SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION

MANITOULIN-SUDBURY DISTRICT HEALTH COUNCIL

SUDBURY DISTRICT PHARMACISTS' ASSOCIATION

ACCESS AIDS COMMITTEE OF SUDBURY

SUDBURY AND DISTRICT LABOUR COUNCIL

COALITION OF HEALTH CARE WORKERS

MIGUEL BONIN
ROSEMARY CHRISTINCK

ROCKVIEW SENIORS CO-OPERATIVE

PROFESSIONAL ASSOCATION OF INTERNES AND RESIDENTS OF ONTARIO

SUDBURY GENERAL HOSPITAL

CENTRE DE SANTÉ COMMUNAUTAIRE DE SUDBURY

SUDBURY AND DISTRICT MEDICAL SOCIETY

REGISTERED NURSES' ASSOCIATION OF ONTARIO

N'SWAKAMOK NATIVE FRIENDSHIP CENTRE

SISTERS OF ST JOSEPH OF SAULT STE MARIE

CONTENTS

Tuesday 9 January 1996

Savings and Restructuring Act, 1995, Bill 26, Mr Eves / Loi de 1995 sur les économies et la restructuration, projet de loi 26, M. Eves

Manitoulin-Sudbury District Health Council

Ken Ferguson, chair

Normand Gauthier, vice-chair

Sudbury District Pharmacists' Association

Norm Grillanda, chair

Claire Shaw, chair, prescription drug plan committee

ACCESS AIDS Committee of Sudbury

Ann Matte, executive director

Paul Ham, HIV patient

Sudbury and District Labour Council

John Filo, representative

Coalition of Health Care Workers

Jan Hibi-LeBlanc, representative

Miguel Bonin; Rosemary Christinck

Rockview Seniors Co-operative

Stan Racicot, president

Peggy Racicot, secretary

Ron Freeland, administrator

Professional Association of Internes and Residents of Ontario

Dr Scott Woodside, president

Dr Margaret Kruk, member of the executive

Dr Michael Franklyn, former member of the executive

Sudbury General Hospital

Carl Roy, associate executive director

Centre de santé communitaire de Sudbury

Juliette Denis, executive director

Sudbury and District Medical Society

Dr Chris McKibbon, representative

Dr Jack Hollingsworth, past president

Registered Nurses' Association of Ontario

Vickie Kaminski, president

N'Swakamok Native Friendship Centre

Pat Rogerson, representative

Sisters of St Joseph of Sault Ste Marie

Sister Winnifred McLoughlin, health care coordinator

STANDING COMMITTEE ON GENERAL GOVERNMENT

Chair / Président: Carroll, Jack (Chatham-Kent PC)

*Carroll, Jack (Chatham-Kent PC)

Danford, Harry (Hastings-Peterborough PC)

Kells, Morley (Etobicoke-Lakeshore PC)

Marchese, Rosario (Fort York ND)

Sergio, Mario (Yorkview L)

Stewart, R. Gary (Peterborough PC)

*In attendance / présents

Substitutions present / Membres remplaçants présents:

Johns, Helen (Huron PC) for Mr Danford

Miclash, Frank (Kenora L) for Mr Sergio

Clement, Tony (Brampton South / -Sud PC) for Mr Kells

Ecker, Janet (Durham West / -Ouest PC) for Mr Stewart

Lankin, Frances (Beaches-Woodbine ND) for Mr Marchese

Also taking part / Autre participants et participantes:

Bartolucci, Rick (Sudbury L)

Brown, Michael A. (Algoma-Manitoulin L)

Hampton, Howard (Rainy River ND)

Martel, Shelley (Sudbury East / -Est ND)

McLeod, Lyn (Fort William L)

Ramsay, David (Timiskaming L)

Clerk / Greffière: Grannum, Tonia

Staff / Personnel: Campbell, Elaine, research officer, Legislative Research Service

The committee met at 0902 in the Ramada Inn, Sudbury.

SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION

Consideration of Bill 26, An Act to achieve Fiscal Savings and to promote Economic Prosperity through Public Sector Restructuring, Streamlining and Efficiency and to implement other aspects of the Government's Economic Agenda / Projet de loi 26, Loi visant à réaliser des économies budgétaires et à favoriser la prospérité économique par la restructuration, la rationalisation et l'efficience du secteur public et visant à mettre en oeuvre d'autres aspects du programme économique du gouvernement.

The Chair (Mr Jack Carroll): Good morning, everyone, and welcome to the hearings on Bill 26 by the standing committee on general government. We are delighted to be in Sudbury this morning to listen to your concerns. Just for the sake of the audience, I will have to explain to you how the process works. Each presenter has a half-hour of time. Any time that they leave for questions is split evenly among the three government parties in rotation. We would be starting this morning with the NDP. I would ask the people in the audience to remember that the dialogue is between the presenters and the committee members and respectfully request that you people in the audience refrain from participating. By the way, we do hold fairly closely to the time line because we're on a fairly tight schedule.

MANITOULIN-SUDBURY DISTRICT HEALTH COUNCIL

The Chair: Our first group this morning represents the Manitoulin-Sudbury District Health Council: Ken Ferguson, chair; Normand Gauthier, vice-chair; and Bob Knight, executive director. Welcome, gentlemen. We're pleased you're here, and the floor is yours.

Mr Ken Ferguson: Good morning, one and all. Thanks for hearing our comments. We're pleased to be here with you. Thank you for this opportunity.

The Manitoulin-Sudbury District Health Council was formed in 1976. We're 19 volunteers appointed by the Lieutenant Governor to advise the Minister of Health on the health needs of our districts. Recently we have focused on the reform of the long-term care and mental health systems, hospital restructuring and health promotion planning. Last spring we completed a major review of the Sudbury hospital system, and I'm pleased to be able to present council's views on Bill 26 this morning.

First off, the Public Sector Salary Disclosure Act, 1995: It has been said repeatedly in our community that the public sector must be more accountable. Therefore, we support the measures outlined in the Public Sector Salary Disclosure Act, except that the minimum threshold should be $75,000 and not $100,000. Also, the salary and benefits should be disclosed for the heads of all organizations funded by government.

Amendments to the Ministry of Health Act: The primary role of the Health Services Restructuring Commission will be the rapid implementation of hospital restructuring. Other duties will likely be assigned. The role of the commission will be to complement the new powers of the Minister of Health.

Generally, we support the establishment of the commission. Implementation of hospital restructuring is chaotic throughout Ontario because the current legislation impedes the sweeping changes that are needed. The creation of the commission has the potential to assist the minister in taking decisive action.

Therefore, we recommend that opportunities be given for input into the regulations, recognizing a rapid turnaround time is needed; that the commission's restructuring be based on planning carried out by the district health councils; that the regulations make it incumbent upon the commission to develop linkages with the DHCs; that at least 25% of the commission members include current or former DHC members; and that a role be defined for the DHCs in advising on the suitability of measures under consideration by the minister and the commission.

The relationship we recommend between the commission and the DHCs is based on our belief that the DHCs offer the best advice available on reform of the health system at the local level. DHCs, largely through the input of consumers and the broader public, advise from a position of objectivity. They offer a system and a district view in their work -- the only local organization with this kind of role. DHCs are capable of making and have the courage to make difficult decisions for improving the quality of life in their communities.

The commission should have as one of its goals the integration of the health system through restructuring. Their decisions and advice to the minister should be based on a consideration of the broad determinants of health espoused by Premier's Councils over the past five years.

Going on to the amendments to the Public Hospitals Act, hospital amalgamations: The amendments refer to the amalgamation of two or more hospitals. We assume this means corporate mergers in one community or in more than one community in a region. This needs to be clarified, because a hospital is not necessarily a corporation. One corporation may own and operate more than one hospital in more than one community, in which case none of the individual hospitals would be a separate corporation.

The amendments refer to the power of the minister to direct two or more hospitals to amalgamate. Once again, a hospital is not necessarily a corporation. We could use the example of the Sudbury General Hospital, owned and operated by the corporation of the Sisters of St Joseph of Sault Ste Marie. Because the Sudbury General is not a corporation unto itself, it appears that a merger of that hospital with the other hospitals in Sudbury would not be possible, given how Bill 26 is currently worded. We have recommended a form of merger of the Sudbury hospitals. It appears that Bill 26 would entrench restrictions preventing the minister from directing such a merger.

A possible solution would be a section that would enable the minister to direct the severing of a part of a corporation -- for example, one hospital -- and the subsequent merger of that hospital with other hospital corporations. Another approach would be to add a section enabling the minister to purchase from a hospital corporation part or all of its assets, with the intent of merging such assets with other hospital corporations.

One of our biggest concerns about the amendments concerning the amalgamations is the illusion they create that they will be applied evenly to all hospitals funded by the government under the Public Hospitals Act. Unfortunately, this will not be the case.

The Premier and the minister have assured the Catholic Health Association of Ontario that Catholic and other denominational governing structures and their missions in the health system will continue. There's nothing wrong per se with such assurances. However, no government interpretation has been offered, giving the CHAO the leeway to develop the most restrictive criteria in North America on the interaction of Catholic and other health organizations.

This has upset the balance in the local hospital governance and restructuring discussions province-wide. The playing field is no longer level. In Sudbury, good-faith negotiation of governance and service issues seems impossible among the key players. Favouritism towards one category of organizations is systemic in the restructuring of hospitals.

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The Catholic nature of health care organizations can be preserved even where mergers may be directed by the minister. We refer to publications of the Catholic Health Association of the United States. Bill 26 should contain a section making it clear that each and every publicly funded hospital in Ontario, including Catholic and denominational hospitals, may be directed to amalgamate. There should be no policies of the government that offer exemptions to certain classes of hospital organizations.

The minister's powers regarding grants and services: Schedule F empowers the minister to alter hospital funding and the scope of services provided by a hospital. We give qualified support to these measures. They are needed to speed up the restructuring of the hospital system. Our qualifications are as follows: The role of the commission and its relationship to these powers of the minister must be clearly defined. Where the minister directs such changes, they should be based on what is in the best interest of the communities affected. The minister and the commission should rely on the advice of the public, through their DHCs, in this respect.

Investigators and supervisors: Schedule F refers to the appointment of an investigator. We would recommend that the wording be changed as follows:

"The Lieutenant Governor in Council may appoint one or more persons to investigate and report on the quality of the management and administration of a hospital or group of hospitals...."

Such a change in wording would recognize the relationships and the interdependence between hospitals in multi-hospital communities. Similarly, the amendments concerning the appointment of supervisors should refer to a hospital or a group of hospitals.

Investigators and supervisors should seek advice from the DHCs in determining what may be in the community's best interests. We recommend the following addition to subsection 9.1(1) of the Public Hospitals Act, "(e) the advice of the district health council."

The physician human resource plans required of hospitals should be subject to review by DHCs. The concept of a group of hospitals should be used. Schedule F should contain provisions enabling the minister to prescribe the medical staff organization for a group of hospitals.

Amendments to the Independent Health Facilities Act: The proposed amendments give much broader discretion to the minister in granting independent health facility licences. The granting of licences and approvals for relocation should occur only upon consideration of the needs of the communities affected, with input from the DHCs.

We agree with the Information and Privacy Commissioner that the measures proposed with respect to the collection and disclosure of personal information are sweeping and inappropriate. If the concern is the elimination of fraud, other means should be considered, such as payment methods other than the traditional fee-for-service approach.

Amendments to the act concerning drugs: Studies have shown that extensive overprescribing of drugs to the elderly is a source of health problems for them. Amendments to the legislation should be made, not just to save money, but also to reduce the overprescribing of drugs to our elderly. Copayments will not be effective in this respect.

We support the amendments that would ensure the minister would no longer pay for a more expensive drug when a cheaper alternative is available.

The prescribing of the dispensing fee should enable competition among the pharmacies on the basis of the dispensing fee. What is prescribed in the regulation could be a maximum. If a pharmacy offers a lower fee to the general public, it should also be offered to the government.

There should be measures to ensure that people with chronic illnesses should not have to make frequent visits to the pharmacy, triggering frequent payment of dispensing fees if frequent visits are not medically necessary.

Amendments to the Health Insurance Act and the Health Care Accessibility Act: The amendments intended to combat fraud and inappropriate use of insured health services are sweeping and inappropriate. We recommend that considerable progress could be made in these areas by the expansion of alternative payment methods for physicians and other practitioners. These approaches would have been much easier to administer. The sweeping measures with respect to personal information would not be needed.

We support in principle the amendments intended to correct the imbalances in geographic distribution of doctors. The measures tend to be negative -- for example, the setting of differential fees -- and continue to depend upon fee-for-service payment. Once again we recommend the aggressive pursuit of alternative means of paying doctors, for example by fixed-price contracts.

Amendments to the Freedom of Information and Protection of Privacy Act: Out of concern for ensuring accountability of government organizations to the public, we cannot support the proposed amendments to the Freedom of Information and Protection of Privacy Act that would have the effect of restricting access. We refer specifically to the measures eliminating the potential for fee waivers and the lack of definition of the term "frivolous and vexatious."

We offer qualified support for amendments to other legislation intended to achieve restructuring and savings. Such amendments affect the Municipal Act, the Conservation Authorities Act, the Mining Act, the transportation statutes, and acts administered by the Ministry of Natural Resources. Our qualification stems from our commitment to the broad determinants of health. It should be possible to amend the legislation to achieve these fiscal objectives while ensuring that a healthy physical environment and healthy communities are also achievable.

Thank you for the opportunity to make this presentation this morning. I would be pleased to answer any questions you may have.

The Chair: Thank you. We have about four and a half minutes per party for questions, beginning with the New Democrats.

Ms Shelley Martel (Sudbury East): Thank you to the presenters. Let me ask about the Public Sector Salary Disclosure Act. In your last line you said the salary and benefits should be disclosed for the heads of all organizations funded by the government. I assume you are suggesting that those groups that are for-profit but receive a substantial amount of money from the province, such as nursing homes, should be forced to disclose salary levels of their CEOs as well. As you know, under Bill 26 at this point, they don't have to.

Mr Ferguson: Yes, I would agree with that.

Ms Martel: Let me ask you about the restructuring process. The minister, when he made his comments at the opening of this committee in December, seemed to suggest that part of the reason the Health Services Restructuring Commission was going into effect, that part of the reason for the rather draconian legislation he's going to assume unto himself, is that for some reason or another there are roadblocks in the current legislation that don't allow restructuring or make it difficult.

You folks have been through a process of restructuring in this community for two and a half years. You came to a consensus recommendation, which was forwarded to the ministry at the end of October, calling for a single governance structure. It would seem to me that the roadblock you've run into is not legislation but the minister himself, who refuses to recognize the consensus you brought forward from the community. I'm wondering whether you'd like to comment on whether any legislation would have been necessary to implement the consensus recommendation you put forward, and whether you have any confidence that a restructuring commission, as it's currently outlined, with no mandate and no powers as yet disclosed, is going to be helpful to you.

Mr Ferguson: Good question. I don't know whether I'm qualified to answer that. I believe part of it could have been accomplished without legislation, but I believe legislation ultimately has to be enabled before amalgamations can be put together if they're not willing to amalgamate.

Ms Martel: Would you say that the change you're really concerned about is that all public institutions are treated the same so that amalgamations can occur?

Mr Ferguson: In our brief, we referred to the imbalance, and I believe that still holds.

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Ms Frances Lankin (Beaches-Woodbine): I want to ask you about your references to the hospital restructuring commission. Personally, I don't think it's a necessary thing, but I'm not opposed to it; it can be helpful. What I'm opposed to is the fact that there are no terms of reference, mandate, limits on powers, and no reference to a relationship to local district health councils in their restructuring reports and efforts. Would you support amendments to the legislation that spelled out a set of terms of reference and a relationship, at least, to local DHC reports and recommendations from local communities?

Mr Ferguson: I guess we have to recognize that our government is our ultimate authority in --

Ms Lankin: I think the legislation is.

Mr Ferguson: I'm not into the finer points, I guess. None the less, they have the authority to change the legislation. To put in a great deal of control, protection, would be nice, but is it going to be in the long run?

Ms Lankin: We hope, if we can convince the government members that those are necessary amendments, that we might be able to get that in.

Mr Ferguson: I'm not political on that end.

Mrs Janet Ecker (Durham West): Thank you very much for coming today and for your detailed brief in which there are some excellent suggestions in terms of changes that might improve the legislation. I thank you very much for offering them.

One of the things we've talked about a lot over the last several days of hearings has very much been the relationship between the district health council and the restructuring process. As the minister has pointed out to your group, that is very important, that those district health council recommendations are going to be the basis upon which restructuring will have to be pursued in the areas. If there's clarification needed in the legislation to ensure that is indeed the case, we've certainly indicated that we'd be quite happy to suggest that to the minister. He is quite clear that district health councils are a very important component of the restructuring we have to do.

One of the questions I wanted to ask about was getting back to the difficulty of attracting physicians to northern communities. As we know, that has been a problem many governments have wrestled with and the problem has been getting worse, not better.

What has been, do you believe, the success this area has had in some areas, in attracting physicians here and keeping them and building various programs? What is it that you think the government needs to do to try and get physicians into underserviced areas and keep them there?

Mr Normand Gauthier: It's very easy to answer this one. If the recommendations that were put together by this community in regard to restructuring would enhance the working conditions of physicians, that would be the best tool available to help keep our qualified personnel at home.

Mrs Ecker: What specific working conditions? The minister has talked about various support mechanisms for physicians in outlying areas. What specific suggestions might you have to do that? Is it a question of money, of people coming in to support, of having time for continuing medical education? What do you think is the key component?

Mr Gauthier: The key to this is making working conditions acceptable and livable for the doctors. The ideal would be one plant, one hospital in the area. Then everybody would know where the services are and all the doctors would be there, and they'd know where they'd go to work in the morning, instead of spending a good percentage of their day on the road going to work.

Mrs Lyn McLeod (Leader of the Opposition): There are a number of areas we'd love to have an opportunity to explore with you. I think the issue of recruitment of physicians will come up later in the day, so I'm going to hold on that one. You've raised a number of issues I'd like to have you talk about. I'm going to hold off on them, but just to acknowledge them.

In a number of places in the brief, regarding the steps the government seems to feel will reduce fraud and in terms of utilization of drugs with the copayment plan, the access to medical records and also the intervention of the government in medically insured services, you make several statements about these being sweeping and inappropriate powers, and I would like to give you an opportunity to expand on that.

Having said that, I will come back to the issue of the hospital restructuring commission, because I think this is one area we're going to hear a lot of discussion about as the committee has its hearings. I think I'm interpreting the brief correctly when I hear you say that you think it's important for the minister to have the power to expedite hospital closures, providing they act on the reports of the district health councils. I would therefore assume that if the minister does not act on the views of the district health council, you would feel that was a real violation of the local planning process.

I think we've got a real conundrum here. Whether the minister needs more powers or has the power to close hospitals now, I don't think we need to debate. I personally think he has the power: He controls the dollars. We don't need this legislation to give him the power to step into any community and expedite decisions about hospital closures.

What is at issue is how we ensure there's a good process of community consultation. That's what I'd like to ask you. You've been through a lot in the consultation, as other district health councils have, and I'm wondering whether there were adequate guidelines put in place in terms of what the minister and ministries expected to see. It would have been previous governments, obviously. Should there be guidelines in place?

For example, if at least a two-governance model is one of the criteria for acceptance at the end, should that be established at the beginning? Should there be guidelines for consultation? Do district health councils sometimes feel as though they're out working on their own without enough understanding of where the minister is going to come from? If the minister is now going to come in and say, "Sorry, folks, we don't like the work you've done," you should have had a better understanding of that, more guidelines, from the beginning. Can we have a more collaborative process from the very beginning so we're not in such a conflict position at the end?

Mr Ferguson: Yes and no. There was a great deal of discussion on the parameters and on which way the study of our communities was going to be put in place, governance first, versus restructuring or services first. To get the players all involved, the restructuring, the planning of services, tended to be the only one they could deal with to start with; governance was to be left to the end to tail it off.

Having said that, governance was considered at the outset of the study to be the single most important part of restructuring, to get rid of duplication, to get a system where there was one of each right down the line, from administration to medical staff to nursing staff to administration people, one, one, one, right down the line -- most efficient, most effective, everybody knew where they were and what they were doing, no confusion about what hospital they were going to be working in today or tomorrow or the next day. All the efficiencies could be worked through one system. There wouldn't be any competition for any of the projects or services; they'd all fall into place as they were needed and where they were needed, logically and clearly, no debate about it.

However, to get the players all involved, the governance part was left to the end, unfortunately. Yes, there was lots of discussion. Several governments were involved in this study, as you're aware, from start to finish, and God knows how many more before it's completed. Hopefully, it will be shortly.

Mrs McLeod: I look towards the future and the fact that we all know there's going to be restructuring. Every community has been going through that. The minister, for better or for worse, is now going to be a larger player at that table. Should the Ministry of Health be part of that from the very beginning in terms of, "Let's all be working together, bringing all the stakeholders, deciding in advance where we want this to go"?

Mr Ferguson: I believe they were involved right from the start. To be honest, I wasn't on the health council when this was initiated. I understand several chairs have done studies in years gone by, and those studies sit on the shelf gathering dust. This is the first one that's come as close as it has to finding implementation, and we hope and have faith that it will find resolution in restructuring and come to fruition to serve the community.

The Chair: Thank you. We appreciate your attendance this morning and your interest in our process.

Mr Ferguson: I have one last comment, if I might. One of our facilities in town has been able to get on the floor to speak with you, but one of our hospitals made a request and was unable to. I would like to ask that you reconsider their request for addressing this committee.

The Chair: Unfortunately, we've only left ourselves even a half-hour at lunchtime here in Sudbury, so we have no additional time. But if anybody wishes to present a written brief to us, it will be considered as equally as any oral presentation. So those who did not get on are invited to submit copies of a written brief.

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Ms Lankin: Mr Chair, I'd like to place a motion before the committee. It's very apropos in light of the last comment you just made about the hospital that is unable to present here. My motion is as follows:

Whereas there has been overwhelming public interest in Bill 26 and that 50 groups and individuals have requested to appear before the standing committee on general government in Sudbury today, which far exceeds the 13 spaces available today for hearings;

I move that this committee recommends to the government House leader that when the House returns on January 29, 1996, the order with respect to Bill 26 be amended so that the bill can be returned to the standing committee on general government so that further public hearings can be arranged for the community of Sudbury;

Further, that this committee recommends that the three House leaders meet as soon as possible to discuss this issue.

Mr Tony Clement (Brampton South): On a point of order, Mr Chairman: I believe that is substantively the same as the motion that Ms Lankin prepared and that we debated yesterday and that this particular request that is embodied in her motion would have been subsumed into the motion that was defeated by the committee yesterday.

The Chair: The motion basically is in order. I would suggest, out of respect to the people who are here to present, that we use our half-hour lunchtime to talk about it. Do I have unanimous consent for that? Okay, so we'll defer that until 12:30.

SUDBURY DISTRICT PHARMACISTS' ASSOCIATION

The Chair: The next group are the Sudbury District Pharmacists' Association, represented by Norm Grillanda and Claire Shaw. Welcome to our committee. You have a half-hour to use as you see fit. Questions would begin with the government at the end of your presentation.

Mr Norm Grillanda: Thank you, Mr Chairman. My name is Norm Grillanda and I am the chairperson for the Sudbury District Pharmacists' Association, which I'll refer to as the SDPA. The SDPA represents the pharmacists and 35 pharmacies of the Sudbury region on matters that concern the profession. The SDPA has approximately 70 member pharmacists.

With me today is Claire Shaw, chairperson for the prescription drug plan committee for the SDPA. This committee is quite active in our community as a consulting service for several local employers, and I might add that they include INCO and many of the public sector employee groups. It has been very successful at achieving significant cost savings for these employers in the provision of their employee benefit programs while still maintaining a high quality health program. This is an ongoing partnership and reflects how cooperation between all the parties involved can lead to the control of costs.

Also with us today is Sandi Hutty, the district 14 representative for the Ontario Pharmacists' Association, or OPA.

We are very pleased to have been given the opportunity to discuss our views on Bill 26 with this committee. We have attempted to take the approach that we would not offer any criticism unless we felt we had a realistic alternative. We have supported our beliefs with unbiased data and feel that it does merit careful consideration. We have also tried to keep in mind the underlying need to get control of health care spending, which is the primary driving force behind this bill. As front-line providers of this very important service to the ODB recipients in Ontario, we are also very cognizant that the level of care and resulting patient outcome is of primary importance and must never be sacrificed in the name of cost savings.

As background, I would like to give you a little bit of information on what we see has happened with the ODB program.

If we look back at the ODB program, we'll see a record of increases from year to year. There have been many attempts to control these cost increases. These efforts included dispensing fee rollbacks, delisting certain products from the ODB Formulary, such as over-the-counter medications, and finally, an attempt to decrease the number of fees paid by encouraging large-quantity prescribing. I think we will all agree that none of these measures have been very successful, and the ones that did achieve cost savings -- for instance, delisting -- caused significant financial burden to the ODB recipients.

Costs have continued to increase at rates much higher than the CPI despite all of these measures. This in itself, I would add, has got to be seen as proof that the measures that have been taken so far have not been effective. It also indicates either the government's inability to understand what's causing the cost increases or its inability to deal with them.

We feel that the reasons for the cost increases are very evident when one examines the situation. In Ontario, the percentage of citizens over the age of 65 is rising, and so more people are eligible for the program. The ODB program has recently been expanded to include the working poor and certain segments of the population through the Trillium program. Although this is quite simplistic, we feel it should be stated here so that there is a more complete understanding of the driving forces. We are in no way suggesting that these criteria are wrong or should be changed in any way.

The ODB Formulary design itself has been responsible for much of the problem. The ODB Formulary has a group of people who make recommendations as to whether a drug should be listed or not, and I'd like to add here that there is only one pharmacist participating on this group. They have attempted to initiate a set of criteria for the selection of various drugs when several choices exist. Unfortunately, for the most part, these criteria are not adhered to for several reasons.

I'd like to point out to you these two government-funded publications that came out last year, one being the anti-infective guidelines and the other being guidelines for the treating of uncomplicated hypertension. These have been put together by experts in the field, and they recommend procedures for prescribing medications for these particular problems. Unfortunately, there's no teeth behind these guidelines and they have not been listened to or adhered to. The results have been an increase in utilization of the newer higher-cost drugs instead of the lower-cost existing therapies.

To substantiate my hypothesis, we cite the Green Shield study which uses Canadian data from 1987 to 1993. Just to give you a little background on what Green Shield is, in 1993, Green Shield processed 3.5 million claims with revenues of $252 million. The study states that the cost per claim for all prescriptions from 1987 to 1993 rose by 11.6% per year compared to a 3.5% annual rise in the CPI. Green Shield goes further and breaks down the causes for the increase into several reasons:

-- 33.9% of the increase was due to the increased cost of existing drugs.

-- 15.1% of the increase was due to an increased quantity being prescribed per claim. This is quite interesting also, as you'll see later.

-- There's a 4.3% decrease in the cost due to a shift in usage of existing drugs.

-- Most notably, I refer you to the last point, which is that 54.6% of the increase was due to a shift towards the use of newer, more costly medication.

Green Shield also reports that there were shifts in prescribing within therapeutic classes of drugs towards higher-cost products and that there was a definite shift towards drugs holding patent protection, which prevents the use of generic alternatives. New drugs made up 49% of claims in 1993, and this compares to 1.5% of claims in 1988, a very substantial increase.

They also go on to compare the average cost of existing therapies -- that would be in 1987 -- that was at $16.92, versus $43.24 for new therapies. I'd like to point out that although this data does not include ODB data, the ODB experience would be a very parallel experience. One examines this data in light of the fact that of the 94 drugs given HPB approval in 1994, the Patent Medicine Review Board of Canada stated that only five of these represented a significant breakthrough or offered a substantial improvement over existing therapies.

I'd like to refer at this point to the Pharmaceutical Manufacturers Association of Canada presentation that was given to this committee in December of last year, where they state that only 23 of their new drugs were included in the ODB Formulary in the period from 1990 to 1993. They imply that that may not be sufficient. In light of the information given by the Patent Medicine Review Board, I would hesitate to say that it's probably more than sufficient.

I know you're all saying that these types of things can't be happening in the ODB program, but let me give you one example, and I hesitated to do this. I don't want to single out any particular manufacturers or any particular drug products, but I could have given many other examples. The reason I chose this one is this particular product was just included in the ODB Formulary within the last few months. The drug in question is clarithromycin, which is an antibiotic in the class of erythromycin. The typical prescription cost for the former is $44.66 versus $3.28 for the latter for the standard treatment period.

Number one, why are doctors prescribing clarithromycin in ever-increasing quantities? It's very simple. The manufacturers are promoting the product quite heavily and spending lots of money doing it. They're telling the physicians that the drug is just as good as erythromycin and it's going to cause less stomach irritation. Well, let's look at the facts. Erythromycin can cause stomach irritation in about 10% to 15% of the people who take it, and a smaller percentage than that will have to stop taking the drug because of these problems. This type of problem occurs in 6% of the people with clarithromycin. So there is a small difference; there is a difference and it is significant. However, does that warrant paying for Biaxin for every single patient who needs an erythromycin prescription? I think not. We understand that flexibilities have to be built into the system so that particular circumstances can be dealt with where a patient may need clarithromycin for very legitimate reasons, and we feel that can definitely be worked in.

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Before we deal with the actual issues in Bill 26, I'd like to give the Sudbury District Pharmacists' Association position on health care:

(1) The SDPA believes that all Ontarians should have equal access to the best health care possible without regard to ability to pay.

(2) The SDPA believes that all Ontarians should be allowed to utilize the pharmacy of their choice.

(3) The SDPA believes that all Ontarians deserve a high standard of care from the pharmacist who serves them and that this standard of care be set and maintained by the Ontario College of Pharmacists.

(4) The SDPA believes that a system of remuneration for the services provided by pharmacy be fair and reflect the level of service that is provided.

With regard to Bill 26, we have to offer the following subjects for discussion:

With regard to plan design, we know that since the drug cost component of the ODB prescription represents over 80% of the total price, this component must not be neglected in attempts to control costs. Large-quantity prescribing has led to high levels of wastage of drugs. Wastage is a very significant problem and one that is not being addressed.

The SDPA has just completed a month-long medicine cabinet cleanup program, and although the final results haven't been tabulated yet, we can offer the following data: Of the 21 pharmacies that have reported to date, $17,000 of drugs have been collected for which the ODB program has paid. These are drugs that are not going to be taken and are going to be discarded. If this number is extrapolated to the 2,500 pharmacies in Ontario, the figure would rise to over $2 million. This was collected in a one-month period. The reasons for not finishing prescriptions can range from suffering an undesirable side effect, lack of effectiveness, resolution of the problem or just poor patient compliance.

There is a trial prescription program in place in British Columbia, and data certainly suggest that very significant savings can be achieved from such a program. Early data state that of all the prescriptions in the program, 57% of the prescriptions were not renewed after the first trial portion was dispensed. The program has been so successful in British Columbia that the Ministry of Health, in conjunction with the BC Pharmacists' Association, has expanded the number of drugs in the program to achieve even more savings. This is just another example of a cooperative effort achieving desired results. This did not cost the taxpayer a dime, nor did it reduce coverage.

The SDPA fully supports the removal of the PC-34 no-substitution form as outlined in Bill 26. This form, when completed by a physician, would allow a prescription to be filled and reimbursed for the name brand product even though a lower-cost equivalent product is available.

Prescribing guidelines must be put into place whereby existing therapies are encouraged over the newer, more expensive alternatives. This is entirely possible in the electronic on-line environment that the Ministry of Health and pharmacies now operate in. This type of system is already in place in the private sector and hospital settings, and there is no reason for the ODB program not to adopt it. If the ODB program were paying $16.92 for the drug cost rather than $43.24, we may not even be here today. Why shouldn't the Ministry of Health utilize pharmacists to administer a drug utilization review program?

I'd like to refer to a study that was done in 89 hospitals in Canada. They found that for every dollar they invested in a pharmacist's time devoted to DUR -- drug utilization review -- they had a $30 return in reduced medication costs. I don't want you for one moment to get complacent about the fact that you hear that drug cost increases are being kept to under CPI, especially when you see the introductory cost of new drugs coming out into the market. This is a very misleading statistic that cannot be considered a sign of any kind of control over drug costs.

With respect to copayments, we acknowledge that many provinces in Canada have a copay system. In theory, copays are meant to curb utilization and to share costs with the users, along with making them more aware of the value they are receiving. The evidence for copays is much too unclear to make recommendations promoting it, for the following reasons:

(1) It is impossible to tell whether savings derived from copays are from decreased utilization of discretionary medication or necessary medication.

(2) What are the costs of hospitalizations or long-term morbidity from lack of compliance with respect to medications like anti-hypertensives?

(3) In Quebec the implementation of copays led to a decreased utilization during the first year, but levels returned after year one to previous levels.

The SDPA does fear that the people who will be hurt the most are the low-income ODB recipients who will not have their prescription filled so that they can purchase groceries.

With respect to the actual recommendations in Bill 26 on copays, which are a $2 flat fee copay or a copay based on the dispensing fee for higher-income ODB recipients, the SDPA has the following comments.

The SDPA can't support the copay proposal because it will not achieve the goals that they are trying to achieve. This copay proposal will cause undue hardship to those Ontarians who can least afford to pay. It does not make the Rx recipient more aware of the value of the prescription. All of the other factors that we have itemized are not fully understood yet by anyone and, finally, there are many other measures for cost savings possible. These measures should be exhausted before any copay system be implemented. At that time, if it becomes necessary to implement a copay system, the SDPA would be able to offer its suggestions on how it might be implemented to better achieve the desired result.

With respect to price deregulation, the current system of best available price, BAP, may not be the perfect system of drug price controls, but we feel that it is a fair system and better than the one that is proposed in Bill 26. The BAP concept allows for a price to be set in the Ontario Drug Benefit Formulary for the drug price at the best price found in Canada.

May I add that this also takes into effect competitive forces, so that when pharmacists or purchasers seek out better prices, those better prices get reflected in the ODB Formulary. There is a changing, evolutionary process in it and competitive forces are in place, so it is a good system. It ensures access to those prices for all pharmacies and, in effect, to the clients of those pharmacies whether they be a cash customer or a third-party payor for a local employer.

The concept of deregulation would take away this access and put pharmacies in northern Ontario at a distinct disadvantage with respect to the purchase cost of drugs. One only has to examine the large variation in drug price for products in Canada, for instance, from province to province. When one looks at the difference between pharmacy purchase and hospital purchase prices. This would have to be reflected in the final prescription price. The people of northern Ontario know well enough the extra costs of living in the north.

The aspect of the drug price being regulated for the Ontario drug benefit prescriptions but not for other prescriptions is a bit puzzling also. How does the government propose we establish a particular regulated price for one tablet in a bottle and another deregulated price for another table in the same bottle?

Finally, with respect to the Ontario Pharmacists' Association as pharmacies' united voice, the SDPA believes that a cooperative effort among all the stakeholders in the ODB program will result in the long-term savings and cost controls that the government is seeking. Many of Ontario's large private and public companies have found that this cooperation and multilevel involvement has been very successful in their efforts to control employee benefit costs. Bill 26 would end this relationship between OPA and the Ministry of Health. This consultative relationship can only lead to further savings through these cooperative efforts and the expertise that the members of OPA can lend to this program. Excellent program models are already in place in other provinces such as Quebec, where the provincial association works as a close partner with the Ministry of Health.

It is for these reasons that the SDPA is suggesting that the Ministry of Health continue to deal with OPA as a representative of pharmacy in Ontario. The result can only lead to programs to help achieve further cost savings and enhanced programs to ensure the highest standards of care are maintained in the province of Ontario. We at this time also would suggest that the Ministry of Health continue its relationship with the Ontario Medical Association in the same light.

In conclusion, the SDPA would like to thank you for this opportunity to express our ideas. We feel that the recommendations made here are based on a sound understanding of the provision of pharmaceutical care to the people of Ontario. Pharmacists, as the experts in drug therapy and as the end provider in the ODB program, not only have a good understanding of the ODB program but must always keep the best interests of the patient in mind. The recommendations made in this presentation preserve this very important mandate while at the same time will ensure a cost-effective and efficient system for the taxpayers in Ontario.

I'd like to point out that I've included at the back of my presentation to you studies and abstracts for all the data I've included in my presentation.

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The Chair: Thank you. We have about three minutes per party for questions, beginning with the government.

Mr Clement: You've certainly given us a lot of information and a lot to think about as a committee, and I thank you for the time that you put into your presentation. You've raised a number of issues.

With respect to the replacement of the best available price, we've been hearing what I guess one could call conflicting testimony or different predictions, because really all we're doing is predicting the future, as to what will occur to drug prices as a result of moving away from that system.

Certainly the pharmaceutical manufacturers are of the view that prices could well go down, and certainly the structure of the industry, as I understand it -- if you look at it from a worldwide perspective, most of the pressures within the industry are to cap costs, to reduce costs. What's happening in other jurisdictions throughout the world is that people are organizing in groups like HMOs or what have you to put a cap on these costs and to have better bargaining power with the manufacturers. Could you see something like that working in the north in some form?

Mr Grillanda: I think that the forces are already in place. When pharmacists and groups -- HMOs, if you want to use an HMO -- seek out a better price and a company agrees to provide a product at a better price under the best available price system, that then becomes the best available price. So there are forces in place to promote competition.

One question I'd like to ask you is, if deregulation is going to end up with lower costs, then why is the Ministry of Health not deregulating the entire drug benefit prescription portion of the drug cost? They want to maintain regulation there, so they're fearing that drug costs may go up as a result of this.

Mr Clement: No, I think we like our bargaining power right now, actually. The government is a big buyer, so we've got some bargaining power that you as a pharmacist don't have, and I acknowledge that.

Ms Lankin: Exactly.

Mr Clement: Let me finish my answer, Mrs Lankin. But that's exactly why the other aspects of the industry are important. The pressure is down, the pressure is buyers coming together to bargain in that way. Ontario doesn't need that added incentive or position, because it's a big buyer of drugs, quite frankly. In fact, by being an active buyer in the market, we will affect prices in terms of a downward trend. But we're all predicting, I guess. To be fair to everyone, we're all predicting.

I'm glad that you mentioned the no-substitutions changes and your group's support of those changes, because we've also had some deputations fearing that somehow this was going to affect citizenry in a negative way. Certainly there are calibrations that can be done through regulations, perhaps, to meet some of the valid concerns that were expressed. But from your point of view, no subs is the way to go?

Mr Grillanda: We don't see a problem with it. There are so many options available that this should not create any undue hardship. Many of the name-brand pharmaceutical companies produce generic equivalents of their products in the same pill presses at 30% less than they're selling their name-brand product for.

Mrs McLeod: Just to follow Mr Clement, I think he's absolutely right when he says the government has a lot more bargaining power to get a good price for medications than a sick individual who's supposed to go from pharmacy to pharmacy to see if they can find a good price for the product before they purchase the drug. That's the implication of this bill.

It is obviously in northern communities, which your brief points out, a particular concern where there is not the same degree of competition or the volume of purchases or sales. It is really frightening that a government brings in such a major change and everybody is just predicting what the drug price may do. Having said that, that's not my question for you.

I want to come back to the copayment issue. I appreciate your brief because you've provided not only a focus on the specific concerns but a great deal of background information. In addressing the copayment issue, I appreciate that you've addressed the fact that the payment itself is a concern for those who are on those low incomes.

But if I'm understanding the information you've given us correctly, and I think this is an important point for the government to understand and to think about in looking at the copayment, you're saying that all the studies that have been done show that a lot of the increase in drugs can be attributed -- in this particular study 15.1% -- to increased quantity being prescribed per claim.

Logic says that if individuals who don't have a lot of money are being asked to pay a copayment or their dispensing fee, physicians are going to prescribe larger quantities in order to save them additional costs of dispensing. So the implication of a copayment is to have larger volumes of the drug prescribed. If that's the case and that in turn increases utilization of the drugs, the government's costs even under the ODB plan are going to go up because more drugs are going to be used under a co-payment system. Am I following the logic through?

Mr Grillanda: No. Increased prescribing doesn't increase utilization. A person who is taking three tablets a day isn't going to start taking four tablets a day because they have a larger prescription. However, there is a greater opportunity for loss of money because of wastage. We just pointed out in our medicine-cabinet cleanup program, people have therapies changed. They can't take drugs any more, things change, and so when they have a large supply of medication in many cases lots of this gets thrown out.

Being smart consumers, they're going to want to get the most prescribed at any time, thinking that they're going to save money by reducing the number of dispensing fees they pay. Well, when you take into consideration that 80% of the total prescription cost is in the drug cost component, there is a big opportunity for wastage and significant cost overruns because of this wastage.

Large-quantity prescribing is one of the things that is going to be promoted by a copay system, and it certainly seems there's enough evidence to show that this is not a way to save money. Large-quantity prescribing is appropriate when somebody's been stabilized on a medication and there is no foreseeable change in the future. In that case it's appropriate. When a patient comes in for an initial prescription on a medication and ends up with a three-month supply of it and throws 99% of it down the toilet, that is criminal.

Ms Martel: I want to return to the issue of drug deregulation because it's interesting that this initiative was not announced in the economic statement, nor was it found anywhere in the Common Sense Revolution, and it's telling that this is the only jurisdiction in Canada that is moving away from regulation of drug prices. People should ask themselves, why are we doing that?

I want to follow up from Mr Clement's comments that the government can get a really good price. Ms Shaw here represents a community pharmacy. How do you think your community pharmacy is going to do, Ms Shaw, when you have to go to the big drug manufacturers to buy drugs and when Shoppers chain goes to the big manufacturers to haggle for the price of drugs? Who do you think's going to get the best available price?

Ms Claire Shaw: Well, it's rather obvious who's going to get the best available price: the person who is dispensing more medication is obviously going to get the best available price, and when Shoppers has 1,000 stores across Canada, they obviously have an advantage over myself or, for that matter, over any buying group that the local pharmacies in Sudbury could put together.

If you do a cross-section of northern Ontario, we're in a big centre in terms of northern Ontario. But if you take the small number of communities that are across northern Ontario -- there are about 185; outside of five of those the rest are quite small -- how do you think people in northern Ontario are going to end up in terms of paying for drug costs? In most of those communities what you're going to have are small community pharmacies that aren't going to have the buying power, the buying authority, that the big chains do or that the government does.

Mr Grillanda: More importantly, I'd like to point out that not only will pharmacies be disadvantaged but also the people who frequent those pharmacies, because they don't have the option of going to any other location. They're restricted because they're immobile, they're seniors, they're homebound. They are restricted to where they can purchase medications, and if the pharmacy's paying more for the medications, then ultimately the consumer is going to have to pay more for those medications. So this is very unfavourable to northern Ontario for the most part.

The Chair: Thank you very much. We appreciate your involvement in our process and your presentation.

ACCESS AIDS COMMITTEE OF SUDBURY

The Chair: Our next presenters are from the ACCESS AIDS Committee of Sudbury: Ann Matte and Paul Ham. Welcome. You have a half-hour to use as you see fit. Any time for questioning that you leave would begin with the Liberals.

Ms Ann Matte: Good morning, ladies and gentlemen. My name is Ann Matte. I am the executive director of the ACCESS AIDS Committee of Sudbury. ACCESS is a community-based, non-profit AIDS organization. We provide service within the districts of Manitoulin and Sudbury. As well, individuals living within the 705 area code have access to us through a toll-free telephone line. Therefore, we do work with people who are living with HIV throughout northeastern Ontario.

In northeastern Ontario there are known to be at least 300 people living with HIV, and since 1989 there are at least 100 people within this part of the province documented to have died from AIDS-related illnesses.

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As you travel this week through this part of the province, I suggest that you pretend that you have to travel the distances yourselves between our communities for health care services. From Timmins to Sudbury you have about a three-and-a-half-hour drive one way. If one lives in Hearst and has to see a specialist at our HIV clinic, that person will travel six hours one way.

Sudbury is the health care centre for northeastern Ontario. It is the centre of excellence for cancer treatment, cardiac care, trauma, paediatrics. Sudbury is also the centre for HIV-related health care services in this part of the province.

I'll take this opportunity to thank you for being able to address your committee about the omnibus Savings and Restructuring Act, 1995, Bill 26.

The title of this act clearly identifies its objective. Economics is clearly the issue at hand. It amends over 40 pieces of legislation, repeals two acts and adds three new acts. This bill addresses a plethora of major areas, ranging from government borrowing to corporate income tax to which physicians will be able to practise where in this province.

There is a phrase that is repeated frequently within the proposed legislation concerning the Minister of Health who "considers it in the public interest to do so." It would appear based on this piece of legislation that the sole criteria that is in the public interest is economics.

We agree that we taxpayers in this province also need to get our fiscal house in order. This bill creates more problems which in the long term will cost even more. This bill lumps the health care of the citizens of Ontario in with changes to the Mining Act. One might assume that Ontarians are, according to Bill 26, a natural resource. We are sure that this government assigns value to the health, and we know that they do, of Ontarians.

We are concerned that this legislation has been drafted in haste. We expect carefully maintained quality health services even with financial restructuring. This bill portends a great amount of power to a small number of people with no checks and balances. This bill is creating insecurity among people living with HIV as it renders people helpless and hopeless in the determination of their health care needs. Put in very simple terms, this bill is scary. Our intent is to highlight some key issues as they might impact on people living with HIV in northeastern Ontario.

About the Health Insurance Act, schedule H, insured services: Which insured services will be covered by OHIP? Who will define what criteria are medically or therapeutically necessary? We understand that the criteria that the Minister of Health can use to determine who is entitled to a particular service will include age, who provides the service and the type of facility in which a service is offered. Will this mean that some people will be covered by OHIP and others not? If a person living with HIV lives in Iroquois Falls and does not go to a physician with the appropriate designation nor near the appropriate facility, will that person have to pay out of pocket for that particular service? Health care service accessibility is not equitable across this province as it is now.

About physicians' eligibility: Many people living with HIV are seen by physicians who may not be affiliated with a hospital or a specific facility, especially in northeastern Ontario. If the specialists or primary care physicians no longer qualify, what recourse will their patients have? This legislation, as proposed, allows for no manner of public challenge to decisions on physician eligibility.

The physicians in this part of the province who care for people living with HIV are precious and few. They are dedicated and want to be in the north. What recourse will patients have should their physicians no longer be classified as eligible?

Hospital user fees: People living with HIV over the course of their lifetime require frequent hospitalization to deal with complex health problems. The regulations proposed under this section may prevent these individuals from receiving health services that they will require to survive life-threatening infections. By the time an individual requires hospitalization, usually one is no longer able to work for a living. Hence, one is surviving on a fixed income. The possibility of copayments for insured hospital services will definitely be a barrier to care.

The preceding have merely been a highlight of some problem areas that we have identified in a short period of time with Bill 26 as it relates to health. We're also concerned with wording in schedule M as it relates to municipalities. Will a municipality have the power to dissolve a local board of health? If so, what happens to anonymous testing, needle exchange programs and AIDS education done by public health?

This bill is all-encompassing. How can this committee possibly bring together all of the expertise required to make the best and most informed decisions surrounding all of these recommended changes? We strongly urge you to recommend splitting this bill into its appropriate sections so that more time can be given to key issues. As well, should your committee recommend any changes, the opportunity for feedback from experts in those areas should be incorporated into these recommendations.

We acknowledge the government's desire to move quickly on fiscal matters. However, this bill addresses directly the health of citizens of this province. The undue burden that will be borne by people who are ill as a result of certain pieces of this legislation cannot be seen as acceptable by responsible, intelligent decision-makers in this province.

Mr Paul Ham: Good morning, ladies and gentlemen. My name is Paul Ham. I have been living with HIV for the past four years.

As a person living with HIV in northern Ontario, I consider myself quite fortunate to be residing in Sudbury, which is the centre for the north for medical technology. In speaking with other individuals who are living with HIV and reside outside of the Sudbury area, they have to travel great distances to obtain specialized medical care for HIV and AIDS.

Those infected struggle with enormous social pressures and stigmatization from this virus. People living with HIV also live in fear: fear of disclosure. Many often die without ever having disclosed their HIV infection to friends and even family.

I will highlight today those recommended changes to the health legislation that are causing great concern to myself.

Proposed legislation changes to the health insurance, schedule H, concerning disclosure of confidential medical information will only amplify the fears of people living with HIV and AIDS. Early intervention has shown to improve the quality and length of life for people living with HIV, making HIV a chronic, manageable disease. For fear of disclosure, some may choose not to get the proper treatment needed. The outcome of this fear will be that the disease will progress at a faster rate. The probability of becoming very ill and having to be hospitalized for an extended period of time will thus occur at the cost of the taxpayers.

We who are living with HIV rely on confidentiality with our care team, and build trusting relationships with them so that our health is of number one concern. Why would a Minister of Health and members of cabinet need to see my personal medical files?

The proposed changes to the Health Insurance Act, the Ontario Drug Benefit Act, the Independent Health Facilities Act and the Public Hospitals Act would be a violation of my fundamental human rights that as a Canadian I am proud of having.

In regard to anonymous testing, people who suspect infection with HIV will be even more hesitant to be tested if there is a slight possibility of disclosure as one enters the next stage of the health care system. As proposed, the minister will be able to obtain this information and, if he so chooses, can share this information with insurance companies without the consent of the individual.

The ramifications of this proposal could be devastating, as fewer people will want to get tested. Those infected will unexpectedly be hospitalized with full-blown AIDS, which again will be a burden on the taxpayer if the individual has no other means of payment.

The proposal to impose a user fee for prescriptions can be very costly to those living with HIV and AIDS. The quantity of medication needed at times to prevent infections can be very substantial. Although the user fee of $2 per prescription appears to be quite low, a person living on a fixed income requiring a large quantity of medication would definitely feel the cost burden.

With regard to the proposed drug list under the Ontario Drug Benefit Act, it is my understanding that this list will specify not only the name of covered drugs, but also the specific concentration and form of the drug. This does not allow for any flexibility for a person living with HIV or AIDS.

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HIV can attack any part of the body, and if the only means of drug treatment is via intravenous and it is not covered, is it fair for the individual to have to pay for it because they cannot take the proposed concentration and form of the drug? Will this mean that I will have to be hospitalized at a much greater cost in order to get my medication?

Furthermore, those living with HIV and AIDS in isolated communities may have a higher financial burden when obtaining AIDS-related drugs and/or treatment because of what is being proposed under this legislation.

As a person living with HIV, part of my life routine is the ongoing monthly visits to the HIV-AIDS clinic. I am deeply concerned about the financial and social implications this bill will have on myself and others living with HIV and AIDS in northern Ontario.

The reality is that we who live in isolated areas have enormous fears of disclosure and the possible consequences of being outed. I strongly urge you to revisit the recommended changes to the health schedule. I believe that more time is needed in drafting the health legislation, as well as consultations with the experts from the community in these specific areas.

Thank you for listening to me. I am an expert on HIV.

The Chair: We've got about six minutes per party left for questions, beginning with the Liberals.

Mr Rick Bartolucci (Sudbury): Thank you very much for your excellent presentation. Let me quote from Tom Wright, who is the privacy commissioner. He states that "these schedules have the potential to significantly increase the amount of personal, health-related information that will be gathered, significantly increase the number of uses that may be made of this information and raise the possibility of new and troubling disclosures of the information." Would you agree with him?

Mr Ham: Yes.

Mr Bartolucci: What impact will that have on the AIDS community and those with HIV?

Ms Matte: Within this community for the last eight years, we have been encouraging people to be tested early, because HIV is a chronic manageable disease today. It has been a struggle because people are so afraid of disclosure, especially living in small communities. We now have anonymous testing. Anonymous testing in Sudbury is used by people who come here from Timmins, who come from North Bay, from areas where it is not offered. However, what happens then is once someone is tested, as they then enter into the next phase, which is then going to see a physician, going into hospital, there will not be a guarantee of confidentiality of that status. Hence, that will then prevent people from seeking further assistance with their health.

Mr Bartolucci: The commissioner has recommended 30 amendments to that section of the legislation. I know that you're in favour of most of those recommendations for amendments. Let me talk a little bit about copayments because the SDPA and the OPA obviously have suggested that copayments don't work. They will have a definite negative impact on your community, and I'd like you to outline the very, very grave concerns you have with regard to copayments.

Mr Ham: Most of the people I know that are living with HIV and AIDS in the Sudbury area are living on fixed incomes. I think by imposing copayments, you're really going to impose on their quality of life also. With HIV and AIDS you really have to manage your health and eat very nutritiously. If you're cutting into their nutritional intake because of paying for medications that they also need, It's going to be a much harder task for them to live on a lot longer in a good quality of life.

Mr Bartolucci: Would you say that it's safe to say that it may be a short-term fix with dire long-term consequences?

Mr Ham: Oh, absolutely.

Mrs McLeod: I just want to follow up on a couple of other questions that arise from your brief, and again appreciate what you've indicated about the impact of copayments. You may not be aware of something else that we've discovered in the bill, that the government can decide to impose different copayments for different classes of individuals. We have no idea what that means and what the implications of that may mean, but that's something else to watch for.

I would think by your comments about flexibility that you would want to see there be at least some process for physicians to ask for a substitute drug without it having to be covered fully because of the kinds of reactions that AIDS individuals particularly can get to specific drugs. Would I be right in assuming you'd like to see some substitution process in place?

Mr Ham: Absolutely. AIDS can often affect your oral cavities and if you can't swallow pills, then you need to take the drug treatments in different means.

Mrs McLeod: Right. You make a very brief comment about people with HIV/AIDS in isolated communities experiencing greater costs. I assume you mean the discussion we had earlier about how deregulation can lead to higher costs of drugs, particularly in smaller communities.

Lastly, a question, and this is a difficult one to read, but in the beginning of your presentation you talked about the government stepping in to determine what is going to be medically insured, covered by the health care system as medically necessary and in some cases therapeutically necessary. I guess one of the concerns I have is, where does something like palliative care fit with a government that is driven by a financial bottom line and has the power to decide whether something is medically necessary? I suspect you would say that palliative care may not be necessary in terms of the prolonging of life but is certainly necessary in terms of the continued relief of pain and the comfort of the individual.

Ms Matte: I think it will be very important to have and to see what the definitions will be of medically and therapeutically necessary services.

Ms Martel: Thank you to the presenters, particularly to you, Paul, for relating your own personal story, which always makes these things come a bit closer to home.

Let me ask you about the copayments. I don't have a good sense of not so much the types of medications, but the amount of medication that you or someone else might have to take. Similarly, what kinds of monthly costs, for example, would we be looking at for you just to purchase medication?

Mr Ham: I think, depending on the type of medication, when you become diagnosed with full-blown AIDS, your cost for medication is really substantial, depending on the infections that you're getting, the infections that you're trying to prevent yourself from getting, because we deal a lot with preventive medication right now. Our doctor at the clinic, if your T-4 counts are at a certain level, will hand over some medication to you, so it could be preventive of PCP, let's say. I'm aware of some individuals who take handfuls of pills three times a day just to keep going. So it can be a very large quantity.

Ms Martel: So when you place that in the context that you're probably already on a fixed income because you may not be working, and you're also trying to pay rent and then go back to a diet that has to be followed, you're talking about most people ending up in pretty desperate straits by the time they're finished even with just the $2.

Mr Ham: Oh, most definitely.

Ms Matte: Some of the costs that we're seeing on a monthly basis can range anywhere from $400 to $800 a month for medication.

Ms Martel: One other thing, and this goes back to the deregulation. Earlier, when this committee sat in Toronto, there was a suggestion by one of the government members that people could kind of go from pharmacy to pharmacy and try to get the best available price that way for drugs.

Let me ask you, for the people you serve, or for the people you know, Paul, or for yourself, particularly those who live in small northern rural communities: What is the likelihood of them being able to shop from pharmacy to pharmacy for the best available price and what is that going to do to their health care?

Mr Ham: For most people who are living with HIV and AIDS and have progressed further with the illness, it takes a great effort to even go to the HIV/AIDS clinic once a month to get tested. So to go out shopping around for prescriptions is really inconceivable for them. Basically, they're stuck with the pharmacist they started with.

Ms Matte: And depending on what small community one lives in, how many pharmacies will they have to choose from?

Ms Lankin: Even if you are lucky enough to have multiple pharmacies, I think one of the very important things with respect to health care management is for you to have a relationship with your pharmacist, who knows about all the different medications you're on and who is helping you manage your drug treatment program. If you could get one drug at a best price at one pharmacy and another drug at a best price at another pharmacy, what happens to your coordination of care at that point?

Mr Ham: I think that after you do establish a good relationship with a pharmacist, you try not to sway from them very often because they are basically looking after your own health, and if there is some kind of contradiction with the drugs, they definitely let you know about it.

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Ms Lankin: So I would think that in this case, persons with HIV and AIDS would want to stick with their one pharmacist, which means that the government's theory that people shopping around will be the competitive force that will drive prices down goes out the window a little bit.

I wanted to also ask you about the concern you raised around specialists and their hospital privileges and whether or not they can continue to practise their specialty in an area, particularly given the problem that we have had in Ontario in general, but most particularly in northern Ontario, in encouraging doctors to develop a practice where they understand and can work with and can be expert in dealing with people living with HIV/AIDS. Could you just elaborate a little bit more on what you see as some of the problems in the act and what it might mean for yourself and the people you know in your community?

Ms Matte: In this brief time that we've had, our concern is in the criteria for physicians to be identified as eligible; there are specific criteria. But nothing is guaranteed. So what happens to that one physician who may not meet all of the criteria, who loses his or her eligibility, and that is the one doctor serving that person in Opasatika and there's not a hospital that's maybe an HIV-related hospital -- the age is wrong? So does that person then have to pay that doctor for services because the insured services are no longer covered?

Those are some of the concerns, because the physicians in the north are limited in terms of seeing people with disabilities, people with HIV. They may not now be identified as specialists.

Mrs Helen Johns (Huron): Thank you for your presentation today. We've heard from a number of AIDS organizations and we appreciate your time. As you may or may not know, the minister has had AIDS as a high-priority item. We believe that it's important to keep funding it and we believe that some of the changes we're making, hopefully, will do that.

I just want to clear up a couple of what I consider to be misnomers and to clarify some issues that have come along through the hearings that we intend to rectify; first of all, confidentiality of information. It was never our intention that your records or my personal records would be plastered throughout Ontario. What we were hoping to do with that was to be able to use that to trace down misuse and inappropriate billings or uses in the health care system. Because it has raised such an issue, we will be making amendments to that. We're listening to what people say, and if you have specific things that you think would help us in making those amendments, we'd love to hear from you in that regard.

Also, what was suggested here today, that different copayments are going to come about as related to age or different diseases or anything we arbitrarily pick, it's just not the case; it's not in the act anywhere and it's not something we've said, so I want to clear that up to make sure it's not the case that people believe that.

The notion of "medically necessary" also. It is broadly determined by the medical profession at large and by experts in the scientific community. These experts, which include the central tariff commission of the OMA and a number of different groups, will continue to determine what's medically necessary, will continue to determine the services. So it's not basically the minister coming along and saying, "No, not medically necessary."

Ms Lankin: Mr Chair, this is outrageous.

Mrs Johns: And what you've said isn't? Give me a break. Implying that we're going to be laying off palliative care? Give me a break.

The Chair: Excuse me. These three people sit nice and quietly while you make your presentations. I think they deserve the same respect.

Mrs Johns: I was saying, I think, that drugs are an important aspect of treating AIDS. In the past, there's been a lot of pressure on which drugs are listed in the formulary and which aren't, and we've in effect taken drugs off to be able to put new ones on. In many cases I view that as being a problem, and the fact that we can't get new drugs on as quickly as we need to for people with AIDS as they're coming out with new ones.

We believe that by putting a copayment on we will be enabling new drugs to be available to people at a faster rate, especially people with AIDS. Can you comment on that for me, the need for drugs in a hurry, new medications that are coming out, that kind of thing?

Ms Matte: With our history to date, that's never happened, that it doesn't happen fast enough, and I don't see how copayment is going to facilitate it -- even something like Gravol, and that's not only for people living with HIV; people with cancer who need access to that, and different forms of it. So based on what I'm reading in this legislation, things have to be changed in it in order to even follow through with what you're saying to me right now. I don't see that happening with what is written in the recommended changes right now.

Mrs Johns: Can I just clarify that? Are you saying to me that the drugs are coming on to the formulary as quickly as they are needed?

Ms Matte: No, they aren't. They aren't at all. I don't see, though, how copayment is going to change that, because even the medications that are needed to be there aren't there now. They've been removed.

Mrs Johns: I want to talk about the physicians for a minute. I heard you say, sir, that there were 300 people with HIV and a specialist, I think you said. Are there enough physicians in Sudbury and the area, enough people who deal with HIV as their primary focus? And what do you think we can do as a government to help that situation if it is a problem?

Mr Ham: No. Actually, people with HIV are really underserviced by physicians up here in northern Ontario. We have to seek out specialists to get our infections looked after. Even general practitioners -- you really have to shop around to find someone who will be comfortable enough to deal with HIV and AIDS. So we're really underserviced up here in that regard.

Mrs Johns: Any suggestions or things that you think we could do that would assist you in that regard?

Mr Ham: We have ACCESS, and the HAVEN program has sent out many requests for doctors to attend meetings and to introduce them to the mentor program through Sunnybrook hospital, but we haven't had a really positive response towards that.

Ms Matte: When physicians take on the charge of people living with HIV, they become extremely busy. They then become the primary care and the specialist in many different facets of the body of a human being, which is very different from a lot of other chronic illnesses. Physicians need support. They need perhaps some extra financial reward, but most of all they need support from the government, from their own medical association, to pursue and continue to offer services to people living with HIV. They don't, I believe, need any more hassles.

The Chair: Thank you for your presentation. We appreciate your interest in our process. Have a good day.

Mr Bartolucci: Mr Chair, a point of information: Mrs Johns made a point with regard to disclosure of information. Is it my understanding then that the government has altered its position, and from here on in, in this bill as we discuss it, the release of information will not take place unless the individual to whom the information relates agrees to it? Is that correct? Is that my understanding?

Mrs Johns: We're saying that we're looking at making amendments to that portion of the act because we've heard so much from the people here.

Mr Bartolucci: Mr Chair, could she directly answer my question?

The Chair: I believe she did answer it.

Mr Bartolucci: No, she didn't.

The Chair: They're looking at making amendments to the act.

Mr Bartolucci: I didn't ask if they were looking to make amendments. I asked, will this be one of the amendments that they're going to incorporate in this act, that disclosure of information will not take place unless the individuals whom that information deals with give their consent? Is that an amendment?

The Chair: Our objective, in coming to Sudbury and going to Timmins and going to Thunder Bay, is to listen to public input; it is not to argue among ourselves about what we are or are not going to do. I suggest we continue along in the vein that we have so far, and that is to allow the people of the community to make their presentations. When we get into clause-by-clause back in Toronto, that is the time for us to talk about those issues.

Mr Bartolucci: But, Mr Chair, we cannot mislead the people here, whether we do it intentionally or unintentionally. If in fact that's not the case, then I'd like to know, because it will obviously determine the way we question over the course of the next week and a half.

Ms Lankin: Mr Chair, if I could add to this, you will recall that in Toronto on the first day of hearings the minister indicated another area of this act that he intended to amend. I asked him very specifically, in my opportunity to put questions to the minister, if he would ensure that for any areas they are considering amendments, those amendments be tabled prior to us going out for these two weeks of travelling hearings so we would have an opportunity to look at those and the public would know, so the very limited time we have to talk with people wouldn't be spent on areas the government already knew it was going to amend.

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The minister said, "Absolutely." In fact, he referred to the fact that he had always found it frustrating himself, as a member of opposition, if that didn't happen and the amendments didn't come in until the very last minute under the rules, which is the first day of clause-by-clause.

We have yet to see any amendments tabled, and I want to put this request one more time to the government, that it table the amendments so the public knows and the opposition members know what's left on the table for us to debate.

Mrs McLeod: Mr Chair, I'd like to table a direct question to ministry staff. I believe that's in order.

The Chair: Yes, that is in order.

Mrs McLeod: I've given up hope that we're going to see the amendments before we continue the debate. Because there has been a very clear indication that the government is looking at amendments in the area of disclosure of information, and based on the fact that this presenter had indicated a concern about disclosure of information under schedule G as well as under schedule H, I would like some clarification from ministry staff about whether amendments relating to disclosure of information will apply both to schedule G, the drug benefits act, and schedule H.

Mr Clement: A point of order, Mr Chair.

Mrs Ecker: Mr Chair, they've had a lot of time. We would like to respond, if we may.

The Chair: I would like to play a little hardball on this issue. We are not here to argue among ourselves; we are here to listen to presentations from the public. I am going to insist that we get on with that process.

Thank you very much for your presentation.

Ms Martel: May I raise a point, Mr Chair? You can tell from the room overflowing with people right now that there is a great deal of interest in these public hearings. I wonder if you might request that the hotel put in more chairs for the people standing at the back.

The Chair: I will do that.

SUDBURY AND DISTRICT LABOUR COUNCIL

The Chair: Our next presentation is from the Sudbury and District Labour Council, represented by John Filo. Welcome to our committee. You have half an hour of our time. The floor is yours. Questions will begin with the New Democrats.

Mr John Filo: I'd like to begin by welcoming the committee to Sudbury. As you can see, the response in our community is overwhelming. We're all interested in what you're doing, and I think the turnout here is indicative of that interest.

I want to emphasize how much we feel this committee can contribute to Ontario society if it takes its mandate seriously and does listen to the public. It can be said that many of the things we do end up as little footnotes to history. If this committee behaves in an appropriate fashion, this committee may in fact make history. A lot of us in this community of Sudbury have a great deal of hope and would like to express a great deal of support for the efforts of this committee. I know you tend to be chippy with one another, and that's maybe part of the process, but we're all citizens and we expect value for our money and we expect reality; we don't expect posturing and we don't expect things that aren't really what they are.

I represent the Sudbury and District Labour Council. I'm a first-generation Canadian. I'm a union man, my father was a union man, and the union movement is proud of its contribution to this province. I know that some of my colleagues who are Conservatives denigrate the contribution of union -- they think we're too powerful -- but if you look back and read some history, you'll see that it was unions that introduced the concept of medicare, introduced concepts of free public education, for example, and a lot of the things that we in this particular society now take for granted.

I've worked in the union movement for 30 years. I haven't seen too many of my colleagues live beyond their means. I've seen retirees and I've seen seniors who have had marginal employment, who worked as labourers, as my father did, and who had the good fortune, the work ethic and the skills to build homes for their families and to educate their children.

By profession, I'm a mineral exploration geophysicist. I've been to every continent, with the exception of Australia and Antarctica, and I can tell you right now that the countries worth living in in the world you can count on the fingers of both hands. Ontario is a blessed province. We want to keep it that way.

I know that this committee and the Tories are well-intentioned, but well-intentioned people make mistakes. The substance of what we're here to discuss will focus the attention of our community on what we feel are mistakes that are being made, and perhaps we can have a change in the process.

For example, this bill was introduced while the opposition members were still in the lockup, and as a presenter, I was given notice only a few days ago that I have standing before this committee. I had hoped to have had 25 copies of my brief ready for you. I do not have it, but I shall mail it to you at the earliest opportunity. My staff, all of one person, is busy working on it right now.

This is a complex bill. About 47 or 48 bills are actually involved, depending on who you use as a reference. One has to be a speedreader to read this bill and the supporting bills it refers to, plus the thousands of pages of commentary these contain. Not only do you have to be a speedreader, but you have to have the IQ of an Einstein.

I have to begin by saying that in my opinion and in the opinion of many people who are committed to the democratic process, omnibus bills were never meant to be such complex documents. They were meant to be housekeeping documents, things where you cross the t's and dot the i's, but not things that make a significant difference to the way our society operates. This does in fact fundamentally change some of the ways in which business is supposed to be conducted in this beloved province of ours.

Democracy is not well served if you don't have a well- informed and involved citizenry. I want to read to you the definition of a political system, and perhaps the members of the committee can then determine the degree of applicability to the present government.

"A system of government characterized by rigid, one-party dictatorship, forceable suppression of the opposition, unions, other -- especially leftist -- parties, minority groups etc, the retention of private ownership of the means of production under centralized government control."

That's a definition I picked out in part from the Webster's New World Dictionary. Friends, it's the definition of "fascism." I know this is an extreme analogy, but democracy -- and I've lived in these other countries. I've lived in countries where the police have the right to execute you. I come back to Ontario, and really, I feel like the Pope. When the Pope visits a country, he gets down, he kisses the ground. Ontario is a very privileged and a very generous and a very caring province. I think we have to do our bit to protect the nature of our province.

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I can give you a few names. Of course, they're just names to many people, but they'll have significance to you: Colin Perry, Eugene Upper, Dianne Cunningham.

You speak about debt, and you say: "We have to get our debt in order. We've lived too high off the hog." Sure, debt is a problem, no question about it, but if you're serious about attacking the debt and the deficit, why do you give a tax break? And if you give a tax break, why don't you give a tax break that really affects the ordinary working people, the blue collar people in our society, that is, take five points off the PST, something like that?

Why, if you're really interested in the debt, would you close halfway houses, which are bending over backwards to perform such a significant service to our society, and put the people into jails where the costs are three times what they are in halfway houses?

The other thing about this process, the unfairness of it -- I've heard Ms Johns here speak about amendments they've contemplated. I've got my presentation here. I'm not sure I'm not going to be speaking about some of these things that are already supposedly amended. How much of what I'm going to say has already been addressed? And maybe the way it's been addressed is something I'd like to comment on too.

Mr Carroll, I want to say that however you were chosen for the chairmanship of this committee, I think it was a lucky break. But I want to emphasize to you that during the election on June 8 the mandate you received as an individual represented one third of the community, so we can't do things in too heavy-handed a manner.

I want to speak about some of the merits of the health issues in this Bill 26. Of course, you've heard these from other things.

The increased power of the minister: Ms Johns has told us that the minister is not going to have the discretion that the bill suggests the minister's going to have. The minister is going to be acting like some sort of czar. The worst thing about Bill 26, the very worst thing, is the process involved in it and the fact that there are so many things in it that say, "And there shall be no appeal from this process."

We live in a democracy where everything is appealable. That's why we have an ombudsman, that's why we have several levels of courts where we can launch appeals. In labour management we have the arbitration procedure. Everybody has appeals. Is it such a horrible thing to appeal a minister's decision?

Let us put it in these very succinct terms: If the bill went through as it had been proposed, without these amendments -- they are now clearly acknowledged as mistakes and they're going to be amended -- what would the appeal have been to that? It would have been the regular parliamentary process where you get in there and you debate and so on and you get chippy with one another, but the point is that society is not served with that type of approach.

The repeal of present laws which is going to make it easy for American health caregivers to come to Ontario: As I said, I've been on every continent. I go to the United States every year. One of the things people talk to me about once they find out I'm a Canadian -- they see it on my licence plate. If I'm in a coffee shop waiting for my truck or car to be serviced, they say, "Oh, you're from Canada, eh?" Well, that "eh" is Canadian. I say to them, "Yes, I am from Canada," and they say, "Could you tell me about how your health system works?"

They don't ask me about Trudeau, they don't ask me about hockey, they don't ask me about Molson Blue or Baywatch; they ask me about our health care system. They say, "My wife's on medication and my daughter's on medication, and $200 off the top of what we earn has to go for health care." Professors who are my colleagues in the States say that in their collective agreements there's a figure of $4,000 to $6,000 per year on top of their salary that's required for the health care system. They're really interested in it.

Ralph Nader came to Ottawa a few months ago and gave a very illuminating talk on how the 10 top CEOs in the health care business in the United States control billions of dollars of assets and take millions of dollars of salary. You can't say Ontario is in that position. Yes, we went through a period of escalating costs. I think, though, that responsible people have tried to bring those costs under control and have done a good job.

I can understand the minister's frustration with the hospital restructuring system. We've got a system right here in Sudbury where we've gone through a process of over two and a half years to get our hospital system restructured. It's a difficult process. We can't agree on it. Yes, there are some people who say it's time for a minister to come in and use arbitrary powers. That's a short-term solution. The long-term solution is solutions that are determined by the people themselves and by the solutions the people buy into.

The role of district health councils: What is the role of district health councils going to be under Bill 26? Traditionally, the labour council has a representative on the district health council. That's one of our most important appointments. We monitor that very closely. Every month we have our representative report to us in detail what's going on in the health council. What touches the lives of working people more than their health? That's a very important consideration.

Section 8 of this bill does not mention health councils. That has to be addressed. We have to have some sort of firm indication of what's going to happen to these advisory councils we have that perform yeoman service and do it for nothing. In fact, in Sudbury they do it for more abuse than compliments.

What about the amendments concerning funding? Bill 26 gives the minister virtually unlimited power to dictate every detail of hospitals, including funding, operation, closure and amalgamation of public hospitals. Is that part of the democratic process? Do we want to assign a responsibility like that to an individual?

I don't know if this is going over the same ground Ms Johns spoke about, but the power of the cabinet to appoint investigators under the Public Hospitals Act: What are these investigators allowed to view? Do they have access to this confidential material? Has that been addressed?

When I read Bill 26, I'll tell you, it's such exciting reading that when I go to bed and I take it up I don't get to sleep till about 4 o'clock, because I see things in here which really bother me, and they bother me because it's not in the tradition of Ontario society to give such unfettered discretion to people.

Our society is built on checks and balances. It's part of the trade union movement, for example. They often libel us by saying that we're autocrats and dictators and so on, yet every collective agreement is signed according to a mutual acceptance by management and by labour. There's no coercion involved in there, and when you hear people denigrating the labour movement because they've got such strong collective agreements, why don't you look at the management side? Why don't you say that you didn't have the appropriate people in management negotiating those contracts, because they were freely arrived at?

What is this business about negotiating directly with doctors that your government has proposed instead of going through the OMA, directly dealing with individual doctors? The present government has a self-interest organization. It's called the Progressive Conservatives. Some of you are professional people. You belong to common interest and self-interest groups, whether it's the chamber of commerce or the Canadian Labour Congress or what have you.

This is something that is part of the democratic feature of our society, that we have groups that speak for us and that you don't seek out individuals. For example, in a unionized workplace, if you negotiated directly with the unionized members, there's grounds for an action against the employer under the Labour Relations Act, even under your act, Bill 7.

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The cost of drugs to seniors and retirees: The people, such as my father came to Canada as an immigrant and settled in Hearst and got some government property there which he could get title to if he cleared so many acres in two years -- he came from a relatively warm part of Europe to a very cold part of Ontario -- are the people who are now the seniors and the retirees. Why should we penalize them? As a society, I think we have an obligation to these people who carved out of the wilderness a very progressive society.

If you don't believe me, go to some of the countries I lived in. I've been in cities like Karachi, Pakistan, for example. I was there for the first time about 30 years ago. I counted 30 beggars per lineal mile and I said to myself, thank God that's not Ontario. Walk down Yonge Street now. Ontario is turning that way. We've got real problems. We're not going to address those problems if we don't do it in a practical, pragmatic, upfront way.

I'm going to leave the balance of my submission to the written submission I'm going to mail you. I certainly won't fax it, because it'll probably be about 209 pages, as compared to your 211-page bill. I want to thank you very much for being patient with me. I want to reiterate again how significant is the work that you're doing, and you can put a real mark on the way in which democracy is evolving in this province if you do listen to the people and you start to show the same sensitivity that your colleagues showed and were in power for 42 years in the not-so-distant history.

The Chair: Thank you. We've got two and a half minutes per party, beginning with the New Democrats.

Ms Martel: Mr Filo, I want to look at some of the arbitrary and increased powers the minister brings on to himself under this act and ask you to comment on them.

Firstly, in the new section 6, the minister is given the power to close hospitals, to order amalgamations or to specify the services that are to be delivered in that hospital if the minister deems it to be in the public interest. Of course, he has the power to do that unilaterally. What do you think about that power being granted to a minister who sits in Queen's Park in Toronto with respect to hospitals in northern Ontario?

Mr Filo: If I were the minister, I would say, "I do not want that power." I would say that the ability to do all these things should be granted to the people who are on the front lines, who actually work with those institutions, who know the community they serve and are professionally committed to be publicly accountable for all their actions. If I were the minister, I would say, regretfully, that I would not accept that power or responsibility.

Ms Martel: The minister not only takes that power unto himself, but in a different section, for example, in section 9, there are some pretty extraordinary increased powers that are then given to a supervisor to deal with the operation of a hospital. The supervisor can go in, the board can be removed, and without any public consultation that supervisor, at the behest of the minister, can take on the day-to-day operations of that hospital.

We know that people in this community, on the boards in all the hospitals, work for free. They do a tremendous job. Why do you think we should be allowing a supervisor, who will probably also come out of Queen's Park in Toronto, to come and start running hospitals on our behalf, without any kind of public input or public consultation from the communities at stake?

Mr Filo: I'm in the education business and we have a saying that we should not play God with our students. Ministers should not play God with the citizens of this province. That type of power: It was in 1215 when society first recognized that you have to take absolute power away from a person. Everybody looks back and cheers how the Magna Carta took some of the power away from King John and shared it among his barons. That was the evolution of British parliamentary democracy. We can't look at those things very lightly. The sharing of power, the use of other people in making joint decisions, in making collaborative decisions, are part and parcel of the way in which this province should continue to work, and so I would say that no minister should have those unfettered powers.

Mrs Ecker: Thank you very much, sir, for a very excellent presentation. You are extremely well informed and we look forward to your written submission. As you know, many people have chosen to do written submissions and we certainly want to encourage that, because the input that we're receiving is very helpful.

You put your finger on the point, though, when you said that we do have problems in this province. They didn't happen overnight; they've been growing for many years. You put your finger on one of the difficulties. As you say, individuals have learned that they have to live within their means, and I think that one of the difficulties is that government is kind of late to that philosophy. That is one thing we're trying very hard to fix so that we can get off the back of working people, who have been carrying a fairly high tax load, so we can try and give them some break here.

The other thing I would like to say is that, just to address the issue of patient confidentiality, as you probably know, information within the health care system about patient records, with or without patient names, frequently, when they can, is currently being shared for fraud and misuse investigations, for judgements that are made about the effectiveness of treatments, for research into what works and what doesn't, and for better management of the system.

That's the intent of any information sharing that is going to be going on in the health care system. If there are difficulties or questions or concerns that this may not indeed be happening, that there need to be more checks and balances in the system, because again, as I'm sure you're aware, there are many checks and balances on confidentiality for use by professionals and the minister within the system, but if that needs to be clarified further, we've indicated our willingness to do that.

I think it would be very wrong for us to come out and release our opinion of how we think changes should be made before we've given everyone else who's coming in and presenting, like yourself, an opportunity to put forward suggestions or put forward their written submissions, so I think that's important to make clear.

The other point you raised is that many groups speak out on behalf of individuals. Political parties, which you're familiar with, speak out on behalf of individuals. The OMA will be continuing to speak out of behalf of physicians. That is the way we would like to see that happen.

Mr Frank Miclash (Kenora): John, I too very much enjoyed your presentation. I think we in northern Ontario are very fortunate to have you, and your views, as a resident of northern Ontario.

You spoke about consultation. A question I've been asking a good number of presenters as we've gone along is whether they, or any group or organization they know of, were consulted during the drafting of Bill 26.

Mr Filo: No, I don't know of any organization that was consulted. It's the same as the other bill, the bill that is nearest and dearest to my heart, Bill 7. It would have been, I think, appropriate to have had consultation with the trade union movement, simply because when you start a football game, for example, the umpire flips a coin but it's decided ahead of time which one is going to make the call and people are given an opportunity to be part of the process. Yet here we have very specialized legislation coming out where the real experts who live and work and breathe the articles in this legislation have not been consulted, maybe in fact have been studiously avoided, in the process of getting a bill out like this.

Mr Bartolucci: John, thank you. Our leader thanks you for your presentation as well. She had to leave.

I'd like to follow up with regard to the commission and the DHC. Certainly, if the commission is to be successful, there must be clearly defined roles and responsibilities of the commission and the DHC, and obviously that's not outlined in Bill 26. Maybe because the government is listening so well, you might want to give them an amendment they might use. What type of regional mechanism should exist within the commission to interface directly with the local DHC to facilitate hospital restructuring?

Mr Filo: The commission should be a locally appointed commission and should probably be what the area here has experimented with over the past half a dozen years, and that's called the interlocking board -- representatives from all the hospitals, people with a stake in the community and the health care system -- to reach some sort of consensus and then carry out their decisions. That's the way in which the commission should be structured.

The Chair: Thank you very much, sir. We appreciate your attendance here this morning and we look forward to your written submission.

Mr Filo: Mr Carroll, I wish you good luck. I hope you do become a footnote in history and one that is gilt-edged.

The Chair: I'm still trying to figure out exactly what your previous comment meant about my selection as Chair, but I'll work on that one.

Mr Bartolucci: If he was paying you a compliment, Mr Chair, you would have known.

The Chair: As the next group, the health care coalition, is coming forward, out of necessity the Chair is going to set a precedent and take a two-minute recess.

The committee recessed from 1102 to 1111.

The Chair: I knew I would set a dangerous precedent; I've lost most of the committee. However, we will get back to work. We actually have no time left to eat today, so I'm not sure what we're going to do with that.

COALITION OF HEALTH CARE WORKERS

The Chair: We have the Coalition of Health Care Workers, represented by Jan Hibi-LeBlanc. I hope I didn't butcher your name too badly. Welcome to our committee. You have a half-hour to use. Questions will start with the government. The floor is yours.

Ms Jan Hibi-LeBlanc: Thank you. Ladies and gentlemen, my name is Jan Hibi-LeBlanc, and you didn't butcher my name too badly. I'm a lab technologist at the Sudbury General Hospital, where I've served this community for the past 20 years. I represent the Coalition of Health Care Workers, a group of community labour leaders with both the Ontario Public Service Employees Union and the Canadian Union of Public Employees. This group is particularly interested and involved in the restructuring of health care in Sudbury.

I will begin today by reading a passage from Maude Barlow and Ken Campbell's book, Straight Through the Heart. It describes a fundamental principle held dear to all Canadians, a principle violated by Bill 26:

"Democracy presumes that power, the capacity to impose one's will, rests ultimately with the people. People delegate power, through the politicians they elect, to a sovereign state to pursue common ends. Democracy presupposes a sovereign state that sets priorities and policies reflecting these common ends. Without state sovereignty, democracy is hollow; without democracy, state sovereignty is tyranny. Democracy is all about inclusion, people being connected to one another and to the political leaders in their community. Democracy is about having people having confidence that the politicians whom they vote into office will act on their behalf. Democracy is about accountability and trust."

Bill 26 is a direct violation of that trust. This government shows its total disdain for the people of Ontario by voiding the very premise of accountability in three ways.

The first is through the repeated use of the no-responsibility clauses throughout the bill, protecting the government from all legal challenge and denying the right to appeal. Not only does this government place itself above the law, but it imposes a dictatorial leadership which screams, "My way or no way." This government is attempting to grant itself total immunity, an absolution from all actions.

Laboratory technologists are a regulated profession. This means I am personally responsible for all job-related actions. This means I take full responsibility for my work in ethical, moral and legal terms. As a local president, I am responsible to the members I represent. The Premier and his ministers are public service employees in that they are paid with public dollars, and they should be as culpable as any in this province for the work they perform in their jobs.

The second insult is the amendment to the Freedom of Information and Protection of Privacy Act. The availability of information is an essential pillar of democracy. Restricting information about the workings of our government, public institutions or the use of public funds smacks of Iron Curtain mentality.

Members of the health care coalition also participate in the fiscal advisory or operational planning committees of our respective hospitals. Although our participation has been limited, we see our role as that of the community watchdog. We believe it is important to ensure that our administrations and boards are accountable to the community. The current legislation regulating access to information is still restrictive but it is a fair system.

To restrict the access by allowing the head of an institution the power to dismiss the access using terminology as vague as "frivolous or vexatious" is admitting to the destructive empowerment of the haves and the belittlement of the have-nots. Restricting access to information implies a need to cover up or hide, which in turn implies side deals and payoffs.

The third disregard for public accountability is one of the changes proposed to the Independent Health Facilities Act where the minister may direct requests for establishing independent health facilities to specified persons rather than through public calls for tenders. This sounds like a legalized old boys' club, a haven for corporate buddies with no liability.

Bill 26 substantiates the fear that Mr Harris in his haste to promote his corporate agenda will privatize our health care system. Removing the requirement to give preference to non-profit Canadian operators of independent health facilities and allowing the Minister of Health to handpick corporations or individuals to open these facilities, with no appeal rights, opens the door to the American corporations.

The bill allows the minister to designate new types of health facilities or services and potentially could allow the minister to determine who will be allowed to provide the services. The bill paves the way to user fees and extra billings. It is apparent that the Conservative Party believes in a corporate-controlled class system, a two-tier Ontario where accessible universal health care no longer exists.

Health care workers have long supported the premise and the need for restructuring. We have attempted to discuss centralizing services, multilayered bureaucracy, to no avail. The empire-building has grown to phenomenal proportions, catapulting us into this mess where the only escape the bureaucrats can visualize is to gut what took generations to build. We can only hope that some members of the Conservative Party will have enough national pride to stop the sale of our Canadian health care to the US by voting down at least this part of the bill.

Mr Harris has gone one step further in his bid to assure maximum profits for his business associates by neutering the interest arbitration process. Since essential service employees, such as hospital workers, cannot engage in free collective bargaining, compulsory interest arbitration determines the terms and conditions under which we work. Arbitrators have stated that basing an award on ability to pay could render the arbitration process largely irrelevant since the use of ability to pay could allow the government and employers to unilaterally determine wages and benefits by simply allocating a fixed or reduced amount for employee compensation in their transfer payments or budgets.

This bill also appears to empower the cabinet or the ministers to make regulations which could override the provisions of contractual agreements. These are blatant displays of the contempt this party has for the working person.

The most frightening clause appears under the minister's authority to disclose health information. We will be living George Orwell's Nineteen Eighty-four. Big Brother will be watching.

This clause is without a doubt the reason the government is attempting to ram this bill through with lightening speed, because even if the average Ontario resident has no understanding of any part of this legislation, they would understand the implications of this section.

Mr Harris's buddies in business must be wringing their hands in anticipation of achieving the power to legally access personal information, including medical data, to use for screening out job applicants or getting rid of employees. The relationship between doctor and patient will be drastically altered. With no right to privacy, the trust is gone. Patients will hesitate to provide physicians with vital information or will refuse to seek medical attention.

Does this open the door to a brand-new private sector enterprise? An agency delegated by the ministry to search out and sell this type of information? How unbelievable that a Canadian governing body should even consider this change.

I have barely touched on the indignities this bill heaps on the people of Ontario. The ministry person who contacted me for the hearings asked if I was going to discuss labour adjustment. The government has allowed no forum for such discussion. The public sector workers are losing their livelihood and the government is so unconcerned that it has not even studied the impact these layoffs will have on our communities.

This government has no redeployment strategies; in fact, HSTAP, the health sector training and adjustment program, which is the system originally put in place to help retrain and redeploy hospital workers in a central job registry, is in jeopardy. Mr Harris has painted the public sector worker as public enemy number one, creating public acceptance that we are disposable. We provide valuable service to our community and we contribute to our local economy.

A government which believes it should merge or close health care facilities without hearings, or dictate to and overrule community boards, has assumed a fascist label. We have hope that communities will exert pressure on their duly elected representatives to defeat Bill 26.

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The Chair: Thank you. You've allowed about five minutes per party for questions, beginning with the government.

Mr Clement: Thank you for your presentation. It will come as no surprise to you that I disagree with your characterization of us as fascists. Certainly as someone who has had relatives who have been victims of fascism, I actually take that as a personal affront, but I'm sure you really didn't mean it that way.

Let me just get to the substance of what you had to say, though, because I don't think we're here to do name-calling necessarily, and I'm sure you didn't mean it in that way. I want to zero in on a couple of things you said, first of all with respect to the disclosure of health information. Other members of the committee, please forgive me for going over some old ground, but this is the first time we've been in Sudbury.

When I read the old legislation and when I read the new legislation, the new legislation under Bill 26, under disclosure of information, has conditions under which information will be disclosed. The old legislation has no conditions. It just says it will be deemed to be disclosed. Have you read the old and new acts? Then you'll know that the old legislation is more general, more sweeping, less constraining on government, on Big Brother, than the new legislation. If you have read the legislation as I have, do you have a different interpretation and can you back that up with any form of interpretation that is valid?

Ms Hibi-LeBlanc: I believe the interpretation comes when you view the bill as a whole. When I sat down and read Bill 26 and took it as an overall document, the overall document supports that this government is about to take over the system in a complete and total way, with no liability. In that respect, I view this mention in the amendment as a way of gaining control over my personal medical information to use within the corporate system.

Mr Clement: If that was the logical result then I would share your concern, but as I say, I've actually read the legislation and I'm sticking to my interpretation of it.

With respect to independent health facilities, you see this as a real threat, but I've got a constituent in my riding who would love to set up an independent health facility to relieve pressure on our hospital. He's saying: "Look, they've got a lineup of two years for hand surgery. I'd love to perform the hand surgery and relieve some pressure on the hospital so you can get quality care at the hospital with less of a wait and quality care from me."

He's requested that power from the local authorities for years, through a request for proposal, and nothing ever gets done. He's eagerly anticipating the ability for someone in the system who cares about waiting lists and waiting queues, namely, the Minister of Health, to break the logjam and get some quality care in my community. Is he wrong to see the legislation that way?

Ms Hibi-LeBlanc: I don't think he is, but look at the way they've set up the act: by removing one clause, they're not just allowing a physician or a health care provider to open up a new independent health facility; what they've done is they've opened the door to the Americans and that is by far our largest objection.

Mr Clement: Let me ask as a consumer of health in our province, and I'm not trying to be provocative here, but if an American or an Italian or a Taiwanese can offer better services at a lower cost, what's wrong with that?

Ms Hibi-LeBlanc: First of all, because I am Canadian and I believe we should be supporting Canadian business.

Mr Clement: Go to the Canadian business then. You don't have to go to the Taiwanese business if you don't want to, but if I want to get the best cost for my family and my children for the system, what's wrong with that?

Ms Hibi-LeBlanc: The problem is we are now talking not only about opening up an independent health facility, but we are also talking about for-profit health care, which doesn't go hand in hand with universal, accessible health care in this province. We're talking about people who can afford to pay Americans for services that Canadians could provide in a non-profit setting.

If you look at the suggestions that have come forward just from this city alone, the Dr Bonins over at Laurentian Hospital have put forward a proposal, and I'm sure you're aware of it, where they have offered a suggestion to offer laboratory services at 75% of the cost of the services that are provided by private laboratories. That means 25% less --

Mr Clement: That's great.

Ms Hibi-LeBlanc: -- but it has been turned down, and as far as I know they're still in the courts --

Mr Clement: But not by this government, it hasn't been turned down.

Interjection: Clearly by your government.

Mr Clement: We'll have to get clarification on that.

Mr Miclash: Just to follow-up on Mr Clement's comments, I would suggest that he read A Voice for the North. It's the Report of the Mike Harris Northern Focus tour, January 1995. This was the document that was floated around in June during the campaign and in it Mr Harris states: "We need answers -- not made-in-Toronto policies, but solutions based on input and ideas from people who live and work in the north." This is a statement made by the present Premier of the province.

Could you tell us if you know of, or whether you were involved in, the draft of Bill 26 or know of any group that was involved in the draft of Bill 26?

Ms Hibi-LeBlanc: You must be joking.

Mr Miclash: This is the thing I get to. Mr Clement, as I indicated, should read this document --

Mr Clement: As a point of order, Mr Chair: I have read this document.

Mr Miclash: Then I would suggest you tell your Premier the commitments he made to people in northern Ontario.

Mr Clement: That's why we're here.

Mr Miclash: And we wouldn't be here unless we sat in the Legislature for 24 hours as well.

Mr Clement: That is absolutely incorrect and I refuse to have that on the record.

Mr Miclash: That's right. You would be in Toronto right now. These people wouldn't be here.

The Chair: A five-minute recess.

The committee recessed from 1128 to 1132.

The Chair: Mr Miclash.

Mr Miclash: I'd like to continue, and as I was indicating before the little ruckus, we have A Voice for the North. This document was waved in my face as a candidate in my riding by the Conservative candidate. It goes on to say, "The people of northern Ontario have given us a clear message: Their needs and concerns are not being met by the provincial government."

Again, Jan, I ask you: Do you think your needs and your concerns were being addressed in the drafting of that bill?

Ms Hibi-LeBlanc: Shall I answer you as a health care worker or as a northerner? As a health care worker my needs have been totally disregarded. In fact, we are blatantly stepped on. We are almost spit upon.

When I read Bill 26 I felt I should move. I started looking at Kuwait or Saudi Arabia because those are good places for lab technologists right now, because Ontario, frankly, is becoming a community or an area that I am wondering if I really want to live in.

Mr Bartolucci: Thank you very much for your presentation. Again, I apologize for the dust-up, as we call it. But you know, in fact, we must ensure that the truth is made known. It's very essential that you advise the government so that they can bring their recommendations back to cabinet.

Do you advise the government to delay passage of this bill to allow for further hearings to take place so that all aspects of Ontario can be listened to and the government can hear and digest what people like you are saying?

Ms Hibi-LeBlanc: Of course I do. When I found out I had standing room, which was Thursday night, I didn't know if I should feel honoured, fortunate or in big trouble, because I realized that there would be very few people or very few groups that would be allowed to speak. I also wondered about the process in choosing the people who would speak at this hearing; how was my group selected?

In that respect, I think it is unheard of in our democratic society that the public should not have a say in how our province is going to be run, and in that respect they should be running hearings on a bill as onerous as Bill 26 for the next year before they even consider bringing it forward.

Mr Bartolucci: One health-related question: Are these amendments going to lead to a two-tier health system?

Ms Hibi-LeBlanc: Undoubtedly. As soon as you have to pay for health care you have, as I said, the haves and the have-nots. If I can't afford to pay, it'll be a system where you have the rich, who will feel very well, and the poor are not going to feel well at all.

Ms Martel: There are two points that I'd like to make first before I ask you the question, Jan.

First of all, let us all be clear in this room that we wouldn't be here today having this public hearing in Sudbury, Ontario, were it not for the fact that the Liberals and the New Democrats together stayed overnight and forced the hand of this government. This government wanted this bill rammed through before Christmas without public hearings anywhere outside of Metropolitan Toronto, and let us not forget that is the case.

The second point I want to make is that we now have over 53 groups that have requested standing in this community to make presentations, because people in this community are so concerned. We only have room for 13, and our party has moved a motion which will be debated over lunch to have those hearings extended. So any of you who are concerned about getting on and want to be heard and think that this should have some broader coverage than it has to date, I encourage you to stick around and listen to that debate.

Jan, I just want to talk to you about one point, and that is your concern about accountability and how this government doesn't have any accountability via this bill, in contrast to you as a health care worker and all of the checks and balances that come into play when you do your work. Time and again in the legislation, when the Minister of Health gives himself increased, unilateral, arbitrary powers, he says he is doing that "in the public interest," yet at the same time in almost every case, the government, also in the same section, makes sure that it is immune, that it will not be subject to any legal action.

Do you really feel convinced that what the government is going to do is in the public interest if, after every section of what it does, it's also protecting itself from any court challenge?

Ms Hibi-LeBlanc: That's an interesting question. I think it was on January 1, 1994, that my profession was regulated by the government. So the government told me on January 1, 1994, that I am responsible totally for every tiny item I do at work. I can be taken to court, and all that has to happen is one person lodging a complaint with my college and I'm suspended. That means I can't work. I am completely culpable for anything I do, and even if it's hearsay, even if it's just a patient complaining that he didn't like the way I looked at him that morning, I'm done until I can prove myself innocent.

This government has decided that even though I am going to be controlled as a worker and that I am watching everything I do, they don't have to watch a single, solitary thing they do. They can just go along and make any decision they want to that will affect thousands and thousands of lives and not be held responsible for it.

The Chair: Thank you for your presentation. I apologize for the ruckus that went on, but we appreciate your input here this morning.

I remind the audience -- some of you weren't here first thing this morning -- that dialogue is between the presenter and the people at the table. You're certainly welcome to listen. You're not welcome to participate.

MIGUEL BONIN
ROSEMARY CHRISTINCK

The Chair: The next group is a group of residents from family medicine. Welcome to our committee. You have a half-hour to use as you see fit. Questions will begin with the Liberals, at the end. The floor's yours. Identify yourselves so that Hansard has a record, please.

Dr Miguel Bonin: Thank you, Mr Chair, committee members, for allowing us to meet with you today. I am Dr Miguel Bonin -- not to be mistaken with the pathologist in town, a different Dr Bonin -- co-chief resident for the northeastern Ontario family medicine program. I'm accompanied by Dr Rosemary Christinck, my co-chief resident at NOFM, and Dr Julie Auger, a first-year family medicine resident.

We are here today on behalf of 26 of 27 family medicine residents presently completing their post-graduate training with the northeastern Ontario family medicine program in Sudbury, also known as NOFM. All of us are eligible to set up independent primary care practice within the next 18 months, half of us within six months.

We are a select group of physicians who have already, at this early point in our careers, made a commitment to northern and rural health care in this province. In so doing, we have been blessed with the opportunity to be in daily contact with both patients and physicians presently living in medically underserviced areas. Therefore, we believe that as a group we can give a relevant, firsthand opinion of the medical underservicing problem as it relates to northern Ontario.

Indeed, I am a native of Sudbury, while Dr Christinck comes from rural Ottawa Valley and Dr Auger hails from Sturgeon Falls. We therefore feel that we can speak for northern and rural parts of this province, not only as providers but also as consumers. During our training in northeastern Ontario, since leaving the major university centres where we trained, we have spent time in communities from Huntsville to the south, Hearst to the north, Mattawa to the east, Sault Ste Marie to the west and all points in between.

As a group of 26 physicians presently training in the north and most likely to participate in the solution of the underservice problem, we have major concerns with the steps proposed within Bill 26 to try and solve the medical underservice problem. Our futures are being decided, with little debate, by people who know little about us and know little about what northerners want from their health care providers.

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The attempt to restrict access to billing numbers by linking access to specific geographic areas is deplorable. We can no longer remain silent in this debate, and as a group of young physicians as yet unconsulted, we have drafted this presentation so that the northern voice can finally be heard. Let me reassure you that we do not wish to be confrontational and simply reject the steps taken in this bill. Rather, we would like to present realistic northern alternatives which in our opinion may finally work.

Some background information. Over the past three decades many projects have been suggested and a few have been implemented in an attempt to solve the long-standing problem of underservicing of medical practitioners in rural and northern regions of Ontario. During that time, almost two generations of physicians have graduated from our medical schools, but the same underservice problem persists. Indeed, similar problems exist in most regions of this country, as well as rural parts of the United States and Europe. This is probably due to the fact that public authorities rarely, if ever, consult the people of these regions as to their proposed solutions.

Presently in Ontario, the newly elected government has committed itself to solving the underservice medical care problem, and it should be applauded for this. Two reports, Small/Rural Hospital Emergency Department Physician Service, by Graham Scott, and Equitable Health Human Resource Distribution: Fulfilling Underserviced Area Needs, by PCCCAR, are often quoted, but by nature such reports are lengthy, idealistic and for the most part unattainable unless implemented in their entirety. Considering the present fiscal realities, this is unlikely to happen. Some of the points that we will be making shortly are contained in these reports but in our opinion have not received adequate attention from authorities.

In a letter to physicians dated November 22, 1995, the present Minister of Health stated, "I am committed to immediately resolving this long-standing problem." This would be ideal, but is unlikely, since Band-Aid solutions such as the ones proposed have been unable to properly solve this chronic problem. We would rather see leadership make statements and take action that would immediately give northern and rural players the tools to finally resolve this problem adequately. We do forewarn that a quick fix does not exist. Rather, a long-term strategy, coupled with short-term measures, may prove to be more beneficial and cost-effective.

Our recommendations:

(1) Geographic billing numbers: As a group of young northern physicians likely to be most affected by the proposed restrictions on billing numbers to certain geographic areas, we simply cannot accept this alternative as a realistic solution to underservice of medical care. It is our contention that such a proposal infringes on our rights and freedoms as put forward by Canadian law. Also, we believe that coercive methods would probably lead to poor work output by the affected physicians. In medicine, as in other fields, unhappy workers are usually less productive than satisfied workers. In the end, those who would be affected the most are, of course, the consumers. Northerners deserve better.

Let us also remind you that physicians have to consider their families prior to making career decisions. Spousal employment has been identified through studies in the north as a major barrier to recruitment and retention in this part of the province. Forcing physicians to come here if their families cannot follow them will lead to the loss of this physician permanently.

We recommend that restrictions on billing numbers be abandoned as an alternative and that any mention of such measures be permanently removed from this bill. Reassurances that the present Minister of Health will not proclaim the relevant sections of the act are not enough. Future elected representatives may act on the threat if the powers to do so are in place. Indeed, this minister has already indicated he might do that.

As you heard in Timmins yesterday, this contentious issue is forcing all physicians, young and old, to re-evaluate their futures in this province. This is not only the case in larger centres but is also being seen in rural settings. In trying to solve the medical underservice problem, this government may be contributing to it with this and other measures contained in this legislation.

If geographic billing number restriction is not the answer, what is? The following suggestions are our recommendations to properly solve the medical underservice problem.

(2) Properly define "overserviced" and "underserviced": In order to find an appropriate and long-lasting answer to the medical underservice problem, we believe independent third parties should survey all regions of Ontario to properly define areas of either absolute need for health care or relative need in specific areas of health care, as suggested by the PCCCAR report. This would allow for databases to be updated and therefore become more meaningful. This study should also note which regions are overserviced in general but may contain specific underserviced populations in need of additional medical service, ie, care of the elderly, aboriginals, francophones, women.

Ici, dans le nord-est ontarien, nous faisons souvent face à des situations où les francophones ne peuvent pas être soignés par des médecins de famille ou, plus souvent, des spécialistes francophones. Le cas est pareil pour les aînés, les aborigènes et les femmes dans le nord-est, ainsi que dans la province toute entière.

In a sense, the underserviced area program should be totally overhauled and should receive a fresh mandate. As stated earlier, 25 years of the present format has not fully resolved the problem and we believe the time has come for a new vision to prevail. If this problem is not properly defined or understood, it cannot be properly solved.

(3) Long-term solution: Ultimately, we hope that the problem of medical underservice will be permanently solved. This will not happen overnight as is the hope of this government. The following proposals are designed to eradicate this problem permanently.

Our suggestions for the long-term resolution of this dilemma are twofold. Firstly, more northerners and citizens of rural Ontario need to be recruited into medical training. This can be done by high school education and recruitment tours. We refer to the University of Ottawa's past and present recruitment policy for francophone medical trainees.

Local sponsorship of candidates by their respective communities may also be a possibility and is increasingly being discussed by northern leaders in order to ensure appropriate access to medical education for their youth, their future. Let us remind you once again that it is well documented that northerners are much more likely to practise in the north on a long-term basis than southerners may be.

Secondly, pre-medical, medical, post-medical and continuing medical education must increasingly be made available in northern and rural Ontario. Physicians are more likely to practise in communities where they have completed their medical training. Examples of recent successes are NOMP in Thunder Bay and NOFM in Sudbury. The latter program's northern and rural retention rate after only five years of existence is reported to be 70%. This is much better than any previous training program in the province. Also, one must recognize that geographic and professional isolation accentuates the difficulties of trying to stay up to date in the ever-changing world of modern medicine. This must be recognized.

Obviously, these recommendations will not lead to rapid results but may in the long run be the most cost-effective. Leaders must realize that physician supply cannot be quickly controlled as is water flow out of a faucet. On average, it takes nine to 12 years of post-secondary education to train physicians. The benefits of admission policy changes made today will only be seen some time in the next century. Regardless, we believe that this option is not receiving its fair share of consideration in public forums addressing the maldistribution problem. As northerners, we see this problem and its solutions from a different perspective.

(4) Short-term solutions: Once again, coercion and billing number restrictions are not acceptable or realistic solutions for the reasons listed earlier. An acceptable short-term solution would be to consider the application of fee differentials to properly defined service discrepancies. In keeping with the theme of the Common Sense Revolution, we believe the solution should be financed within the government's present budgetary allocations. Unfortunately, recommendations within government-sponsored commissions often do not address the financing of their recommendations. We would like to do otherwise.

Disincentive payment schemes for physicians working in properly defined overserviced areas should be used to finance incentives in underserviced areas. For example, a 1% reduction in payments to physicians in properly defined overserviced areas -- the majority of the physician pool -- would generate a large sum of money to finance the solution in underserviced areas.

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These funds could be used to finance a 1% to 5% increase in payments to all physicians in properly defined underserviced areas; to fund continuing medical education programs in properly defined underserviced areas; and/or to fund efficient locum programs to provide for respite time for physicians in areas with limited medical support systems, such as is the case in northeastern Ontario. Indeed, this could be looked upon as an isolation package of sorts, which is often seen in the private sector.

Because of population discrepancies, a 1% premium on health care dollars spent in the greater Toronto area would generate a significant pool of funds to finance programs in northeastern Ontario as suggested above and by the Scott and PCCCAR reports. Indeed, the medical profession has finally realized the merits of such a fund to address the medical underservice problem and is proposing this at this time.

The premium could slowly be adjusted to appropriately control the flow of physicians, ie, increase or decrease the overserviced disincentives or underserviced incentives as required. It could also be stipulated that physicians in properly defined overserviced areas could avoid paying the premium by committing time and service, two to four weeks, in a properly defined northern or rural underserviced area through a structured respite locum program. During their time in the underserviced area, they would receive billing amounts appreciable to that region, 101% to 105%, minus reasonable overhead costs.

We want to stress that the numbers used in this description serve only to illustrate a case and may need to be progressively adjusted in order to reflect the realities of the day. No one knows what the appropriate disincentive value needs to be to solve this problem, but realistic remuneration will also have to be maintained in larger centres.

(5) All physicians should be affected equally: As a group of young northern physicians, imminent graduates, we believe that all physicians should be part of the solution in an equal fashion. We, as young physicians, have not created the medical underservice problem nor the existing health care budget shortfalls. Regardless of this fact, we want to and must be part of the solution. Previous negotiations in other jurisdictions have seen government and medical associations transfer the bulk of financial burdens and legislated solutions onto the next generation of physicians.

We believe, as does CAIR, the Canadian Association of Interns and Residents, that all physicians should provide the same level of care and should shoulder the burdens on an equal footing to prevent the overburdening of the future of health care in this province.

In summary, we, as northern health care providers, believe that these solutions are realistic and in keeping with the will of northerners who have a vested interest in this problem. They are not the only possibilities, but they are our best recommendations. Any action taken by the government should affect all physicians equally, regardless of age or year of graduation. We reiterate, once again, that we, as young physicians, did not create the problem but wish to be part of the solving process.

Give northerners the tools they need and have been asking for in order for us to deal with this problem, which we truly understand, since we face it every day. Physicians, bureaucrats and politicians cannot solve this problem from their offices in Toronto. This bill, with its theme of centralization of power, goes against everything northerners have requested over the years.

We would also ask for a quick decision on the fate of our access to billing numbers in July 1996 since all of us must make the necessary plans to set up our practices. Many small northern communities are anxious to receive our answers. For the moment, given the present turmoil, we are unable to make any commitments as to our own futures. One thing is certain, with the passing of every day, this province is losing young physicians who can no longer envision practising medicine in such instability and coercive situations. The investment made in their education is forever lost to the people of this province.

In addition, future generations of physicians, medical students and junior residents, need to have a long-term predictable vision of what practising medicine in Ontario will be like. The annual indecisiveness, turmoil and threats surrounding licence acquisition in this province cannot be allowed to continue.

The Chair: We have about two minutes per party left for questions, beginning with the Liberals.

Mr Bartolucci: You say that the Sudbury family medicine program has a retention rate of about 70%, yet you mention that we are losing young physicians daily. Is it a morale problem, or what explains the statement you made with regard to our losing physicians?

Dr Rosemary Christinck: The program we are in is unique in that it does retain approximately 70% of its residents. That's very unique in all of Ontario. We are losing many physicians, partly from Timmins, which we heard yesterday on the news -- also from larger centres -- and that will decrease the resources we have to supply the north.

The feeling we have received when we've gone through our training program is initially we were given the promise that we would have portability to practise throughout Canada, which most of us would have seen as a bonus. That was removed a few years ago, and now we have no portability left in this country.

In addition, the new measures that are going to be introduced will reduce our mobility within Ontario itself, and we'll find ourselves required to stay in certain area. For some, that will be an impossibility due to spousal factors, child factors, all kinds of different reasons. As a result, we might find that they will leave the country completely. That's something we'd like to avoid and that's why the suggestions we have made provide options that will not lead to these kinds of results.

Mr Bartolucci: And they're excellent suggestions.

Ms Lankin: I was interested when you were referring to some of the programs that have been initiated in the last little while, and in particular I'm thinking of the northern residency programs. As I recall from my time as Minister of Health, that was an area we felt had great promise for encouraging northerners to enter the practice of medicine and to stay in the north and practise and to also encourage others to come and do their residency here and then perhaps stay on.

Can you tell me any knowledge you have of the likely results of that? Some of those students are just coming out the other end of it and we haven't really had time to see full-blown, but it would be helpful to get your impressions of it.

Dr Bonin: Actually I just got the newly updated results from our program director today. It's our fifth year in existence. We've had three graduating classes, for a total of approximately 35 or 36 physicians. There are 12 physicians graduating every year from the program: 77% of all graduates of the program are presently in northeastern Ontario or small-town Ontario or Canada; 14% are in urban centres; 6% are pursuing further studies; and 3% are out of work or lost to follow-up. Those numbers surpass any expectations we had prior to getting going.

For a young program our reputation across the country is growing. It's a well-sought program, not only for northerners but for all people wanting to go into small towns. We get one-on-one teaching, hands-on experience, which is not the case in the major centres.

Ms Lankin: The government has indicated that it is going to continue some negotiations, and if a satisfactory result could be arrived at, they may never use the powers in this bill. It's sort of an extraordinary approach, to pass the powers and have them there. But you said very specifically that you need some certainty, that students who are graduating are having to make choices now about where they're going to practise. I've got letters upon letters upon letters from doctors to Conservative MPPs and ministers, and many of them refer to decisions that they are making about leaving the province. Do you have a sense of what your colleagues are deciding?

The Chair: Your time is up. The government, please.

Mrs Johns: I'd like to thank you for your presentation. I'd like, first of all, to say that I know the program you're in is an excellent program and was set up by a previous government and is doing excellent work. We are trying to do some things with the new government to get medical schools to put people into a northern training program at the early stages, so we have tried to do some different things.

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The fee differential you talked about, I was really interested in. I know it's not a new idea, and in fact, rural sections of OMA have been trying to promote this for a number of years. One of the things we've said is that OMA should come to us with suggestions about how we can not implement this billing, that we can do something else. Do you know if the professional bodies will accept this, if the OMA is considering using this as an approach to us? Can you comment on that?

Dr Bonin: Yes. Basically, we're here as a group of northern residents. We do belong to other groups of people that have presented or will be presenting to you. We felt that what they were presenting was not truly what we as northern residents wanted to say, and that's why our presentation varies a bit on the themes that they present. The fee differential is not formally being considered by any of those groups, but we feel that's the only way to get this.

In Canada the rich help the poor. Let's do the same thing as a province and let's get the bigger centres helping out the rural centres. I was told that 1% of billings in Toronto is about $35 million a year. That's a lot of money. I don't know if it's 1%, 1.5%, 5%; I don't know what the number is. We can get people working on those numbers. But that's the only way to get around this. I know the OMA is considering the creation of a fund from the existing fee-for-service fund that would put money aside for programs such as the ones we were describing. We're the first group, as far as I know, that is formally presenting this option as a realistic option.

The Chair: Thank you, doctors. We appreciate your involvement in our process.

ROCKVIEW SENIORS CO-OPERATIVE

The Chair: Our last group of the morning is representing the Rockview Seniors Co-op homes, Stan Racicot, the president. Good morning, folks. Obviously there's more than Mr Racicot here, so if the rest of you would identify yourselves, we would appreciate that. You have a half-hour of our time. Questions will begin with the NDP, so the floor is yours, sir.

Mr Stan Racicot: Thank you very much, Mr Chair, and good day, ladies and gentlemen. I see you're all members of the Ontario government. Am I right? Okay.

I have your big book. We had problems getting it but we finally got one. We're short a few pages, though. There are only 234 in ours, so I hope we don't have to go into that too much today.

Now, to start, my name is Stan Racicot, president of Rockview Seniors Co-op, and on my left is my good wife, Peggy, who is our corporate secretary, and on my right is Ron Freeland, who is our office manager. I might say, on Ron's behalf, if it wasn't for him, we would not be there now. The place wasn't just given to us to start up, run the way we like and so on. With Ron as our guide, we built this place. With his guidance, we survived all the problems that come with such a building.

I believe it's the only all-seniors co-op in northern Ontario; that is, I haven't heard of any others. I believe there's room for lots more with the growing population of senior citizens, and yet we hear where 14 co-ops -- I heard on TV one night -- I clip a lot of newspapers and I have the proof in front of me, but at that time, and it's not so long ago, maybe a couple of weeks ago, I heard the words "closing down 14 co-ops in Ontario;" where, they didn't specify. However, this is scary and we've been scared all along over things that happened here and there, the threats of closure and the threats of giving things over to the landlords to run for profit, and that is scary.

But a little more about ourselves. Who are we? Rockview Seniors' Co-op Homes is a 40-unit seniors' non-profit housing cooperative located at 211 Caswell Drive in Sudbury. The corporation was formed in 1985 by members of Inco Pensioners who became aware of the housing crisis for seniors in the Sudbury region. This group incorporated and pushed for a housing allocation and was successful in securing and constructing a seniors' housing co-op in the fall of 1990. We have 35 one-bedroom and five two-bedroom units which house 46 members who actively and democratically participate in the operations of our co-op. It should further be noted that we have over 400 persons on our waiting list for affordable housing.

We have a board of directors comprised of seven live-in members which meets monthly and general members' meetings are held a minimum of four times a year. We operate under the six cooperative principles:

(1) Open and voluntary membership.

(2) Democratic control: one member, one vote; no special favours to some that you would not give to others; free flow of information to encourage feedback; our membership is the supreme authority.

Maybe this government could take a page from our principles and enact democratic control at the provincial level.

(3) Limited interest on shares.

(4) Return of surplus to members.

(5) Co-operative education.

(6) Co-operation among co-operatives.

With these principles in mind, Rockview strives to provide decent, secure, affordable, democratic and independent living for the limited number of elders in our region whom we house. Further, we act on issues that will have a direct impact on our members.

Rockview has actively participated in municipal, provincial and federal issues over the past five years. We have attempted to be open-minded and objective in our approach to all issues. It is difficult to work with people and always come to a consensus. However, we attempt to do so.

The current-day government, until now, has shut the door on our efforts to get information and have told us on numerous occasions that they do not have to talk to us. They were given their mandate by being elected with a majority with the Common Sense Revolution in tow. Let us note that we have also requested copies of this document, but have not yet received it.

We are affiliated with United Senior Citizens of Ontario, Steelworkers Organization of Active Retirees, Co-operative Housing Federation of Canada, Co-operative Housing Association of Ontario and many more.

We appreciate the time given to us today to voice our concerns. However, we hope that it does not fall on deaf ears and that this committee is sincere in its limited sessions to consult with the people of this province. We wonder how you will digest the information, report back to your superiors and pass this legislation before the end of the month. We will be watching to see if this was a creditable process or simple lip service to somehow appease the people of this province.

We have participated and voiced our concerns in discussions with the long-term health care committee, substitute decision-making, drug benefits for Ontarians and much, much more. It appears now that the provincial government does not want our help, the wealth of knowledge of the elders, but would rather tell us how we should live and that we must do more with less. Don't forget, we have been through rough times and we know what it is to do without, but never have we had it legislated like this.

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Now I want to speak on a petition that we drew up to be sent to Premier Mike Harris and it's on the go now. We've mailed it out to so many people and passed it around to so many groups, mostly seniors but other interested people too. We haven't sent it in yet, but as soon as we get them all back in, we'll be shipping them on. I should say this is from two seniors' organizations headed up by myself, in the beginning, as the president of the two organizations; that is, Rockview Seniors Co-op and the Steelworker Retirees. It goes like this:

"Mr Premier:

"Over the past several years, our two groups have been united in efforts to protect, preserve and improve the way of life for seniors and their families. The board and members of both groups have formed an alliance for continued mutual support now and in the future.

"We, the undersigned seniors, families, supporting groups and people of Ontario are now petitioning you and all members of the Ontario government to stop the Common Sense Revolution which deprives the elderly and favours the greedy, non-caring rich. We list some of our problems:

" -- Health care comes first and hospital closures plus cuts in services affect seniors very seriously.

" -- Affordable housing: Co-op and non-profit housing should be increased and subsidized to provide for the growing number of seniors instead of cutbacks which please greedy landlords.

" -- Pensions" -- I know we're here to talk health, but this is a petition that you can expect; we're letting you know ahead of time -- "should be properly indexed to the true cost of living, with no cutbacks.

" -- Welfare payments should be adjusted to the needs of many unfortunate seniors; cuts are not the answer to this problem.

" -- Unemployment" -- you wonder why seniors are worried about that? -- "ranks high among seniors disgusted at the unnecessary layoffs of their sons, daughters and grandchildren...."

There are a few other things here, but I'll skip them.

To date, we have thousands of signatures to support this petition and believe that all these issues deserve attention.

Now some more general concerns with Bill 26:

This document compares to an encyclopaedia and deals with so many issues, it is difficult to understand the content and meaning of each. As I said before, it was hard to get. We didn't how many pages there would be, how many items in it. But it's scary. It tells nobody, certainly not seniors, "We're going to do this for you, we're going to do that for you," other than cut, cut, cut. We question the reason for such speed in passing this document too. It's beyond us.

Our concerns with the content of Bill 26, specifically health care: Our first concern with the bill is that it is difficult to understand. We have tried to read the document with the limited time we have and make sense of it. We have drawn our conclusions on what we believe we have read.

Our objections: We object to the way that this public consultation has been conducted and wonder how it could have possibly been set up this way. The lead time for participants is limited and access to information is non-existent. We believe that the document itself should have been circulated with ample time to review and understand its content. Further, we would have liked to have had time to present the document to our members for their input, but the lead time does not allow for proper consultation. Less than a week's notice is not acceptable and does not allow for the democratic process that our co-op has and needs to operate.

To date, we have received nothing in writing to confirm our participation, the agenda, information or specifics of this public hearing. We fully support public consultation but with due notice and opportunity to be fully informed before the event itself.

We understand that this session deals with health care, which is very near and dear to our hearts, so let's deal with some of the issues, as follows.

The Advocacy Act: We have a concern that this legislation will probe into our personal lives beyond our will or wants. There is a right to privacy of information; we want that right protected. We do not see how eliminating the Advocacy Act will allow us to make our own decisions with the help of family -- advocates -- and advisers. We want the right to make decisions for ourselves that will allow us the dignity to live as independent, responsible citizens. It now seems that the work and discussion with our membership will have been wasted if these proposed changes are made.

Health care unknowns: The unknown in this document has caused stress and hardship among our members, who are so confused they don't know what health care they will or will not have. Some will forgo much-needed health care or prescriptions simply because they cannot afford the user fees or dispensing charges. It states that the charge for prescription drugs, other than dispensing fees, will no longer be regulated. Our members have written several letters on user fees and dispensing charges and that it will allow those who can afford the extra cost to get the medication they need and those who cannot afford will go without. We have made our case time and time again without response. When it comes to choices, poorer seniors will choose food and clothing over prescriptions. Is this what you want?

Removal of benefits: The document states that the minister can make changes to remove services from the OHIP schedule of benefits. Once again, this will only ensure that those who can afford the service will get it.

Control of hospitals: It appears that the minister will have the authority to control all aspects of hospital operations. This person will have the power to tell physicians where they can work. How will this be done and what gives this one person the right, knowledge or experience to make such decisions?

The rest of the health care issues are grey at best and we need to know exactly what you mean. Could someone take a few minutes, days or weeks to tell us what you mean? We do not want to buy a pig in a poke.

We cannot support any government that feels it is above the people of this province. We need to live in harmony, with an understanding of the needs for all and a plan of how to accomplish this. You cannot feel that you are superior to the people, and for this reason we ask your committee to relay that we want responsible government, not dictatorship. This can only be accomplished with good leadership, caring and understanding. Are you up for the challenge?

Finally, we would like to also talk about other issues that concern us, such as non-profit housing, pensions, welfare and jobs. However, we'll have to wait and see if we can get on the agenda of the next meeting, a week from today, I believe? Right.

That's it. Thank you very much, sir.

Ms Martel: Mr Racicot, I appreciate your presentation and your concern about the complexity of this bill, but there's one bit of business in this bill that's not terribly complex and I wonder if you can respond to it. During the election campaign, in fact even before that, in the Common Sense Revolution, the Premier and then Tory candidates during the election made it absolutely clear that there would be no cuts to seniors and the disabled, and secondly, there would be no new user fees.

Mr Racicot, in this particular legislation you will know that there are changes to the drug benefit plan particularly that affect seniors. If you're a single senior and you make over $16,000, you'll pay the first $100 of your drugs yourself, and after that $100 you will now pay the dispensing fee and a $2 copayment on every prescription. If you're a couple, like the case of you and Peggy, and you make over $24,000, again the same thing: The first $100 you pay for yourself, then the dispensing fee and the copayment.

I want to ask you a simple question, Mr Racicot. You and the other seniors, who may have voted for a Mr Harris based on those promises: Do you feel betrayed now? I'm not suggesting you voted for him.

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Mr Racicot: It's such a long question, I'd have to tell you a long story and think back about the different people. You see, seniors are over the hill, physically and --

Ms Martel: Talk into your mike.

Mr Racicot: Oh, I'm sorry. It's always been my problem. Speaking at union meetings and other places, I forget to talk into the mike.

As I said, it is a tough question to answer all in one mouthful, because problems are different with different people. But do I get the main point of your question, though?

Ms Martel: Well, there was a promise made by this Conservative government to have no new user fees, and for you folks, who would not have paid any fee for drugs because you would have been on the Ontario drug benefit plan, now certain categories of seniors are going to pay a whole lot more and every senior is at least going to pay a copayment. Do you feel betrayed by that promise?

Mr Racicot: Well, we've had that happen. People are now either buying or doing without.

Mrs Peggy Racicot: Could I answer that question? I certainly do feel betrayed. I have never in my life seen, in all the years that I've lived in this province, or anywhere in Canada, such a dictatorship as what we have right now. I think Mr Harris better come down off his horse there and realize that he can be thrown out just as fast as he got in, before he destroys this whole province, because that's exactly what he's doing. The seniors have fought all their lives to get the best for everyone, and I think he's destroying it not only for our seniors but for our children and everything else. He's destroying this whole province and it's time he woke up.

Mrs Ecker: Thank you very much, Mr Racicot and Peggy and Ron, for coming today and taking time to give us your concerns. I very much appreciate the suggestions and the comments and the points that you're making.

I guess one of the concerns that we have is that the future of Ontario for all of us and our children is in serious jeopardy because we've forgotten one of the lessons that I think our parents and our grandparents were very familiar with, and that was the lesson of knowing how to live within your means. Unfortunately, because we've forgotten that, as many governments in the past, we are now having to pay the price for that, and it is very difficult and very painful but also unfortunately very necessary in very many ways.

I guess one of the things I wanted to clarify, you talk about the Advocacy Act and you say in your presentation that you have a concern that "this legislation will probe into our personal lives beyond our will or wants." I wasn't sure if you were referring to the Advocacy Act or Bill 26 when you made that point.

Mrs Racicot: The Advocacy Act.

Mrs Ecker: It's on page 7.

Mrs Racicot: You answer that.

Mr Ron Freeland: It is the opinion of the co-op that they do go hand in hand and that in fact it's both documents. One gives the opportunity for a probe into a person's health condition, and we believe that that's under the bill, but we also believe that there is an attempt to repeal the Advocacy Act and that that in itself does not protect the interest of the seniors.

But I think one thing you want to be clear of is that, as administrator for the co-op, we have 46 members, our youngest being 60, and you have totally confused -- totally confused. When we got a copy of this document of 234 pages, people now are coming into the office saying, "Do I have benefits or don't I have benefits, and what is this government doing?" and quite frankly, we can't tell them.

You have not taken the opportunity to consult us. We have written you on numerous, numerous occasions since your appointment, we have been on your bulletin board, we have been on the Internet trying to make contact with Mr Harris. We wish you'd update those as well.

But we're saying to you, "Confusion, you gave it to us," and confusion we have, and the fear of God is there. These seniors are going to go without, because they simply do not know what it is that you're doing.

Also, we believe -- and this is in consultation with the other association that we belong to -- that the Advocacy Act, as we understand it, will be repealed in part and parcel and that you will give the opportunity for people to probe into medical records that indeed could affect the lives of people in our co-op adversely, that because of medical reasons they could be put away or be put somewhere else. We have that happening in our co-op right now where families try to put away their parents for greed and things like that. It takes a long time to understand that. Five years in the business, I still have a concern.

So the fear of God is there. Please take that back. These seniors need to be informed what the heck it is that you're doing, because we don't know.

Mr Bartolucci: Thanks, Stan, Peggy, Ron, for an excellent presentation. A few very, very simple questions, but I think they're important.

The government does not consider a copayment to be a user fee. As a senior, Stan, do you consider a copayment to be a user fee?

Mrs Racicot: Yes.

Mr Racicot: Well, I don't know, it's pretty hard when you put it that way. Should I or shouldn't I? I'll come back at you with that. Anything is a user fee. I hear now there's a $2 user fee on every drug, every single purpose. If there are two different kinds, you pay $4; three kinds, $6. Am I counting right?

Mr Bartolucci: You are, Stan. A second question, Ron, and it goes back to what you were saying. Clearly, you are one of a few, you are privileged. You are one of only three seniors' groups that is going to be heard. Do you think that this government must extend these hearings to allow for more seniors' groups to be heard?

Mr Freeland: Absolutely. I do not understand how this government thinks the way that it thinks when you're dealing -- and especially I want to focus on seniors because those are the people that we represent. You need to give these people some time to understand what you're dealing with. You all will get there, and you all, as parents and responsible grandparents and with grandchildren beneath you, will need to understand what the government is doing. This province of ours was forged by these people. You've got to give them some time, and one month is simply not enough.

I read in the paper yesterday where this hearing has given more time than any other. But you know something? You're dealing with more issues than any other.

Let's face reality. Give us some time. Let us understand. We invite you, Janet Ecker, to come to our co-op, talk to us and tell us exactly what this bill means. I say to you, for the seniors -- and we have a lot of them in the front row and there in the back -- they're here today because they want to understand. But you're not going to stand up and tell us what this means. You're only here to listen to what our concerns are.

Our concerns are that we do not know what it is that you're doing. We want to keep the doctors. We want to keep the hospitals open. We want to be financially responsible. But we want to work together to do it. Give us time to work with you.

The Chair: Thank you, folks. We appreciate your presentation this morning and your involvement in our process. Have a good day.

Mr Racicot: Ladies and gentlemen, I forgot to mention that we do have some of our members here with us today. They're at the back. But they're always with us.

The Chair: Thank you very much, Mr Racicot.

Before we deal with this motion, a couple of things. Lunch will be served in this room, some sandwiches and soup, I understand. Our next presenter's at 1 o'clock, which is a half an hour from now.

Ms Lankin has submitted a motion. Out of respect for time, can we have all-party agreement that we limit the debate to one presenter for five minutes, as we did yesterday? Everybody agree with that?

Ms Lankin: Again with the understanding that I'll split my time between opening and closing.

The Chair: All right. Ms Lankin, we'll let you begin.

Ms Lankin: For those who are listening and to remind people, the motion we're debating is for this committee to recommend to the government House leader that he consider extending the hearings and coming back to Sudbury to hear the people who have applied to be heard here today and won't have that opportunity. There are just over 50 groups or individuals who wanted to be heard here in Sudbury today and there are 13 hearing spaces. So a whole lot of people have been shut out of this process.

The government speaks often about the number of hours of hearings that were offered prior to Christmas. Let me say that in fact they did offer substantial hearings, from 9 in the morning till 10 at night in the week leading up to December 14.

As you heard from the group that just presented -- it could be no more eloquently put -- this is a complex bill. People didn't even have access to copies of the bill at that point in time. There wasn't an opportunity for people to prepare, let alone consult with their organizations.

As a result of the efforts of the opposition parties working together, we were able to insist on the hearings being put over to January and to insist on travel so that we were outside of Toronto. Both of those things were very important to us. We had to trade off the number of hours. The government House leader said, "Fine, if that's the way it's going to be, there are going to be fewer hours."

At that point in time, in those negotiations, compromises had to be made on all sides. That's what happened, and a deal was struck. Mr Clement often speaks to this issue and says, "We're going to stick by the deal."

At that time, we had no idea the kind of public response there would be. These two weeks that the committees are travelling, there are over a thousand people have applied to be heard for 274 hearing spots. That couldn't have been predicted, that wasn't known; that is a changed circumstance. It is the responsibility of this committee to report back and to advise the government.

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I urge the government members to listen to the presentation you just heard and the concern with the process and the people who want to be heard and who need the time to consult with their memberships to come forward; to support this motion that would bring us back to Sudbury so we can hear from the other people who have applied already and the others who would like to be heard on this bill.

It is important. We've heard you say you're now going to make amendments. You wouldn't have known about some of these areas if you hadn't heard from people. The more we have an opportunity to explore some of the big policy areas which have long-term ramifications for this province, the better-informed we'll be and the better legislation we will pass. I urge the government members to please support my motion.

Mr Clement: I find myself unable to support the motion. I would like to amend it. I think we have 14 spaces today, by my count. That's a minor change, but we might as well be accurate about it.

From my perspective, if you combine all the spaces available both in Toronto and elsewhere for the two sides of this committee, there are 750 slots, by my calculation -- I admit it's a personal calculation -- for members of the public to have their say, either as individuals or organizations or groups or unions or corporate interests, whatever.

Even in the hearings outside of Toronto I'm pleased to see the diversity and the multiplicity of the groups represented and of their viewpoints. There have been some wide-ranging differences of views we have heard, and all that has been very helpful to me as an individual member of this committee so I can wrap my head around what sort of amendments are appropriate and which ones I would not be prepared to support. That process must continue. We've got nine cities left to go, and I'm quite looking forward to hearing from those other centres and persons who live around those areas.

From my perspective, I disagree with Ms Lankin's premise. I think the process is working quite well. I can only speak for the government side, but it gives all of us on the government side an ample opportunity to hear points of view -- points of view in favour of our position, points of view that are very much dead set against our position. That's precisely what this committee is all about. Hopefully, we can get some amendments that make sense out of this process, and I'm looking forward to the nine other cities' input on that.

At the end of the day, as Ms Lankin knows, government is there to govern and to decide, after having the requisite amount of input. The House leaders, in their wisdom, decided that this was the process we are to follow. I'm committed to this process. By the end of the day, when we come back on January 29, certainly members of this committee and other MPPs who have participated in a number of cities will come back with a wide knowledge of what Ontarians think about this bill and how it can be best improved.

Mr Bartolucci: I speak in support of the motion. It is inconceivable that a committee could be travelling around the province, listening as we have for three and a half days now, personally, to people who all have one thing in common when they address the committee: They say it is too vast and you are not allowing for input the way we should be allowing for input to take place.

If we allow more time, you are going to get more opinions, more amendments that will make this bill better. There is no question that we should be returning here. My constituency office has been flooded with requests from people who, because of many factors, weren't able to get the opportunity to even apply. They want to be heard, and they know the only way they can be heard is through paper. Let me tell you, that is not a fair way to be heard. The fairest way for a presentation to be made is to sit down and discuss face to face so a dialogue can take place. You cannot dialogue with paper; you can only read it.

If we look at the provincial scene, we have had now approximately 1,200 submissions for presentations, 800 of which will not be heard. That should tell us without a doubt that the people of Ontario want extensions to these hearings. We have to ask ourselves the question, what does the government side fear from extending the hearings? What do we fear as a committee, or what do you fear as the government side of the committee, about returning to Sudbury and listening to those groups that are being shut out, that are being refused the opportunity for their submissions to be heard?

We had reference this morning to Dr Bonin and his suggestion. It is an excellent suggestion. It should be receiving public input. The public should hear what he has to say, not only the minister. As I heard Mr Clement's response to Dr Bonin's idea about decreasing the costs for health care, he has not been made aware of what Dr Bonin's presentation is all about. The minister has, and has responded to it in the House. I would clearly say it is imperative that groups like Dr Bonin's group be allowed the opportunity to present.

If common sense can be interpreted as listening to the people of Ontario, clearly common sense is not the rational approach you're using with regard to these hearings. There is absolutely no problem, and Stan, Ron and Peggy said it: Ultimately and finally, at the end of the day, you're going to pass this bill. Why, then, can you not ensure that the amendments you're going to bring forward are those amendments that will best make Bill 26 a workable one for all the people of Ontario?

It wasn't the case initially. You have now heard some presentations. There is a need for more presentations to be listened to. You are not hearing all of what Ontario is saying. You can only do that by extending the hearings. You are not listening to what all of northern Ontario is saying. You can only do that by extending the hearings and returning to the city of Sudbury to hear future submissions, very important submissions. I would request that the government side change its approach to allowing input. There is no reason you should be voting against this motion by Ms Lankin.

Ms Lankin: Mr Clement, not to split hairs, but there were 13 spaces available today because of an inadvertent booking error on the part of the clerk's office. A group was double-booked and we as a committee decided to add a half-hour at lunchtime. The motion, when it was developed this morning and printed, was correct. We found out that information later upon arriving here this morning.

I want to say to you -- and I have said this publicly many times -- that the government absolutely has both the right and the mandate to govern and to pass legislation, and I do not in any way believe it is my role as a member of the opposition to try to stop you from passing legislation. I try and change your mind about legislation; I try and ensure that there is a process by which the public has input and that the public might be able to change your mind about all or parts of legislation. In the end, I believe in your right as the government to pass legislation after, as you said -- and you used the words; I was amazed -- "a requisite amount of input," and I would add "due process."

That is not what we have seen with this bill. Without getting into the history of it, what I want to say to you is that people are coming forward and bringing suggestions in what even you are acknowledging are important areas where you might have to look at amendments. Listen to the other things people are saying: that they haven't had a chance to do the full analysis, to finish their analysis, that they haven't had a chance to consult with their memberships or their clients or their organizations. This process is moving too far, at a speed at which people are unable to have informed input, and a whole lot of people are not able to have any input at all.

I want to remind you what this motion says. It says that this committee "recommends" a course of action to the House leader. The government House leader, with his cabinet colleagues, will still make a decision. He will still discuss that with other party House leaders. You're still in control of the agenda. It's simply a recommendation from this committee.

It is an acknowledgement of what you have been hearing from people, an acknowledgement that people want to participate and that the process that had been set out by the government House leader and the other House leaders isn't sufficient to meet the needs of the public demand. That's all this motion is. I encourage you to recognize the people of Sudbury who wanted to be heard who are not getting a chance to be heard, in a simple way to recognize that by making a recommendation to the House leader that he consider an extension of the hearings to come back to Sudbury.

The Chair: It's time for the vote.

Ms Lankin: A recorded vote, please.

The Chair: A recorded vote's requested by Ms Lankin. All those in favour of Ms Lankin's motion?

Ayes

Lankin, Miclash.

The Chair: Those opposed?

Nays

Clement, Ecker, Johns.

The Chair: The motion is defeated. We'll recess for 20 minutes.

The committee recessed from 1241 to 1304.

PROFESSIONAL ASSOCATION OF INTERNES AND RESIDENTS OF ONTARIO

The Chair: We're about set to reconvene. Our first presenters this afternoon represent the Professional Association of Internes and Residents of Ontario: Dr Scott Woodside, Dr Margaret Kruk, Lois Ross, Steven Barrett and Dr Michael Franklyn. Obviously, I've named one who's not here.

Welcome to our committee. You have a half-hour of our time to use as you see fit. The floor is yours.

Dr Scott Woodside: Good afternoon. My name's Dr Scott Woodside and I'm president of the Professional Association of Internes and Residents, or PAIRO, and a resident training in psychiatry. With me today are Dr Margaret Kruk, a member of the PAIRO executive and a family practice resident in the Thunder Bay training program; and Dr Mike Franklyn, a former member of the PAIRO executive and a family doctor practising in Sudbury. As well, we have Steven Barrett, PAIRO's counsel, and Lois Ross, our executive director.

PAIRO very much appreciates the opportunity to appear before this committee to address our concerns with Bill 26. PAIRO represents approximately 2,400 residents or doctors in training across the province of Ontario.

PAIRO chose to make its presentation here in Sudbury because much of the focus of our activity over the past several months has been, and over the months and years to come will be, on working with communities in the north, with other underserviced communities, with the Ministry of Health and with interested stakeholders in helping to identify and develop effective and lasting recruitment and retention measures. We have been emphasizing the importance of retention measures because keeping doctors in the north, solving the real problems facing underserviced communities, cannot be done by force. No matter how many doctors might set up practice in underserviced communities, doctors will be able to stay in those communities only if the underlying problem of physician burnout is addressed.

We want to begin by focusing our comments on the provisions of Bill 26. At the outset, we should be very clear that PAIRO has a number of very significant concerns with many aspects of the health-related provisions of Bill 26. Given that many other presenters have already made representations on those issues, our primary focus today will be on the proposed billing number restrictions.

If enacted, these provisions would provide the Minister of Health and cabinet with the unilateral authority, in their sole and unfettered discretion: (1) to force a doctor to practise in a particular geographic area; (2) to prevent physicians from practising unless they agree to perform services specified by the minister; (3) to impose numerical quotas determining how many physicians can practise in a particular geographic area or area of practice; (4) to prevent specialist physicians from practising unless they are affiliated with a facility; and finally, to effectively prevent many new physicians from practising medicine in Ontario at all.

Separate and apart from questions of constitutionality, legality and morality, the plain fact of the matter is that billing number restrictions will not work to solve the real problems of recruiting to and retaining physicians in underserviced communities in the north and elsewhere.

This is not just PAIRO's view. The fact is that virtually every study of the distribution problem has concluded that billing number restrictions do not work and has recommended against imposing coercive measures on new doctors. To give just two examples, the government's own PCCCAR, underserviced area needs committee, with underserviced community representation, concluded in its 1995 report that "providers should continue to be encouraged and supported -- rather than compelled -- to choose to practise in underserviced areas."

As well, Graham Scott, a former Deputy Minister of Health under earlier Conservative governments, was jointly appointed by the Ministry of Health, the Ontario Hospital Association and the Ontario Medical Association to make recommendations concerning physician services in underserviced communities. In his 1995 fact-finding report, based on his discussions with stakeholders in northern communities, he recommended that "the Ministry of Health should provide assurance to physicians who undertake to practise in the rural areas that they are not going to be required to stay there by government decree."

Clearly, there is an overwhelming consensus that coercive billing number restrictions proposed in Bill 26 will not work. There is also widespread support for the principle that underserviced communities deserve to receive medical care from doctors who wish to live and work in those communities. As many communities have already indicated to PAIRO representatives, they would rather have doctors who choose to practise in their community than ones who are forced. This is because most communities know that securing new doctors isn't the main challenge; it's keeping new physicians. The real task is to put in place for the first time effective retention measures and programs which will keep doctors in underserviced communities and reduce physician burnout. PAIRO is committed to working with northern communities to help to develop a program which will both recruit and retain new doctors.

We should add that billing number restrictions would not work for southern Ontario either, because they won't get any doctors, period. There are many communities in both southern and northern Ontario which either currently have a need for new doctors or anticipate such a need in the future, whether because of retirement, physician movement and aging population or a host of other factors. It makes no sense for the government to deprive many Ontarians of access to the skills of newly trained physicians when, for the first time in 20 years, the number of doctors in Ontario is actually decreasing, or when expert bodies such as the Association of Canadian Medical Colleges have predicted a dramatic shortfall of physicians in the next five to six years. It also makes no sense to deprive many Ontarians of new doctors when the face of new doctors is for the first time increasingly comprised of women and visible minorities. And it makes no sense for Ontario taxpayers to spend millions of dollars training new physicians to provide medical care to Americans.

Dr Kruk will now provide the committee with an overview of PAIRO's activities in this area.

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Dr Margaret Kruk: In late 1995, PAIRO representatives visited with seven communities to explore measures for new recruitment and retention programs. These included Timmins, Manitouwadge, where I visited on December 2, Sioux Lookout, Campbellford, Renfrew, Kirkland Lake and Wawa.

At the same time, and to be continued into 1996, PAIRO launched an advertising campaign called Let's Get It Right This Time, committing PAIRO to working with northern communities and the ministry to help get and keep doctors in underserviced areas.

Later this month and throughout February, PAIRO representatives will extend the earlier PAIRO visits to dozens of underserviced northern communities to discuss an effective and reasonable recruitment and retention program. These visits are being made at the specific request of the communities involved. The PAIRO visitors will include doctors in training who are currently considering practising in underserviced areas. PAIRO has made significant efforts to identify these doctors through its unique access to its resident members. The results of the visits, which PAIRO is calling Dialogue '96, will be discussed with representatives of northern communities and submitted to the minister in March 1996, hopefully in time to affect new doctors' decisions on where to practise as early as July 1996. I have with me an advertisement we'll be running in northern newspapers to inform the public up here of our Dialogue '96.

This committee heard earlier today from a group of PAIRO members who are family medicine residents training in the northeastern Ontario family medicine program here in Sudbury. I am training in the other northern training program in Thunder Bay and intending to practise in the north.

We all agree that the issue of underserviced communities is primarily a northern Ontario issue that deserves northern Ontario solutions. That is why, in November, PAIRO initiated our first visits. We were so impressed by the enthusiasm of northern communities for our involvement in solving this problem in December that we decided to undertake Dialogue '96 with northern communities, an undertaking which the minister supports. And we are here in Sudbury today because PAIRO's members are committed to developing solutions that will attract and keep both new and established physicians in northern Ontario. Indeed, many of our members, including seven of 11 members of the PAIRO executive, have told us that they want to practise in underserviced areas so long as appropriate recruitment and retention measures are put in place. Many of them will be participating in Dialogue '96.

Dr Woodside: At this time, we'd like to outline just two of the possible measure PAIRO intends to discuss with northern communities during Dialogue '96.

The first of those measures is the direct contract or alternate payment program. Since it was first conceived in 1993, PAIRO has been committed to the direct contract program, which is a non-fee-for-service alternate payment plan for underserviced communities. This commitment is evidenced by PAIRO's agreement, back in 1993, to participate and assist in direct contract recruitment activities and to participate in a committee that was to guide and oversee the direct contract program. Indeed, both PAIRO's membership and underserviced communities themselves have identified the absence of a non-fee-for-service payment option as one of the most significant barriers to recruiting and retaining physicians in northern communities.

Unfortunately, while the direct contract program was supposed to come into effect in early 1994, the former NDP government never implemented it and the present government still has not implemented it; this, despite the recognition by the Graham Scott fact finder report that direct contracts are "the most advanced alternate payment plan with the potential for immediate use," and would "address the challenge of attracting and retaining physicians."

What would a direct contract program look like?

All of the communities we have already consulted, and others which have expressed their views, agree that the key to the structure of the direct contract program is the recognition that the present fee-for-service system may not be appropriate in smaller underserviced communities for a variety of reasons. For instance, it does not recognize the all-day, everyday commitment required of a doctor in a rural or underserviced area. In addition, the fee schedule is oriented towards office-based work and so does not address the broader range and mix of services provided by rural physicians.

In contrast, a direct contract program would encourage physician recruitment and retention in underserviced areas for the following reasons:

First, in return for agreeing to provide medical care to the community, the doctor would receive stable, reasonable, annual compensation.

Second, in order to prevent physician burnout and isolation, a doctor would be entitled to take reasonable time off, while being guaranteed locum physician replacement services.

Third, a direct contract program would ensure that municipal or hospital clinic facilities and other resources would be made available to the physician as part of the direct contract. This is of paramount importance for the newly trained doctor.

Fourth, professional isolation would be reduced, through increased accessibility to continuing medical education opportunities and also through formalized academic health science centre support.

Fifth, reasonable on-call coverage would be required, but the direct contract would protect the physician from being required to provide such coverage at an unreasonable frequency.

Sixth, spousal and family support measures would be implemented, which have been recognized to be crucial for physician retention in underserviced areas.

Finally, established physicians in northern communities would have the opportunity to convert from fee-for-service to direct contracts, which would help reduce some of the competitive tensions inherent in the present fee-for-service system.

Dr Kruk: A second critical PAIRO suggestion is the expansion of northern and rural training programs. At the present time, there are only two family medicine training programs in northern underserviced areas. One is based here in Sudbury and the other in Thunder Bay, where I'm training. These training programs have an excellent record of training doctors who decide to practise in the north, with retention rates of over 65% of graduates working in underserviced communities upon the completion of their training. As well, these residency training positions are highly sought after by residents, with up to 200 applying for the 12 positions each year.

However, as the Scott fact-finding report concluded: "Family practice training of residents, other than those at the new Family Medicine North facilities in Sudbury and Thunder Bay, does not fully prepare...(family doctors) for the differences between the well-supported general practice in urban areas and the wider skills burden on" family doctors "in rural areas. This creates an immediate barrier for many young physicians who feel unprepared when exposed to the northern challenge."

PAIRO's membership agrees wholeheartedly. We are committed to actively working with the Ministry of Health, academic health science centres and other stakeholders to bridge this gap between expectation and reality. If rural training opportunities for both family practice and specialty residents are expanded, we can build on the successful track record of the existing northern training programs. Northern communities are entitled to be served by doctors who want to live and work there. Experience has demonstrated that the best way to develop those doctors is by ensuring that they are exposed to training and living in the north as an integral part of their residency programs.

Shifting resources to train doctors in northern communities in areas such as family practice, obstetrics, emergency medicine, anaesthesia, general surgery and psychiatry would also help to provide service support to established doctors already practising in those communities. This would ease their workload, reduce professional isolation, forge links with academic health centres and provide those doctors with reasonable time with their families.

The Minister of Health, in his October 11, 1995, letter to the chair of the Council of Ontario Faculties of Medicine, or COFM, specifically noted that various reports have all concluded that the location and content of training is one of the most important factors in influencing a physician's location of practice. Yet now the minister, through Bill 26, proposes to undermine the real promise and success of those measures in the name of short-term political expediency.

Time doesn't permit us to detail the remaining measures in our brief, save that they include locum system improvement, the creation of a central needs registry, voluntary return of service with restructured financial incentives, expansion of re-entry positions and a responsive specialist backup system.

Dr Woodside: As well, PAIRO is looking forward to the northern communities telling us, during Dialogue '96, which measures they feel are necessary for recruiting and retaining physicians.

The truth of the matter is that, as Mr Clement recognized yesterday, positive, ongoing, comprehensive recruitment and retention measures have never seriously been implemented in Ontario. However, the fact that no prior Ontario government has yet had the will or the capacity to put in place viable, effective and sustained measures to meet the needs of the underserviced communities should not now be used by the present government as an excuse to impose negative, coercive and ineffective billing number restrictions. This is particularly the case when, for the first time, the medical profession itself, through the OMA, has stated that it would be prepared to pay for effective recruitment and retention measures out of the fee-for-service pool.

At present, the minister has publicly committed himself to holding off on implementing billing number restrictions in order to give non-coercive measures a chance to work. However, we must admit to being somewhat sceptical about the minister's real motives and intent. The minister is still insisting on including the power to impose billing number restrictions in Bill 26, despite his professed commitment. Then, during the first day of hearings by this committee, he threatened to implement the Bill 26 billing number restrictions unless the 1996 graduating class fills all the underserviced area positions identified by the government. The minister himself must recognize that this is not a reasonable expectation.

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PAIRO respectfully requests that instead of threatening new doctors with billing number restrictions, the minister and the government consider the following:

First, one graduating class cannot be saddled with the responsibility of solving decades of inaction by both the government and the profession. Constructive and effective measures must be developed and given time to work.

Second, if Bill 26 is enacted to give the minister the legislative authority to impose billing number restrictions at any time, this will have a chilling effect on the ability and willingness of new doctors to practise in northern communities and will create a climate of uncertainty and instability.

Insisting that the spectre of billing number restrictions continues to hang over our heads will have a precisely opposite effect to the minister's professed objective of giving positive and supportive recruitment and retention measures a real chance to succeed. Keeping the proposed sections 29.1 through 29.7 in Bill 26 undermines the credibility of the minister's commitment to non-coercive solutions which will really work.

If you knew that, after setting up practice in an underserviced community, legislation could be proclaimed at any time preventing you from ever moving elsewhere, what would you do? Indeed, it may well be that if Bill 26 continues to contain the power to impose billing number restrictions, even established physicians in northern communities may seek to set up practice in the south to avoid being affected by future billing number restrictions.

Third, equally important to ensuring effective and successful recruitment and retention of doctors in the north is for the minister to stop claiming that he has put in place the most comprehensive incentive package ever to attract doctors to underserviced areas, when he has not. Let us be very clear that all MPPs and northern communities understand one critical fact: The minister has yet to put in place any of the measures which northern communities, expert bodies and other stakeholders have all recognized as critical components in recruiting and retaining doctors in underserviced communities.

These include a direct contract program or similar alternative payment plan. The only measure the minister has implemented, the $70 per hour fee for small hospital emergency service, was never conceived by Graham Scott who recommended it, or by anyone else, as a measure for recruiting and retaining new doctors in the north.

I'd now like to ask Dr Franklyn, who is a member of the first graduating class from the Sudbury program in 1993, to speak to the issue of defining what constitutes an underserviced area.

Dr Michael Franklyn: I would like to address a simple point and that is, who determines and how is it determined whether an area is underserviced? I am a family physician in Sudbury and was one of the first six graduates of the Sudbury program two years ago. Five out of six of us are still in this community. In the summer of 1993, one of my colleagues and I opened a family practice in Sudbury and were closed within six weeks; I had accepted 2,000 patients in six weeks and closed my practice because I wanted to limit it based on my areas of interest in terms of obstetrics and women's health.

We collected names until Christmas and I still have 600 names sitting on a waiting list, collecting dust, that are very likely never to be served by me. These kinds of services are provided by the newest and brightest doctors who are graduating today.

I'd like to take you back to my struggle in 1993 to open a practice in Sudbury. I was a PAIRO executive member at that time and was told flatly by representatives of the Ministry of Health that Sudbury was not underserviced and that were I set up here, I would get 25 cents on the dollar as per the legislation of the day. I found this hard to believe, since I had been working in communities in and around Sudbury and had been asked by some 500 families to accept them into my new practice. The Ministry of Health numbers seemed dramatically higher than those I had counted myself and I undertook a detailed survey to compare the realistic numbers to the ministry numbers.

The ministry at the time counted 138 full-time practising physicians in Sudbury, when in fact the survey revealed there were 79, for a discrepancy of 58. Those 58 were made up of a number of physicians who had been dead for years, as well as full-time retired physicians and a number of specialists including psychiatrists, oncologists, radiologists, all of whom were counted as full-time practising physicians. Perhaps most astounding was the fact that my name was on the very list and was counted in the head count that prevented me from practising here, along with all six of the residents currently in training who were not in private practice.

Where are we two and a half years later? We're sitting here in Sudbury in January 1996 and I would say the situation is much worse. There's been a citizen's coalition working for two years now to get the city of Sudbury declared underserviced. As we sit here today, it is not.

This was the front page of the Sudbury Star. It covered an 80-year-old physician who was watering his daisies. He had billed OHIP $500 in the previous year, giving his friends flu shots to go to Florida, and he was counted as a full-time doctor.

The number of doctors who have come to Sudbury since I have includes these names. The first five are graduates of the Sudbury program. Two came from out of country and two of these are now on maternity leave. This is the list who have left Sudbury. We're down 13 doctors from where we were in a desperate situation some two and a half years ago, and I only see it getting worse and this legislation can only worsen it further.

Conservatively, if you count 1,500 patients per doctor and 13 have left, that represents almost 20,000 patients who have lost a primary care doctor in Sudbury alone. Some of them may have managed to find a new doctor, but I'm sure that areas in northern Ontario are even worse off. As a family physician, I consider myself first and foremost to be a patient advocate and have nothing to gain by being here today, and I'm here simply to draw your attention to the inability of the government to determine just what an underserviced area consists of. The situation is desperate in Sudbury and other areas are worse off.

I certainly am very interested in any workable solution that would find some sustainable mechanism to correct the maldistribution, but as someone looking for a colleague, I certainly don't want somebody who was forced up here against their will. I suggest we should look for sustainable and workable solutions.

Two final points: I would like to say that it occurs to me that the proposed legislation flies in the face of logic and, to coin a phrase, common sense. We're talking predominantly about a northern Ontario problem. To now propose that we'll concentrate and centralize sweeping new legislative powers in the hands of a few politicians and southern bureaucrats in Toronto seems like taking one step forward and three steps backward.

My second and final point is that the new graduates who have spoken to you before this presentation are generally the brightest, keenest and most highly trained physicians ever made available to the public to provide excellent patient care. They have generally had a minimum of eight to 15 years of post-graduate education, which taxpayers have footed the bill for. They have struggled financially and worked incredibly long hours with awesome responsibilities throughout their medical training.

I'd urge all the members of the committee as well as those of the public to take a minute, take a big breath, and think about these people as being your children or grandchildren and ask yourself, what would they do in that situation? After working so long and so hard, having put their lives on hold for years, if presented with the option of being assigned perhaps indefinitely to a northern or rural community not of their choosing or fleeing to the US, I submit to you that even those who have never considered leaving Canada as an option will pack up their skills, their stethoscopes and flee in droves rather than be conscripted into service in northern Ontario.

Finally, I'd like to say, let's listen to those who with their youth and ambition, motivation and ideas, have the best solutions to this long-standing problem.

Dr Woodside: Two and one half years ago, at a time when the NDP government threatened to impose similar restrictions on new doctors, the Conservative Health critic, now the Minister of Health, stood in the House and drove home to the NDP the "frustration and anger felt by new doctors when they are told that their home province doesn't want them."

We ask the members of this committee and the government to accept the views of the former Conservative Health critic and therefore, first, to endorse PAIRO's approach to getting and keeping doctors in northern Ontario; second, to support PAIRO's upcoming initiatives, including Dialogue '96, and our ongoing involvement in the placement process; third, to recognize that communities prefer doctors who choose to come and stay over doctors who are forced to come and will likely leave; fourth, to recognize that a non-coercive effective recruitment and retention program will get new doctors to the north who will want to stay, whereas billing-number restrictions will not get and keep the doctors the north deserves; fifth, to advise the minister that leaving billing-number restrictions in Bill 26 would create significant uncertainty and instability, leading many new graduates who would have practised in underserviced communities to stay away, and potentially driving away some of those doctors who are currently committed to practising in the north; and finally, as a result, to recommend that the proposed billing- number restrictions contained in Bill 26 be removed.

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The minister may have already done irreparable harm to the efforts to recruit and retain physicians in northern communities by including billing-number restrictions in Bill 26. The only way to begin to undo the damage is, first, to immediately remove billing-number restrictions from Bill 26, and, second, to introduce a comprehensive recruitment and retention program comprised of many of the measures identified by northern communities themselves and those that we have listed today.

PAIRO's membership would much rather use its energy, commitment and resources to work with northern communities and other underserviced areas to develop effective and lasting solutions, instead of being forced to use those same resources to combat coercive and counterproductive billing-number restrictions.

Thank you very much for your time.

The Chair: Thank you for the presentation. You've used up the time allotted to you with your presentation, so there's no time for questions. But we do appreciate your input and your interest in our process.

Mrs McLeod: Can we just join in thanking PAIRO for the presentation. It's so compelling that I know it will lead to immediate amendment.

SUDBURY GENERAL HOSPITAL

The Chair: Our next presenters are from the Sudbury General Hospital Association. Good afternoon and welcome to our committee. Unfortunately, I don't have your names, so I'll ask you to introduce yourselves. Any time you leave for questions at the end will start with the government. The floor is yours, gentlemen.

Mr Carl Roy: Just to correct the record, my name is Carl Roy and I'm the associate executive director. I think it's the "associate" in the title that resulted in the typo around "Association." I'm the associate executive director, as I've said, of the Sudbury General Hospital.

Like everyone else who has spoken today to the committee, I thank you for the opportunity to present, especially given that space is at such a premium. With me today is Michael Park, chief executive officer of Network North. Since November 1992, our two organizations have had a formal partnership agreement which has allowed us to organize mental health services into one system in the Sudbury region. This was a voluntary agreement that was motivated by a desire at all levels of our organizations to improve mental health services by reducing duplication and reinvesting our scarce resources in order to fill gaps in the continuum of services that were available to our clients. We are also both members of the Ministry of Health-led hospital restructuring implementation working group that is currently implementing our local restructuring study.

Some of you will be aware of the long and painful hospital restructuring process we've been through as a community. At the initiative of the previous NDP government, since June 1992 we have reviewed our present programs and services and, as a community, determined our future needs. This vision for the future is contained in our hospital services review report. On August 8, 1995, the Minister of Health accepted this report as the blueprint for hospital restructuring in Sudbury.

In the early days of the review process there was an appearance of coordination and co-operation among all the players. However, as our review process dragged on and on and on, what goodwill had existed dissipated, particularly as it became clear that the outcome of the study would be to move from four to two hospital sites and major relocations of clinical programs. This prompted immediate defensive survival campaigns on the part of the hospitals that viewed this outcome as a loss. Rather than celebrating improvements to patient care which were the focus of the report, our community was encouraged to mourn the supposed loss of programs and buildings. This was accomplished through intentionally orchestrated campaigns that have built on fear-mongering and misinformation.

Thus, at the conclusion of a process that had provided a blueprint for the future, we were still left as a community with arbitrary and uncoordinated cuts to service that often resulted in transferring the costs of care from one facility to another rather than producing efficiencies. As the only facility that receives patients 24 hours a day, every day of the year, in this region we often bore the brunt of these cuts and the inconvenience and risk that they created for patients and their families. Much-needed and long-anticipated capital projects such as a redeveloped emergency trauma facility, which has been on the books since 1987, and the first MRI in northeastern Ontario have simmered on a back burner while we awaited the final restructuring report and the minister's approval. Programs and services at individual sites have been reduced and, at times, completely closed in order to meet financial obligations such as those imposed under the social contract legislation and flat-lined hospital budgets.

Even once our review was approved by the minister himself and clear direction was received repeatedly to implement the service and siting recommendations in the report, local hospitals are still dragging themselves kicking and screaming through a tumultuous and divisive process that has yet to bring about one single improvement to patient care.

As well, here in Sudbury we have a DHC that is very resentful of the commitments made by all three political parties to respect denominational governance in the restructured health care system. You heard this morning that they continue to make direct attacks on Catholic hospitals in particular. We do not believe that the commitments made by the party leaders were designed to give special status to denominational facilities during the local planning for restructuring. We do believe, however, that all parties were committed to the concept that, where a denominationally sponsored hospital was identified to continue as a provider in the restructured system, they should be allowed to retain the structures that ensure their continuance as a denominational facility.

Based on our experience, we recommend that once the advice of the local district health council has been forwarded to the Minister of Health, as per their advisory role as it relates to hospital restructuring, this role should end and they should not be allowed to interfere in the implementation of local studies. To that end, we're supportive of the minister's continued statements outlining the value of DHCs in terms of planning.

Having lived through our hospital services review and our attempts to implement the recommendations, I can fully support the Minister of Health's plea that we not play politics with the health of the people of Ontario. We understand that this bill, particularly as it pertains to health care, is designed to provide the necessary tools to facilitate restructuring. We hope, as always, that voluntary cooperation can form the core of this process. However, we hold out little hope of a voluntary process being successful where there is ongoing resistance to the approved restructuring plan and implementation process.

Currently, the Public Hospitals Act has limited provisions to encourage cooperative support for restructuring initiatives if individual hospital corporations are opposed and, consequently, sustains the type of resistance we have witnessed in Sudbury. Therefore, we understand the need for the legislative, regulatory and policy changes that will provide the necessary tools to facilitate an orderly restructuring and to clarify the roles of the players, including hospitals and government, in this process.

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Let me emphasize that, based on our experience of hospital restructuring here in Sudbury, we both support and welcome the creation of a restructuring commission. We base our support for the commission on our experience of having been through a review of services which now needs implementing. It is our profound hope that no other community has to undergo the division and bitterness that has occurred here in Sudbury.

We agree with the Ontario Hospital Association's position that the commission must be able to accelerate the implementation of restructuring plans once they have been completed and approved by the minister. We suggest, however, that the commission should only have limited flexibility when it comes to varying the plans proposed by the DHCs once these plans have been accepted by the Minister of Health. We believe that the regulations will need to be quite specific about the issues or situations that may warrant a change in approved plans. While some fine-tuning of program realignment may be necessary during implementation -- and this is indeed provided for within the Sudbury hospital services review report -- we would caution against too broad a statement allowing for flexibility that could result in further delays or calls to redo studies rather than just fine-tune their recommendations.

We can give numerous examples of repeated initiatives to alter the approved outcome of the study and the resulting delays. Not unexpectedly, this type of resistance comes from those hospitals that do not support the outcome of the local study. With 11 hospitals slated for closure in Toronto alone, the slightest indication that the commission will consider revisiting already-approved studies will compromise successful restructuring across this province. Resistive behaviour should not be reinforced once studies have been completed. Neither should the commission become another forum for lobby efforts or the last court of appeal.

As communities like ours proceed through this often difficult process, it is important that an overall vision for the future provision of hospital services is presented, to reassure our patients, to encourage our employees and to keep all of us on the same track.

We support the Ontario Hospital Association's position that the commission's role be time-limited, and four years seems reasonable. We're pleased to have received notification that the minister has also supported this change. We think that this will allow for communities to complete their planning and implement the results within the foreseeable future. Here in Sudbury, we have firsthand knowledge of the effects an overly drawn-out process can have on patient care, staff and physician morale and achieving financial targets. We welcome the opportunity for the commission to refine its mandate based on the experience here in Sudbury, where our report is approved and our very bumpy implementation process has already identified the pitfalls and the minefields of translating vision to reality.

When we began our process, we were optimistic that we were planning for a hospital centre that would serve northeastern Ontario into the future. As a community, we have worked hard for many years to develop primary and tertiary care programs and the necessary infrastructure to support these services. We had been able to recruit and retain specialists, usually with promises of the great things to come. Throughout it all we received excellent support from our local MPPs and especially our regional government, which lobbied when necessary, promoted the region and set aside hundreds of thousands of dollars towards the local share of capital funding requirements. All of our local hospitals and the cancer treatment centre, which is now five years old, have run successful fund-raising campaigns that time and time again have tapped the generosity of our citizens. Always there was the promise of better things to come.

We now know the reality is that we need to implement restructuring to plan for reductions and hopefully minimize the destructive impact this may have for Sudbury. But at the Sudbury General we also believe we are lucky that our review is done and that we have a vision on which to base our plans for the future. If we move ahead quickly to implement the restructuring recommendations, we may still be able to enhance our services.

By implementing the vision as contained in our hospital restructuring report, we will also have the opportunity to plan for system-wide labour adjustment strategies in order to ensure fair and equitable treatment of those who will be affected by the process. The hospital budget reductions announced in November are lower in the first year and higher in subsequent years. We believe this provides us with a window of opportunity to achieve these financial targets through restructuring the system as a whole rather than making deep cuts at each institution. Taking approximately $25 million in reductions over the next three years out of our hospital system on top of the money already lost through the social contract legislation results in a total decrease in funding of over $30 million in this region. This magnitude of reduction cannot be met without restructuring the entire hospital system, and this includes the closure of hospitals as recommended in our approved restructuring study.

The delays to restructuring the system that result from resistance to implementing review recommendations are not only important because of the fiscal context but, as I've already mentioned, in a community such as Sudbury the delay has also meant that much-needed patient care improvements have been held at ransom as individuals and organizations obstruct attempts to move the process forward. This, sadly, has been clearly demonstrated by the unacceptable delays to implementing most of the recommendations from the coroner's inquest into the death of young Jenny Lavoie. Many of the flaws and gaps in the system that were identified as a result of that inquest have also been the basis for the decisions that our hospital services review committee made in its report to the DHC. As a community, we've known for years that many of our services are fragmented while others are unnecessarily duplicated or triplicated. As a system of health care providers, if we are honest, we know that we can better target care by cutting waste and duplication in the system. We also know that, given the opportunity and the tools, we can be part of the solution.

The tools proposed in Bill 26, as long as they are focused on and time-limited to facilitating the accelerated implementation of restructuring, will ensure that talk about the importance of restructuring is followed by a timely commitment to act on the part of all hospitals. In Sudbury, we believe we are at the appropriate point for the minister to exercise his power through the commission to implement our restructuring plan. He has received advice from the DHC, which supervised the work of the hospital services review committee. The HSR committee spent two and a half years, $500,000 and thousands of hours in staff and volunteer time to come up with its recommendations. Hospitals had the opportunity to submit their views and to be part of the process. Our community has proposed its solution. Now is the time to act.

We make this recommendation as part of a community that has prided itself on its abilities to develop its own solutions and would not want the commission or any other outside group to intervene. However, it is our opinion that the community stakes are too high in light of the financial challenge and the need for patient care improvement, and the time too short.

If a community accepts the outcome of their review and embraces its implementation, there will in all likelihood be no need for the commission to intervene in the process. However, if, as in Sudbury, you have institutions that do not support the outcome, and in fact do all they can to discredit or overturn the recommendations, then the process can become inextricably bogged down in actions that can best be described as subversive and obstructionist. This is to the detriment of patient care and eliminates opportunities for change and improvement that could otherwise mitigate the impact of the type of massive restructuring that communities such as ours need to undergo.

We note that the OHA has suggested that the minister not delegate the power to close or amalgamate hospitals. In Sudbury, we believe that once the minister accepted the service and siting recommendations and approved that the ministry and the hospitals begin implementing them, he accepted that a hospital would be closed or amalgamated as is outlined in the report. The unknown question is the time frame. The commission should facilitate the smooth transition of programs, human resources and funding in order to achieve the vision that is contained in the report that the minister has already accepted.

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We believe this government is committed to the continuation of voluntary governance of the hospital system. Hopefully, the more extreme measures that appear in the act, such as the appointment of a supervisor or the withholding of funds, will only be invoked when it is truly in the public's best interests, because valid attempts at a cooperative and collaborative process have failed. Unfortunately, we here in Sudbury know only too well that the public good can be held at ransom by politics. We must refocus our energies on restructuring to provide the best patient care possible within a more efficient system. If this is done, there should be no need for the Ministry of Health to micro-manage the hospital system.

Only if the commission meets continuing resistance should it be necessary for them to appoint a supervisor. However, we can foresee that if a hospital digs in its heels and chooses to resist the implementation of restructuring, it may be in the best interests of patient care and the public good to have a way of ensuring participation in the restructuring process.

At the Sudbury General, there is no question that we believe in the continuance of voluntary governance. We are pleased that the minister has not endorsed or supported regional boards and has rejected the concept of sole governance. This is consistent with the OHA position that voluntary governance be preserved throughout the implementation of restructuring. However, again based on experience, we must say that if existing hospitals are not willing to implement the service and siting recommendations that result from local reviews, we understand perfectly well why mechanisms such as the restructuring commission or the appointment of a supervisor may be required.

Change is always difficult. It's hard for people to accept realignment and closure of programs and facilities. In many communities like ours, families and individuals have devoted years of loyalty to "their" local hospital. Hopefully, the commission will be able to build upon the voluntary contributions of board members and assist in reorganizing their talents to meet the needs of the redesigned system. The same will be true for staff and physicians within the system. In reality, what is needed from the commission is to act as an outside arbitrator to facilitate and accelerate the implementation of approved plans. And above all else, we need a way to ensure that we are able to maintain the public's confidence and get on with providing the best patient care we can for the residents we are here to serve.

We can also understand the need for another of the strategies proposed in the legislation; namely, the power to impose terms and conditions on loans and grants to hospitals. The unfortunate reality is that withholding financial support or transferring funds from one facility to another may be the only meaningful incentive to ensure cooperation in the restructuring process, short of appointing a supervisor.

In section 6(d) of the proposed bill, reference is made to the power of the minister to make any direction related to a hospital that is considered to be in the public interest. We believe that in Sudbury, the public interest as it relates to the provision of hospital services, specifically where, how and by whom these services are provided, has been well served by the 2 1/2-year HSR study. This comprehensive study reviewed how the Sudbury hospital centre could be better managed as a health care system within the available resources.

We are gratified that the minister and the ministry will now have the tools and, when necessary, the big stick to enable communities such as Sudbury to move beyond the quagmire of endless debate and stalling tactics and on to doing the best that we can for the benefit of our citizens with the resources that are available to us.

Thank you, Mr Chair.

The Chair: Thank you. We appreciate your presentation. You've left this committee with one of its largest challenges, the chance at one quick question each, with the emphasis on quick, starting with the government.

Mr Clement: Thank you for your presentation. It certainly is a cautionary tale which you tell. I only wish I could bottle the presentation and share it with other cities, because it might provide help to them as well. From your perspective, then, the powers that the minister has under this bill are necessary and in fact welcomed in order to break some logjams?

Mr Roy: Most definitely.

Mr Clement: Can you expand on that?

Mr Roy: We have been at the table with a number of Ministry of Health staff since September 18. I just came from a meeting. We met last evening as well. We've been meeting roughly two days a week to implement the plan. We've had extensive discussion groups making recommendations for how we can best implement the recommendations on patient care service improvement.

We still have two hospitals that, when the ministry asks, "Can you agree with this?" say, "I'm sorry, but the position of our hospital is that we will do nothing until sole governance is established." Up until the minister's direct, face-to-face clarification in November of his position -- this was the fifth clarification this minister has provided -- hospitals were saying the review hasn't been decided.

I think this points to, to be fair, the tremendous stakes in restructuring, and as long as these provisions are based at reshaping and reforming the system, then they're well needed and will ensure that we expedite getting on with improving patient care for this community instead of squabbling about who's going to control the system.

Mrs McLeod: I'll try and be very brief in respect of the time of the committee, because I think the minister is giving himself somewhat unenviable powers to step into local rationalization/restructuring discussions, and I actually think he does have the power now. One of the reasons why ministers of Health tend to step in and then rather tentatively withdraw is because it is so difficult to find what is a consensus among a community and what a community feels is in its best interests. That's become apparent as we've heard presentations in Sudbury today, and I think all of us knew some of the history coming in.

You should know that the district health council made a very strong representation today also in support of ministerial powers provided that the minister's powers were exercised in accepting DHC reports and including changes to Bill 26 that would allow for a sole governance model. Mrs Ecker from the government indicated that the minister intended to utilize his new powers by acting on DHC recommendations. If that were to be the case, I suspect you would have some concern about the minister stepping in and making that kind of decision.

I guess it comes down for me, and I will make it as direct as I can, that I don't think there's any way around communities having to wrestle with what is in their best interests. I'm wondering whether or not -- and you can't answer this in two seconds, I know -- there is a better way of getting the stakeholders at the table, of determining what is community and how does a community have its say, so that we don't have to continue to go through the divisiveness. These are going to be tough decisions, and I don't think the Minister of Health can make those decisions in Queen's Park without having come in and really understood the nature of a particular community.

The Chair: Unfortunately, Mrs McLeod, you didn't do nearly as good a job of asking a quick question.

Ms Lankin: There are two areas that I would like to touch on quickly. One, with respect to your recommendation that the restructuring commission be sunsetted, I wanted to point out to you that the Ontario Hospital Association in its presentation said that the minister's stated intent to amend the bill and to put a sunset clause on the commission wasn't sufficient, that in fact the extraordinary powers that the minister takes on to himself with respect to hospital restructuring, mergers, closures, appointments of supervisors, a whole range of things, should be sunsetted. While some of us may debate how necessary those measures are to accomplish the goals, putting that aside, if they're there in the bill they should be sunsetted. So I wanted to ask if you were in support of the powers as opposed to just the commission.

Secondly, very quickly, you make some very strong arguments about the DHC's reports being at the basis of the action of the hospital restructuring commission. I agree with that completely and I'm wondering if you would be supportive of amendments to the bill that at least gave the restructuring commission some terms of reference or mandate and at least some reference to DHC reports, because as it is right now, there is nothing in the bill that builds that linkage in.

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Mr Roy: In terms of the first question, yes, we do support the OHA's suggestion that the elements of section 6, I believe, around the appointment of a supervisor also be sunsetted. Sister Winnifred McLoughlin, on behalf of the Sisters of St Joseph of Sault Ste Marie, will be addressing that particular point in her presentation later this afternoon.

Again, we link it to restructuring and see these provisions as tools to get the job done, because we need to get the job done. In terms of reference to DHC-approved plans, yes, I firmly believe that the DHC plans must be the blueprint. To give credit to the DHC, I think it did an admirable job in a process that was designed to significantly reduce the hospital system, inform the public of that reality and give them full opportunity to express their point of view, but I wouldn't give it a perfect report card in the process either. I think there needs to be an acknowledgment of the DHC's work, and that's why I stressed the importance of the commission responding to approved studies, after the minister has received the advice.

The Chair: Thank you very much, gentlemen, for your presentation. We appreciate your interest in our process. Have a good afternoon.

CENTRE DE SANTÉ COMMUNAUTAIRE DE SUDBURY

The Chair: The next group is the Centre de santé communautaire de Sudbury. I understand the presentation will be made in English, but if anybody wants a copy of the French version, it can be made available to you. Welcome to our committee. You have a half-hour of our time, and questions will start with the Liberals, should you leave any time. The floor is yours.

Ms Juliette Denis: I would ask the committee to go to page 6. I would like to start by explaining a bit what the Centre de santé communautaire de Sudbury is all about. We're a non-profit community health centre that provides a wide range of culturally sensitive health and social services in French to the francophone population of the regional municipality of Sudbury. Special attention is provided to the youth, women and the elderly. Particular emphasis is placed on prevention, health promotion and education relating to the determinants of health.

Our mission is to assist our community to improve its level of wellbeing and, ultimately, to attain an optimum level in this respect. We believe that in order for this to happen, each individual member of our community must take responsibility for his or her own health. This is why the centre invites and greatly values public participation in all matters relating to the wellbeing of our community members.

Centre de santé communautaire de Sudbury recognizes the need and the urgency for reforms to Ontario's health care system. We support such reforms provided that the following principles are not placed in jeopardy: democracy and the rights and responsibilities of all Ontarians; the Canada Health Act, such as comprehensiveness, universality, accessibility, portability and public administration; quality of care; and fairness and equity for all Ontarians.

We are concerned about the potential negative impact that some provisions of Bill 26 can have on these principles. We believe it is possible to bring about reforms that will on the one hand provide for a more efficient and affordable health care system and on the other hand protect these principles and improve the wellbeing of Ontarians. This belief forms the basis for our presentation today and for the recommendations we are submitting.

I'll just explain a little how the report is prepared. We have identified areas of concern, and you will find under most of them the area of the proposed bill that's involved, the one we are particularly worried about. I'm not going to go through that while I'm reading, but it's there for your reference at a later time.

The first area of concern for us is the use of legislation to effect change. We appreciate the need, as well as the urgency, for reforms, as we've said before. However, we are concerned about the potential for an overutilization of legislation to bring about change, for the following reasons. Every time a law is passed, it restricts, to some extent, our rights and freedom. Once a law is passed, it is often very difficult to modify, as Bill 26 serves to prove. It is even more difficult to have it repealed.

Our society seems to have reached a point where practically every change has to be effected through legislation. There are often other alternatives available through already established mechanisms or organizations to allow for the same changes to be effected. For example, we believe that with clear guidelines, hospital restructuring could undoubtedly be done effectively through the district health councils, in collaboration with the Ministry of Health. This would prevent having to resort to additional legislation to attain the same result.

As a recommendation for this point, we would recommend that where feasible and appropriate, district health councils, in collaboration with the Ministry of Health, be made responsible and accountable for the health services restructuring.

Recommendation 2: that if Bill 26 is deemed to be essential, it be reviewed to determine if it properly addresses the true causes contributing to the need for health reform, and if not, that it be amended accordingly.

The second area of concern is the unqualified sweeping powers and their implications, and the reasons for our concern are as follows:

These provisions provide the potential for the powers to be used beyond their original intent at a later date. It could be by a subsequent government, for example. They provide the potential for the erosion of our democratic system. With all due respect, such unqualified sweeping powers, if legislated, are comparable to the acquisition of a duly signed blank cheque. Existing legislation already provides the Minister of Health with a wide range of authorities and powers which might be adequate to bring about the necessary reforms.

Third, legislative process could be subordinate to the regulation process, and the reason this creates a concern for us is that the regulation-making process is not subject to public debate in the Legislature or in a legislative committee. Regulations should be used only to detail broad powers that are already contained in the statute. Since Bill 26 does not clearly define the broad powers for the proposed Health Services Restructuring Commission, the regulation process could be used to assign new powers to the government.

In order to prevent that, we'd like to offer recommendation 3: that if additional legislative powers are necessary to bring about the required health reform, they be clearly delineated in the legislation.

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Another area of concern is the lack of government liability and accountability towards its electorate. This creates a problem because the provisions dealing with that severely limit the public's ability to question government action and to hold the government accountable, except through the political process. The general absence of opportunities for public consultation or appeal creates undue risks.

The recommendation on that point is that Bill 26 be amended to add provisions for appeal mechanisms.

The fifth area of concern is the potential for duplication, and the reasons for our concern there are that the establishment of the Health Services Restructuring Commission provides the potential for duplication in regard to district health councils, and the assignment of a hospital supervisor who has "the exclusive right to exercise all the powers of the board" provides the potential for duplication in regard to hospitals' boards of directors. This provides the potential for undue additional costs, which goes counter to the very purpose of Bill 26 itself, dealing with fiscal savings, streamlining and efficiency.

We are further concerned about the implications for district health councils for the following reasons: The establishment of a health services restructuring commission could render our health care system more complex and confusing by adding yet another level of bureaucracy. This does not seem to support the purpose of streamlining and efficiency. Further, it creates the potential for undermining the role of district health councils.

We are also concerned about the implications for the duly incorporated local boards of directors, for the following reasons: Bill 26 does not make provisions for public input and consultation. The assignment of a hospital supervisor provides the potential for the erosion or nullification of the authority and autonomy of duly incorporated local boards of directors. This further provides the potential for total lack of local autonomy, authority and accountability of decision-making.

Concerning the last three points, we would like to offer this recommendation: that Bill 26 be amended to eliminate the potential for duplication, the undermining of district health councils, and the erosion or nullification of duly incorporated local boards.

Another area of concern is the extensive use of the term "in the public interest" and lack of public consultation, both taken together. The reason for that is that the term "in the public interest" is not defined; there are no specific criteria for determining what constitutes "public interest."

Bill 26 does not make provisions for public input or consultation. This is not consistent with the Progressive Conservative Party's pre-election position, as stipulated in the document Bringing Common Sense to Health Care dated December 1994, and I quote: "The public should be a key player in determining local community health care priorities." This is also inconsistent with the Progressive Conservative Party's commitment in the document Health Care Bill of Rights, which stipulates the "right to participate in decision-making."

Lack of consultation limits the government's access to valuable input that may identify innovative and viable alternatives that may further improve the system. It also provides the potential for making decisions based on false assumptions.

It provides the potential for unfair and inequitable treatment among the various areas of the province due to lack of knowledge, understanding or consideration of their specific needs and health status as influenced by gender, age, disability, socioeconomic status, geography, culture, ethnicity and language.

It provides the potential for greater resistance to change due to a lack of opportunity to input during the planning process.

We have two recommendations on this point, the first one being that Bill 26 be amended to add the following:

-- A definition of the term "public interest";

-- Criteria for determining what constitutes public interest, including reference to the diversity of Ontario's population as it relates to the varying levels of health status as influenced by gender, age, disability, socioeconomic status, geography, culture, ethnicity and language.

Recommendation 7: that Bill 26 be amended to add provisions for public consultation before major decisions are made.

Our ninth area of concern is the potential for unfair and inequitable treatment.

The first area concerns the establishment of the Health Services Restructuring Commission for the following reasons:

-- Bill 26 does not clearly define criteria with respect to the composition, the mandate, the duties and the duration of the mandate of the proposed commission.

-- This provides the potential also for unfair and inequitable treatment among the various regions of the province due to lack of knowledge, understanding or consideration of the particular needs and differences.

-- Subsection 8(8) provides the potential for unfair and inequitable assignment of duties to members of the commission itself, thereby undermining the role of the remaining members.

-- The potential thus created is also inconsistent with that of a democratic system.

We would like to offer the following recommendation: that, if the establishment of a Health Services Restructuring Commission is deemed to be essential, Bill 26 be amended to add the following provisions:

-- A clear definition of its mandate, duties, powers and accountability;

-- A clear definition of its composition, one that ensures fair and equitable representation for each region;

-- A clear delineation of the duration of its existence to ensure its dissolution once it has accomplished its mandate;

-- The same mandate, duties and powers for all members.

The second area of concern in that respect, where you're talking about establishing independent health facilities, is for the following reasons:

-- Bill 26 does not make provision for public consultation, thereby creating the potential for major changes to be implemented in this respect without public input.

-- The removal of the provision giving preference to non-profits and Canadians provides the potential for serious prejudice against non-profit organizations and Canadians.

-- The proposed clause 5(1)(a), relating to requests for proposals, creates the potential for both unfair and inequitable treatment and for conflicts of interest when proposals are invited.

-- These provisions are inconsistent with that of a democratic system.

We would like to offer the following two recommendations in that respect.

Recommendation 9: that the present provisions, 6(3) and 6(4) of the Independent Health Facilities Act, be retained.

Recommendation 10: that Bill 26 be amended to delete clause 5(1)(a) of the Independent Health Facilities Act.

The third area with respect to inequity etc is that it limits choice for some patients or clients. The reasons for our concern are:

-- Extensive powers are, once again, given to the regulation process, thereby curtailing public discussion and debate.

-- There is no clear definition of the terms "family status," "family unit," "expenses incurred" and the class of patient referred to in section 23, thereby creating the potential for discriminatory practices.

-- These provisions have the potential to be discriminatory by limiting the choice of certain classes of individuals.

-- They also have the potential to ignore or underemphasize important health issues which may also affect drug choice.

The tenth area of concern is unprecedented disclosure of personal information. We are seriously concerned with these provisions for the following reasons:

-- Confidentiality is a most crucial fundamental right.

-- These provisions pose a real threat by providing the potential for serious infringement of clients' rights.

-- These provisions go against the principles of democracy.

-- Quality of care has the potential to be diminished since some clients might withhold some information for fear of its being divulged to some third parties.

-- The mechanism used to collect personal information directly or indirectly, and the purpose of collecting such information, are not defined.

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-- There is no provision to require client consent or to ensure that the information cannot lead to client identification, especially when such information is disclosed.

-- There is no apparent appeal mechanism in situations where confidentiality has apparently been breached.

-- This contradicts the Progressive Conservative Party's commitment expressed in the health care bill of rights, "...right to participate in decision-making regarding one's own health and the right to treatment free of discrimination and which recognizes one's privacy, dignity and individuality."

Recommendation 11: that Bill 26 be amended to provide for the protection of patient-client confidentiality.

Another area of concern for us is the lack of provision for consultation or input of significant partners or key players. As already mentioned, the government can greatly benefit from public input and consultation. This applies equally to significant partners and key players such as the Ontario Pharmacists' Association, the Ontario Medical Association, hospital boards of directors, employees etc.

The next point we'd like to address is physician management distribution. We appreciate the intent of these provisions and we can identify with them, as our centre has been experiencing great difficulties in recruiting physicians for over a year now.

Although we have no concerns about the provisions themselves, we are concerned that they target the symptoms of the problem and not the true causes underlying the problem, as identified by physicians themselves. These include, among others, lack of replacement to allow for time off and lack of access to colleagues to allow for consultation. We believe that, in order to solve the problem on a long-term basis, we must address these causes and find appropriate solutions such as, for example, maybe a travelling team of physicians ready, willing and able to provide replacements from town to town, the use of technology, such as medical imaging, to allow for consultation etc.

We'd like to conclude with the following comments. Within the time constraints, Centre de santé communautaire de Sudbury has reviewed the provisions of Bill 26 relating to health issues. We recognize that some aspects of Bill 26 might be essential to bring about reforms to our health care system. We also appreciate the fact that the government is anxious to attain the goals that it has been elected to accomplish.

We further appreciate that time is of essence and that this decreases the amount of time normally taken at the various phases of the change process. Nevertheless, we are concerned about the potential negative impacts that some provisions of Bill 26 can have on the principles that we have outlined.

We are particularly concerned about those provisions that grant unqualified sweeping powers to the government, coupled with the absence of provisions for public consultations or appeal.

We are also seriously concerned about the implications of the proposed amendments relating to access and disclosure of personal information.

Finally, we're concerned about the potential for unfair and inequitable treatment in a number of areas.

-- We believe that Ontarians have a right to a democratic system;

-- That the government must remain accountable to the public and must ensure that there are mechanisms in place that allow for this to happen on a regular basis;

-- That Ontarians have a right and a responsibility to provide input into the areas that affect their wellbeing;

-- That the government can greatly benefit from public consultation. For example, it can help to identify additional pros and cons and alternatives, some of which might be more easily acceptable, lead to greater improvement and be more efficient and economical;

-- That making a change that is deemed to be in the public interest without consultation may lead to an action based solely on a false assumption.

-- We also believe that what may be in the public interest in one area of the province may be very different in an another, due to geography, socioeconomic factors, cultural and language differences, diversity etc.

We therefore urge the standing committee to seriously consider our recommendations. We do believe that it is possible to bring about reforms that will, on the one hand, provide for a more efficient and affordable health system and on the other hand protect these principles and improve the wellbeing of Ontarians.

Thank you for having provided us with the opportunity to provide input on Bill 26. We take this as a positive sign that the government does in fact value public input.

The Chair: Thank you. You've left the members of this committee with their second consecutive challenge at one quick question each.

Mrs McLeod: Having failed the last time.

Mr Bartolucci: Thank you for your very excellent presentation and recommendations. I kept on thinking about the principles of the Canada Health Act as you were speaking: those of comprehensiveness, universality, accessibility, portability and public administration.

Do you think Bill 26, in its present form, strengthens or erodes the principles of the Canada Health Act?

Ms Denis: In its present form I do believe it has the potential to erode some of those principles.

Mr Bartolucci: Quick enough, Mr Chair?

The Chair: Very good. Thank you, Mr Bartolucci. Congratulations.

Mme Martel : Madame Denis, c'est bien évident que vous-même, et je pense d'autres membres de votre organisation, avez étudié très bien le projet de loi. Vous avez aussi donné des recommandations pour améliorer, si c'est possible, ce projet de loi. Alors, merci pour votre travail.

The one question I wanted to ask has to do with the definition of "public interest." The government wants to give itself some very broad and some very exceptional powers and says it will do all of this in the public interest, which has yet to be defined. At the same time, the government also protects itself from any possible court challenge or legal proceedings while it does all of these things "in the public interest." Can you tell me what confidence you have, then, if the government is trying to protect itself from court proceedings, that what it wants to do will be in fact in the public interest?

Ms Denis: I have a hard time comprehending how public interest can be determined without implicating the very public itself.

Mrs Johns: Thank you very much for the presentation. I especially appreciate both the concerns and the recommendations you have. They're very well laid out.

I wanted to say the government is committed to maintaining the Canada Health Act. We haven't taken a stand like Alberta has at this particular point.

Can you just explain to me a little bit about why you believe in limiting choice of some patients with the Ontario Drug Benefit Act? I was just interested in that section. I never read that out of it. It's on the top of your page 15.

Ms Denis: I have the bill with me. I won't be able to quote by heart, but if you want, we can take the brief back. It does mention that the government can limit drug choices and it does stipulate for certain classes of individuals and it doesn't qualify those certain classes, so the door is wide open. It's a worry because, which classes? For what reasons? We can't weigh if they're good or bad, so it's really a reason for concern.

The Chair: Thank you. We appreciate your being here to make your thoughts known to us.

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SUDBURY AND DISTRICT MEDICAL SOCIETY

The Chair: The next group is the Sudbury and District Medical Society. Good afternoon, doctor, and welcome. Identify yourself and then the floor is yours.

Dr Chris McKibbon: I'm Chris McKibbon, a doctor practising medicine in Sudbury. I was born and raised in northern Ontario and have spent most of my life both growing up and working in northern Ontario. Mr Chairman, I thank you for the opportunity of being here.

Honourable ladies, gentlemen, it's a challenge to be here to attempt to respond to the changes that are envisioned for health care in the Savings and Restructuring Act, Bill 26.

I refer to it as a challenge because the amendments proposed that would affect health care touch virtually every aspect of patient care. The way in which hospitals are run and administered, the medications that are available and how those medications are made available, and the shape of the interaction between an individual patient and his or her physician are all influenced by the package of legislation which is under consideration before this committee.

It is something of a paradox that because the act is so comprehensive it may well ultimately be incomprehensible. To work through the implications of any one of schedules F, G, H or I is in itself a mammoth task. As such, the best that I can do this afternoon is to draw your attention to some of the concerns that prompted our request to appear before your committee this afternoon.

Let me say at the outset that we understand and support the need for a financially responsible and fiscally sustainable health care system. We believe we can no longer mortgage the future in order to pay for the wants, wishes and whimsies of the present. Clearly we need to define what health care is, what it's about, how it should be provided and who should provide it. We thank this government for bringing those concerns to the fore.

Within the Sudbury and District Medical Society we've been saying for years that we cannot have infinite health care with finite dollars. There are certainly ways in which we can do more within the funding envelope the minister has promised. There can be no doubt that there is some waste, that there is duplication within the health care system, but it also needs to be recognized that in health care, as in all other aspects of our life together as a society and as a province, government need not do for people what people can appropriately do for themselves.

This desire to be all things for all people at all times, dressed up under the guise of accessibility and universality, is eventually leading us down a path where our health care system will lose the capacity to respond to the acute and real needs of people that cannot be met by individuals and families themselves.

I recall another revolution where the rallying cry was for free bread, and bread in fact was free, except there was no bread. Here in northern Ontario, we're acutely aware that a magnetic resonance imager is to be free, but there is no MRI. We're acutely aware that the services of an endocrinologist are to be insured and available and accessible, but there is no endocrinologist.

I would like to briefly focus on each of the sections that are under consideration and to share some of our concerns, convictions about their potential and very real problems.

Schedule F deals with those amendments necessary to accomplish a significant restructuring of hospital services. In his address to the committee, the minister quite rightly pointed out that almost 7,000 beds have been closed piecemeal across the province in recent years. Physicians, nurses and the people who work in those hospitals -- administrators, dietary staff, housekeepers -- have in the face of this downsizing provided an increasing quantity, complexity and quality of care of which we can all be proud.

We've reached the point, however, that we can no longer labour under the infrastructure, the bricks and mortar, the competing institutional agendas and the duplicated and triplicated administrative structures that rob the patients of our community of the front-line, hands-on care that they deserve and expect. Like 30 other communities across the province, we are knee-deep in the muck and the mire of hospital restructuring. It's been a difficult and a painful task at times. At times it seemed as though we were knee-deep in the muck, but knee-deep, down face first.

A Health Services Restructuring Commission, functioning in an arm's-length relationship with the minister's office, working cooperatively with district health councils, hospital boards and medical staff, would be a welcome relief. There needs to be a recognition, however, that communities about the business of restructuring can depend and rely on secure commitments for financial support, and the ability of the commission not only to downsize and remove funds but to distribute and reallocate the funding both between hospitals and across communities, if hospital restructuring is to work.

At present, one of the crucial questions to be answered in our experience is the need for a comprehensive, fair and equitable labour adjustment plan for both union and non-union workers alike. We are concerned that in Bill 26, this concern is conspicuous by its absence.

Of even greater concern are the provisions of schedule F which will allow for the revocation, suspension and non-renewal of physicians' hospital privileges where hospitals close or where their mandates are substantially altered. It seems unconscionable to believe that physicians who have served their patients and their communities, some for many years and often at great personal cost, should suddenly be bereft of any right to appeal changes that will dramatically affect their life and their livelihood.

Amendments are urgently needed that would recognize the physician's de facto contract with a hospital, perhaps as it's determined by the period of time served, and provide, if not through the courts then by an alternative dispute resolution mechanism, a means to address and resolve the very real issues that physicians will experience in this situation.

Amendments are further required, as questions of physician supply and distribution prompt consideration of often draconian solutions, that will protect the eligibility of physicians to find opportunities to continue their practice in the communities where they have long served. Such an alternative dispute resolution mechanism might play a very constructive and creative role, not only in mitigating damage but in matching hospital needs and physician services as restructuring proceeds. It would ensure that valuable skills are not lost to the people of Ontario. Victims have a tendency to protect turf and parochial interest in a situation of uncertainty.

I would like to briefly hand the floor over to my colleague, who I'm quite glad has arrived, Dr Jack Hollingsworth, who is the past president of the Sudbury and District Medical Society.

Dr Jack Hollingsworth: I'm glad to see this committee's running exactly on time, just when I got stuck with a sick patient. It would have to happen.

It's indeed an honour to be allowed to present, albeit briefly, to this committee.

Most responsible citizens, and indeed physicians, respect the need for fiscal restraint in the face of a mounting deficit. It is clear that the government of Ontario cannot continue to spend 10% or 20% more than its revenue, and there's a broad sympathy for this government's commitment to live within its means.

The old adage "Don't tax you, don't tax me, tax the man behind the tree," is often changed by special interest groups to say, "Don't cut you or me but the man behind the tree." But this is not the purpose of my presentation.

The physicians of Sudbury have consistently attempted to work with all governments, and most recently this government, in attempting to find creative solutions to often severe health care problems. The Sudbury and District Medical Society has been very active in promoting and assisting in the restructuring of local hospitals because of our understanding of these fiscal realities I just referred to.

The purpose of my presentation is to bring to your attention some points you may not have considered in this legislation, which was drafted without consultation with the medical societies around the province or indeed the Ontario Medical Association. I will direct my comments to schedule G, which refers to pharmacology and drug issues, and I'll try to illustrate to you some potential unintended effects of Schedule G.

Schedule G is a series of amendments to the Ontario Drug Benefit Act, the Prescription Drug Cost Regulation Act to be renamed the Drug Interchangeability and Dispensing Fee Act, and the Regulated Health Professions Act. I'm just going to cover some points which I hope I can make reasonably quickly, and if I go too fast, you could perhaps stop me and ask questions if you like, but I'm going to try to cover several points and give several illustrations of what I'm talking about.

The first thing I want to focus on is the small group in society of about 15% of people who do not have any drug coverage from their workplace and have no insurance provided by their employer. These would include workers at fast-food restaurants who may exemplify the working poor. These people do not qualify for ODB and yet have a low income. Other people in the same category would be uninsured small business people, and this would include many self-employed people. Indeed, it would include many doctors.

Unlike doctors who know about alternative and cheaper therapies and can perhaps bargain with pharmacists, many of this 15% of our general population cannot negotiate and don't have the knowledge to select a cheaper drug or know where the lowest dispensing fee is in any particular city.

Under the current changes in schedule G, pharmacy fees will be deregulated and this may result in two things: either lower fees or higher fees. There's to be no regulation of this as far as I understand. Some of these people will therefore be possibly charged more for dispensing fees, and the groups of people involved in this may be many people laid off under the current realities in the province; in other words, corporate restructuring. This would include the nearly old-aged, the person who is 54 who's been laid off because of corporate restructuring, who's not old enough to be 65 to get an ODB card. You many find that many of these people indeed voted for the Conservative Party in the last election and you may wish to consider this group of people carefully.

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As I go through each point, I'll try to illustrate a potential solution.

Some consideration should be given to expanding ODB coverage on an income-based cost recovery basis. This would work out at about $200 to $800 per year and would allow these people to have some drug coverage.

The second point I want to illustrate for you is government control. While a government system may save many people from hardship and suffering, unfortunately it can never be as efficient as the marketplace in keeping up to date with recent breakthroughs. The current amendments would see the government taking a greater role in establishing eligibility and coverage and establishing clinical guidelines. One problem with government setting clinical criteria is that there is a vast literature to be surveyed. There are about 12,000 medical journals out there and about 10,000 new articles per week, so best of luck if you're going to take over the drug regulation industry.

My solution to this would be to allow exemptions, to allow physicians to prescribe some unlisted drugs and some indications you don't already have covered, or to perhaps employ expert physicians in each specialty to umpire requests. You already have a mechanism, special authorization forms, which have been around for several years, but actually it would become a lot more stringent, as far as I can understand.

One example of this government control where you really can't keep up to date is a bug that causes ulcers, called H-Pylori. As of yet, the Ministry of Health seems unaware of this, even though they've been told many times, by me, physicians around the province, Ted Boadway at the OMA, many people, that to treat this bug we need to use certain drugs such as Losec and Prevacid. The only indication the ministry allows is for a severe reflux disease or hiatus hernia problems. So we have to regularly lie on your special authorization forms. It doesn't come easy to us, but we do it.

Another example where you're perhaps going wrong in going to cheaper drugs is only allowing drugs to be given three times a day, for example, the older drugs, whereas once-a-day dosing is quite possible. This is particularly important where you've got a young family with two parents working and Johnny goes to school and no one's there to give him his medication, or you've got an elderly person in a nursing home and the nurse has to make four trips a day instead of one. You don't really save any money.

My solution to that would again be to allow some exemptions and to listen to the physicians.

Issues of confidentiality have already been covered. I won't dwell on this -- you've already been hammered quite hard on this -- but there is a specific point I want to make, that some of these amendments under schedule G will allow you access to College of Physicians and Surgeons of Ontario information on physician prescribing and ODB information from the computerized network.

Under the amended version of section 13 of the ODB Act, government will have further discretionary authority to "collect, directly or indirectly, use or disclose personal information for purposes related to the administration of this act or for other purposes prescribed by the regulations." This would mean that the minister could impose penalties or sanctions to physicians who do not prescribe according to your clinical criteria. I've already stated that your clinical criteria may rapidly become outdated.

My solution to this problem is not to gather information you don't need and don't intrude into physicians' offices or practices, and don't fall into the trap of blaming all ills on physicians.

I want to briefly cover two other points, if I can have two or three more minutes.

Drug substitution is another issue that's quite important. I did bring some information for those of you who are interested afterwards. The current amendments make no allowance for instructions by physicians for selected patients to have proprietary, brand-name medications with "no substitution." If write a scrip for you and put "no substitution," then it cannot be substituted. But the current amendments won't allow for that. The problem with this is that there have been serious drug interactions when patients have been denied their proprietary, brand-name medications. Some of these have involved cardiac and respiratory drugs and some have been quite severe. Under the proposed amendments, patients affected by these interactions would not be entitled to receive coverage for their proprietary, brand-name drug.

My solution for this is to continue to allow no substitution for selected patients.

I have several other issues that are perhaps going to take more time than is allowed. I'm trying to run through this fairly quickly.

Part of the solution to your problem may be to look more closely at drug utilization review, which is the concept of looking at the usage of medications on a community basis. This may be a solution to some of your problems. We know that for every $1 spent on that, you can save $20. So there's some role for drug utilization review, preferably at arm's length from the government. If it's driven by only cost containment, it will not be as helpful as if it was driven by improving patient care.

The final point I wanted to make was the effect of formularies on physicians and patients. In many areas, there are four or five formularies. If you're a physician in Kitchener-Waterloo, you've got to deal with Manulife, Mutual, The Co-operators and the ODB. Some of these will change; some will be frozen at particular times. Physicians become confused as to which drugs a particular patient is allowed to get. You should try to encourage some consistency between public and private plans. This has been recommended in the past by the Ontario Pharmacists' Association and the OMA.

In closing, I would ask that the Common Sense Revolution be applied to health care as much as possible, that you try to get away from central planning and government bureaucracy. We need to allow physicians to prescribe drugs in a cost-effective way, with allegiance to patient care. We mustn't just use cost containment as the only measure of success.

I'd like to thank you very much for your time. I don't think we'll have time for questions. I'll pass the floor off to Dr McKibbon.

Dr McKibbon: Thanks, Jack. Schedules F and G, the formation of the Provincial Health Services Restructuring Commission, deals with the need for an institution to deal with other institutions. The institution of the Ministry of Health quite properly exercises its authority over the management of other institutions and industries under its umbrella. Problems arise, however, when institutions attempt to interpose themselves and interfere with relationships between individuals, and it is precisely this problem that comes to the fore when we consider schedule H of the Savings and Restructuring Act.

In his address to this committee, the minister made the assumptions underlying this section of the legislation clear. "Physicians," he said, "act as the gatekeeper to the health care system. This role brings with it serious responsibilities not just to the individual...but to the strength and viability of the health care system itself."

What is wrong with this? It seems in many ways very sensible. Well, ladies and gentlemen, what is wrong here is that it places the state, the ministry and its bureaucracy, on equal footing, having the same rights, as the patients seeking care. This conscription to dual responsibility and the odious measures contained within this act to enforce compliance, coupled with the complete absence of any alternative to state-run medicine, is objectionable in the extreme.

I want you to know, ladies and gentlemen, and to remember, if you remember nothing else from our presentation here this afternoon, that we are not gatekeepers, bureaucrats or bean counters; we are doctors. When I close the door to my consulting room, when I stand at the bedside of a sick patient, when I sit with the family of a terminally ill person and struggle with them and their family to determine the next and best course of care for that individual, there must be no question of divided loyalty. Whether it is in ordering a test or seeking the opinion of another colleague to clarify a patient's problems, there must be no doubt, in my mind or in the minds of patients, who is being served. Medical decisions must be made, because of the application of a physician's training, experience and commitment, that are unreservedly committed and confidently received to the service of one single goal: the best interests of the patient.

The minister states reassuringly that the necessary authorities of schedule F will be tested against the criteria of the public interest; institutions are necessary to deal with institutions. But as a physician and as a patient, I do not have the luxury of divided loyalty. I must make decisions based not on personal interest, not on public interest but on patient interest.

As legislators, it's your responsibility to encourage, facilitate and to resist any attempt or authority that compromises this fundamental principle that lies at the heart of the privileged relationship between a patient and his or her physician. It's at the heart's centre of all understandings of the ethical, moral and effective practice of medicine.

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What follows from this is the need for amendments which apply this principle to the proposed legislation. Sections of the act which propose that doctors will be liable for the cost of investigations, referrals or treatments later determined to be medically unnecessary -- a term as yet to be defined -- must be removed in their entirety. It is impossible to practise medicine in an environment where decisions made in good faith can be second-guessed. These proposals will cripple medical decision-making and further an atmosphere where defensive medicine becomes the prominent concern and which fails to serve patients well.

Amendments are further required which will specify the situation in which a review of practice is required. What is objectionable and requires further attention is the appearance and very real possibility of an unwarranted and arbitrary set of actions driven by debt reduction and book-balancing rather than by the need to ensure quality and responsible patient care.

Amendments are further required which specify the time of practice, the duration of practice, that is subject to review. Will the review look at two years, one year, three months, one month of medical practice? Clearly, a prolonged period of eligibility for review, potentially occurring long after particular services are provided, is by its very nature punitive. A defined period of eligibility, the results of which are removed, in their first instance at least, from financial penalty, offers the opportunity to improve and enhance medical practice rather than to second-guess it and destroy it.

We share the minister's concern that scarce financial resources must be directed to the provision of front-line, hands-on medical care. Amendments are required which limit the growth of the government bureaucracy that is implicit in the provision of powers to appoint inspectors to facilitate schedule H.

We welcome this government's commitment to achieve control of the size of government bureaucracy and its conviction that the people are best served by less government, not by more. We are concerned, however, that the provisions of schedule H envision a veritable army of bureaucrats that will cost the taxpayers of this province dearly and will divert the resources that we agree are needed for patient care in a wasteful witchhunt.

One of the most interesting articles in recent years appeared in the American Journal of Medicine early last year. It was an analysis of the rising costs of medical care in the United States, attempting to determine where the money was being spent. It graphically contrasted the rising cost of medical bureaucracy against the commitment of funds for direct patient care. Expenditures on patient care were either flat-lined or falling, but the cost commitments to administration and bureaucratic control rose progressively. We must reverse and not reproduce this American experience.

The question of physician payment is the subject of much of schedule H, and I want to remind the committee that in recent years the physicians of this province have provided somewhere between $300 million and $400 million in medical services for which they received no compensation. This was provided in a health care system which the minister referred to in the closing paragraph of his remarks to this committee as the best health care system in the world. Mrs McLeod, Ms Lankin, you also have referred to this province's health care in the same sense. These comments have been echoed by physicians, by patients, by politicians both inside and outside the Legislature. We agree, and we agree unreservedly. The problem is not the quality of care. The problem is that we cannot afford it.

Is there anything right in this legislative proposal? Well, there are the seeds of an honest recognition that we cannot go on as we are, that radical change is necessary. This lies behind the minister's desire for the authority to unilaterally set fees, determine what are to be considered insured services, and raise questions concerning medical necessity. In many ways these are the right questions to ask.

However, the answers ought not to be provided by legislative fiat that gives the ministry bureaucracy an unprecedented power and unbridled authority to shape the direction of health care. What is necessary is a wide-ranging, urgent public discussion aimed at shaping the boundaries of accessibility.

The federal Minister of Health has demonstrated herself incapable of giving leadership in this vital area, continuing only to write cheques with promises that her treasury cannot cash, when what is needed is a radical reconsideration of what the Canada Health Act not only says but what it must mean in the day-to-day provision of health care in our province.

Those of you who are opposition members of this committee have heard your leaders and colleagues call for this legislation to be broken up, to allow for the legislative and public discussion and debate necessary to determine what services will be provided, by whom, where, at what cost and who will pay. Certainly, the dialogue is urgent. The fiscal realities are pressing. We support, with amendment, the need to restructure our hospital sector. There has been a wide-ranging discussion in many communities throughout the province, and that discussion will continue in still other communities. We need to get on with the job.

This, after all, is where we spend the largest share of money in the health care pie, and pharmaceutical costs represent probably the fastest-growing item in the health care budget. Clearly, there needs to be an opportunity for innovative control here. We need to get on with reshaping these vital areas now. But let's not miss the opportunity to involve the people of the province in the dialogue which is necessary to begin the revolution they voted for on June 8.

I would urge you to withdraw schedule H in its entirety, not because it affects me but because the people of Ontario must have an opportunity to engage in an urgent dialogue about the direction of health care in our province as it affects the personal, privileged relationship between the physician and patient.

Mr Chairman, my apologies that I don't have the typewritten text of my remarks here this afternoon. I'll fax them to you and make them available to your committee in the morning. I'd be pleased to answer, with my colleague, any questions I may have provoked.

The Chair: We have our third consecutive challenge; it's getting tougher all the time. We've got about a minute per party, one quick question.

Ms Lankin: Thank you, Dr McKibbon and Dr Hollingsworth. Your presentation was helpful and there was a very measured and constructive tone to the suggestions that you've made and to the criticisms you've made.

I was particularly struck by your use of the term "conscription to dual responsibility." It really captured for me what you were intending and it helped me understand that very clearly.

The government says both with respect to confidentiality but also with respect to transferring the decision-making about review of medical necessity of treatment that's been provided to the general manager of OHIP as opposed to a review by the Medical Review Committee, that that's to follow up on fraud and inappropriate billings etc.

One, I'm concerned about the nature of powers that are being given to follow up on a problem which I still believe is a very small rate of occurrence in our health care system, physician billing fraud. I think we would all admit it does occur, but I think it's a very small problem. How do you feel, as a doctor, about having somebody in the Ministry of Health who is neither a physician nor a professional peer of yours making decisions retrospectively, I guess, about what has been medically necessary treatment that you have prescribed for your patients?

Dr McKibbon: I think that what you raise is the question of what is medically necessary and who is in the best situation, by training, by talent and by commitment, to make those determinations. I do not believe there presently exists a mechanism in order to do this for the purpose of the recovery of moneys. And you have to be sure and clear that the intention of this act, a savings act, is about the recovery of moneys. So I would appeal that we need some definition to the question of medical necessity. We need to be quite clear. And this is not something that Dr Hollingsworth and I can give you an answer to, nor is it something that you will likely come up with.

Basically, what we can tell you is that as a people, as a community of communities in this province, we need to be about the business of defining and determining what is medically necessary. Otherwise, we're left with what is very arbitrary.

Mrs Ecker: Thank you very much for an excellent presentation. I appreciate your advocacy on behalf of your patients and the system.

A quick question of clarification. I thought, Dr Hollingsworth, you were talking about how you thought drug utilization review was a good thing to do, but I wasn't clear. At the same time, you seemed to be saying that the information sharing, the access to information that is needed to do the clinical guidelines and to measure the outcome of the clinical guidelines and how well it's working -- you were questioning our ability to access that information. I just wanted to clarify; I wasn't sure if I understood that's what you were saying.

Dr Hollingsworth: You've got a good question there. Drug utilization review is useful on a community-wide basis, and that's generally accepted by most people. The problem is when you get down to the individual patient and individual physician and you become quite intrusive in the physician-patient relationship.

But if you look at how much Losec we're using, how much Zantac we're using, how much of any drug you'd like to name, that's an important question. How much codeine are we using in Ontario? Do we need to use as much? These are important questions to ask. But to ask, should Dr McKibbon be using a certain type of arthritic pill or not is a bit more intrusive and I think less valuable to society. That's the point I was making.

The other point is the health care network, the ODB network. There have been a lot of problems with confidentiality. The information the pharmacist gets, as far as I know, is very limited in its usefulness, for confidentiality reasons.

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Mrs McLeod: As you're undoubtedly aware, in schedule H when it comes to determination of "medically necessary," it sets out a new framework of "prescribed medically necessary...under such conditions and limitations as may be prescribed." The old act would have a definition of "medically necessary" determined. It would be "all services rendered by physicians that are medically necessary," and where there is any dispute about that, it would have been determined by the Medical Review Committee. I think that the old act is consistent with the Canada Health Act, which defines "insured services" to include, among other things, physicians' services, and that means "any medically insured services rendered by medical practitioners."

To make it a direct question, do you believe the dialogue that you've said needs to take place, and I agree, in terms of defining the boundaries of medical accessibility and therefore the boundaries of our publicly available health system can take place still within the framework of a Canada Health Act definition of services to patients being those rendered by physicians? Secondly, do you think that, before we get into a discussion of dialogue that is premised on rationing, there is more work to be done in terms of clinical evidence of effective treatment that can be shared, not for the purpose of recovering funds but for informing good clinical practice?

Dr McKibbon: On the question of the development of ongoing clinical evidence, one of the first rules in the courtroom of medicine is that the evidence is never always in. We can't wait forever for evidence to begin to practise medicine. One of the first things you learn in medicine is that you need to be able to function in a situation of ambiguity, so I would not wait for crystal clarity before we engage in the debate.

The question of medically necessary services being those services which are provided by a physician raises the question of who will provide medical care, and I hope that I'm hearing your question correctly. I think this is an important question. I think that the people of the province of Ontario and the nation have generally felt well served, both by physicians and by other people within the health care system.

The question of whether we can broaden who is providing insured coverage is again something that we need to talk about, something that we need to dialogue about, because the answer may be very different in Hornepayne than it is in Hamilton. It might be very different in Attawapiskat than it is in Windsor.

The Chair: Okay, doctor, I'm going to have to cut you off on that. I've been a little generous with the time anyway. We do appreciate your time. I'm glad that Dr Jack had an opportunity to join us. We appreciate your interest in our process and being here this afternoon.

Ms Lankin: Mr Chair, I'd like to table a question, if I might, at this time. I had hoped to be able to follow up on this with the representatives of the medical society but because of the shortness of time I couldn't.

This morning, in response to a presentation by the ACCESS AIDS Committee of Sudbury, Ms Johns made a statement informing them that they should not be concerned about the changes in who was going to be judging or determining medical necessity. In the process of providing that response to them, she suggested that the job of the tariff committee of the OMA was to assess and determine medical necessity and that they would in fact continue in that role, so that the people who had raised the concern should not be concerned.

This is very big news to me, that the tariff committee of the OMA is responsible for determination of medical necessity. In fact, I think it was misinformation that was provided. But I would like to table a question directly to ask if that is the ministry's intent in the future or if something has changed in the recent past that would have provided that responsibility to the medical tariff committee of the OMA.

Mrs McLeod: Mr Chairman, I also have a question to table for the Ministry of Health staff, following again on this discussion and assuming that section H is not about to be struck through a government amendment process, although it seemed like a highly desirable suggestion.

I would like to know from the Ministry of Health staff whether or not they believe that under section 1 of schedule H, which prescribes conditions and limitations, there can be any regulations made which would not be in contravention of the present definitions under the Canada Health Act of "medically necessary."

REGISTERED NURSES' ASSOCIATION OF ONTARIO

The Chair: Our next presenter is Vickie Kaminski, the president of the Registered Nurses' Association of Ontario. Welcome to our committee. You have a half-hour of our time. Questions, should you allow time for them, will begin with the government. The floor is yours.

Mrs Vickie Kaminski: Thank you very much. It is indeed a pleasure to be able to address a provincial committee in Sudbury for a change instead of having to travel to Toronto. I don't have a handout for you. The Toronto office decided it would be foolish to courier it to Sudbury to give to you to have to carry back. It will be available to you in Toronto when you get back, which will cover this. But I'm confident that my presentation will be memorable and captivating and you won't feel deprived of not having notes in front of you.

The Registered Nurses' Association of Ontario, just for background, is a professional nursing association that represents a network of about 13,000 nurses across the province of Ontario who work in a variety of settings throughout the health care system. One of RNAO's main goals is to help empower the people of Ontario to achieve and maintain optimal health and promote healthy public policy in doing that. We're very pleased to be able to be here today, and I will attempt to be brief so there is time for questions should you have any.

We are very concerned that the health components of this bill do not represent true health care reform but are instead a fiscal attempt to introduce restraint and control into a health care system that's already fragmented and will continue that fragmentation unless there is some revision to the bill as it stands.

Our system is definitely in need of reform, and reform in the health system is something that RNAO has gone on record in the past and still believes in, through the past two government and again with this government. We're very happy to be able to work with you in reform in a very much-needed environment.

However, the proposals in Bill 26 are a reflection we believe of what happens when a fiscal agenda attempts to define health care reform. Fiscal constraint is not appropriate as the sole rationale on which to base reforms. I would like first to comment generally on the implications of this type of legislative package and then move to more specific comments on some of the content.

In December 1994 Premier Harris indicated an important government direction in Bringing Common Sense to Health Care. He promised "to empower the consumers of the health care system with the rights to proper care and to participate in decisions regarding that care." This government gave a commitment to public input in the determination of programs and services for each community, and I recognize that this kind of consultation is part of that commitment.

However, we believe that it is not enough and that public input has been noticeably absent in the introduction of this bill. The initial push to pass the bill through without the opportunity for debate and the difficulty experienced by many members of the public to access hearings such as this are but two manifestations of this problem. We are very concerned at this disregard of critical public debate on issues affecting all Ontario citizens. This bill has compromised partnerships and trust built over time between the governments and the public.

Therefore, RNAO strongly recommends that the government consider dividing this act into smaller acts, thereby permitting more discussion. This allows the government to fulfil its promise by allowing more opportunity for public participation in these critical health care issues.

Turning to the specifics of the proposed legislation, there are many components that fundamentally challenge our health care system, and that's good. Some of the principles, however, of the Canada Health Act will be seriously jeopardized, and that we believe to be a situation of grave concern to everyone.

In our presentation today, I will discuss areas of general concern that pertain mainly to schedules F, G and H, and I will go through them as quickly as I can, with the recognition that there will be some additional comments that I won't be making today that will appear in our written brief. Specifically around some of the health human resource planning issues, we will touch on them but I would invite you, after you've read the brief, if you have questions, to be in touch, since we won't be going into it in detail today. Indeed I was challenged last evening by my colleague Dr McKibbon to come today and have the nerve to say that physicians should go on salary and expect to leave the room alive. I think he will be pleased with what we have to say as we move into that portion.

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First of all, we recognize and applaud the government's efforts to introduce more quality assurance measures into health care provision; for example, an investigator assigned to review the quality of a hospital's administration, management and patient care will now potentially have greater ability to determine the presence of organizational impediments to achieving good client care. We believe this carries significant potential to address some of the care problems that may be beyond the power of individual practitioners to resolve.

Many of our members have witnessed difficulties in delivering optimum care because of inadequate or inappropriate staffing, resulting, for example, from restructuring efforts. We are relieved that there will be entrenched recognition of the accountability of organizations for quality care. However, we do have some concerns about the actual changes in ensuring improved care, since there is very little recourse for appeal or consultation prior to that decision-making.

Generally, the increase in ministerial powers is evident in many of the proposed changes. The minister is empowered to reduce, suspend, withhold or terminate services or funding and accept or reject proposals for the establishment of facilities and services with little or no appeal by the public. There is little, if any, definition of these powers, how these powers will be exercised or their extent and duration. This much power cannot afford an ambiguous definition.

Therefore, RNAO recommends that the minister's power be defined and the terms and conditions be clearly articulated to avoid any ambiguity as we move through this process. Furthermore, we urge the introduction of a sunset clause, to ensure that these powers are appropriately limited.

We detect a general tendency in the proposed extended powers to move the government into a more micro-management role in some aspects of clinical decision-making. We believe that the government's energies are better spent in designing, supporting, coordinating and funding a comprehensive health care system.

This is certainly a critical government role in assisting and guiding the public and providers to determine an appropriate health service for each community. However, we are most concerned that in its efforts to cut costs, avoid duplication and increase efficiency, the government is forgetting some of the important elements of the change process, such as appropriate consultation. Therefore, RNAO recommends that the government continue to consult with the public and health provider groups in its health care reform agenda.

According to current legislation, the minister has the power to determine fraud and to investigate fraud. These powers already have implications for compromising privacy or confidentiality to records. Health and patient records are highly confidential and access should ideally be restricted to the client, the health care provider and, when necessary, a specified or regulated reviewer such as an OHIP investigator. However, Bill 26 contains provisions that will allow the government unprecedented access to personal information.

While RNAO does not dispute the government's right to investigate fraud within the system, we believe these increased powers of access and disclosure are unnecessary, given what we believe to be the advent of fraud. Going back to a question posed earlier by Frances Lankin, does fraud happen that often? Do you need this kind of sweeping power to investigate that sort of situation? We believe you don't.

The opportunities for unnecessary breaches of confidentiality are enhanced when more individuals have access to confidential information and data. Furthermore, the government's freedom to disclose information with any party it chooses is troubling because of the potential loss of control to organizations that may be beyond Canadian governance. We have seen that across Canada in other jurisdictions already.

RNAO recommends that appropriate criteria, therefore, for accessing patient records and health information be clearly delineated and strictly enforced. There must also be consistency with the Freedom of Information and Protection of Privacy Act. We further recommend that whenever the government deals with external agencies or organizations, there exist clear criteria regarding the control and protection of that confidential information, so that we don't see lists of patients' names, for example, being sold to outside agencies or to foreign companies outside Canada.

In several sections of this bill, the government or its delegates are protected from liability. Again, in Bringing Common Sense to Health Care, it's emphasized that there is an importance of accountability at all levels of the health care system. RNAO considers the government an integral and vital link in the health care system. It is responsible for setting policy, funding, articulating of vision, and coordinating an integrated and comprehensive system. Just as all health care providers are accountable in this system, so too should the government be accountable for its actions. We have great difficulty in accepting this double standard being proposed by the government.

We recommend, therefore, that as an integral link in the health care system, the government must be held accountable for its actions, and we suggest that the way to do this is through criteria and guidelines for some of the minister's intended actions, that they be made clear to avoid ambiguity and chance for error.

In a related accountability issue, this bill provides for unprecedented ministerial power but lacks a corresponding set of appeal mechanisms by the public. Where appeal mechanisms do exist, there is often a financial charge in order to lodge an appeal. This prohibits, or restricts at least, those unable to pay from being able to appeal. That, we think, is a fundamentally undemocratic process.

Therefore, we would recommend that in the interest of the public good, alternative mechanisms must be instituted to facilitate an appeal process.

On the issue of restructuring, we read with interest what the act was proposing. The Ministry of Health Act allows for the establishment of a province-wide Health Services Restructuring Commission to carry out duties assigned by the minister. While the commission's role is to facilitate and accelerate the implementation of hospital restructuring, it appears only to address the restructuring of the hospital sector. Reform that addresses only one piece of the system will encourage a fragmented rather than a more integrated system in health.

We recommend, then, that the role, mandate and terms of reference of the restructuring commission, again, be clearly articulated to take other sectors into consideration and to avoid public confusion and critical gaps in care being created or exacerbated.

We are concerned about the possibility of service gaps that will compromise the health of Ontario's citizens. The expressed intent to accelerate the process alarms us. While we do believe that hospital reform and restructuring are necessary and we're happy to participate in those discussions, we believe that the changes in hospital services are both the cause and the result of changes in community service and medical practice. Recent trends in health service clearly indicate that community support services must be available, and in sufficient quantity, to support hospital restructuring.

For example, with reduced lengths of stay in hospitals, there is an increased need for home support nursing services for the medically complex patient. The increased use of ambulatory care centres increases the need for accurate assessment both pre-admission and pre-discharge. To restructure hospitals to move in these two directions without having the community supports in place will cause the restructured hospital to be inappropriate in its dealings with patients and will provide less than appropriate care for people as they move through the system.

That's not to say that we should not be restructuring or reforming hospitals. We should, and indeed we must, carry on with the work that's been started in communities like Sudbury and in fact across the province. But we must also do that looking at the community piece and keeping that as important and as front and centre as some of the big-bang hospital restructuring seems to be.

The trends to deinstitutionalize patients in order to care for them in the home and the use of more volunteer labour must be addressed at the same time as province-wide hospital restructuring begins. This dependency on volunteers requires a more flexible, educated and knowledgeable workforce that can quickly assess changing circumstances in a client population. If these service gaps, again, are not addressed up front, we believe that there will be more suffering experienced and more money eventually spent dealing with complications arising from inadequate care.

We recommend, therefore, that changes in non-hospital sectors such as long-term care must not only be identified but that strategies for implementation must be articulated and resources must be committed to these activities in advance of implementing any system-wide hospital restructuring program, or at least at the same time.

The restructuring commission is set to commence work as soon as the bill is passed. However, restructuring has occurred at different rates in all regions across this province.

Again to quote the document Bringing Common Sense to Health Care, the public is identified as "key players in determining local community health care priorities." We agree that there must be an opportunity for each community to discuss and articulate its needs for successful province-wide restructuring to occur. We believe the current district health council structure enables this type of public participation to occur and should not be ignored in this process.

We therefore recommend that the commission strengthen and work with the existing district health councils to allow for planning and decisions about regional health service needs that are sensitive to the community differences that only health councils are in a position to articulate.

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The proposed legislation states that commission members from the health sector, business and broader community are to be appointed by the ministry. We would like to urge that you ensure that the health sector representatives have nursing representation on this commission. Nurses are active participants across the entire spectrum of health promotion and care provision. This breadth and depth of experience is critical to any comprehensive health care planning and restructuring.

The proposed legislation contains frequent use of the expression "public interest." The minister is given power to reduce, spend, withhold or terminate funding to a hospital if it's in the public's interest. While we commend the government's intention to determine services and funding in consideration of the public's welfare, the concept is not well defined in the bill. Who determines what's in the public's interest? Whose value system defines those criteria?

"Public interest" is also inconsistently applied throughout the bill's terms. While it is used extensively in the Public Hospitals Act to rationalize the minister's powers to intervene, it is conspicuously absent in the Independent Health Facilities Act. For example, while RNAO recognizes that public interest is a changing reality that depends on specific community values, there must be province-wide consistency in the appropriate consideration of public interest.

We would recommend that "public interest," again, be clearly defined and that there be consistently applied rationale underlying all of the health care reform.

As we move into the issue of privatization, again we would like to make the following presentation.

The amendments to the Independent Health Facilities Act may well challenge our universal, accessible, publicly administered health care system in Ontario by creating an environment that allows for more privatization. Proposed amendments in section 7 repeal the language that directs the minister to give preference for non-profit facilities and protection of priority to Canadian-based proposals, which will encourage, we think, proposals from for-profit, non-Canadian organizations. Although this may signify the government's receptivity to foreign firms entering the Canadian health care market, we are doubtful that the majority of Ontario residents would share this view.

These amendments increase the opportunity for conflict of interest and enhance the potential of a two-tiered health system emerging in our province. Proponents of the two-tiered health system argue that those who are willing and able to pay for service should be allowed this choice. However, there are considerable data indicating that a two-tiered health system is not only more costly in the long run, but also leaves millions of citizens without equal access to service. RNAO believes strongly in preserving the tenets of the Canada Health Act and the Canadian health care system, and accessibility is one of those main foundations.

We would recommend clear direction, guidelines and controls to ensure non-Canadian corporations and organizations, if they are invited to enter Canada and Ontario for the purpose of health care delivery, meet the standards integral to the Canadian health care system; and that mechanisms such as quality assurance controls be an essential aspect of any contract we may enter into as a province with these agents.

With user fees and insured services, again, under the Drug Benefit Act, what's being proposed, we would express to the government, is fundamentally the introduction of user fees and is contrary to election promises made in relation to health care. These fees have severe ramifications for social assistance recipients and seniors receiving guaranteed income supplement, who will now be required to pay an annual deductible fee and all dispensing fees. We are in effect punishing the elderly and disadvantaged for being ill and old or disadvantaged. Furthermore, the human costs of this policy will be tremendous for children and families.

User fees and copayments will not reduce the need for prescription drugs, but they will reduce the number of prescriptions that are filled. We believe that when confronted with these extra charges, many individuals will be forced to choose between food or medication.

We are convinced that instead of saving money, this particular approach will result in greater expenditure. The complications and side-effects suffered by those unable to afford needed medication will be even more expensive to treat.

The issue of drug use needs to be addressed in a way that does not disadvantage the elderly or those on social assistance.

We recommend, therefore, that the government address the issue of a proper drug utilization program as opposed to charging user fees; and that this be the solution to deal with the rising costs of the drug plan.

In this proposed legislation, the government will no longer pay the difference between what it considers interchangeable products, even if the prescription calls for no substitution. This means that if the individual requires a specific drug no longer paid for by the plan, he or she will have to pay the difference.

While we agree with the principle of interchangeability, in practice this is not always feasible. I'm sure you've heard that articulated earlier in your hearings. A cheaper drug may not be a feasible alternative for all individuals, so we would encourage you to allow for individual need and difference to be considered in the development of drug policies.

We would recommend that you consider alternatives to the generic approach, such as the BC drug plan, which considers not only generic substitution but does have provision for therapeutic substitution and has been somewhat effective in bringing drug costs back into line.

Within the Health Insurance Act changes, the minister is now able to determine unnecessary insured services. This means services could be removed from the OHIP schedule of benefits at the minister's discretion and, more importantly, without consultation.

This has significant implications, we think, for the health status of Ontario residents. Those who can afford it will be able to obtain delisted services. Furthermore, this government promised Ontario citizens that OHIP decisions would not be made behind closed doors and would become public input, debatable issues. We are concerned that the government is taking a path that would inhibit what it's promised: public input.

We would recommend that any changes to insured OHIP services and benefits, while they may be necessary, should be made in consultation with the health care providers and the public.

Pay equity is an important issue and it's again raised in Bill 26. The proposed amendments to this act remove the proxy method of comparison in determining pay equity in January of 1997. This provision was added to achieve pay equity for female workers in the broader public sector who were denied pay equity because there were no male comparators in the workplace. The elimination of this proxy indicates a lack of understanding or recognition of the relationship between income level and health status. Poverty and unemployment have considerable impact on illness and subsequent need for care. The largest bulk of people working in low-paid jobs are female. Pay equity is an attempt to redress this.

Since recent evidence suggests that poverty and unemployment are on the increase, we are very concerned that this policy change may be even more costly, again in human and financial terms, to the women in Ontario.

We therefore recommend a continuation of the pay equity amendment for those women who experience systematic discrimination.

Health human resource planning is indeed an important issue. The issue of supply, demand and distribution of health care providers is the subject of many, many committees. The nursing profession is quite familiar with fluctuations, especially in the need for nurses. Many of our 1995 graduates from the schools of nursing, prepared at taxpayers' expense, are currently not being utilized. The proposed province-wide hospital restructuring signifies significant staff layoffs, not only of nurses but of other health care providers. As it stands, our system is currently preparing health care practitioners and then either not employing them or limiting their ability to practise fully, and this is not an efficient system.

Long-range health human resource planning must be a part of the larger picture of health care reform. This kind of planning considers present and future health human resource requirements and uses health care needs as the starting point. Once these needs and goals are identified, issues such as education and distribution can be appropriately dealt with.

We recommend, therefore, that system-wide, comprehensive and integrated health human resource planning be initiated.

Relatedly, it is logical that practitioners practise according to their full scope. One notable example of underutilization is the nurse practitioner. Freeing the nurse practitioner to provide care according to their full scope and ability allows the medical practitioner to attend to more complicated medical problems. The public can only win in a situation in which the appropriate provider is able to give the care he or she has the skill and expertise to provide.

On the issue of physician manpower, we believe it cannot be ignored. We must look at how many physicians we are preparing and how many people have guaranteed employment while underserviced parts of the province continue to go without what's considered medically necessary.

We believe strongly that alternative payment mechanisms must be pursued for physicians. We believe that simply staying with fee-for-service is not an appropriate way to service the needs of the residents of Ontario across this province.

We also believe, however, that simply putting physicians on salary is not the answer. It is a very complex problem. Taking one, simple swipe of the pen and changing how physicians are paid will not go very far to redress some of the fundamental issues we have heard and have expert advice on as we move through underserviced areas.

We would encourage the government, therefore, to set up a consultation to look at what needs to be done to encourage alternative forms of payment for physicians that look at blended funding systems and that will help to achieve more even distribution of the care across the province.

In conclusion, thank you again for the opportunity, and I would be pleased to answer any questions, if I may.

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The Chair: You've done a masterful job of using up your time, unfortunately, so there's no time for questions. But we do thank you for your interest and for your presentation this afternoon. Good afternoon.

Mrs McLeod: Mr Chairman, may I table a follow-up question to the Ministry of Health? It relates to schedule H, section 35, which would allow hospitals to charge insured persons for providing an insured service who are permitted to do so by regulation. Again, I would understand that any regulation under that would be currently in contravention of the Canada Health Act. I'd like the Ministry of Health's opinion as to whether any regulations could be made under that section of the act that would not contravene the Canada Health Act.

N'SWAKAMOK NATIVE FRIENDSHIP CENTRE

The Chair: The next group is the N'Swakamok Native Friendship Centre. Welcome to our committee. We have Pat Rogerson. You have half an hour to use as you see fit. The floor is yours.

Ms Pat Rogerson: Thank you very much. I'd like to open my presentation by thanking you for this opportunity to present on behalf of the N'Swakamok Native Friendship Centre's concerns for the upcoming omnibus legislation, or Bill 26, as it pertains to health issues.

We would like to take this opportunity to recognize the role played by hospitals and health professionals in the treatment of disease and trauma in Ontario. Sometimes we forget that people are here trying to make a workable system work and we can sometimes lose sight and try to make people good guys and bad guys.

We would also encourage the recognition of the need for universally accessible health care for residents of this province without regard for individual ability to pay.

Most important is to note that both Ralph Nader and President Clinton reviewed Canada's health care system and found it compared very favourably on a cost for quality and quantity of service basis. In fact, the cost was considerably better than the costs found on the open market, especially due, they felt, to the efficiency of the administration processes. I'd like you all to keep that in mind when you're looking at health care changes.

Finally, the quality and the standards for service must not be jeopardized.

So what do we have here? We have a quality service provided by a variety of contractors whom we presently call physicians and public corporations we presently call hospitals, who deliver a universally accessible service at better than market value, and a province that feels it cannot continue to accommodate the costs of the health care system.

Decisions have to be made and plans have to be developed and implemented. This brings us to the impasse of today.

The environment as we know it is rapidly changing. Economically, sociologically, people and communities are facing rapid change fuelled by technology and science. In a time of change people often feel a sense of chaos and hope that increased power or control can be the answer. But whenever you're in uncharted waters, innovation is required, and this process of accommodating and directing within rapid change needs people to talk about pros and cons, it needs criticism, it needs support, but most of all time and energy to review and discuss. I have great faith in the democratic system, where the ebb and flow of analysis and discussion, criticism and complaint focus ideas, build answers, where regular and varied information is shared and interpreted. I fear greatly the focusing of more power and control in the Minister of Health's office. Regardless of political affiliation, no matter how far-seeing or wise that man is or can be, isolation in decision-making is especially dangerous in times of change. I request -- no, I beg -- that this committee and the Ontario Legislature recognize the need to amend this bill significantly, especially where such tipping of the locus of power and control occurs away from the duly elected Legislature. Poorly informed decisions in health care can be deadly.

In relation to closing hospitals, the ministry must know that hospitals are not owned by the government. In fact, they are often owned by charities or churches or public corporations and foundations. As such, the government may choose not to fund them under its present legislation, but the government, despite whatever legislation they may enact, cannot close them. To justify the omnibus legislation of Bill 26 as a method to control hospital costs implies a plan to change the ownership rules in Ontario that's going to lead to a lot of legal wrangling.

With regard to physician services for underserviced areas -- of which, by the way, Sudbury is one -- we need people who want to live and work in the north. I know many of us here find it hard to believe, but there are people who are emotionally and socially unprepared and unable to settle in northern Ontario. Forcing them to come here is not going to solve the problem. It takes a different attitude and different skills to survive here. We already know that people who are trained in the north in a northern-style program stay in the north and make excellent professionals. Open the training opportunities, and the underserviced area problem will take care of itself.

In terms of health decisions, one of Ontario's most important and necessary health infrastructures is the district health council process. With support and processes that allow forced prioritization of need, health councils can provide locally made answers to problems and difficulties. Such a strong process must not and cannot be bypassed or made impotent, as regionally diverse needs and information are essential to effective planning.

We, as communities, have finally learned how to believe in and rely on health councils. This process is necessary to our community getting regional representation. Your legislation would close down their processes and would make one-size-fits-all solutions for Ontario.

An issue that I can't face each day, as a person, is the continuing erosion of my privacy as a citizen of this province. Everywhere I look, somebody else has access to private and personal information about me. No one has the right to invade my privacy, especially about my personal health. This is totally unjust. I have no alternative source of service.

When I did not like article 14 in the Royal Bank client card PIN contract allowing access to my financial information, I could go to the credit union and set up a whole new banking relationship based on different privacy standards. However, I can't do that here, can I? There isn't any other place to get health services. I can't find a medical system that recognizes my privacy needs if you don't.

There are methods of verifying service delivery without violating medical record privacy. Call the Auditor General; use the processes that are presently in place and available through regular privacy channels, the same as every other insurance company in the world.

I would like to say that everything we do in this world is interconnected. Everything I do affects you, and everything you do affects me. We form a circle, and each part leans on the other. Health is not fixing what's broken; it's a way of living. If people can't find good food free from toxins and pollutants at a price they can afford; if they can't get clean air and clean water; if a vehicle is not safely built, operated or maintained; if people fill themselves with alcohol, cigarette smoke, fats; if there is no economically easy, accessible place to play and exercise, all the cost savings and all the corners you cut are not going to save health dollars, or not going to save tax dollars either. Good health is a way of life, and it's affected by the entire environment and everything we come in contact with and how we live.

To close, I've got several points I'd like to return to.

Health care must be universally accessible, with no barriers for those who are economically disadvantaged.

Decisions about our health care system have to be made with a maximum amount of information, debate and input through our duly legislated process, not by a Minister of Health working in relative isolation with one-size-fits-all solutions, especially in these times of really rapid change.

Underserviced areas especially need committed physicians who know their patients and their communities and are willing to build those healthy communities, not just fix bodies.

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Health councils and legislative decisions and discussion are necessary to provide solutions to costly health issues.

Personal health privacy is a responsibility that you can't ignore because it's inconvenient.

Health is a way of life that needs to be supported and developed within a balanced circle of spiritual, emotional, mental and physical need. Each individual in that circle of the community impacts on the next. If the community is not healthy -- clean air, water, safe places to play -- then health is the ultimate problem, and one of the most expensive problems, that you're going to have to fix.

The Chair: Thank you. We have six minutes per party for questions, beginning with the government.

Mr Clement: Thank you for your presentation. You gave us a lot to think about and it was very well thought out. At the risk of derisive laughter from the other side, when I heard the principles that you just mentioned, I think the government agrees with you absolutely on each of those principles, and perhaps the two sides disagree on how best to get there. I sense that, but --

Interjection.

Mr Clement: Just a brief chuckle from Mrs McLeod. But I think the goals are worthy and it's a question of how we get there, where there is legitimate debate and reasonable debate and reasonable positions on both sides. It's very good for you to refocus us on where exactly we have to get to.

On a couple of those points, I just wanted to test the adequacy of some of the provisions of Bill 26 based on what you said. One of those things was local and public input. The way I read the bill, there's not really any mention of district health councils in the bill, which means that the sections pertaining to district health councils are still valid and still exist because the bill is an amendment bill, it amends pieces of legislation, so that which we don't amend still exists. So the purpose of DHCs to advise and to plan locally, to get that input from the local community, to be representative of the local community and then to plug into what -- we all must admit there still has to be some sort of provincial strategy to health care, I would hope. That still exists. Does that satisfy you at all?

Ms Rogerson: I think the role that health councils have played has been much stronger and much of the role that this legislation designates for the minister would usurp some of that control and power. It's not seen as direct control and power, but it certainly is a negotiation and a consensus-building process that makes the changes viable for that community. I have real concerns that those kinds of changes get lost when they go beyond our community and when the changes are in somebody else's hands.

Mr Clement: DHCs, to be fair, only have the power to advise, even under the current framework.

Ms Rogerson: That's correct, but when they worked well -- and many of them worked very well in building consensus about how service would be delivered and who would deliver what service -- then generally speaking, with a little bit of forced prioritization, support from the government, I think those processes could be used much more diligently than they are and would in fact reflect some of the things we need done without involving provincial-level changes that are imported or imposed.

Mr Clement: That's a fair point. I return to access to records, disclosure and confidentiality requirements, as I have done on several occasions today. I'd make the point once again that based upon my personal reading of the legislation, in fact, because the new legislation as proposed has some restraints or some conditions for which you are deemed to disclose your records, whereas the old legislation has no conditions -- it just says you're deemed to disclose -- I'm making a bit of a personal campaign to argue that the new legislation is more restrictive, more circumscribed than the old legislation. If that is in fact a valid view, would that allay some of your concerns?

Ms Rogerson: The legislation is very vague, okay? You don't have any policy or procedures going with it. It's going to be open to a lot of policy interpretation. I have some real concerns about the use of information about me personally. I've had a long history of fighting on this issue. In fact, I have changed banks because they wanted to be able to have access to that information. I think it's necessary for us to guard particularly health information, which can be very damaging to individuals and can limit their access to health services. So I feel it's really important that it be much more carefully written and I have major concerns about that. The legislation really opens some doors that I have some concerns about.

Mr Clement: We'll keep that in mind. You're from the native friendship centre. Is there anything particularly from an aboriginal point of view that you want to get across to us?

Ms Rogerson: Two things. I work with a community that is disadvantaged economically, and barriers to access for health services in user fees or copayments are difficult in this community. I think it can lead to a much costlier result; it can cost a lot more in the long run when you deal with copayments. There has to be another way. I think if you talk to the pharmacy association, you will find that they have some alternatives in terms of having shorter prescriptions: that you try a drug first so you don't have leftovers etc before you actually assign a year's supply kind of thing or whatever it is you assign. Those kinds of things have a much better possibility of successfully saving Ontarians' money and I think it's important that they be explored.

Second, I come from a community where consensus-building is used to get the best decision and that public input and input from your community is most important to structure information so that you find the best answer to a problem. Anything that limits that in any kind of legislation is very discouraging, from our community's point of view.

Mr Miclash: Thank you for your presentation. At one point, you talked about retention of health care professionals in the north by opening up the training opportunities to them. Do you have any other suggestions for ways we may not only attract but retain health care professionals in the north?

Ms Rogerson: I've worked in this field in northern Ontario for a long time, and what I have found is that doctors generally are overworked. They have little chance to get a vacation or to get away from it all; they find themselves isolated with few or poor training opportunities, and they can't get away from their communities because they're often the only person there.

I would suggest that the provincial government may like to set up a doctor relief program similar to what they have in Britain or New Zealand where they traditionally had doctors who went in and gave doctors leave. As part of your payment back to the government for the investment they made in your training, you agreed to spend a year or two years doing locums, where you went in and gave the doctor two months off for his holidays or a month off or whatever, or allowed him to take a training course while you took over his caseload. That kind of program might possibly allow our doctors to survive in a much healthier way than they are now.

Mr Miclash: Pat, we hear a lot about government forcing health care professionals to relocate in certain areas, and of course I'm talking about the underserviced areas. Can you comment on what that will do in terms of what you see in the health care area?

Ms Rogerson: I'd just like to draw your attention to a couple of the doctors we have here in town. Dr Sivers, Dr Garrioch and Dr Gluck are part of this community and have chosen voluntarily to be here. Each one of them takes part not only in their own profession but they coach hockey, they're involved in local fund-raising, and they're part of developing all sorts of local initiatives that make health care services better and that are more appropriate and responsive to this community. They make such valuable resources to our community that to lose them would be devastating, and we would never have gotten them if we had said, "You have to come to Sudbury for two years" or five years or whatever. They would have come and been drop-in visitors for a year and be ready to leave.

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Mr Bartolucci: Pat, thank you very much for your presentation. I'm sorry I missed part of it.

The recent reduction in social assistance and in programs has had a major impact on many and in particular the friendship centre, which has been highlighted in the House by Shelley. Already people are not going to be able to cover the basic prerequisites of good health care such as food, clothing and shelter. The omnibus bill just heightens this inequity. Can you outline to the committee how it will heighten this inequity for the group you work with?

Ms Rogerson: The community I work with is mostly under 40. They are 75% female, and 60% of those females have children. For most of those women and young families, they're living in Sudbury to try to establish a new lifestyle for themselves. Over 10% of those people have returned to the reserve in the last three months because they can't survive here. That means they can't feed their children. They can't get jobs in this community because there aren't jobs for unskilled moms. Many of them were here to try to get education that would allow them to have the skills to compete on the job market, to give them an opportunity to open some doors for their children and themselves. For many of these women, once you go back, you never make it out again. We're losing a whole generation of people who would be able to make a change, to make themselves independent and able to get along.

I'm a great believer in prevention. I have worked very hard over the last few years to build a prevention program designed to make people stronger and better able to take care and control of their own lives. We deal with about 2,000 young people a year traditionally who have had improvement in skills in anger management, cooking skills, nutrition, budgeting, careful buying, all those good things; also the social skills, the ability to deal with people, to meet people in both the native and the non-native community, to handle job interviews, to send out résumés. We no longer have the programming that deals with that. Those programs have been cut.

I have kids sitting in my office who are saying: "Pat, what do you want us to do? My feet are making the choices again. I'm going to get into trouble." When I say, "My feet are making the choices," I mean that we used to map the community and say: "Where are your support systems? Where are the good things that are going to happen? Go there. The bad things you know about. Make the choice with your head when you're leaving your house, instead of your feet." Our YOA offences have gone up. Our youth facilities were all full over Christmas. Things are really tough here.

Ms Martel: Let me follow up on part of Rick's question and talk to you a bit about copayments. You didn't mention that, at least while I was in the room. You've got a lot of folks who come into the native friendship centre, about 500 people who come in every day for service. I suspect some of those folks are on social assistance who will now pay a $2 copayment.

Given the cut in funds they've already achieved, if they haven't already made a decision to return to the reserve because they can't afford to stay in the community, how long do you think it will be before some of those moms take their kids back because they now can no longer afford to deal with copayments and drug costs that they didn't have before?

Ms Rogerson: One of the things that will happen is that moms will not be able to look after the medical needs of their children, particularly if those moms do not have status. About half our population is non-status. We have about 14,000 aboriginal residents in this district. If half of them are non-status, if 75% of them are female with young children, you're looking at the kind of response that is really devastating.

If you just look at the cost of antibiotics, our children are much more susceptible to all the diseases that are available for everybody to catch. Our kids also get a lot sicker. Most times, if you have measles your kids get pneumonia. Most times, if they get chicken pox it develops into a whole host of other things. We're looking at kids who get really sick from minor ailments. If you can't get to the druggist and get yourself a prescription because you just don't have that $2, what happens is that your child goes into the hospital.

Mr Howard Hampton (Rainy River): I noted that you are concerned about protection of patient privacy. Mr Clement is the only person I know who says that this is not an interference with privacy. In fact, the Information and Privacy Commissioner of Ontario has publicly said that he's very concerned about these sections. I think you're on better ground with the privacy commissioner than you are with Mr Clement.

I wanted to ask you about that, because I think the health records and the patient information stuff here has more to do with the government's rhetoric than it has to do with the reality of health care, and I'd be interested in your views. The government has put out a lot of rhetoric that people are defrauding the health care system, they're defrauding the WCB, they're defrauding social assistance. They're trying to create this aura of fraud. I really think this being able to grab your records, your patient information, has more to do with that rhetoric than it has to do with the reality of health care for people. You work with people. I'd be interested in knowing your views.

Ms Rogerson: Generally speaking, my experience has been, in Sudbury anyway -- and I don't work in the rest of Ontario so I can't speak for the rest of Ontario -- that our population is relatively law-abiding when it comes to use of services. There's a feeling in this community of regret and concern that anyone would cast further aspersions on the users of services. They have enough to carry without carrying the extra load of supposed guilt without proof.

We had a snitch line in Sudbury for welfare recipients and that snitch line netted us, I'd say, about 400 times the number of names. After investigation, the snitch line netted us 27% fewer convictions. The names were given because people didn't understand about services, didn't understand about what you were allowed to do under the legislation of the time, didn't understand that you could work and so long as you claimed it and told your welfare worker that you were working, it was permitted. They didn't understand that if you had child care you could get that child care paid for and still be on welfare. A lot of the reports were lack of understanding.

A major proportion, unfortunately, were grudge reports or abusive husbands who were trying to make it impossible for wives to leave home. It was a very sad situation for us to review, but it was certainly very clear when it was reviewed that this didn't surface a whole lot of fraud. It surfaced less than 0.03% in Sudbury. Most insurance companies feel that a 5% fraud rate is tolerable, and if you have less than that it's not worthwhile financially and legally, in terms of costs, to go after it.

The Chair: Thank you, Ms Rogerson. We appreciate your involvement here and your presentation.

SISTERS OF ST JOSEPH OF SAULT STE MARIE

The Chair: Our final presenter is Sister Winnifred McLoughlin, representing the Sisters of St Joseph of Sault Ste Marie. Welcome to our committee, Sister. You have our last half-hour. Questions, should you leave time for them, would begin with the Liberals.

Sister Winnifred McLoughlin: Good afternoon. As you know, my name is Sister Winnifred McLoughlin. I am the health care coordinator for the Sisters of St Joseph of Sault Ste Marie, and I'm here this afternoon representing our general superior, Sister Mildred Connelly, who was unable to attend due to the short time frame for presentations here today.

We are a religious congregation that has been involved in the delivery of health care in the north since 1884. We have worked in communities from Thunder Bay to North Bay and in all areas of the health care ministry, including acute care, rehab, long-term care, addiction treatment programs and community-based services. Our role has changed and evolved as the needs of the communities we serve have changed. Today we continue to sponsor hospitals in Sudbury, Elliot Lake, Blind River and two facilities in Thunder Bay.

Our hospitals were initially staffed with sisters, a few lay nurses and student nurses. A great deal has changed since then. Today, many lay people have joined the sisters in the hospitals and other health care facilities sponsored by my congregation. In 1960, with the advent of universal health insurance, the government began a partnership with religious communities. This system was designed to provide health care services to the public, and was not intended to compromise the rights of religious congregations and the church to witness Catholic values in health care.

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With respect to Bill 26, we understand and clearly appreciate the desire to control health care spending and that the way to do this is through restructuring. While we are supportive of restructuring to eliminate duplication and to provide effective and efficient service delivery, we are also mindful that we must ensure that the proposed legislative changes allow denominational providers to continue to play an active role in the health care system.

As has been the case in the past, we feel that the rights and responsibilities of local communities and providers must be balanced with the powers and authority of the Minister of Health as we strive collaboratively to restructure health care and meet the economic challenge that we are facing in Ontario today.

The partnership between government and denominational providers has meant that the Catholic health ministry has become an important contributor to Ontario's health care system. Across the province of Ontario, more than 30,000 people are employed in Catholic-sponsored institutions and the hospital sector alone accounts for $1.3 billion of the $7.5 billion to $8 billion spent annually on hospital care in Ontario.

However, the Catholic health care ministry is not really about numbers of employees or billions of dollars. It is about health care that is rooted in the ministry of healing that is a fundamental aspect of the Catholic church. As a group of religious women, this has been an important part of our commitment. In the communities where we have been invited to serve, we have a history of shaping and reforming health care to meet changing needs and priorities. We have long understood the need to control health care spending through restructuring and have voluntarily engaged in efforts to improve health care across the north.

For example, in North Bay in 1984, when it became clear that there would only be sufficient funds to rebuild one facility, we entered into a 10-year process to voluntarily withdraw from hospital-based care in order to ensure that the scarce dollars available would not be wasted on duplicating services and infrastructures. In Elliot Lake, we saw the need for an alcohol treatment centre and expanded chronic care services, while in a smaller community, such as Blind River, we recognized that our efforts should be focused on community-based and outpatient services rather than trying to rebuild an acute care setting that would never be able to provide the range of services available in a larger centre, such as Sudbury.

In Sudbury, long before government-initiated restructuring began, we recognized that our expertise had developed in acute care and the infrastructure and support services that are necessary to deal with the provision of care 24 hours a day, often under traumatic and tragic circumstances. Out of respect for the expertise of other providers in our system, we entered into a partnership with Network North, the community mental health group. This required the voluntary transfer of responsibility for our mental health services to them. We also identified a number of additional programs that other facilities could better provide and had offered to transfer responsibility for these programs to them. We also entered into a number of voluntary partnerships and shared service arrangements as interim steps to achieving the much-needed realignment of programs.

In Thunder Bay we have recently decided to cease providing a number of duplicated acute care programs and concentrate instead on rehabilitation and long-term care. Therefore, in that community we have been able to focus on developing a continuum of services that include rehabilitation clinics, EAP services and a nursing home.

To ensure the future viability of our health care ministry, we have expended great effort to transmit the depth of our commitment to the laity with whom we work, such as our administrative staff, board of trustees and front-line workers. As I have clearly indicated, our facilities have been responsive to the communities wherein they operate. This is due in large part to our governance structures which allow us to achieve the goals of our ministry while working with representatives of local communities and government. Through representative and voluntary boards of trustees, our Catholic health institutions and community-based services are good stewards of scarce financial resources and are anxious to find ways to eliminate unnecessary duplication and to bring about progress and change in Ontario's health care system.

Our commitment to restructuring has been based on the philosophy that a great deal can be done voluntarily when people come to the table with goodwill and respect. Unfortunately, we also know that there are situations, such as occurred in Sudbury, when government-imposed restructuring has deteriorated into a struggle for power and control that results in attempts to eliminate the denominational provider by using a focus on governance rather than patient care. Objectively, there are some in the community who believe that the only way to improve patient care is to have one governance structure or one board. We know from our success across the province that this is unnecessary when people are motivated by community need and patient requirements.

We commend the government for acknowledging that patient care improvement and efficiencies can be achieved with more than one governance structure in place. We agree that what is needed are the tools to cut through the destructive politics that have divided a community such as Sudbury and that we hear are also occurring in communities such as Pembroke, Windsor, St Catharines, Chatham, and perhaps will likely occur down University Avenue where the denominational facility is being threatened by proposals for one board.

Based on the involvement of the Sisters of St Joseph in hospitals across the north, I can come here today and tell you first hand what happens when a community focuses too much on form and structure rather than on the functioning of the system.

First, on a positive note, in Thunder Bay, as I have already mentioned, the community decided to divide the provision of services by grouping related programs and building on areas of expertise. The implementation of this plan is now proceeding.

In Sudbury, however, despite similar recommendations 10 months ago by the hospital services review committee that programs should be realigned to minimize duplication and maximize efficiency, there has been no progress in implementing the report. This is because in Sudbury the focus has been mistakenly placed on the form of the system rather than its function. The Sudbury community has been divided by debating structure, form and governance. Meanwhile, change is not taking place, economies are not being achieved and the elimination of duplication and improvements in care have been delayed.

One of the reasons I am here today is because, as a religious congregation, we must be vigilant that proposed legislative changes do not threaten the continuation of our health care ministry. Under the proposed changes to the Public Hospitals Act introduced by the NDP government, we experienced extreme concern that traditional voluntary governance structures would be eliminated, and consequently our opportunity to fulfil denominational health care ministries would be removed forever.

We are extremely pleased that prior to the last provincial election, each of the party leaders committed to preserving and enhancing denominational health care. We have been very reassured to date by this government's affirmation that denominational hospitals and their boards do not need to be eliminated in order to achieve the goals of health care reform. There has been a positive recognition of both the historic and future contribution to be made by facilities such as those sponsored by my congregation. In Sudbury, we have appreciated Mr Wilson's assistance in defusing the misuse of governance and the resulting abuse of denominational providers. By emphasizing that the restructuring plan could proceed without change to our hospitals' governance structure, the minister's directions have been extremely valuable.

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I must say that, based on the local Sudbury reaction to the minister's very clear direction that the restructuring plan be implemented, and the continuing stalling that has occurred, we well understand the need for a different set of tools to enable the process to move forward as quickly as possible. The benefits of restructuring would then be realized by our patients sooner rather than later. We welcome the establishment of the restructuring commission and are pleased to hear of the Health minister's commitment that this will be a time-limited mechanism to implement approved restructuring plans. To date, we have been reassured by the commitment of the minister that this commission will not be used as another way to threaten the continuation of the denominational ministry by eliminating or marginalizing our role or that of our boards.

By using our approved restructuring study as the blueprint for implementation, this government has reinforced that patient care improvement must be the motivation for all hospitals. For this reason, we feel it is important that the regulations only allow the implementation of plans that have been approved by the Minister of Health. While some fine-tuning may be necessary as final implementation details are worked out, we must caution against any regulations that would allow the commission to be lobbied to change their outcome. Not only would this further delay implementation of much-needed restructuring, but based on our experience in Sudbury, we feel that any such latitude could also provide another venue for attacking denominational health care and voluntary governance structures.

It is important that the members of the commission understand, as the government and the leaders of the opposition and third parties have, that the corporate integrity of Catholic and denominational hospitals must be protected. Our mission focuses on holistic care which embodies the physical, emotional and spiritual needs of patients. It is a ministry that is available to all, regardless of creed. In all of our efforts, the dignity of the person created in the image of God and re-created in the image of Christ is paramount. While we make no claim that such aims are exclusively Catholic, we insist that Catholic health care must embrace these components.

I know that the Catholic Health Association of Ontario will be making a presentation to this committee on behalf of all congregations across the province. We of course share many of the same concerns about certain aspects of this bill, particularly the uncertainty around the regulations that will accompany changes to the Public Hospitals Act. We trust that the regulations will respect the commitments made to the CHAO and its member hospitals to preserve the corporate structures of Catholic and denominational hospitals now and into the future. We also support the OHA's position on the need to respect ongoing voluntary governance.

We do, however, believe that if the extraordinary measures contained in this legislation are limited to the period of time it takes to accomplish restructuring, they will go a long way to ensuring that communities have the opportunity to develop plans to meet their future health care needs. They will also see their efforts bear fruit as these plans are implemented.

In order to respond to the financial challenge in the short time frame available, the power to transfer funding, merge and close hospitals is necessary to offset the politics of isolation or domination, or, in the case of our recent experience in Sudbury, the attempts to eliminate denominational providers. By aligning funding with service provision, as recommended in restructuring studies, this tool will return all providers to the focus on patient care improvements and community service.

In Sudbury, these powers could be used to immediately establish the new reality called for in our study, a two-hospital system. We would encourage a merger of the two public corporations, as has occurred in Thunder Bay, Windsor, London and is being planned for in Metro Toronto. This is the fastest way of implementing our study and provides the opportunity for expanded cooperation and collaboration between the public and denominational corporations while achieving the economic objectives that Bill 26 sets out as imperative.

We are called to be advocates of due process and fair and equitable treatment for all. In cases where a supervisor is appointed for reasons other than implementing restructuring, we would support the incorporation of some due process which involves a response from the minister. However, based on our experience in Sudbury, we cannot support further opportunities for appeal by those who have intentionally obstructed and resisted the implementation of our approved restructuring study. Having a 30-day or 60-day due process opportunity to rationalize these actions will only allow further unwarranted delay.

For this reason, we believe that the minister should have the authority to appoint a supervisor, once the community's plan has been endorsed by the minister, if no progress is made in implementing the plan within a reasonable period of time. Failure to come to the implementation table in a supportive and cooperative manner would be grounds for such action. Without this type of authority, numerous hours and much effort can be wasted dealing with attempts to derail less popular aspects of studies. As with the restructuring commission itself, we support the recommendation that this expanded criterion for the appointment of a supervisor should be time-limited ending March 1999.

Voluntary arrangements always seem to work the best. Based on my congregation's experience across the north, we believe that there is a variety of collaborative arrangements that can achieve the objectives of hospital restructuring while respecting corporate integrity for those who wish to see their missions continue. In all the communities where we sponsor health care facilities, we are committed to working with the government to reform and restructure our system and to ensure that real change takes place. We also look forward to the continuation of the tradition of denominational hospitals thriving in an atmosphere of pluralism and tolerance, characteristics which are an important part of this province's strength.

The Chair: Thank you, Sister. We have three minutes per party for questions, beginning with the Liberals.

Mr Bartolucci: Sister, thank you for your presentation. You agree with the restructuring commission, certainly, that's clear, but should the restructuring commission only implement the decision of the minister or should it have the power to merge or close hospitals?

Sister McLoughlin: I would think they should have the power to implement plans that have been approved by the minister. That follows after a lot of study with community involvement.

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Mr Bartolucci: So we're not excluding the DHC in the process?

Sister McLoughlin: No. The DHCs make the recommendations if they're the ones charged with conducting or being responsible for a study that is carried out.

Mr Bartolucci: Very briefly then, could you just clarify for me -- we know the reason for the DHC -- how does the commission fulfil its mandate if there is no communication between the commission and the DHC? In other words, if there is to be communication, what types of regional mechanisms should be in place to ensure that this happens?

Sister McLoughlin: I think that if there is an approved implementation study that the DHC has recommended to the minister, they would collaborate with the commission in the implementation of that study. So I would think there would have to be regular meetings if there were a misunderstanding or a need for clarification.

Mrs McLeod: Just following up on what Mr Bartolucci was asking, I would gather then that you would have some concerns about the minister's ability to delegate the responsibility for making decisions about the supervision of hospitals, or indeed the closure and merger of hospitals, to someone other than the minister himself.

Sister McLoughlin: Yes, I think that should rest with the minister.

Mrs McLeod: I appreciated the very positive orientation you put into the presentation that you made today. I wish that in all the restructurings that are going on in communities, it could be taken as the fundamental guideline that we look at function rather than form.

Even in Thunder Bay, where I think we have made real progress in resolving some of the governance issues, and particularly the issue of denominational governance in acute care, other new governance debates seem to emerge in terms of who owns businesses. If we could just keep it on function and what's best for the community, a lot of the divisiveness could be resolved.

Sister McLoughlin: Yes.

Ms Lankin: Thank you for your presentation. We appreciate your presence here and the information that you've brought before us. I also wanted to follow up on this issue of the restructuring commission.

I should tell you that I am not convinced it is a necessary structure. I agree that it is necessary for the minister to be able to implement the approved plans of district health council local planning. I'm not sure why a commission is necessary, as opposed to the ministry and all of its structures that are already there. I would be interested in what thoughts you might have on that.

I also agree with you completely that the process of local planning should in fact be one that is led through a district health council or similar process in that whatever the minister, or a commission, if that's the case, implements should be whatever the approved version is coming out of that kind of report. I would like to see some amendments to the legislation that build in some linkage between the commission and the DHC. Would you support a move in that direction for amendments?

Sister McLoughlin: Yes, I would, and I also feel strongly about the commission because of our difficulties here in Sudbury.

Ms Lankin: Could you tell me what a commission would do that the powers of the minister can't?

Sister McLoughlin: In Sudbury he had to tell the DHC five times that governance was not an issue, that restructuring should go ahead regardless of governance. I really question then, if the minister didn't have that power, could another group be given the clout to do it?

Ms Lankin: That's my point.

Sister McLoughlin: I don't know but it has been a horrific year for us and we are just looking at some solution that would put an end to all of this political interplay.

Ms Lankin: Lastly, I just wanted to make a comment and perhaps correct the record. Unless my memory's very faulty, at the point in time, under the previous government, that there were discussions of changes to the Public Hospitals Act -- I was the Minister of Health, it was a few years ago and I might be wrong about this -- but I believe we didn't introduce changes to the Public Hospitals Act. We did publish a report which was done as the result of a lengthy consultation with a lot of people, and I know the provision that you were most concerned about was a proposal to elect local hospital boards.

In fact, after lengthy consultation we decided as a government not to proceed with those changes or any changes to the Public Hospitals Act at that time. That consultation took place over a long period of time, considerably longer than the two months we have to deal with this huge bill.

So I just wanted to set the record straight that sometimes ideas come forward from a process of consultation, and then when checked back with people, governments make a decision based on the input they get not to proceed. I'm hopeful that this government, based on the input it's heard over the course of these hearings, decides not to proceed with some of the measures of this bill.

Mrs Ecker: Thank you very much, Sister, for coming forward this afternoon and providing your very well argued case. As someone who's had some familiarity with the quality of care in denominational hospitals, I certainly can understand where you're coming from.

I would also agree that voluntary is best but that, as is indicated in Sudbury, sometimes a community, despite its best efforts, needs someone, from the government in this case, to try and resolve it. I know in my own community we've had a similar problem, where the district health council had gone through a process, we had recommendations and we needed some influence by the minister to try and keep things going along.

Where you probably hit the nail on the head -- there has been a fair bit of debate about whether there should be the power with the minister to close hospitals or whether it should be with the commission to close hospitals. I think that the minister's commitment, first, is that it's very clear that the district health council recommendations would be the basis for restructuring.

But second, his concern is precisely, as you mentioned, the political interplay, the politics that start to get into the restructuring and hospital decisions, and his recommendation, his suggestion, was that the commission would somehow, by taking one step removed from the minister, perhaps eliminate that problem. Do you see that as being perhaps hopeful in that way?

Sister McLoughlin: I would be hopeful that this would be the process that unfolds, but I think the ultimate responsibility will rest with the minister.

Mrs Ecker: Ultimately. Okay.

The Chair: Thank you, Sister.

To the people of Sudbury, thank you very much for your hospitality. We've enjoyed our time here and we'll come back some day.

Ms Lankin: Are you going to vote in favour of my motion, Mr Chair?

Mr Bartolucci: The OMA has presented a very excellent brief. Although they didn't get on the agenda today, as I know they wanted to, I would certainly encourage the committee to read their presentation very carefully, as it contains excellent recommendations.

The Chair: Thank you, Mr Bartolucci. We will now adjourn to Mrs McLeod's favourite place, Thunder Bay.

The committee adjourned at 1628.