people to go elsewhere?

Hon. Mr. Miller: Not recently. But I have to say it has certainly been a proposed means of getting physicians to go where you need them and it is certainly not one that has been rejected out of hand. There have been suggestions made by people who are looking at the problems and trying to resolve them that you could pro-rate the OMA fee schedule by a factor or have a factor multiplying it to serve the needs of the various parts of the province. You might have a 0.8 factor in one part of the province and a 1.2 factor in another. Do you follow me?

I’m saying that was one of the academic -- that’s not a good word -- that was one of the alternatives that have been thought of by people who are looking at the problem and saying how, without legislation forcing people to go to a specific point, do you induce them to go where you need them?

We have tried this within our own ministry. If I’m not wrong, we have a different payment schedule authorized for, say, psychiatrists in the north than we have in the south because of the same problem. We had difficulty in getting these people to go where they were needed, so we paid what I think was a 20 per cent bonus.

Mr. Roy: On their fee?

Hon. Mr. Miller: No. I am talking about those who are employed by the Ministry of Health in the provincial hospitals.

Mr. Roy: Oh, I see. Okay. If I may move to the next point, and that is a question of the percentage of that total budget that goes to what we consider to be primary health care. As you know, the Mustard report and a number of other reports talk about the question of the distribution of the total budget here of some $634 million. The concern of many people looking at this budget and the distribution of it is that too much of this money is going to the specialists and not enough of it is going, let’s say, to the family physician. Going back to the question of primary health care, I have figures here which seem to indicate that the primary health care services get something to the tune of about nine per cent of the total health care budget. In a sense, Mustard seems to suggest that that should be your key. This should be the area where you have control. This is where people approach the plan, generally speaking. That is the door to the plan where you have not only the doctors but related health professionals within the field, and from that point you go to the specialist when required.

I’m just wondering what your ministry is doing to bring a better balance. In other words, within the health insurance budget, is there consideration being given to encouraging this approach? I know we talked yesterday, on this point about the problem of specialists, about too many specialists in a related field and not enough in another and not enough family physicians. I would just like again to get your comments on that point.

Hon. Mr. Miller: Last night I was asked some questions by the member for High Park (Mr. Shulman) who was challenging me to say that he had got a fair shake as a general practitioner and that basically the primary care person had got a fair shake in the last round of OMA fee changes and the 7.75 per cent increase in the fee schedule. Although I am sorry he is not here, I do believe I turned out to be right and he turned out to be wrong in his interpretation of the specific ones that we were talking about last night. I want the opportunity to discuss it with him.

One factor that I could point out is that while we gave a 7.75 per cent increase to the medical profession, effective May 1, 8.85 per cent was the average increase to general practitioners. Therefore, presumably, somewhere around 6.75 or 6.65 per cent was the increase to specialists. I can’t be sure of that, but one could argue it.

That is based not on any given fee change but on the computer printout for the mix of billings that the general practitioners and primary care people are putting into the system, if you understand what I mean. On the average, general practitioners should have got roughly 1.1 per cent over the 7.75 per cent we gave the profession as a whole. We still feel, within limits and within the scheme of the way we are doing things now, that the actual individual fees are a matter for the medical profession to decide and the total cost of the medical package is our business to decide. Okay?

Mr. Roy: What you are saying basically is that here is your budget and you split it up the way you feel best. Do you think that is adequate?

Hon. Mr. Miller: Look, it is fine to say it isn’t, but is it not better -- ? That reminds me of the father whose will to his two sons said one son would divide it and the other son make first choice -- to keep them both honest I guess. In this instance both groups have to discuss the impact upon their salaries within the numbers of dollars we are willing to spend -- we had stated that we wanted the emphasis on general practitioners. This was borne out by the fact that they perhaps got almost a third more increase than the specialists did.

Mr. Young: Not in money terms. In money terms?

Hon. Mr. Miller: Yes, in money terms.

Mr. Roy: But unfortunately very often the profession -- and I am talking not about the profession as per individual, but let’s say the Ontario Medical Association -- we are talking about the problem of how in this province it has sometimes been too slow to react to the community need. For instance, do we have enough specialists or do we have too many people in this specialty? Should we be having more family physicians?

They are not as sensitive, for instance, as you as a government should be as politicians, as people who represent the people. So if you leave it up to them we see their slowness to adapt to the community need. Of course, if you are paying a specialist more you are going to get more people going into the specialties. They lead a better life and are working more secure hours, then of course the incentive is to have more specialists. I am just wondering whether you are not giving them -- I am not saying they should be treated like children and given directives every day -- but on the other hand it is the taxpayers’ money. You as the minister should know what the community needs.

With respect to the medical profession, maybe they should not always have the last say as to how the money should be divvied. I think you should have more to say than just giving them a global budget.

Hon. Mr. Miller: I think we may have more influence than may appear at first sight, but we are not simply legislating it -- we are doing it by discussion. We have this Clawson committee which gets into the discussion of all these things and a great deal more is done by this kind of negotiation than by arbitrary, regulatory steps, I would say.

We negotiated a pay increase package with the medical profession this year that we can be proud of, from the point of view of the other increases in salaries that have gone through in other areas of the health care field. They hadn’t had a pay raise for two years at the time we negotiated -- or three years I think, at that point.

Mr. Roy: Yes, but they are still making an average of $40,000 a year.

Hon. Mr. Miller: Okay. I simply turn the question around to you. Lots of people who were demanding 12, 14, 15 and 20 per cent pay increases were also being --

Mr. Stokes: Oh yes, but you can’t base it on percentage terms, you have to do it on dollar terms.

Mr. Roy: Mr. Chairman, I intend to move to another point. The only comment I would like to make to the minister is that he may well be proud of the agreement that he reached with the doctors in relation to fee increases. But because of his accessibility and his easiness in giving the doctors these fee increases, and not having considered the hospital workers who were caught in a bind and the nurses and everybody else within the system, then the minister left himself open for increases all the way up. I felt that the increases should have been negotiated much sooner for the hospital workers and the nurses and the technicians than those for doctors.

Mr. Chairman, I just want to ask the minister this question: Are you satisfied now with the regulation and the discipline being taken by the profession in relation to abuses in the health insurance plan? You recall that your predecessor had great difficulty with, or experienced headaches in relation to certain doctors who had abused the plan in relation to their billings. We had lengthy discussions in this House here about charges that were going to be laid. They had been given to the Attorney General, apparently -- this information and the decision as to whether some of these people should not be prosecuted for fraud.

The first question is are any going to be prosecuted for fraud? Secondly, as it would appear that that is not going to be the case, are you satisfied with the way the profession itself disciplines its members, and have in fact the abuses been curbed, because of the actions of the profession?

Hon. Mr. Miller: Well, action has been taken to prosecute a certain number of physicians for fraud. I believe the number is seven.

Mr. Roy: Any convictions?

Hon. Mr. Miller: No convictions yet. At the same time, I would say the medical review committee, which has been the agency -- the practitioner-review group -- looking after the physicians who were suspected of incorrect billing practices, had been extremely successful. It is not at all popular with a good number of the people in the medical profession. It is made up of medical practitioners and is run as far as I know by the College of Physicians and Surgeons. It takes the information handed to it by OHIP, makes a decision which is binding, as I understand it, upon the general manager of OHIP, and then follows out the instructions of that committee.

Now, I personally see every single report of that committee. They all come to my desk, with a report on whether they found the physician who was suspected of billing incorrectly or excessively or whatever it may be, or fraudulently, and it tells us the findings of their study, and it gives a recommendation to the general manager saying: (a) we found nothing wrong; therefore pay this man’s bill, or (b) we found that 52 per cent of his general assessments should be billed as office visits, or something of this nature; therefore take the following action to recover it -- things of this nature. I think the most important effect has been its deterrent effect, rather than its effect in bringing people to court or recovering money.

Mr. Roy: Do they publicize their findings?

Hon. Mr. Miller: No.

Mr. Roy: Why not?

Hon. Mr. Miller: Well, I think that there are very good reasons why they should not be published. I think it is not the kind of information that would be in the general public good.

Mr. Roy: One of the best deterrents for keeping people in line, according to anybody who knows anything about justice, is the fact that matters are dealt with openly and the public is made aware. The dental association, as I understand, publicize much of their discipline against abuses. The lawyers publicize their --

Hon. Mr. Miller: They are publicized.

Mr. Roy: You say the discipline that is taken against the doctors is publicized? Well, that is what I wanted to know.

Hon. Mr. Miller: These are not disciplinary actions. These are actions to determine whether the billings were correctly done and whether the services were rendered as shown. Now, if there is fraud, that is a different thing altogether, isn’t it?

Mr. Roy: Yes. Well, we have had individuals we have read about in the paper who, let’s say, saw 150 patients in one day or in one afternoon when it was absolutely impossible to see that many. Once the finding is made and the reimbursement has to be made to the plan or you decide to prosecute him or not, is that finding publicized?

Hon. Mr. Miller: No, it is not. At least, we don’t make them public -- in other words, we don’t publicize them, but if there is a reason for a disciplinary action, then it goes through the normal route and that is initiated by the college.

Mr. Roy: By the college.

Hon. Mr. Miller: Yes.

Mr. Roy: I asked you a question in my opening remarks and I wonder if you are in a position to answer it now.

I asked if you had figures to show the percentage of population which takes a large percentage of the global budget, for instance health insurance. In this health insurance programme, payments to the doctors and other professionals cost $634 million. Are you in a position to tell me, whether, generally speaking, about 25 per cent of the population take up 75 per cent of the budget, or something along that line? Do you have figures on that?

Hon. Mr. Miller: I was just checking with the general manager of OHIP to see if we have this kind of data breakdown. We have all kinds of data on file. The patient profiles are basically there. Some day I think you would be interested to see how an OHIP office records information. As the opposition critic, you should know.

Mr. Roy: You talked about curbs. You know there’s great concern about the rate of increase of the global budget, not only the question of health insurance but on the question of hospitals and the amount of money that costs, and the rate of increase. Are there any curbs or constraints at all on the general public in the use of health insurance?

Hon. Mr. Miller: No, there aren’t. That’s one of the areas that is difficult to do much about. You are talking about action against a patient who is an abuser of the system.

Mr. Roy: I am not talking about action.

Hon. Mr. Miller: If we found out they were getting things like general assessments too often at the same place, we have a mechanism, don’t we? We have three a year? One a year. And two reassessments. So we have a total of three. In other words, if you kept going to see your doctor and saying, “Look, check me over and see how I am,” we have a procedure by which the IBM -- I must never use a specific company name; what do they call those things besides IBM?

Mr. Roy: It was IBM.

Mr. Stokes: Computerization.

Mr. Roy: You had the right name. It is publicly tendered now so you can talk about it again.

Hon. Mr. Miller: It could be something else. The computers do store that kind of information. For example, if you have had an appendectomy and you are billed for an appendectomy, the machinery has to grind out the fact that you only have one appendix.

Mr. Roy: I appreciate that. But I am sure I have read that there’s a relatively small percentage of the population who take up a very large percentage of the total budget. You will recall back in the days of the Liberal government in Saskatchewan, Premier Thatcher tried to put a deterrent fee on the use of it. What happened to him, of course, was he lost the next election. But aside from the fact --

Mr. J. R. Breithaupt (Kitchener): Would you like to do the same?

Interjection by an hon. member.

Mrs. Campbell: That’s one way of putting it.

Mr. Roy: You talk about the general assessment. That’s an improvement, because I recall your predecessor, Mr. Lawrence, saying they had evidence that certain 18-year-old individuals would get three different assessments in the same week from three different doctors. That must have been changed since. Are there any other curbs or limits to the use of the service by a patient?

Hon. Mr. Miller: Not that I know of. But I think you have got an incorrect assumption if you say that a small part of the population utilizes the greatest part of OHIP. I am told this is not so. If we change it around and look at the ages of the population using OHIP, we have a more meaningful picture of what’s happening. I have seen figures on the relative usage of the system by the various age groups. I can’t remember exactly what they are. But it seems to me the under-25 age group uses one quarter as much as the over-65 age group.

Physicians often ask what you are going to do about the patient profile, and what action you are going to take against the person who shops from doctor to doctor. But it’s pretty hard to do anything because you are dealing after the fact in most cases, aren’t you? I am told we have statistics that say it is not a problem in that sense --

Mr. Roy: It is not a problem?

Hon. Mr. Miller: Yes, if the statistics are there perhaps I can --

Mr. Roy: The reason I ask is that my discussions with the medical profession and many people around the field suggest that a good percentage of the people who come to see them and fill up their schedule and cause their working 15 hours a day and seeing this large number of patients per day, need not be there. They get this day in and day out, week in and week out.

Hon. Mr. Miller: The hon. member for Oshawa might correct me, but I’ve heard that about three-quarters of the people who have services rendered by general practitioners are deemed to be psychological rather than medical. I don’t know if he’s going to nod his head up or down or sideways or backwards.

Mr. Roy: He doesn’t want to answer that.

Hon. Mr. Miller: I was looking for my one point of assistance from you. We were just saying that, in fact, we heard doctors say that perhaps up to 75 per cent of the services they render to people in their offices are of the reassuring or psychological type, rather than of the medical type.

Mr. C. E. McIlveen (Oshawa): I think 90 per cent would get better without them.

Hon. Mr. Miller: Well, I don’t know whether we want to use you as an example. It’s an awful admission to make in public.

Mr. Roy: It would appear that the only curb -- but you say that is not a problem. The medical profession seems to think that it is.

Hon. Mr. Miller: Well, quite honestly, you and I attended a psychologists’ meeting last January, I think it was, in Ottawa. He was their classic case.

An hon. member: He’s beyond hope.

Hon. Mr. Miller: Their argument was the cluttering up the doctors’ offices demanding attention, in their opinion -- I’m not quoting mine right now -- were better looked after for their fears and anxieties by the psychologists. This would take a load off the doctors in their offices. Because they said that as long as you don’t treat the basic social problem the person has or his concerns, he remains a medical problem.

Mr. Stokes: Would it be cheaper to send them to a masseur?

Hon. Mr. Miller: You may be right.

Mr. Roy: I’m trying to think of ways to try to keep some control over the increases in your budget and of ways which could improve the system. You’ve said many times, and we’ve said to your predecessors many times, if the increases keep going at this rate we’re going to bankrupt ourselves with this plan. I’m just quoting you when I’m saying that. It would appear that the only curb on the use of the patient, aside from a few isolated instances, is in fact the doctors themselves. That may be one of the reasons why it’s difficult to control the cost. When you increase the number of doctors you can see the geometric progression of the cost of the plan very easily.

I think that should be looked at, frankly. Because as unpopular as it might be, I think you’re better off with a plan which might not be found universally acceptable, but at least it’s a plan that works. As you’ve said yourself, if we keep continuing at this rate, somewhere along the way somebody’s going to have to take much harsher measures to bring it back into line.

The other point: Do you think any money could be saved at all on the question of remuneration to the doctor? This famous fee for service? I’m not talking about forsaking the fee for service completely, but as you know, Mustard again --

Mr. Young: Why not?

Mr. Roy: Basically for this reason, Mr. Chairman. Because if you start putting everybody on salary, the first thing that happens is that then you get people working 9 to 5 or 9 to 4, and you need that many more doctors so you’re paying that many more salaries and you’re not saving any money.

Mr. J. Dukszta (Parkdale): I think that should be done with lawyers’ salaries, too.

Mr. Roy: If you start paying us out of the public funds we might go on salary. That wouldn’t be bad. If you were paying us $40,000 -- I saw some advertisements in the Sudbury paper the other day for a doctor to work in a hospital from 9 to 5, five days a week, $40,000 a year. That’s what the going rate is.

But in any event, what I’m talking about is that Mustard has suggested different systems of remuneration for doctors. For instance, the mixture of annual capitation along with a reduced fee for service. Are you giving any consideration to some of these alternatives? For instance, specialists that are working out of hospitals -- how come these people are not on salary? That seems to be a situation where certain doctors, who continue to work out of one particular institution, should, in fact, be on salary. Pathologists, for instance, who are always using hospital facilities and working in a hospital, possibly should be on salary, especially in light of the fact that if you look at their billings it is just fantastic.

An hon. member: They have got it made.

Mr. Roy: Pathologists, radiologists -- people like this. What I was wondering is whether you are giving it any consideration or discussing it with the profession. I know this is very touchy with the profession. Again, this is one of the things that they said to you the other day -- that the government has no say how they are going to be paid. I suggest to you that when you are paying with public funds, there should be some say by the government as to how they are going to be paid. Are you giving any consideration to saving money by alternative methods of payment like this?

Hon. Mr. Miller: Yes, we are, as a matter of fact, and that goes back to several things. The Clawson committee had as one of its terms of reference the suitability of alternative methods of reference for different specialties or different modes of practice. Now, I mentioned earlier that we had some 23 clinical groups working and that we were talking to another 40 groups, all of whom are talking about different payment mechanisms in direct contact with the patient, either capitation salary of some form of global budget.

We also have been talking about putting certain types of specialists, like pathologists and radiologists, on salary in the hospital system where it is suitable. I think you will find this is starting to be done in a number of cases.

Mr. Roy: Is it?

Hon. Mr. Miller: Yes, it is. I can’t give you figures but --

Mr. Young: Could I ask the minister where radiologists and pathologists are going on salary in hospitals?

Hon. Mr. Miller: Other than fee for service, you mean? I think in my own area, as a matter of fact, there is one pathologist who I understand is paid a contract fee for coming and doing the work.

Mr. Roy: Contract?

Hon. Mr. Miller: Yes.

Mr. Roy: But not on salary.

Hon. Mr. Miller: Well, it is a contract, which is not a fee for service. In other words, it is a mechanism of payment that is not necessarily related to the number of specimens that he personally examines.

Mr. Roy: If I could just follow up on this, Mr. Chairman, the last point I want to raise is the question of payments. This is something that I had raised with your predecessor, (Mr. Potter) that certainly this is something that should be considered. I am surprised, Mr. Minister, that this process in relation to salaries to certain of these specialists has not been accelerated.

For instance, I was reading in the paper an advertisement -- I think it was from Sudbury -- where I understand he was to work in emergency, where they work from 9 to 5 five days a week, and I think it was $40,000 a year. Does the ministry have anything to do with that, or is it the individual hospital that decides on putting certain of these people on salary?

Hon. Mr. Miller: I understand in that case it is the hospital that does that.

Mr. Roy: It is the hospital, out of the hospital budget?

Hon. Mr. Miller: Yes. I have some statistics here on group costs that might interest you. The average per capita costs -- I think these are for medical payments only. By “groups” we mean people who have been insured in a group plan, I assume. The average per capita cost of those patients who are in group payment forms is $63.40 per year, I guess. For those like myself who pay directly, it is $75.37 per year. Partially assisted premium people -- maybe we should start assisting a lot more people partially, by the look of this -- pay $26.77 per year; fully assisted pay $58.39 a year.

Mr. E. R. Good (Waterloo North): That would include over 65?

Hon. Mr. Miller: Those 65 and over pay $72; DVA, $80.19; municipal or provincial welfare people, $61.45. The overall average is $65.66.

Mr. Roy: If I just might finish the point I raised about the question of payment to doctors, I take it from your response that what you are doing basically is waiting on the profession to come up with the initiative. You might suggest it to him but the initiative in a decision, basically, will have to come from the profession about deciding alternative methods of payments.

Like I say, we’ve mentioned that to your predecessors. I can’t get over the fact that the plan here; which started when -- in 1968-1969? When did this plan start?

An hon. member: After that.

Mr. Roy: Let’s say, for the sake of argument, 1968. A similar plan such as this had been in operation in Saskatchewan since about 1960. So you had eight years to look at the system working and you’re getting the same problems here that they had in Saskatchewan. Yet, you seem to be operating here on a hit-and-miss experimental situation, when you’ve had Saskatchewan to look at for 10 years and when you’ve had England to look at for however many years they had a system of payment.

Hon. Mr. Miller: Both of those are the very best reasons we have not been moving too fast in the directions they did.

Mr. Roy: Oh yes, but surely whether you adhere to their philosophy on politics or anything else, the system was working down there. Every time you encounter a new problem -- whether you’re talking fraud on the part of the doctors, or abuses, or certain specialties making too much money or not enough money, or whether they should be on salary -- all these problems were encountered in other jurisdictions, yet you seem to be experiencing them for the first time here and reacting accordingly on your own sweet time and making sure that you’ve had full discussions with the profession.

I suggest to you that there has not been sufficient leadership. There’s been a lot of talk. Lawrence has been talking, Potter’s been talking and now you’re talking about how things have got to get tougher. But, frankly, I suspect that when it comes to consultation and discussions with the profession you really back off.

Hon. Mr. Miller: I’m glad to hear that if you were Health Minister you would have a confrontation with the groups; that you would dictatorially, unilaterally make decisions and ram them down their throats.

Mr. Roy: No, no, that is not at all what I was saying, Mr. Chairman. I’ll tell you this. When I look at the amount of money we’re spending -- when we’re talking about a 20 per cent increase in the budget again this year; when you talk about ceilings and their farce, when you talk about a seven per cent ceiling in hospitals and it turns out to be more like 20 per cent; when you’ve heard a minister like Lawrence talk about the abuses and how it’s going to bankrupt us and you’ve heard Potter, now you’re hearing Miller -- I’ll tell you something, I think something should have been done before and I don’t consider that confrontation. I consider that to be leadership.

Mr. Chairman: The hon. member for Yorkview.

Mr. Young: Mr. Chairman, just to continue part of this discussion, the minister has warned us, as the member for Ottawa East has told us, that 16 per cent compounded annually would mean that in 10 years time the provincial health-care bill would be around $11 billion. That’s from his speech on Sept. 19.

I would like to ask about one of the facets which we have discussed here before tonight, that is the matter of the procedures offered to the patients. In an “immediate release” from the Ministry of Health we have this: “The increase resulted for October in some 175,000 more patients being treated, and 941,000 more services being rendered in October than September.” The November increase mentioned here “was brought about by an additional demand on health care -- 104,000 more services were rendered although the number of patients treated remained constant.” What are these services that are skyrocketing in this manner? Can they be specifically pinpointed?

Hon. Mr. Miller: I think that one needs to get the annual chart that shows the monthly variations in the numbers of services rendered, the number of hospital days and things of this nature. You’ll see that we have an annual cyclical variation, dropping to a low point across the summer months and then going up as we reach the fall and wintertime, dropping down around December.

Mr. Young: It drops in December?

Hon. Mr. Miller: Yes. It’s simply that in the summertime physicians are on holidays and so are patients.

Mr. Young: They are feeling better then.

Hon. Mr. Miller: Yes. Maybe it’s because the weather is better, but there is traditionally a drop in all the factors across those months, and then many things are elective and, of course, can be put off until the fall. I believe we had some hospitals around Toronto that actually had to close wards across the summer because they were not busy enough to justify staying open.

Mr. Young: That’s true.

Mr. Stokes: Could you send some of those active treatment beds up north?

Mr. Young: Many hospitals did have to close certain quadrants and I know of some of them.

Could I ask about a situation in regard to pathologists and radiologists, Mr. Chairman? Some hospitals have been trying to get these people to work on salary, and this is why I ask the question, but the organizations that these people represent, say, “No such thing. We are not going to have any of our people working on salary.” Even the students coming out of medical school, trained in these techniques, are told that there is a fee for service and that is it.

This is one of the problems we face as far as the costs are concerned, particularly in hospitals, and it may well be that the minister has some solution for this -- or is working toward a solution.

I wonder whether or not there is some answer to this matter of a pathologist in his lab testing blood samples. If a bleeding station takes a blood sample, it goes to the lab in the hospital or perhaps to another lab outside, and that particular sample may be tested for one, two, three, half a dozen, up to 20 or more different things. That is, we want to know certain things and so you have a dozen or 20 tests. Is it not true, Mr. Minister, that each one of those tests is paid for separately by OHIP? If so, then perhaps here is a place where we ought to be looking. Could I have an answer to that question about this kind of payment?

Hon. Mr. Miller: I let my attention waiver halfway through and I am not sure I got the full import of your question, but you are talking about laboratory diagnostic tests?

Mr. Young: That is right.

Mr. F. A. Burr (Sandwich-Riverside): On one body.

Hon. Mr. Miller: I will try to explain what we have done. This is the LMS bit that we have at the present time, if I have my terminology right.

Mr. Young: You mentioned it the other day and I was interested.

Hon. Mr. Miller: Yes, labour, material, supervision. We have taken each of the lab tests that are done and have given them a value in terms of units of work. We price a unit of work at 0.33 cents. If a test is worth five units, then it would be $1.65 that we would pay.

These LMS units were worked out pretty carefully and in general are based upon the best technology available for doing a given test, rather than the way it may be done in a specific laboratory. I don’t know whether you have been through some of the more automated laboratories lately, but some of them can handle blood tests so quickly that it curls your hair. That’s something I have been trying to do. In any case that has been a major change in the last year in the approach towards the payment of laboratory services in the Province of Ontario. It’s now under review because the laboratories have been convinced they are not getting as much money in total as they used to get, and that they aren’t getting a fair return on their investment. But we have a mechanism to look at this, and we are doing it. I think their last estimate was they were making 92 per cent of the amount they were before we went to LMS.

Mr. Young: What actual cash amount would be paid for the average test?

Hon. Mr. Miller: I don’t know that I have that figure. Do we have a figure for the average cost per test? The average number of units? If we can hold on a second I can get it for you. Do you want to go on with another question and let me return to that in a few moments when we find the page?

Mr. Young: My question is of the average costs for tests and how it is split up. What does the bleeding station get? What does the lab get? And I presume today the doctor who refers gets no part of it -- that if he is caught getting something then he is in trouble. I think this is the case at the present time.

Hon. Mr. Miller: Well, you know, we went to a laboratory licensing programme too. I don’t know whether that’s under this vote or not --

Mr. Young: Well does part of --

Hon. Mr. Miller: I would think it is under vote 2803, item 6, as a matter of fact.

Mr. Chairman: But I think the member for Yorkview is relating it to health insurance.

Hon. Mr. Miller: Again, I can’t answer that question off the top of my head, but I think the doctor is only paid for those services he personally renders in the diagnosis and treatment of a patient.

Mr. Chairman: Perhaps the member for Yorkview could save that question until we come to item 6 as far as laboratory services and costs are concerned.

Mr. Young: All right, I can save that part of it. But I am thinking in terms of the amount of money that comes out of the OHIP fund at this particular point.

I would like to ask the minister again -- and I suppose this question should come later too -- what proportion of the labs and the bleeding stations may be owned by doctors themselves. Let’s go into that later, and perhaps we’ll get some answers.

I want to ask the minister this: Where we have labs and x-ray facilities in hospitals, is it not feasible that the pathologists and radiologists who are working in hospitals, with hospital facilities, should go on salary? I know this has been talked about for some time, and the member from Ottawa mentioned it, but it seems to me these people are part of hospital staff, and instead of thinking in terms of the units of work done, they should go on salary and be part of the salaried staff.

Hon. Mr. Miller: Well, I can answer that. There is no reason why they can’t be treated that way at the present time. The hospital is free to do this. There is a growing number of people electing to do this kind of thing, whether it is in primary care, tertiary care or secondary care.

I only suggest that I am not as yet convinced that there is a saving in money for service rendered by that method. There will be, I think, a saving in a couple of the specialties you just talked about, but I’m not satisfied yet about the others --

Mr. Young: Those are the two specialties I talked about.

Hon. Mr. Miller: I think you have chosen the best two to talk about in terms of the terms of the fee-for-service setup versus the salary setup. I think I would tend to agree that there are a lot of reasons to look at those two and to encourage it.

Mr. Young: What is happening today is that because they can’t get the people to work on salary, hospitals are being forced to rent the facilities to the pathologist or the radiologist and, of course, he pays his rent to the hospital out of his fee for service. That’s the way it is done.

It seems to me that the more sensible thing would be to work it out on a salary basis, but I think it’s going to take some real persuasion or a bit of leaning on the part of a minister on the organizations concerned to accomplish this result.

Hon. Mr. Miller: Well, that is one of the areas where I would think supply and demand will have a great deal to do with the eventual solution of the problem. I think one needs to look at the breakdown; and we have the breakdown here for diagnostic radiology in terms of the amount that is the professional component and the amount that isn’t. Radiologists, I am told, have more hidden costs than other specialties, so they don’t retain as much of their fee schedule as you may assume they do.

Mr. Chairman: The hon. member for Brant.

Mr. R. F. Nixon (Leader of the Opposition): Thanks, Mr. Chairman. I want to ask the minister a question pertaining to ambulance service, which I gather comes under this item. Specifically, I think the minister probably has been getting some of the mail I’ve been getting, which has been somewhat critical in a few areas of the decisions pertaining to the awards of the franchises for ambulance service.

Mr. I. Deans (Wentworth): That is the next vote, isn’t it?

Mr. R. F. Nixon: I’m sorry. I thought that --

Mr. Deans: That’s the next vote. I have been waiting for that.

Mr. Stokes: Yes, there is $18 million for emergency services in the next item.

Mr. Haggerty: Sure. Right on.

Mr. Chairman: We are dealing with health insurance. Does the hon. member have anything to say --

Mr. R. F. Nixon: It says, “Payments for ambulance and related emergency services,” -- oh, okay. All right.

Mr. Stokes: We will get to you later.

Mr. Chairman: The hon. member for Sandwich-Riverside.

Mr. Burr: Well, Mr. Chairman, I came in and I thought we were talking about how to keep the cost of OHIP down. Is that okay? I come from Essex county where the physicians pioneered in this type of programme. Windsor Medical Services was the pioneer, I think, in Ontario, or at least in at a very, very early stage. They had a very simple system. They took the total amount of their premiums from all the customers and they paid the money out to the physicians on a basis of approximately 90 per cent for the physicians and 10 per cent for the overhead. In fact, I think that is why, when OHSIP started that figure was used, the 90 and 100 per cent.

The doctors in Essex county loved this system, because for the first time they didn’t have to worry about collecting the money or, if you like to call it, working for nothing for large numbers of their patients. I know very well a doctor outside of this system in Ontario who worked 50 per cent of the time for nothing. Until OHSIP came in in his part of the country, he was getting $16,000 a year and when OHSIP came in he immediately got $32,000. So the doctors loved this system. I don’t see why you couldn’t extend this system to the whole province.

This would mean that you would have a definite sum collected in any given period from the premium payers and from the government’s contribution. Does the federal government still contribute? It does. You would have a definite sum and this would be paid out to the physicians on a pro-rated basis of approximately 90 per cent. If the doctors were putting in what seemed to be excessive accounts, then they might have to settle for 88 per cent. If a period of good health came along and there were fewer bills, they might go up to 92 per cent. You would allow for the administration off the top, and the physicians would pro-rate the rest of it.

The Windsor Medical Services had a few problems. There was one doctor who always sent in about twice as much as he deserved in bills. The association or the board always paid him 50 per cent of what he asked for and he never complained. The board members knew their fellow physicians and they employed a self-discipline or an interdiscipline upon the members. It worked out very, very well and the people in our area were quite sorry to see Windsor Medical Services discontinued. It seems to me that this kind of a system extended throughout the province would solve your problem of uncontrollable budgets.

All the ministry would have to do in estimates each year would be to provide the escalated budget in response to inflation. That would be your problem. You wouldn’t find that you were getting excessive bills every month and going $2 million or $3 million or $5 million over the ceiling that you had budgeted for. This seems to be a very sensible system that we had. It seems to me that you could use this system, adapt this system and achieve your aim of controlling the health budget for Ontario.

Hon. Mr. Miller: Mr. Chairman, to say that kind of system hasn’t been considered would not be correct. Let me give you what is currently the way we are paid by the federal government. The federal government pays us a percentage of the actual expenditures for doctors services in the Province of Ontario, estimated at 50 per cent of the national cost. It means Ontario gets a little less --

Mrs. Campbell: Same as Ontario and Metro Toronto. Exactly the same thing.

Hon. Mr. Miller: -- because we send more than our share to the have-not provinces. I am not going to argue that particular point. We get a share from the federal government of the actual expenditures to physicians. The OHIP premiums, which are only a small part of our total income, plus the provincial share, plus the federal share, are not a constant. They are variable depending upon the number of people who go for services. The OHIP part, the premium part, is a constant.

Mr. R. F. Nixon: Five hundred and sixty million dollars.

Hon. Mr. Miller: It was $505 million last year so it’s coming along. Pardon? Five hundred and forty; you have just jumped it a bit.

Mr. R. F. Nixon: Oh, sorry. Don’t let the Treasurer (Mr. White) know.

Hon. Mr. Miller: The other way of attacking it, of course, is simply to set a maximum figure for payments to doctors. If we were following your procedure, we would say $600 million will be paid to doctors in the year 1975-1976 no matter how much they bill us.

Mr. Burr: Right.

Hon. Mr. Miller: And then pro-rate them? It has not been discounted as being impossible, but, at the present time our budgeting methods and prediction methods are so accurate on OHIP we are virtually doing the same thing. When we negotiated with the doctors we could tell, within a very very small margin of error, how many dollars would be needed for the year. For example, the total increase over last year for OHIP claim payments was $62,218,000. That’s an increase of 10.9 per cent over last year. Of that, 1.7 per cent was because the population went up; 3.9 per cent because people were using doctors and dentists more per person; 5.3 per cent because we allowed a rate increase midway through the year.

We have been very accurate. Our monthly projections of the demands on the system, and the actual demands, are almost identical, so we have effected that to some degree. Ours is open ended and you are suggesting a closed system. Ours is open ended only in the sense that we negotiated with doctors for a 7 3/4% per cent increase in salary. We said that’s how many millions of dollars we can give you and we will work it out and see how we will divide it up among the various fee schedules.

Mr. R. F. Nixon: Mr. Chairman, I would like to try again on a matter that is more closely related to health insurance.

Mr. Chairman: Is this question the last one?

Mr. R. F. Nixon: Yes, I hope so. Perhaps the minister has already expressed his view about this, but one of the things I find personally in my own family, when members of my family make use of medical services, is the fact there’s never any indication of what the practitioner is paid for providing those services. Would it not be some means of control, if a bill were rendered not only to you or the OHIP programme, but also directly to the patient or the family person responsible for meeting those costs? I believe it would have a salutary effect and would not be unduly expensive.

Hon. Mr. Miller: I would tend to agree with the Leader of the Opposition. It would have a salutary effect. To a degree, there are some technical problems in the way. I set out as parliamentary assistant to get just that kind of a system working.

Mr. R. F. Nixon: Something happens to all you fellows when you become ministers. You give up on your good ideas.

Hon. Mr. Miller: Yes, right. I haven’t given up on it at all but I will try to explain some of the intermediate problems. First, we have gone to a system of auditing that does allow a certain percentage of people to be aware of the amount that has been charged on their behalf by a physician. They are getting detailed statements saying, “You got the following services charged under your name by Dr. So-and-so. If you did not receive any of these services please advise us of this.”

Mr. R. F. Nixon: Does that cover a year?

Hon. Mr. Miller: It is a monthly statement that would be given.

Mr. R. F. Nixon: Why can’t you require the doctor to send a bill to me at the same time he sends it to you? Let him do it -- let him pay the postage.

Hon. Mr. Miller: When you look at the things I was talking about in the second phase of the hoped-for plan that I had in mind -- and I think you have heard other ministers talk about it -- there was some type of a Chargex card that would allow you to get an instant copy of the bill which you were remitting.

That isn’t done as simply as it seem. The doctors have a lot of arguments as to why that doesn’t work. For example, they do multiple billings on one card. Sometimes a physician bills for a patient he is seeing regularly once a month on only a single solitary card. If you will notice the way the card is made up, he can do that. There is no use filling one out every time he sees a patient because --

Mr. R. F. Nixon: Are you talking about the Chargex cards?

Hon. Mr. Miller: No, I am talking about the actual computer card that he sends to OHIP showing why he is charging and what services he rendered. He is allowed to put a multiple series of visits on it. For example, if he is seeing you in the hospital every day for the next two weeks, then he may show these all on one card and make one charge.

Mr. R. F. Nixon: I think we could cope with that.

Hon. Mr. Miller: Yes, well, secondly and more importantly though is the question of the identification of the patient to whom this information is sent. Is it in fact the policy holder or is it in fact the patient who gets the information? Now you are into an area of personal information that is not easily resolved. Would you like to say something at that point?

Mr. R. F. Nixon: Suppose OHIP didn’t exist. Why wouldn’t the bill be sent to the person it would be sent to under those circumstances?

Hon. Mr. Miller: It happens to be that we handle you according to the policy holder at the present time. Our whole numbering system is based on the policy holder, not upon the individual in that policy, and there is no simple way at this time of identifying him.

I am convinced there will be. I am sitting here telling you that as soon as we can get the federal government to give us the right to use SIN numbers as a birth-identification number and then become the unique identifier, we will have the system going.

Mr. Roy: Bert Lawrence was saying that in 1971.

Hon. Mr. Miller: He was talking about the credit card, he wasn’t talking about the BIN and the SIN.

Mr. R. F. Nixon: Are those different?

Hon. Mr. Miller: That’s the “sin bin.”

Mr. R. F. Nixon: Are they different numbers?

Hon. Mr. Miller: They are now.

Mrs. Campbell: Give us any more numbers and we will all go for psychiatric care.

Hon. Mr. Miller: Sure, that’s the problem. This is why we have done a very complete study. I can tell you that it is my opinion that sooner or later that will happen.

Mr. Chairman: Item 1 carried?

Mr. A. W. Downer (Dufferin-Simcoe): Mr. Chairman, I would like to ask a question.

Mr. Chairman: The member for Dufferin-Simcoe.

Mr. Downer: The patients that are in hospital under workmen’s compensation -- are their medical costs and hospital costs paid by you or do you pass that back to the compensation board?

Hon. Mr. Miller: Paid by the compensation board.

Mr. Downer: Do you charge it back?

Hon. Mr. Miller: It never comes to us, I am told.

Mr. Downer: Well, they do. In our local hospitals -- the people go from the compensation board to the local hospital.

Hon. Mr. Miller: I have now had the explanation of the arithmetic. The hospital bills the compensation board?

Mr. Downer: Yes, the medical --

Hon. Mr. Miller: The compensation board pays the hospital and we get it back because it is shown as offset revenue. In other words, it comes off the amount of money we transfer to the hospital. Does that satisfy you?

Mr. Downer: No, that doesn’t answer the question.

Mr. Roy: Go get him, Wally.

Mr. Downer: That doesn’t answer the question. After all is said and done, that money should be paid directly to you from the compensation board. You should be reimbursed completely. Otherwise industry is getting away with it.

Hon. Mr. Miller: No, no, don’t misunderstand me. It comes off the amount of money we would have given the hospital. Let me try to explain it the way I understand it. It is like a number of other offset revenue scheme we use with hospitals. If you are in there as a workmen’s compensation patient and the bill was $1,000, the hospital would send a bill to the Workmen’s Compensation Board for $1,000, and it would get it. It would go into their books as a receipt, $1,000. We have told that hospital it can only have $1 million from us for the year’s operations. Since they got $1,000 from somebody else, they get $999,000 from us. Okay?

Mr. Downer: Fine. What about the US citizens in the border cities coming into our province?

Hon. Mr. Miller: Oh, that turned out to be a falsehood in terms of the statements. Somebody juggled the figures in one hospital and came up with an incorrect conclusion. The truth is, every province, every state, has a certain number of patients who, for one reason or another, obtain their medical services outside of their own home area. This is either because they’re visiting abroad, or because it’s convenient to go to a facility that’s closer to them. I think in northwestern Ontario --

Mr. Stokes: In Warner Lake they go to Winnipeg.

Hon. Mr. Miller: They go into Winnipeg, yes. In Hull they go to Ottawa. In some areas around the US border they come to Ontario. At the same time, many of our patients utilize facilities in the States. You know, we’re one of the few jurisdictions where our insurance covers you when you’re out of your home province. A lot of people don’t know that. But if a British subject comes to Canada, he’s just s.o.l.

Mr. Stokes: What does that mean?

Mr. Breithaupt: Let’s just say he’s not going to get any.

Mr. Chairman: The hon. member for Parkdale.

Mr. Downer: If that’s true of the compensation board --

Mr. Chairman: Oh, I’m sorry. The hon. member for Dufferin-Simcoe.

Mr. Downer: If that’s true of the compensation board, that you charge it back to them, then do you charge the same thing back to the Department of Indian Affairs for looking after the Indians, and also the veterans’ allowance people? Do you charge that back?

Hon. Mr. Miller: I’ve been having a long running argument. I’ve even made some quotes in the papers in the north that got me into some trouble. I’m afraid I might lose my scalp, as a matter of fact, literally --

Mr. Roy: Keep at it. You don’t have much to lose.

Hon. Mr. Miller: I’m going to take them along and show them your picture.

Mr. Roy: It’s misrepresentation; that’s what it is. Terrible!

Hon. Mr. Miller: Yes it is. You haven’t seen his picture in the paper today, sir, but it shows him in a very good light.

There is an argument between the federal government and ourselves as to the responsibility for Indian payments. The federal government, I think, if I’ve got the story straight, looks upon many of them as being residents of the Province of Ontario who should be treated as other residents. And since the great bulk of them are eligible for free OHIP, they simply say when they come into the hospitals, they are normal residents and they should be paid for by the province. And yet, at the same time, they insist on running at least two of our hospitals for Indian people, charging us, in the process, for supplying that service. And in my opinion that is not fair.

Mr. Downer: I agree.

Mr. Chairman: The hon. member for Parkdale.

Mr. Dukszta: I just want to make a point, which you must be aware of, Mr. Minister. It is the difference in the rise in salaries of physicians, as compared with other industrial groups. I want to ask you what you propose to do about it?

I think I will quote to you the figures which are available from the Department of National Health and Welfare. They are largely applicable to this province. In 1960, the average, net professional earnings of an active fee practice physician in Ontario were $16,754. In 1971, it was $41,363.

Now, I have made a comparison on an annual basis of physicians’ earnings and the average weekly salaries in Ontario for the industrial composite, multiplied by 52.

In 1961, the average net professional earnings of an active fee practice physician was $17,682. In 1971, it was $41,363. The percentage increase in that decade is 133.9 per cent. The average annual per cent of change is 8.9 per cent. Now, the industrial composite for 1961 is $4,228, and in 1971 industrial composite is $7,437. The percentage of increase is 75.9 per cent and the average annual per cent of change is 5.8 per cent.

Now, those industrial composites are general. I have no particular figures here for the hospital workers, but I suspect they are much smaller. Can you give me an explanation why it should be so? What you are preparing to do about it? Will you compensate further the hospital workers, who are grossly underpaid in comparison with physicians?

Hon. Mr. Miller: I take exception to the last statement you’ve made -- they are no longer grossly underpaid. I think the facts and the figures that came out this year will illustrate that. I had no regrets this year when major changes amounting to 50 per cent over two years were granted to the low-paid service employees at the hospitals; in those same two years, the total amount given to doctors was 11.75 per cent.

Now, surely that was where the argument stemmed last night. I recognized that the doctors had increased their relative pay from 4 to 5.4 times the average composite pay. I don’t know whether your figures or mine would show those as being exactly the right ratios, but in the periods of time I had, doctors had improved their relative position.

One of the members was just speaking about how when we changed to an insured plan, doctors got paid for a much higher percentage of the patients whom they saw. It wasn’t simply a change in rates. It was simply that they now received money -- it was the member for Sandwich-Riverside who was talking about 50 per cent in the old days versus the 90 per cent now. So we have taken, I think, the proper measures. The service employees got a 50 per cent raise over two years; the doctors got 11.75 per cent.

Mr. Dukszta: Well, are you saying that the proper measure is now to keep them about the same level increase, or are you proposing to give them less in the next five years so that other people can catch up? That surely would be more fair.

Hon. Mr. Miller: Look, you are a member of the profession. I don’t believe in equality of pay for everyone in the world regardless of their training, and I don’t think you do.

Mr. Dukszta: Well, in our society we don’t have equal pay, though maybe it would be an ideal. But if you compare a physician to a social worker with an MSW or a teacher with an MA, the physician makes approximately 2 1/2 times more than what would be paid for an equivalent type of training, almost. Now, maybe he has an extra responsibility, though I wouldn’t even consider it to be that much, but there is very little difference in terms of years of training between a general practitioner and an MSW. Yet the difference is enormous.

Hon. Mr. Miller: I assume then, sir, that when you were working for us you must have returned part of your pay to the organization, because you were paid more than the fellows beside you.

Mr. Dukszta: No. As a matter of fact, I did not return it -- you damn well know I did not return it. You have been checking on both me and the member for High Park. That is not the point. The point is that this type of voluntary effort which you are saying is blazing the trail is absolutely useless. It needs a general approach, which is your responsibility -- not a moralistic approach from me.

Hon. Mr. Miller: I have done it properly.

Mr. Chairman: Shall item 1 carry?

Item 1 agreed to.

On item 2:

Mr. Chairman: The member for Wellington South.

Mr. H. Worton (Wellington South): I don’t know whether mine is under item 2 or not, Mr. Chairman. The question I would like you to answer is the result of a telephone call I received about an hour ago from a constituent who had received a letter from a superintendent of the psychiatric hospital in Hamilton. Briefly, the letter said that in the event of a close-down of a hospital he was expected to take his son into his home while the close-down was in effect.

Now, in this particular case the man is 80 years of age. The son is 46. He has been in there 30 years. I thought it was a little bit of a shock for a man this age to receive a letter from the superintendent indicating that he should be prepared to take the son into the home if need be. I feel that if it has got this bad, then your department should come up with some alternatives in the case that that happens.

Hon. Mr. Miller: Well, I would be very glad to look into that specific case for you. I have checked with Mr. Maynard, who is responsible for our psychiatric hospitals. He is unaware of this specific problem. And if you could give us more details we can look into that very quickly.

Mr. Worton: I will bring you the letter on Monday.

Hon. Mr. Miller: Fine.

Mr. Chairman: The hon. member for Ottawa East.

Mr. Roy: Mr. Chairman, I’d like to discuss with the minister the other aspect I’d raised in the opening remarks. They have been discussed by the member for High Park, but I had refrained from discussing this question of the closing of hospitals and the alternative.

You mentioned in your remarks of Oct. 1 that one of the areas you had some control over was the number of beds and this type of thing. I want to ask the minister first of all about the question of some hospitals closing. Was it yesterday or the day before you were reported in the Star thus: “He’s being opposed strongly by the public and the hospital people in trying to cut health costs by closing some hospitals”?

First of all do you feel that you will have to close some hospitals? Or in the alternative, rather than close the hospitals will you have to turn them, for instance, into a public health centre or public health unit or some alternative form in the health service field?

Hon. Mr. Miller: It’s probably the most difficult of the projected cost-saving mechanisms to turn into reality. To say that I will be able to effect any of these changes without popular support is unlikely. I’m convinced one cannot unilaterally close a hospital in the community without some degree of understanding on the part of the people, and some provision of services in place of that facility.

I’m not talking about short-term measures, but over a period of time some of these hard decisions are going to have to be taken. This was one of the key reasons for going to the district health planning council concept. It was to allow some of these decisions to be taken with the co-operation of local people who knew full well that in order to get the services they want they have to give up some of the services they may already have and don’t need.

In other words, I don’t have a list of hospitals in my pocket that should be closed tomorrow morning or the day after the next election, if you want to be that suspicious of my motives. I simply say that it will be, hopefully, an evolution.

In some cases some hospitals may close because they get old, and in other cases we will redefine their function and turn them into what are basically community health centres with only emergency standby facilities. I could name some towns where that kind of solution would probably be quite adequate.

Mr. Roy: I’m not questioning your motives at all as minister. I’ve been around here for a short period of time and I can question the motives for instance, of your government generally. I know I could wager you any sort of money that no hard decisions will be made on the closure of hospitals before 1975, before the election. Maybe after, we’ll look at some of the things. Your people will feel that we can ride with this problem of escalating health costs for a little while longer until we get through another election.

But the question of hospitals certainly has to be looked at. Of course it is not going to be a popularity contest or universally acceptable. Serious problems require hard decisions and you are not doing that for a popularity contest. You are going to have to make some hard decisions, because in the long term if you don’t make these decisions, obviously we are just heading for disaster at the other end of the scale.

Is your strategy therefore to work toward health councils, and then once you have health councils, to reduce the authority and the jurisdiction of local hospital boards? Then you will have health councils who can start rearranging their priorities in the area and determine which hospital is going to be a medical centre, and which hospital is going to have this or what priorities are going to be put on another hospital.

Hon. Mr. Miller: A good deal of what you said is the hopeful evolutionary pattern. I disagree with one point, namely the dilution of the management function of the hospital. Planning and management are two different functions. Mustard has suggested amalgamation of some management boards. I am making no comments at this time because we are still looking at the replies people have sent in.

It’s a contentious suggestion but management and planning are two different functions. Usually, people have been managing a unique institution and have focused all their planning attention on that. We want to separate those two functions so that the planning is done on an age basis for a wider area such as Hamilton is done.

Hamilton keeps on being one of those happy examples. Kingston is another area which has done a lot of this kind of work. We have shining examples that it can happen. The savings those two cities have assisted us in making could be counted in the millions of dollars on an annual basis.

Mr. Roy: Mr. Chairman or Madam Chairman, I am sorry, there has been a switch here -- Madam Chairman? Chairperson? Chairman? Shall I argue with her or not? No? Madam, can I say, before I get into any sort of trouble, when you talk about closure of hospitals, I keep walking up University Ave. and see a section of the old Mount Sinai Hospital which appears to have been empty for a year. There is a whole wing --

Hon. Mr. Miller: Mount Sinai?

Mr. Roy: Yes, on University. It’s empty. We are talking about lack of chronic care facilities and things of this nature. Here we have a building, just on University Ave., that has been empty for a period of about a year. What do you plan to do with that?

Hon. Mr. Miller: The current long-range plan is to turn it into a rehab facility. Short-range, it will probably be a chronic hospital. The planning needs, in other words, the re-design costs and so on, for the long-term purpose and the short-term purpose, will be the same. We have Queen Elizabeth Hospital and we have --

Mrs. Campbell: Riverdale.

Hon. Mr. Miller: We don’t have any others just as yet.

Mr. Roy: Are there renovations going on in the place now?

Hon. Mr. Miller: No, but they are getting very close.

Mr. Roy: It has been empty for a year.

Hon. Mr. Miller: Yes. Look, this is a problem I inherited. It is an existing building that has to be utilized.

Mr. Roy: That is the advantage of changing ministers. Your predecessor said the same thing. When you leave the ministry your successor will say the same thing.

Hon. Mr. Miller: I would hope, in fact, I think the decision is all but final to go ahead with the renovation to get this into the type of function we need in the city of Toronto. We have a couple of other hospitals that will, in the short-term interval, either be relocated or rebuilt because of the terrible state of their physical plant. I’m talking chronic facilities. The facility down there would, in fact, make an ideal holding point while these were being done, if you give us the time on the long-range rehab and the short-term chronic plans.

Mr. Roy: All I am suggesting, Mr. Minister, is that I think you will agree, planning certainly must be lacking when you have a facility like that hospital, which has been empty now for a period of over a year, and we are crying for facilities in other areas. You know we are crying for facilities. I suppose, not only for hospitals. We are crying for facilities for all sorts of things.

What I want to discuss now with the minister is the question of the ceilings. The headlines a couple of days ago said the ceilings were removed. I got it from you yesterday, and, from the papers again yesterday, that there is some form of control. What control is there?

First of all, I think the ceilings to start with were impractical. You know, we were being kidded about the question of ceilings for this year because your projection of seven per cent for an increase in the hospital budget was sort of ridiculous when we look at an increase that is going to be something like more than 20 per cent.

I appreciate there are some factors that could not be predicted. The inflationary factor certainly was one that might have been difficult to predict two years ago but nevertheless, it is this type of planning which leads to the problems we have, and makes, for instance, hard-nosed policies like establishing ceilings look ridiculous when you have to remove them overnight. You have indicated that the hospitals must submit their budgets by Dec. 2 or around that date. In fact, didn’t many of the hospitals submit their budgets when they thought the ceilings were still on, and their budgets are in now?

Hon. Mr. Miller: The budgets I am asking for by Dec. 2 are the 1975-1976 budgets. Today’s editorial in the Globe touched on this. I am sure you read it, and I think if you read it you would agree it was relatively supportive of the change in the point at which the ceiling is applied.

Interjection by an hon. member.

Hon. Mr. Miller: The point at which the ceiling is applied is the key thing. There is a ceiling on hospital spending for next year. It is the sum total of all the costs of all the hospitals in the Province of Ontario, but because we have applied -- I forget for how many years -- flat percentage increases to all hospitals we have had, as we realized, a growing inequity in the application of that formula. You can’t keep on adding a constant percentage for all hospitals to bases that, in the beginning, didn’t necessarily reflect the efficiency of the hospital or the things that have happened to it in the meantime.

Mr. Roy: I appreciate that.

Hon. Mr. Miller: So in this year we have estimated our total hospital costs. The sum total of the budgets submitted must remain within that, and we have put other riders on it. No increases in staff was one, and secondly, a two per cent reduction in the 1974 base budget.

Mr. Roy: Could I just complete --

Mr. Deans: Yes. I couldn’t stop you if I wanted to.

Mr. Roy: No, you probably could not. The last point I want to raise is the question of a story that appeared sometime in September in the Globe. I think that you have replied somewhat on it, but I would like to hear your answer today on the question of hospital privileges and the different standards tor people who are on OHIP and those who had a bit extra who were getting different treatment.

The headline goes, “Money Buys Hospital Privileges That Patients With OHIP Don’t Get,” and there is a further article by a Dr. Cynthia Carver, who is quoted as saying that she encountered a double standard and talked about different menus in hospitals for people in private and semi-private and people in the general wards. It goes on to say: “Two sets of rules exist for admitting patients to Wellesley Hospital by general practitioners, one for the rich and another for the poor.”

If I recall, reading the article -- and I don’t want to go through it all now -- apparently there were certain areas where people who were just on OHIP were sort of the guinea-pigs of the system, and all the young doctors would come around and examine them but they wouldn’t go and bother the people who were in private or semi-private accommodation. Have you investigated this and what are your comments on these suggestions?

Hon. Mr. Miller: If you recall, I expressed some degree of surprise and lack of belief when I heard of the paper’s comments, and yet I have learned not to be so sure that something isn’t happening that you don’t look to find out if it is. I certainly wouldn’t like to think that people got second-class care because they were in a teaching hospital or because they were in a ward bed.

I referred to my own experience, and it was a fairly lengthy one, and I felt that I had been given top-grade treatment in a ward bed in a teaching hospital in the city of Toronto; in very poor physical conditions, admittedly, because some of the ward beds in those days were.

But because there could well be some truth to the press comments, I asked both the Ontario Hospital Association and the College of Physicians and Surgeons to do a joint investigation on our behalf to see if there was any substance to them. Both of them have indicated their willingness to do this. In fact, I understand these are under way, and I should hope that before long I will have some indication as to whether these conditions truly exist, and if they exist, to what extent, and what steps might be taken to remedy them.

Mr. Chairman: The member for Wentworth.

Mr. Deans: I have three matters to discuss. One is purely local and I will raise it first. There has been a feeling in the city of Hamilton for some considerable time that there was need for some kind of facility, perhaps an emergency service type of facility, in the eastern end of the city. If you are familiar with the city of Hamilton, you will appreciate that all of the --

Hon. Mr. Miller: I know the east is where the west should be.

Mr. Deans: Looking from Toronto I suppose that might be true. But everything in Toronto is a bit backward, anyway.

Mr. Stokes: And never the twain shall meet.

Mr. Deans: The fact of the matter is that all of the hospital services in Hamilton are centre and centre-west. McMaster, of course, is in the extreme west end. St. Joseph’s the General Hospital, even the Henderson Hospital, Chedoke Hospital, are all in the western end of the city. All of the growth in the lower city is taking place in the east end and all the way out into what is now the town of Stoney Creek.

It is pretty obvious, with the horrendous traffic problems that we have, that transporting people all the way through the city in an emergency situation in order to get them to one of the facilities that exist, is becoming increasingly more difficult. I am going to talk about the method of transportation in a moment.

Hon. Mr. Miller: I suspected that might come.

Mr. Deans: I thought you might suspect that I might want to talk about it. Nevertheless, given the Mustard report and given the kinds of things that are happening within the health council’s ambit in the city of Hamilton, it may well be that they might tend, for cost purposes, away from locating any further facilities in the east end of the city.

I am not asking for a hospital because I realize that we probably have on a bed-to-citizen ratio a sufficient number of hospital beds available. But I am suggesting to you that recognizing the kinds of developments that are taking place and the many tens of thousands of people who are now going to be living east of what was the city limits five or six years ago, we should give serious consideration to the location of an emergency hospital service.

People who are injured on the Queen Elizabeth Way in the many accidents that occur on there, and people who take sick and have to be transported quickly during rush hours, could be taken to this emergency service. I don’t know exactly how it would be done, except that I know that it would serve a very useful purpose and we could probably transfer some of what might now be occurring at Chedoke or in some other hospital, to the east end, in order to provide a wider range of services. It could be in conjunction with a laboratory service, it could be in conjunction with some other type of medical service that could be made available.

But I really do urge you, if you have the time and you are able to direct someone to take a look at it, that you give serious consideration to that.

Hon. Mr. Miller: Can I answer that one specific thing?

Mr. Deans: Yes.

Hon. Mr. Miller: I think this is probably news at this point in time, but I think I reached a fairly important conclusion and decision for Hamilton about 3 o’clock today. Because I have conveyed my decision to the Hamilton Health Planning Council, I am very pleased to make you aware of it. As you may know --

Mr. Stokes: I thought you were going to dump the Mountain into the bay or something.

Hon. Mr. Miller: -- on Monday or Tuesday -- Tuesday -- the Health Planning Council came and made a presentation to me. They were deeply concerned that the lack of a decision on the rebuilding of the Hamilton General was throttling all the other problems in planning for health-care services in the city.

As I mentioned, they have done perhaps the finest job of any group of people in Ontario in resolving most other problems. I was keenly aware of the points they put before me. They would rather have had a negative decision than the decision they wanted. They simply wanted a decision out of me to help with their planning process.

We pointed out the fact that you had an under-utilized facility on the McMaster campus, that you had a conglomeration of hospitals in the centre core of the city, that the east end of the city was not properly serviced, and that we felt therefore that we should not rebuild the hospital at the Barton St. site.

That received a pretty violent reaction from the group present, including the members of the regional government and the council. They countered with traffic flows, which they had studied carefully; flow routes; times for transportation of a patient from a given point in town to the Barton St. site; the ethnic population in the centre of the city, and these kinds of things.

I today notified them that I was prepared to have the hospital rebuilt on that site provided these considerations are included: (a) That they come up with a plan for the optimum use of the McMaster site; (b) They reduce the total number of beds to 1,999, right? which was our 1979 planning standard; (c) They review the role of the new hospital in view of its other purposes in the community, apart from being a specialized hospital; (d) They find a solution to the east end needs in the city, a health clinic or whatever it may be.

Those are the riders we put to them in our letter today. We are asking them to work out the solution within those parameters.

Mr. Deans: That is interesting. If I had known that you were considering such a thing I would have been delighted to have made a submission on it because --

Hon. Mr. Miller: It can be done now.

Mr. Deans: -- I happen, for funny reasons, I suppose, not attributable to any effort on your behalf, to represent much of the east end of the city. I am concerned, and I recognize that many people might tend toward the centre. Everything seems to want to go in the core. Did you give them any timetable for their answer?

Hon. Mr. Miller: No, I did not give them a timetable but they are the people who are pressing me for a decision so that they could proceed with their planning. The moneys for this come out of the health resources development fund, as you probably know. We have to be able to schedule it into the moneys available. I think Hamilton was given $40 million out of that total. This one facility is estimated to use between $20 and $25 million.

Mr. Deans: Remember the discussion we had in the city council where I said it operated like a secret society? It does. You would never know they were trying to do anything until after it has happened. This is the position I am always in.

Hon. Mr. Miller: The city council was represented at this meeting, in all sincerity, and so was the regional government.

Mr. Deans: I am sure they probably were.

Mr. Stokes: They talk to themselves but to nobody else.

Mr. Deans: They have a very funny view of things. But that is beside the point. I wouldn’t deprive the citizens of that simply because they weren’t co-operating. There are sites in the east end that have been offered at what would, I think, be considered fairly nominal cost. One site in particular is a farm site within the city limits. The people who own it are, to say the least, not poor. They were quite prepared, as I understand it from discussions I held with them, to talk about making the site available at considerably less than its market value if it were to be used for some kind of health-care facility in the east end.

I am delighted to hear what you have to say. I trust that out of it all you will stick to that aspect of it, that you won’t let that fall by the wayside regardless of what pressures are put on you, and no matter how carefully they set out how willing they are to abide by the other three points -- (a), (b) and (c). The point regarding provision of some kind of health-care facility in the east end of the city -- emergency, community health centre, whatever it can be that will adequately meet the needs -- I strongly urge you not to let drop. That is absolutely essential to the people in the east end.

I don’t know how we are ever going to be able to come to grips with the salary schedules and wages paid to many of the non-medical staff in hospitals. They obviously are not considered by the hospital administration to be essential when it comes to paying them, although they are considered essential when it comes to their threatening to take strike action. They are deprived of that right because they are recognized by some as performing an essential service.

Mr. Stokes: Trick or treat.

Mr. Deans: I told you they were coming to get you. They were marching up Yonge St. a moment or two ago. That’s the remains of the Tory party as depicted in the body politic.

Hon. Mr. Miller: I hear voices but I don’t know whether I can speak to it or not.

Mr. Deans: I don’t know either. It sounds like we’re being invaded. The problem of trying to find ways of providing an adequate salary or wage schedule tor non-medical personnel is always going to be very difficult. I suspect that to some extent if it’s left up to the individual hospital boards to make their decisions they will always be low man on the totem pole. I don’t know how to overcome that. Quite frankly I don’t.

I think the ceilings played a large part in creating the problem that they had over the last number of years. The fact that they didn’t have the right to strike -- they might not have used it in any event. In fact, I suspect they wouldn’t have used it -- played some part in it. They were taken advantage of because that right wasn’t there, not because they would have used it, but because the people who were negotiating with them recognized that they couldn’t do it anyway.

As I look at what the minister said the other day about hospital ceilings. There’s no question that the ceilings are still in place. There are still ceilings on hospitals. You’ve a ballpark figure and that ballpark figure is going to be cut up. The individual budgets will have to fit within the overall ceiling which you’ve established.

That leaves some problems for me. I don’t know how you’re going to differentiate between one hospital and another in determining what kinds of budgets will be allowed and what kinds of money will be allowed to flow into them.

I certainly admit that I don’t know how the budgets are arrived at in hospitals. I don’t know where they spend the money. I’ve asked and I’ve wondered and I’ve looked and I’ve got some serious reservations about where some of the money is spent. I’d love to know, at some point, perhaps in a committee -- and this might not be such a bad idea. I’m not one for establishing select committees. Maybe we could refer to the social development committee or whatever it is, the job of investigating the methods used by hospitals in arriving at their budgets, not because you might want to know, because maybe you do know, but so that we in the Legislature might also find out.

I don’t see the care that is provided, given that it now costs $100 a day or more to get a hospital bed. It certainly isn’t in wages to the nurses. It certainly isn’t in wages to the support personnel and it isn’t in food, so where does it go? I think that you might give some consideration to referring a project from your estimates or from the Legislature to the social development committee. That project is to call before it some of the hospital boards in the province and to have them take a serious look and explain how they arrive at their budgets and what their expenditures are over the year and how they capitalize their major expenditures for equipment and the like so that we can all understand it.

I believe probably the hon. member for St. David (Mrs. Scrivener) is on a hospital board, as I recall. Perhaps she may understand it. I personally don’t. So I think it might not be a bad idea to do it.

I have another problem. I’m going to come to the ambulances in a second. This is the last of the ones before the ambulance. Why would the hospitals purchase their packaged food items from a US company? Why would they be imported from the United States into Canada? Surely, with the number of hospitals that we have in the general Metro area from Oshawa to Niagara Falls, there’s a sufficient intake of food to justify one or more of the various processing companies in food production operations providing that kind of service.

I was amazed to find that the Henderson Hospital in Hamilton, for example, purchases substantial quantities of packaged goods from outside the country. My understanding is -- and I have not had a chance to check it, because it only came to my attention in the last couple of days -- that this is also true of the McMaster Clinic and it is true of a number of hospitals. I don’t understand that.

I would like if the minister could take a look at that, to try and find out what the problem is with the provision of food here in Canada. We seem to have lots of it and it would make some sense that we might use what we have here to meet the needs of the people who are sick.

Finally, ambulance service --

Hon. Mr. Miller: Do you want me to deal with that now?

Mr. Deans: No, I’ll do it all and then you can answer me all at one time. I think you know that I have grave reservations about the ambulance service. I think the Leader of the Opposition, in fact, wanted to speak on this.

Mrs. Campbell: Yes, he did.

Mr. Deans: There is no overall standard in the Province of Ontario. The service varies as much as there are ambulances. Every ambulance provides a different level of service. I wrote you some letters about the city of Hamilton service and there was a change made. One of your letters didn’t really reflect what had happened, by the way, but that is beside the point; I am not going to nitpick.

The problem was -- and still is, as I understand it -- that though there may be five ambulances running all night there is only one additional stretcher. One emergency stretcher, for the whole city. If you happen to be at the wrong hospital, the ambulance is out of commission until they get the stretcher made up and taken away again. I understand that was brought to the attention of the emergency service branch some considerable time ago. What happens is that as the ambulance arrives -- oh, there are two now are there? I see him holding up his fingers. Well, dammit, now there are two emergency stretchers.

Hon. Mr. Miller: It is a 100 per cent increase.

Mr. Deans: It certainly is. So if we have three ambulances in service, one is out of commission until they get the patient off the stretcher, and if it happens that you are delivering the patient to the wrong hospital -- the one that doesn’t happen to have the emergency stretcher available -- then you are out of commission until you get another stretcher. That is ridiculous. That’s absolutely ridiculous. It makes no sense. I’m willing to suggest that for the cost -- whatever it is it can’t be that great -- there has to be one additional stretcher per ambulance, so that the ambulance is always in service and the delivery of the patient is then to the hospital, the new stretcher is put in the ambulance and it is then available and on call and ready to move. The way it is right now is almost unbelievable.

Let’s go on. In my opinion, the ambulance and emergency service should be province-wide under the jurisdiction of the government. There are so many unusual things occurring within the ambulance service at the moment that it makes my head spin. People get fired for no reason, without any justification. This has happened now on three occasions that I am aware of, and I’ve brought at least one to this minister’s attention and, on previous occasions, to his predecessor’s attention. Because someone stands up and says, “Look, the service is not very good and we should be improving it,” he gets fired by the owner of the ambulance service. You should establish in the province one overall ambulance service that has standards that are adequate to meet the needs, that has trained personnel on the ambulances, that is able to meet emergency situations and to cope with them; and a person -- no matter whether he is injured in North Bay or Niagara Falls or in Kingston -- should expect and receive the same level of ambulance service no matter where it occurs.

That just isn’t the case right now. There are no standards for training that are mandatory, there is no standard for pay across the province and there are no standards for the capabilities of the employees across the province. Until you do that, you can’t call what you’ve got an emergency ambulance service. It is not nearly adequate.

We’ll go to another point, one that has aggravated me. You’re moving away from what I happen to think is the best method of dealing with it. Ambulances should run out of hospitals. Ambulances should run out of medical centres. Ambulances shouldn’t run out of somebody’s back garage, for heaven’s sakes. They shouldn’t be building little brick buildings all over the place to house an ambulance.

Mr. Stokes: Or undertakers.

Mr. Deans: Or undertakers or funeral parlours or whatever you want to call them. In Hamilton, if we had what I was asking about -- the emergency health service -- in the east end of the city we could have an ambulance out of there, we could have an ambulance or two out of the Mountain and we could have ambulances in the west end of the city running out of the hospital. Those ambulances could, wherever necessary, take qualified medical personnel with them where that was warranted and justified.

As it is right now, we have one or two ambulances running out of a brick building on Locke St., an ambulance running out of a wooden building on Mohawk Rd. and we have an ambulance -- do you know where it was sitting? -- on a garage lot outside, waiting with a telephone inside so the guy could get in and drive it to wherever it was that he was required to go to in the east end of the city.

It’s a damned disgrace. You should be prepared to set it up in some orderly fashion and to recognize the worth of it. Nobody realizes how important an ambulance is until they are phoning for it. Don’t expect a great hue and cry from the public or a great deal of support to suddenly burst out for a new type of service, because it won’t happen. The only people who realize how bad it is at times are the people who are waiting for it or who have to use it.

Given the inadequacies of it, I want to tell you that I am satisfied that most of the people that I have met who work on ambulances are both dedicated to the job and eager to improve their position. They are eager to learn. They are eager to provide a better service. They are prepared to take courses at their own expense, as I know many of them have. They are prepared to upgrade their education. They are prepared to upgrade their standards at their own expense in order to provide a public service.

There are not many ambulances across the Province of Ontario in actual fact. It would serve you better to get rid of this nonsense of reprivatization of the ambulance service, because it can only serve to be a downfall. The person who owns the service is more interested in making bucks off the service than he is in providing an additional service to the people of the area. They are looking to see how few ambulances they can get away with rather than how they can upgrade or improve the service. That is occurring far too often. Maybe I have an entirely warped view of it.

Hon. Mr. Miller: I am glad you recognize it.

Mr. Deans: I am saying maybe I can appreciate from the look on your face that you think I have. I want to tell you something about the look on your face, and it’s appropriate to the estimates funnily enough. You are not always going to get away with the glib remark and the smile. It’s not going to work forever. It is nice, and I like you, but that isn’t going to solve all the problems.

Hon. Mr. Miller: I am quite aware of it.

Mr. Deans: You are not quite aware of it, and that’s the difficulty. For some reason or other, the moment you get to your feet you think that a friendly smile or a glib remark solves the problem. Well, it doesn’t. Some of these problems are serious. I think you are being taken in by some of the advice that you are getting.

I suggest to you that you should go out and take a look at the problem. You can’t have men who are accustomed to working 48 hours and earning $4.50 an hour or so cut to 40 hours overnight and expect that they are going to be satisfied and happy, because their earnings have been cut by about 20 per cent. You can’t allow the service to deteriorate the way it is deteriorating. The morale in the service is very, very low. If you don’t understand it, it will suddenly hit home one day when there will be very little left for you to recoup from.

I don’t know who is giving you your advice and I don’t much care. But I ask you one thing, would you please go out and see for yourself what is happening? Would you go out and take a serious look at that service? It is every bit as important as having a doctor in the emergency room. The doctor can stay there all day but if you can’t get the patient to him it is not going to do any good. That is one of the problems you are going to be faced with.

When I wrote you the letter about the level of service in Hamilton, what I said was absolutely correct, and whoever gave you the information you sent back to me didn’t understand. In fact, there was little overnight service available. It was only after we raised the matter that they put additional ambulances on. They told you they had the availability of Waterdown, Aldershot and Ancaster, but those services are very much voluntary, and are closed for much of the night.

I think you are not too well informed about the level of service available. I urge you to spend a little more time looking at the realities of it. Don’t pay so much attention to those people in your department who appear to be experts. Go and see for yourself. I have done it, and spoken to the people who are operating it. Not the people who claim to be doing it but the ones who are actually out on the road. They are quite worried about the levels of service.

Was an additional allotment made to the ambulance operators in April which was intended to provide salary increases retroactive to January?

Hon. Mr. Miller: I will get the answer by the time I reply.

Mr. Deans: Okay. That is a specific question which I think is important.

Second, if it is possible to contemplate, will you please give some consideration to establishment of a provincial ambulance service that will provide an adequate level of service and training for everyone, rather than relying on individuals to do it?

Third, what is the relationship between the emergency ambulance service group in Toronto and the Oakville operation? How did the sale take place? Better, how did the recent sales take place in Hamilton and who decided the value and the price of the ambulance service? The private operators who have their ambulance services up for sale expect a far greater return than was paid to the government for the sale of the service in Oakville.

Finally, I don’t think the method of payment to the owners, assuming you are going to leave them, which I suspect you may, is conducive to a better service. You can’t pay them by the call, but you do. You pay them X number of dollars for every call up to the first 200 --

Hon. Mr. Miller: In addition to their global --

Mr. Deans: I agree, but that doesn’t improve their service one bit. You pay them a certain amount of money for the running of the service, plus so much per call in addition. One ambulance owner told his employees, “Do you realize we are running 50 calls behind our competitor? Get up off your butts.”

I don’t know what they are supposed to do. Call their friends and have them call the ambulance?

There is no reason to put money in people’s pockets for nothing. I don’t think you have a very close check on the method of auditing. I don’t think you know where the money goes. I know you went in recently and audited, maybe not at my request but certainly after some discussions we had had. I am not at all convinced there is a close enough check kept on actual expenditures as per the budgets submitted.

I strongly urge you to completely overhaul the whole service or you are going to be faced with some very serious difficulties.

Mr. J. Riddell (Huron): Smile, Frank. Nobody can deny you that privilege. We like your smile on this side.

Hon. Mr. Miller: Thank you.

Mr. Deans: I like your smile. I just don’t think it is solid.

Hon. Mr. Miller: I think the assumption that if one smiles, one isn’t determined, is a rather poor one.

If you assume that because I can smile, I have no other abilities, it is a rather poor assumption.

Mr. Deans: I didn’t say you had no abilities. I said you had adopted a policy --

Hon. Mr. Miller: I try to deal with things objectively. I don’t try to get personal.

Mr. Deans: Well, then, try to deal with this objectively.

Hon. Mr. Miller: I will.

Mr. Deans: And I am waiting.

Hon. A. Grossman (Provincial Secretary for Resources Development): And he ain’t smiling now.

Mr. Deans: I don’t care. I am pleased that he is not smiling.

Hon. Mr. Miller: First of all, talking about the ambulance service, if I listened to you I would think we had the worst ambulance service in the world. As a matter of fact, it’s recognized as the best. Now, let’s face that.

Mr. Deans: In the world?

Hon. Mr. Miller: In the free world.

Mr. Deans: Oh, I see.

Hon. Mr. Miller: I have no idea about the ones behind the iron curtain.

Mr. Deans: Neither do I.

Mr. S. Lewis (Scarborough West): It probably has a triple-A rating.

Mr. Stokes: Don’t challenge me on that. Don’t give me this stuff about it being the best in the world. I appreciate there are a lot of places in the province where you have a good ambulance service, but don’t say in the world -- and don’t say Ontario-wide, because that just ain’t so.

Mr. Chairman: Order, please. The minister has the floor.

Mr. Stokes: It just ain’t so.

Hon. Mr. Grossman: You are even going to get an ambulance service in Armstrong.

Hon. Mr. Miller: This ambulance service was formed a few years back when the Province of Ontario took upon itself the responsibility for providing an insured service. It was formed out of a hodge-podge of services in the province, most of which were limping along at that time with an assortment of vehicles that ranged from the sublime to the ridiculous. In that period of time we have put together, fairly well, a comprehensive network with standardized vehicles in most parts of the province.

Mr. Deans: And then gave them to the owners.

Hon. Mr. Miller: Just the opposite is true. They do not belong to the owners. The capital plant is ours.

Mr. Deans: That’s right. Everything belongs to you except the money.

Hon. Mr. Miller: You are totally wrong. I think it would do you good to look at some of the facts and figures.

Mr. Deans: I have looked at them.

Hon. Mr. Miller: You and I have a fundamental ideological difference which we cannot resolve in this discussion, and that is whether a person operating on an incentive basis works better than a person working for the state. I tell you I believe people working on some kind of an incentive basis still do a better job.

Mr. Lewis: Just a second. How the hell do you work on an incentive basis on ambulance calls? What do you do? Do you phone people up to make calls?

Hon. Mr. Miller: The incentives are in the management of the process.

Mr. Deans: That’s right. You can rake off anything you can get. That’s no incentive, my friend. That isn’t an incentive.

Mr. Lewis: What incentive is there in providing ambulance service?

Mr. Young: Your civil servants work for a salary. They are not on an incentive basis.

Hon. Mr. Grossman: And look what the member for Wentworth said about the civil service a minute ago.

Mr. Lewis: We are not opposed to incentives, but this isn’t piecework, you know. Or maybe it is.

Hon. Mr. Grossman: Want to reword that?

Mr. Lewis: Well, it struck me afterwards.

Hon. Mr. Miller: In any case, we have that difference of opinion.

I have to admit that I am not concerned that the original philosophy of ambulance bases in hospitals was correct. I accept the responsibility for that. In fact, we had a number of hospitals that insisted the ambulances be removed from the hospitals because of a number of problems that resulted from them. I don’t say that those hospitals that have willingly gone along with the system haven’t done a good job, but there is not a unique pattern that will necessarily resolve all the problems.

As far as regulations go, yes, we don’t have a set of regulations, but we still have had about 2,100 ambulance employees who have taken the course at Base Borden -- and it’s a good course.

Mr. Deans: At their own expense, because they are dedicated.

Hon. Mr. Miller: At their own expense, because they are dedicated.

Mr. Deans: I said that.

Hon. Mr. Miller: The fact remains that it will be a requirement of service in the ambulance system before long to take an approved course, and these regulations should be ready early in 1975, probably in January, 1975.

Mr. Deans: Are you going to also then regulate the salaries paid to them when you regulate the standards?

Hon. Mr. Miller: No, I am not going to regulate the salaries paid to them. That is where the little ideological difference comes in.

Now, we have had critics of the training procedures, and they are generally people who are very closely related to the trauma sections of hospitals. There are a couple of doctors who I respect very much, who have in their minds a higher opinion of the degree of training required for all ambulance employees than I have. I think it has been proven that in fact our standards of training more closely approximate the need than theirs do. We, in fact, ran a trial course for some time in Kingston, as you know, of a more intensive nature that really made a paramedical person out of the driver. I understand that these people found it difficult to be utilized within the system so that their training was properly appreciated.

I believe there are three community colleges currently giving the courses on a one-year basis, and I believe there will be 10 within the year doing it. All entrants to the system in the future will come through this type of training. So we will have a standardized level of training, a standardized set of vehicles, a provincial-wide network of dispatch and a set of controls for the quality of care and delivery of service.

In those years in between we have had some disparities of service, but I believe in the main the service has been very good. We have tried to get along in some of the remote areas. Armstrong is an example of where it is very difficult to give the service, I think you would agree, but we are putting an ambulance in there and there will probably be service on some type of volunteer basis, because I think the last count we had was 10 ambulance calls in a year.

Mr. Stokes: Some of them were flown out, too.

Hon. Mr. Miller: Yes. Well, we are quite willing, if the preferred method is to fly them out --

Mr. Stokes: And some of them go out by train.

Hon. Mr. Miller: And the ambulance is only there in the event that the other service couldn’t be made available. We recognize there were times when in fact the other service wouldn’t be available, so you had to have some vehicle present.

The question of stretchers, I think, was one we dealt with in the city of Toronto. I quite agree with you, rather than disagree with you -- it is silly to have a $10,000 unit tied up because a $400 stretcher isn’t available. I can’t disagree with that. I think one of the first moves we made in Toronto to make the system more mobile was to order extra stretchers so that in fact ambulances coming in could quickly transfer a patient -- leave them on the stretcher, pick up a spare stretcher and be gone. It is, I think, good business to do it that way.

I feel that while there will be certain management-labour problems between when you allow for individual negotiation, as we have done to date, this is not a bad thing. I think that we are covering the global budgets based on the salaries negotiated, just as we do in the hospital. In other words, the operator doesn’t make more profit if he pays a lower salary, providing he lives within the overall constraints we apply to him.

Mr. Deans: Of course he does, because he gets his extra money on the numbers of calls.

Hon. Mr. Miller: I am trying to get this specific statement you asked about the retroactive increase in April.

Mr. Deans: I’ll let you think about that for a second.

Let me just ask you something. If you provide the vehicles, all of the equipment, all of the dispatching methods, audit the budgets, provide the money and set the standards, where is the free enterprise part of it that you are worried about? What you do is you hand the guy the money and you say to him: “Now, if you can get away with paying less, or if you can get away with less service in whatever way you can do it, or if you can have more inter-hospital calls, or if you can somehow or other corner more of the market, then you can have whatever is left over to put in your pocket.”

Doesn’t it make sense to take a person with a basic knowledge of the system and administrative skills, pay him a decent salary to do the job, and when that buzzer goes and the ambulance is called, they will go out? You can’t sell an ambulance service. You can’t put somebody on the road --

Hon. Mr. Miller: But you can manage it.

Mr. Deans: -- knocking on people’s doors asking them to “call my service.”

Hon. Mr. Miller: You can manage it efficiently.

Mr. Deans: Of course you can manage it efficiently. But you can only manage it within the global budget that you established.

Hon. Mr. Miller: First I think you are making an assumption that the current payment mechanisms will be continued in the future as they are; that is not a valid assumption.

Mr. Deans: Well, what are you going to do?

Hon. Mr. Miller: We are at the point of discussing these very things right now.

Mr. Deans: It boggles the mind.

Mr. Lewis: There is something almost Roman about the incentives to pick up people in an ambulance service.

Mr. Deans: It really boggles the mind. I can understand a paint company having somebody else selling paint on a private enterprise basis. That makes sense to me. But, damn it, why don’t you put the fire department on the same basis then?

Mr. Lewis: Hey, that is not a bad idea. Think of the possibilities.

Mr. Deans: Why don’t you have the police on incentive? By the way, some people think the police are on an incentive.

I don’t understand it. You can only go and pick up people who require the ambulance service. Those are the only people they can get. You can’t have someone on the road knocking on doors asking if they’d like a friendly ambulance service to drop by.

Mr. Lewis: Unless you have an ambulatory pickup.

Mr. Deans: Your whole system is crazy. All you are doing is you are handing money to people who are doing virtually nothing for it. They are driving Cadillacs and Mercedes-Benz, for heaven’s sake -- at public expense.

Hon. Mr. Miller: Again we are touching on probably the most fundamental differences in your approach to government and mine.

Mr. Lewis: Come on! We are going to abandon it.

Mr. Deans: It is giving money to your friends.

Mr. Lewis: This isn’t philosophy. This is just silly.

Hon. Mr. Miller: That’s your privilege. The 1974 budgets were allowed to go up 6.5 per cent. The negotiations in Hamilton began about that time and, therefore, we haven’t finalized their budgets yet. It is as simple as that.

Mr. Deans: None of the Hamilton budgets?

Hon. Mr. Miller: They are in the middle of their negotiations and we’ll be basing them --

Mr. Deans: They are not all negotiated.

Hon. Mr. Miller: All Hamilton ambulances?

Mr. Deans: They are not all negotiated; only one of the services is currently negotiated.

Hon. Mr. Miller: Fleetwood is negotiated.

Mr. Deans: They are negotiating one service in Hamilton and one in Welland.

Hon. Mr. Miller: Fleetwood is negotiated and the budget went up 6.5 per cent.

Mr. Deans: Did Fleetwood get the 6.5 too?

Hon. Mr. Miller: Yes.

Mr. Deans: Is the 6.5 available to Fleetwood and has it been since April?

Hon. Mr. Miller: It is available to them and they haven’t passed it on yet, because they are still in negotiations.

Mr. Deans: You haven’t even told them it was there.

Hon. Mr. Miller: All budgets went up 6.5.

Mr. Deans: You didn’t even tell them it was there.

Hon. Mr. Miller: You are funny in that sense. I talked to the health minister in a province called Saskatchewan the other day. He said to me, “Do you have to go for supplementary budgets for your health-care costs this year?” I said, “I sure do.” He said, “I have to too, because I didn’t dare tell them what I would have in my budget before I concluded my negotiations.”

Mr. Lewis: A vile slander! Saskatchewan plans in advance.

Hon. Mr. Grossman: What does it plan for?

Mr. Chairman: The hon. member for St. George.

Mrs. Campbell: Mr. Chairman, at this point, I seem to be repeating history. I think I was still on the question of hospital admission policy when we closed off last night. I was told that I would have answers on it when we came to it at this point. The minister, Mr. Chairman, has answered in part one of my concerns about hospital admission policy in that he is investigating some of the comments which have appeared in the press about hospitals in downtown Toronto.

Why do I have so much trouble getting your attention?

Hon. Mr. Miller: I have to change ears. I listen with one ear to each person.

Mrs. Campbell: You missed the whole bit on glue sniffing. I don’t want you to miss this too.

One of the things that was not covered in the answer to my colleague from Ottawa East was the statement which was attributed to the minister at the time that these discussions in the press took place, that the hospital boards were autonomous. I would like the minister to deal with that matter.

I cannot accept the fact that with the funding which is going into hospitals at this point in time that they could be regarded as autonomous in that context of admission policy. Otherwise, I don’t know how we can subscribe to a service which is costing the taxpayers so much and then permitting, if the allegation is proven, not only in one hospital certain differences of admission, but as between hospitals differences in admission policies.

I would like the minister to advise me as to what his position is vis-à-vis the board. I have had the opportunity of serving on the boards of two major hospitals in the city. I would say without question that it would be difficult to find a body which has less opportunity as a whole to investigate the operation of a hospital than those boards really do have.

I can recall my first meeting with one hospital board. I had the temerity to ask a question and it threw the whole operation into a flap. One did not get involved in asking questions about the operation of hospitals. These meetings were run very carefully, the same way I would assume bank boards are run. But it wasn’t an opportune time to get down to the nitty gritty of the hospital function.

Like an earlier speaker, I would like to know if there is any way this Legislature could come up with some facts; some greater understanding of hospital costs.

I would suspect we would have to divide the hospital operation into the hostel or hotel care section which goes with it and, second, into the total service, separate and distinct. Would the minister inform me, from his great knowledge of the subject? Or, if he can’t answer, we might have a committee to help us understand the operation and financial functioning of the various hospitals.

I suspect they don’t all operate on the same principle. I think the minister met with the student administrators of the hospital. They were very critical of the operation of hospitals generally, regarding efficiency. I feel we have an obligation to see whether anything could be improved in the operation.

Your ministry has known the problems of ambulance service in the metropolitan area for years. It was of deepest concern to members of the council years ago, and I am of the opinion you have not moved to correct some of the obvious difficulties which resulted from the attempt at empire-building which took place at the Metro level.

I note that the commissioner is hopeful that he’s going to have a further $7 million from you at this time. Maybe he’s already got it. He seems to be very able to obtain funds from several sources, as he sees fit.

One of the problems which occurred, and it was one of the very evident problems, was the fact that during this period when there was an interval between the private operator and Metro working almost on a par, if you like, was that Metro at no time considered the areas which had to be served. But we found, by some strange happenstance, that the commissioner always recommended introducing the stations next door to or across the street from where there was a private ambulance. It didn’t really improve the service to the total metropolitan area.

We found, at the same time, that those ambulances which operated outside of Metro and on the periphery were not permitted into the metropolitan area after a certain time, because licensing wouldn’t permit them to enter that great closed area of control. We saw the situation where an ambulance coming in to deliver a patient from St. Catharines to the Toronto General Hospital went back empty, while the ambulance that was needed to take a patient home to the same area was called in from Scarborough to make the trip. These were the sorts of inefficiencies and the sorts of things that went on. It was an unbelievable, unbearable bureaucracy. I am saddened if this is continuing under the closer-knit -- hopefully -- affiliation with the provincial service.

Mr. Chairman: Excuse me. Would this be a convenient place for the hon. member for St. George to break at this time?

Mrs. Campbell: And come back on Tuesday? All right, can I have your promise that I’ll be able to continue on Tuesday?

Mr. Chairman: Oh, I promise.

Hon. Mr. Winkler moves the committee rise and report.

Motion agreed to.

The House resumed; Mr. Speaker in the chair.

Mr. Chairman: Mr. Speaker, the committee of supply reports certain resolutions and asks for leave to sit again.

Report agreed to.

Hon. E. A. Winkler (Chairman, Management Board of Cabinet): Mr. Speaker, before I move the adjournment of the House, as I previously announced, we will be on the budget debate tomorrow, and on Monday we will deal with the balance of the estimates of the Ministry of Consumer and Commercial Relations. On Tuesday, we will return to the estimates of the Ministry of Health -- and the hon. member for St. George (Mrs. Campbell) has unanimous consent to proceed at the opening of the House.

Hon. Mr. Winkler moves the adjournment of the House.

Motion agreed to.

The House adjourned at 10:30 o’clock, p.m.