SAVINGS AND RESTRUCTURING ACT, 1995 / LOI DE 1995 SUR LES ÉCONOMIES ET LA RESTRUCTURATION
PROVIDENCE CONTINUING CARE CENTRE
SOUTHEASTERN ONTARIO HEALTH SCIENCES CENTRE
NORTH KINGSTON COMMUNITY HEALTH CENTRE
CANADIAN ASSOCIATION OF CHAIN DRUG STORES
HASTINGS AND PRINCE EDWARD COUNCIL ON AGING
KINGSTON AND DISTRICT LABOUR COUNCIL
ONTARIO PUBLIC SERVICE EMPLOYEES UNION
PETERBOROUGH COMMUNITY PHYSICIANS
NORTHUMBERLAND COALITION AGAINST POVERTY
ONTARIO PUBLIC SERVICE EMPLOYEES UNION, REGION 3
CANADIAN UNION OF PUBLIC EMPLOYEES, DURHAM, NORTHUMBERLAND KAWARTHA AND HALIBURTON REGIONS
PETERBOROUGH CITY RADIOLOGISTS
RENFREW AND DISTRICT LABOUR COUNCIL
PETERBOROUGH COUNTY MEDICAL SOCIETY
CONTENTS
Friday, 12 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
Providence Continuing Care Centre
Sister Sheila Langton, vice-president, Providence health system
David Bonham, chair of the board
Southeastern Ontario Health Sciences Centre
Dr Robert Maudsley, representative; vice-dean, faculty of medicine, Queen's University
Dr John Marshall, representative; chief of staff, Kingston General Hospital
Terry Stafford, immediate past chair; chair, board of directors, Hotel Dieu Hospital
Paul Rosenbaum, director of planning and secretary
Guy Legros, representative; CEO, Providence Continuing Care Centre
North Kingston Community Health Centre
Tanya Beeler, president, board of directors
Charlotte Rosenbaum, executive director
Kingston AIDS Project
Evelyn King, representative
Paul Waltenberry, community worker
Canadian Association of Chain Drug Stores
Rochelle Stenzler, chair
Sherry Porter, president and CEO
Terry Creighton, member
Hastings and Prince Edward Council on Aging
Dr Margaret Cahoon, representative
Kingston and District Labour Council
Charlie Stock, president
Gavin Anderson, member
Vince Maloney, member
Ontario Public Service Employees Union
Warren Thomas, executive board member
Peterborough Community Physicians
Dr Paul Leger, representative Ontario Society of Obstetricians and Gynaecologists; Ontario Medical Association, section of obstetrics and gynaecology
Dr Richard Johnston, chair, OMA section of obstetrics and gynaecology
Dr Marshall Redhill, secretary-treasurer, OMA section of obstetrics and gynaecology
Northumberland Coalition Against Poverty
Carolyn Blaind, member
Pat Gardner, member
Ontario Public Service Employees Union, Region 3
Bonnie-Lee Baker, OPSEU Local 345
Annemarie Powell, OPSEU Local 339
Thomas Veitch, president, Peterborough and District Labour Council
Canadian Union of Public Employees, Durham, Northumberland, Kawartha and Haliburton Regions
Gwen Hewitt, representative
Marie Boyd, representative
Casey Thomson, representative
Bill Nichol, CUPE national staff representative
Peterborough City Radiologists
David Swales, representative
Renfrew and District Labour Council
Robert Patrick, representative
Peterborough County Medical Society
Dr Marshall Trossman, president
Dr Carlos Bos, representative
Dr John Gray, past president; chair, OMA board of directors
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
Clement, Tony (Brampton South / -Sud PC) for Mr Kells
Ecker, Janet (Durham West / -Ouest PC) for Mr Stewart
Also taking part / Autre participants et participantes:
Curling, Alvin (Scarborough North / -Nord L)
Galt, Doug (Northumberland PC)
Gerretsen, John (Kingston and The Islands / Kingston et Les Îles L)
McLeod, Lyn (Fort William L)
Miclash, Frank (Kenora L)
Rollins, E.J. Douglas (Quinte PC)
Clerk / Greffière: Grannum, Tonia
Staff / Personnel: Campbell, Elaine, research officer, Legislative Research Service
The committee met at 0900 in the City Hall, Kingston.
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): Welcome to the hearings on Bill 26 conducted by the standing committee on general government. We're delighted to be here in Kingston in this magnificent building. Obviously you people are very fortunate in Kingston to have buildings like this. We're delighted to be here.
I just want to let you know that the dialogue is between the presenters and the members of the Legislature sitting at the table. We're delighted to have so much interest from the audience, but I would expect that the dialogue would be kept between the people at the table, just to forewarn you about that.
Before we call our first presenters, I understand that there's a motion. Mr Gerretsen.
Mr John Gerretsen (Kingston and The Islands): Yes, I have a motion.
Whereas Bill 26 will have a major impact on every individual in Ontario; and
Whereas Bill 26 requires broad public input before being passed into law; and
Whereas there are nearly 60 groups in Kingston that want to provide input into the bill but only 16 will be heard; and
Whereas the community of Kingston only has two half days of hearings;
I move that when the House returns on January 29, 1996, the order with respect to Bill 26 be amended such that the portions of the bill that do not require urgent passage for fiscal reasons be returned to the standing committee on general government so that further hearings can be arranged across the province, including the community of Kingston.
The Chair: Thank you. In other cities where this motion has been introduced we've delayed discussion on it until lunchtime. Since we don't have any opportunity for lunch today, is there a possibility for all-party consent to a two-minute maximum for one person to speak for each party and, if there is, we'll discuss it now?
Mr Tony Clement (Brampton South): Agreed. Is there a written copy of this motion?
The Chair: We'll pass out the written copy. If we have all-party agreement to one person speaking for a maximum of two minutes, we'll discuss the motion and dispense with it now, please.
Mr Gerretsen: As has become quite clear not only in these hearings, I'm sure, since it's the first day that I'm involved with these hearings, but I've been involved mainly this week, for the other four days, with the evidence hearings, which is the parallel committee holding hearings across the province as well, there are roughly three times as many groups in every community that want to present on a daily basis than there is time to hear the presentations.
It seems to me from what we've been hearing, and undoubtedly I understand from what you've been hearing here as well, that people want more time to discuss the implications of this bill. There is a wide-ranging aspect as far as what's involved in the bill -- it deals with just about everything under the sun -- and it's our feeling that only those areas that deal specifically with the immediate fiscal impact as it relates to the province of Ontario should be dealt with on January 29. There's interest in it. People want to talk about it.
I have great reservations about the hearings that have been held. To call them "public" consultations, quite frankly, is stretching the word. I know there was an agreement among the parties, it was reluctantly agreed to by both opposition parties to have two weeks of hearings outside of Toronto, but the point still is that we really haven't had true consultation. True consultation means a dialogue on what's in the bill and the various aspects of it. I think what we're really getting across the province are presentations and, usually in two or three minutes, quick questioning on very minute aspects of the bill.
In any event, I'm here to present this motion. I also would like everyone to know that following the adjournment of these hearings this afternoon, we will be holding parallel hearings when at least two other members of the opposition will be joining me for hearings this afternoon for those people that couldn't present during the morning.
Mr Rosario Marchese (Fort York): I'm happy to support this motion. As some of you know, Frances Lankin, my colleague, has moved a similar type of motion in the past, and I would have done very much the same based on the past experience. I read through Hansard and there have been a number of people, if not the entire group, who have come forward and said, "We need more time to assess the implication as it relates to the specific profession and as it relates to communities as a whole." This bill was so hastily prepared and introduced in a mulish sort of way, I would say, that it has not given time to anyone to assess what the implications are to our communities.
We know there are more people who want to depute than there are spots for, because they feel the issue strongly based on what they're hearing, not so much based on what they're reading because many can't even get a copy to read. Based on their fears of what they're hearing, they want to be able to come before the committee to state their concerns, although more and more people are now getting access to specific portions of Bill 26 that affect them particularly and in a general way. We feel it's the essence of democratic participation that people be given that opportunity.
Given that Bill 26 affects us so greatly, because of the extraordinary powers it gives to cabinet and to particular ministers, we believe that, because it changes much of what we have understood in the past, people need that opportunity. I'm very happy to support this motion and hope that some of the Conservative members on the other side will reconsider their past positions on this matter.
Mr Clement: I find myself speaking against the motion. I understand the rationale presented by Mr Gerretsen but I guess I disagree with the premise a bit. I think that the public process is working quite well from a number of different perspectives.
Firstly, on both sides of the committee, both the health and the non-health, the total number of presenters by my calculation will have reached 750 by the end of this process. Dealing with the health side, if I can speak for my colleagues, there has been a very high quality of discussion by the presenters representing their communities, labour or the pharmacists or the doctors or the patients.
We've had a very diverse group of people in every community, and I expect the same in Kingston today. That diversity of representation also has reflected a multiplicity of views, some favourable to what the government is doing and some very unfavourable to what the government is doing, and that's what this process is all about.
From my perspective, it has been very helpful at least to the government side, and I suspect for the other side as well, to hear from these groups. They have helped us grapple with what potential amendments we may wish to deal with in the third week of January.
I note that the motion talks about not requiring urgent passage for fiscal reasons, those sections that don't deal with the fiscal realities of the province. But there's also another facet of these particular schedules in this committee, which is the need for urgent passage for health reasons. We currently have a health care system which is mired in the status quo, which means that there are empty hospital beds that we as taxpayers pay for, yet we have such urgent needs in our communities: urgent needs for long-term care, urgent needs for palliative care, urgent needs for HIV sufferers, urgent needs for cancer sufferers.
Those are urgent requirements as well, I would say to the mover. They may not be fiscal reasons, but they are health reasons, and the sooner we can restructure our health care system to provide the health care that is necessary for Ontarians the better we are all --
The Chair: Thank you, Mr Clement. Before we call for the vote, I just want to let you know there are only five people at the table who have the chance to vote because they are the five official people of the committee. There are three representatives from the Conservative Party, one from the New Democrats and one from the Liberals, just if you wonder why some people are not putting up their hand on the vote.
Those in favour of Mr Gerretsen's motion? Those opposed? The motion is defeated.
Mrs Lyn McLeod (Fort William): I did have a second point to raise, obviously not to debate a motion which we know, with the voting odds stacked in a way that you've just described to the audience, we have no hope of winning unless the government realizes that there are significant numbers of people, including people in this audience, who want to make a presentation, who should be heard because this bill affects them very directly and who do not have the opportunity to be heard in this community and in many other communities.
I want to draw to the committee's attention the fact that one of the groups that cannot be heard this morning in Kingston is the physicians of this community, the Kingston Academy of Medicine. That is clearly a group that, in Mr Clement's own terms, is affected and should have been heard.
Mr Chairman, I want to draw your attention to the fact that the Kingston Academy of Medicine, because they could not get on the agenda, have tabled a written brief. I think it's important that people know that they have made a presentation and that they are present in the audience today.
The Chair: Okay, thank you, Mrs McLeod.
0910
PROVIDENCE CONTINUING CARE CENTRE
The Chair: Our first presenters this morning represent the Providence Continuing Care Centre: Guy Legros, the president and CEO, Dave Bonham, chair of the board, and Sister Sheila Langton, vice-president of the Providence health system. Good morning and welcome to our committee. You have a half-hour of our time and questions, should you leave the opportunity for them, would begin with the New Democrats. The floor is yours.
Sister Sheila Langton: Thank you, Mr Chairman, for the opportunity today to appear before your committee and also for the public hearings on this important legislation. I am going to begin the presentation with a very brief community and service profile of Providence Continuing Care Centre in Kingston, and Mr Bonham then will deal with our concerns regarding Bill 26 and our recommendations.
Providence Continuing Care Centre is a Catholic health care organization sponsored by the Sisters of Providence of St Vincent de Paul, offering a continuum of services in the long-term-care field.
My community, the Sisters of Providence, have ministered to the health, education and social needs of the citizens in the Kingston area since 1861. The mission of the sisters over the years has been to develop and provide services for which there is an identified need and no other existing service to meet that need. The goal of the programs offered by Providence Continuing Care Centre is to provide compassionate, holistic care to those requiring long-term-care services. Care is delivered with sensitivity to the dignity and wishes of the recipient, within a context of the individual needs of patients, residents and clients.
The sisters have worked in partnership with the community from the beginning to identify the changing needs of its citizens, primarily in the field of long-term care. The linkages they have developed with consumers and other health care providers have contributed to a well-coordinated health system in the Kingston area. Over the past 10 years Providence Continuing Care Centre has participated in the rationalization of a variety of clinical program streams among area hospitals.
Indeed, St Mary's of the Lake Hospital has been identified through a community planning process as the future single site for all rehabilitation services in the greater Kingston area. The hospital at this moment awaits a Ministry of Health response to its request to transfer rehabilitation programs from Hotel Dieu Hospital and Kingston General Hospital. St Mary's has also requested a capital subsidy in order to renovate St Mary's premises to accommodate the incoming rehabilitation services.
Just to give you a very brief service profile, Providence Continuing Care Centre offers a number of community and institutionally based services funded primarily by the Ontario Ministry of Health.
We have St Mary's of the Lake Hospital, a 223-bed chronic care and rehabilitation hospital serving a six-county regional area. The hospital provides continuing care, geriatric medicine, rehabilitation medicine, palliative care, respite care and a day hospital. Services are increasingly delivered on an outpatient basis.
Providence Manor, a 223-bed long-term-care facility, provides nursing care in a homelike residential environment for seniors who can no longer remain in the community.
The regional community brain injury service program offers residential and community-based assessment and treatment services to victims of acquired brain injury in the six counties surrounding Kingston. This program has already repatriated a number of individuals receiving care in the United States and has developed the infrastructure necessary to prevent further referrals of people from their areas to services outside Ontario.
Under the umbrella organization as well, we have the attendant care program. It provides attendant services in the home and in a residential supportive housing program to 52 severely physically disabled adults in Frontenac, Lennox and Addington counties at any given time.
The Hildegarde Centre is an adult day centre which provides personal care, counselling, activity programming and respite care for aging seniors living alone or with family members in the community.
I think that gives you a bird's-eye view of our umbrella organization, Providence Continuing Care Centre, sometimes called PCCC. I'll ask Mr Bonham to continue with our concerns.
Mr David Bonham: Thank you, Sister Sheila. I want to say on behalf of Providence Continuing Care Centre that we're very happy to be able to meet with the committee today and to talk about some of our concerns.
We certainly recognize the need that the government has to tackle some of our problems relating to the deficit etc, and we don't quarrel with that in any way. As a matter of fact, we strongly support those efforts. But we're concerned to some extent with the impact of Bill 26 on our organization particularly -- we'll be speaking from that perspective only -- and we're concerned about some of the powers and the procedures and the implications we see in this, and I think that is a common concern of everyone here.
If I'm not mistaken, this bill has been referred to by the government itself as its toolkit, so we're here to talk about the tools the government needs to do this job, and the shape of those tools and the size of those tools and the number of those tools. I would also like to say as a corollary to that that I hope the members of the committee recognize the fact that we have a job to do as well and we need some tools. Therefore we want to talk about those things, in what I hope will be a constructive way.
There are some very broadly based powers here. We recognize that some of these may be necessary, but those are certainly areas of concern.
I would also like to address one other broad theme that runs through our deliberations, and that is the impact that these developments and others might have on --
The Chair: Can I ask you people to remove those signs, please. No signs, no protests allowed in here. Please remove the signs. Sorry for the interruption. Carry on, please.
Mr Bonham: I was about to say that one of our ongoing concerns generally, and not only with regard to this legislation, is the effect the changes may have on the voluntary governance of organizations such as our own. In saying that, we recognize very clearly that changes are necessary. We're not opposed to changes. The society we live in is changing, and we must change with it. But as Sister has pointed out, the Sisters of Providence have been a very active and positive part of this community since 1861, since before there was a Canada, and we intend -- hopefully -- to be here for a long time yet, doing the work we have been carrying on for those many years. That, I will say very clearly, is a concern we have.
0920
Following up from that, some of the powers in Bill 26 we feel could have -- and I say "could have," not necessarily will have -- an adverse effect on the voluntary governance of our organization, and we want to raise those concerns. I'm not going to go into detail, and you've been through this before many times, but some of the powers that are described in schedule F, part II, section 6, including the power to close hospitals, to increase or decrease services, to direct the boards of various hospitals to amalgamate, could have the effect of impacting on our right to conduct our own affairs. Also, we've noted the expansion of the powers where a hospital supervisor can be appointed by the Lieutenant Governor in Council to exercise all the powers of the hospital board. That could very clearly interfere with the independence of an organization.
We're not saying that these powers are absolutely unnecessary, and there may be a case to be made to have them, but we would like to suggest that these are very extreme and unusual powers and they're not the normal powers that one would expect to find in a democratic society such as ours. We would ask the government to recognize that these are extraordinary powers and that these are unusual times. Therefore, our first recommendation in this area is to strongly request that there be a sunset clause on some of these extreme powers. If they are necessary, and I think that's a government decision, our position is that they should not go on forever. They should be recognized as being unusual, and there should be a sunset clause so that at some appropriate time, further meetings such as this will be held to discuss whether they are still necessary. We would strongly request that consideration be given to that approach.
We also hope that in whatever manner these powers or others like them might be implemented, there will always be recognized the need for consultation as full as possible with the parties involved. Without suggesting any bad intent or being negative, some of these powers could be seen as being arbitrary, and we hope that in our society we will do everything possible at every stage to try to avoid that kind of result. Therefore, we leave that as the second recommendation. Admittedly, it's a very broad recommendation, and we're not trying to shape it in a specific way, but we sincerely hope that attitude will go through whatever develops as a result of these hearings.
We're also concerned about the broadness of the catch-all provision in the draft legislation whereby it's possible to "make any other direction related to a hospital that the minister considers in the public interest." If it is necessary to have such a broad power, this might be referred to, I suppose, as a supertool if we're talking about a toolkit here. This is a very powerful tool, and if it is necessary to have such a tool, we would hope there might be some way to establish boundaries or limits or some further specifications related to it. There's nothing one can imagine in the field that would not be captured by such a broad provision, and we really wonder whether a provision of that extent is necessary in this toolkit.
I'd like to shift now, recognizing the constraints of time, to a few brief comments about the hospital restructuring commission. We recognize that we may be in a period of reorganization and restructuring, and all of us of course are concerned about how this might play itself out. While, according to my understanding, the detail of this has not been fully determined, it appears that there may be some delegation of authority from the government to the restructuring commission, and that is something that really does concern us. If it is necessary to take some of these extreme decisions -- and I only say "if" it is necessary -- we are then concerned with whether they are delegated.
We would strongly recommend that the restructuring commission be seen only as an advisory body to government so that it does not have, in and of itself, the power to make final determinations. That is certainly a recommendation we would like to leave with this government. We feel that if it is necessary to take some of these decisions, they should be made at the highest level and accountability for them should be seen to exist at that level.
We would also like to request that in whatever work the hospital restructuring commission might do, it be requested to respect the government's commitment and I believe the Premier's commitment to the voluntary governance of hospitals such as our own. I have already said this and I don't want to repeat myself, but we do feel that there is some possibility of erosion and difficulty for us in this area. We'll leave that recommendation with the committee.
I would now like to make a few brief comments about the labour situation and the arbitration provisions etc. We recognize that in any restructuring the role of labour is going to be very significant. We are very concerned about the impact of some of these things in our capacity as an employer as well as in our capacity as a provider of services. We certainly want to treat our staff, who have been so loyal to us for so many years, in a very positive way, But we do recognize that labour costs are part of the discussion and they will be part of the future development in this province.
We have of course noted the provisions in the draft legislation relating to the requirement that arbitrators consider certain elements, which will include ability to pay. We recognize the good intent that lies behind that. We are concerned, however, with how effective that will be. Again, I don't want to be negative, and we don't have time to go into detail, but I think it's fair to say that the history in this area in Canada has not been entirely positive in terms of giving directions to arbitrators, and I'm not negative towards arbitrators in saying that.
Our recommendation is that we would request that the government implement a more precise mechanism for achieving these objectives. Rather than delegating that in a very broad sense to arbitrators, we would recommend that some consideration might be given to a legislated moratorium on salary awards or a salary rollback or some other such device which would be established more directly to achieve this, with the hope that in the longer term as much as possible can be preserved in our collective bargaining process.
In a related vein, we would also request that more latitude be given to us in any restructuring in this very difficult question of contracting out. We recognize that there's a long history -- I'm not going to even mention it beyond that -- and we know how sensitive this is, but it will become a very important part of the process. We are concerned about that and we would hope that in the longer term this can be done in a way that will be in the best interests of the citizens of the province and of its workers. We would therefore ask that some further consideration be given to this issue of contracting out.
The last item I would like to refer to, and I'll do so quite briefly, is an important one in so far as it affects our organization and our style of operation: the Ontario drug benefit plan changes. We know these items are all very difficult and very broad, and it's easy to be critical and negative, and financial considerations are important, but most of the residents of our long-term-care facility, Providence Manor, are really not well-off at all in a financial sense. We hope they're well-off in other ways, I might add. Finances are very difficult, and many of them -- not all of them, of course -- really have just a little over $100 a month for their own needs. If my information is correct, and if these charges go through, we could find people in these circumstances with virtually no disposable discretionary funds whatsoever. Therefore, we want to draw this to the committee's attention. We feel it is an important issue, because a little bit of quality of life and freedom to make those kinds of decisions, for people who are in those circumstances, is extremely important.
0930
Therefore, we would ask that there be a further consideration given to these recommendations as they now exist which might provide for an exemption for the residents of long-term-care facilities from the user fee for drugs, or certainly a review of that situation.
Mr Chair, I realize that time is very pressing. There are many, many other things that we could have addressed. We have attempted to select just those few items which we felt were of particular relevance and importance to Providence Continuing Care Centre. We wish you well as you grapple with these important issues. I hope some of the things that we've said relating to the tool chest the government is building will be helpful and will allow us to do the job and we hope you will take these views into consideration for the overall best interests of this province. Those are all the comments that I want to make.
The Chair: Thank you. We've got a short time left for questions, about two and a half minutes per party, beginning with Mr Marchese.
Mr Marchese: Thank you, Mr Bonham and Sister Sheila, for your presentation and comments. I appreciate the gentle and restrained critical approach you're taking to this bill and to the Tories. There may be a reason. I'm not quite sure why you have been so gentle.
Mr Bonham: Because we're reasonable people.
Mr Marchese: Oh, I see. So far I have not witnessed that, but there's still time for that to change.
You talked about the ability through this bill to appoint a hospital supervisor who would have similar powers of the hospital board, and you're again in your gentle way saying it might be necessary but you don't quite agree with that.
We don't agree with that kind of power either. We think that if the government intends to do something as it relates to hospitals and it requires a change in the bill, or a bill, that it should be presented in the House for debate, giving the opposition the opportunity to be able to talk about those changes, giving as well the public an opportunity to hear the discussion, the debate, to bring it, if it's a change to a bill, after second reading to committee to allow people the opportunity to discuss. We think that's part of the democratic process.
This does not allow for that. So I'm sure you don't want to be gentle in saying this is wrong. We shouldn't apply a sunset clause to it. It's fundamentally wrong. Do you want to perhaps rephrase some of your comments around that?
Mr Bonham: Thank you very much for that kind of invitation to be more direct. We recognize the points you make. In our considerations, we have not yet been able to envisage a situation where this would be invoked.
Mr Marchese: So we don't need it then.
Mr Bonham: Well, we feel it is not necessary. What we were hoping to achieve is that realistic limits would be set on it in some way. It's the open-endedness of it that disturbs us more than anything, without any test or criteria.
The Chair: Thank you, Mr Marchese. For the government, Mr Clement.
Mr Marchese: Ah, time flies.
Mr Clement: Thank you very much for your important comments. Certainly you gave us quite a bit to think about and I thank you for adding your comments to the process.
With respect to supervisors, just since that's where Mr Marchese left off, I might add parenthetically that his colleague Frances Lankin has said at previous committee hearings earlier this week that she did recognize the need for some tools for hospital restructuring and we were quite excited by her comments on that.
Mr Marchese: Depending on what those tools are.
Mr Clement: Let me just talk a bit about the hospital supervisor, because of course that was in the previous legislation, as you well know. This is not a new concept that we are proposing. There are some changes, though. We eliminate the 30-day waiting period, and obviously we want to deal with situations where there's been a paralysis in the hospital environment. In a particular hospital maybe the entire board has resigned or there's something going on that might affect the quality of care in a community. If we focused in on those reasons to appoint a supervisor, would that satisfy you?
Mr Bonham: That would certainly go a very long way. I think it's the broadness of it, just the very open and unrestricted situation that we now see, that gives us the greatest concern. I think that would be helpful, certainly. Again, without knowing just what those issues are, it's hard for me to go beyond that.
Mr Clement: Sure. Let me turn then quickly to, you emphasized the need for local consultation. I think that's absolutely critical for the restructuring commission to do its job properly. I might add that under this Bill 26 we did not mention district health councils. So in fact that means that their current powers -- their advisory powers, their planning powers -- which are ensconced in the current legislation, are not changed; they're still there. If we made that more explicit, the connection between the district health councils and the groups that they represent and the restructuring commission, would that satisfy you?
Mr Bonham: Again, that would be very helpful. It was a broad issue we raised. We were not trying to be specific as to how the consultation would take place. Our only concern is that somewhere in the process, on a timely basis, there is a real opportunity to have views made known by the parties that will be involved. I don't think we're particularly concerned just where that is in the process, whether it's at district health council or somewhere else. We want to be heard if we're going to be involved. That's what we're saying.
Mr Clement: Quite right.
Mr Gerretsen: Mr Bonham, I too have been impressed with your gentleness about the entire situation. But Providence Manor and St Mary's of the Lake Hospital have been operating for over 135 years. It's a privately organized institution and has been for years run by the sisters, and very effectively so.
You've read schedule F of the act. The minister is not bound by any regulations under the Public Hospitals Act. He has unilateral power. "The minister may direct the board of a hospital to cease operating."
Now, I can see how a minister could say, "I'm not going to give you any funds any longer," but it's a private organization, started by a group of private individuals here. How can a minister, in your opinion, just unilaterally, without the consent of the Legislature, tell a private organization that's been operating for over 140 years in this community, "Now you will cease operating"? Don't you think that those are extreme powers?
Mr Bonham: Absolutely. I hope that nothing I said indicated that I felt otherwise. I may have been accused of being gentle, which is certainly not the worst thing I've ever been called -- I'm not going to tell you what that is -- but, yes, those are very extreme powers. And maybe I don't have an active imagination, but I cannot imagine a situation where that could be justified in any manner. I think what we would be talking about in a real life situation, if such ever developed, would be a set of circumstances where there would have to be some justification. If that was done just as an arbitrary thing, it would be a declaration of war.
Mr Gerretsen: But of course he doesn't have to justify it now.
Mr Bonham: No, I realize that.
Mr Gerretsen: Under regulations he would have to justify it. Under the way this stands in this act right now, the way it's proposed, he can just do it unilaterally, without any kind of liability to him either.
Mr Bonham: The door is open. We feel that is far too extreme, frankly.
The Chair: Thank you very much, folks. We appreciate your presentation this morning.
0940
SOUTHEASTERN ONTARIO HEALTH SCIENCES CENTRE
The Chair: The next group is the Southeastern Ontario Health Sciences Centre, represented by Terry Stafford, John Marshall, Robert Maudsley, Guy Legros and Paul Rosenbaum. Good morning, gentlemen, and welcome to our committee.
Dr Robert Maudsley: Good morning, Mr Chairman, members of the committee. Thank you for the opportunity to speak with you this morning. We are representatives of the Southeastern Ontario Health Sciences Centre, and in a moment --
The Chair: Excuse me. So Hansard can record it correctly, I wonder if I could get each one of you to identify yourselves so we know who's speaking.
Dr Maudsley: Yes. I'm Robert Maudsley, the vice-dean of medicine, Queen's University.
Dr John Marshall: I'm John Marshall, chief of staff, Kingston General Hospital.
Mr Terry Stafford: I'm Terry Stafford. I'm the chairman of Hotel Dieu Hospital.
Mr Paul Rosenbaum: I'm Paul Rosenbaum, director of planning and secretary to the health sciences centre.
Mr Guy Legros: I'm Guy Legros, one of the CEOs of the member institutions of this centre.
Dr Maudsley: If I just may make a couple of brief remarks before Mr Stafford will speak to our brief, Southeastern Ontario Health Sciences Centre represents six organizations. Those not at the table today are the Kingston Psychiatric Hospital and the Kingston, Frontenac and Lennox and Addington Health Unit.
We're a voluntary group. We work together. Simply put, our objectives are to have the most effective health care and medical care for the citizens of southeastern Ontario. Secondly, we prepare health professionals for the future, and we are very actively engaged in health care research. That's our broad mandate. We work very closely and cooperatively to try and foster those missions in this region. I'd ask Mr Stafford to speak to you, sir.
Mr Stafford: Our objective in this submission to the standing committee on general government is not to present a clause-by-clause analysis of Bill 26, nor do we intend to suggest a specific wording to correct problems in this bill. You are aware of the position taken by the Ontario Hospital Association in its submission to the committee. We agree with it. We do not intend to repeat the OHA's detailed suggestions with regard to wording change. Rather, we wish to address the basic principles underlying this legislation and to identify some areas in which the legislation actually subverts the government's principles rather than supports them.
The position which we take in this submission is not unique to the hospital sector. Similar concerns have been expressed to you by other providers of health services. We note, for example, the excellent submission by the Association of Ontario Health Centres.
Please recognize the significance of the similarity of our concerns. The Association of Ontario Health Centres represents providers of primary care health services and of health promotion programs serving small, underserved communities. Our members, on the other hand, represent the other end of the health care continuum. Kingston hospitals are tertiary care teaching hospitals providing the most sophisticated treatment services to Ontario's most severely ill patients and those with the most complex illnesses. From both ends of the health care continuum, you will have heard support for the principles of the draft legislation, along with a limited number of legitimate and deep concerns about how some of Bill 26 attempts to address these.
The objectives of Bill 26 espoused by the Premier, the Honourable Mike Harris, and by the Minister of Health, the Honourable Jim Wilson, are consistent with the broad policy framework clearly set out in the Common Sense Revolution. Throughout the election campaign, the Progressive Conservative Party clearly enunciated principles which would guide them in setting policy for health care in Ontario. We believe in these principles. We wish to see the proposed legislation amended to make it more consistent with these principles and with the policy objectives of the government.
Repeatedly, the government has stressed the need for genuine partnerships between it and its transfer partners, such as hospitals. The role of government is to set policy, establish standards and define the objectives by which public institutions must operate. The role of our public institutions is to manage their organizations in accordance with policy established by the government.
Bill 26 confuses these roles. Bill 26 would provide the Minister of Health with broad powers, indeed unprecedented powers, to direct and to manage individual health care organizations. Government should set policy for management, but it should not, and indeed it cannot, directly manage individual health care agencies.
The legislation would allow the Minister of Health to write hospital bylaws, thereby deciding the basic internal rules by which hospitals and their staff will operate. The legislation would allow the Minister of Health to determine the specific services to be offered within individual hospitals, and even the specific levels of service. These are not powers to establish policy, but rather the power to manage the day-to-day operations of the hospital.
We do not believe these new powers are necessary, nor do we believe they are consistent with government objectives. The Minister of Health, the Honourable Jim Wilson, in speaking to the annual meeting of the Ontario Hospital Association, said:
"At the Ministry of Health...we started by asking ourselves some fundamental questions, such as `What is our core business?' `What should we be doing and what can be done better by someone else?'
"To answer my own question, our core business will move from the position of direct service provider to that of strategic system manager. In the words of Peter Drucker, we will be `steering, not rowing.'"
The impression is that these broad and often unrestricted powers move the government from partnership to direct management of individual hospitals. Mr Wilson said that the government would work with the hospitals "jointly and individually, each working in our respective spheres." Give government the tools to set policy. Let hospitals keep the tools to manage in accordance with those policies.
Approximately one year ago in the Mike Harris Forum on Bringing Common Sense to Health Care, called "Bringing Common Sense to Health Care," the Progressive Conservative Party identified goals for the health care system. We support this document, which called for "a coordinated system of management, with health care professionals leading the way, working with government and incorporating community and consumer concerns." In part, Bringing Common Sense to Health Care promised "improving management and accountability at all levels of the health care system to make it more responsive and accountable to the people who provide care and the people who receive it."
Bill 26 in its present form will not improve management and accountability. Bill 26 threatens our collective ability to manage the health care system by allowing those responsible for developing policy directions to attempt to manage the health care system. Paradoxically, the bill would provide a disincentive to effective hospital management by allowing, or requiring, that difficult decisions be kicked upstairs to the government in Toronto. Effective hospital management must be in the hands of those in our hospitals and communities. This was clearly recognized by the government prior to the election, and it has continued to be the government's policy objective since coming to power.
Bill 26 attacks the systems of accountability which currently exist. The bill gives government unrestricted powers to write bylaws, unrestricted powers to determine the types and levels of service that should be provided, and unrestricted powers to set conditions for funding and thus micromanage the day-to-day operations of the hospital.
One year ago, the Progressive Conservative Party wrote in Common Sense: "We believe that Ontario's health care system would benefit from a team approach to management at all levels. Under our approach, professionals would be encouraged to bring innovative ideas forward and assist in system management, creating more of a team environment. This would lower barriers between professionals and management and focus everyone on improving health care for the people of Ontario."
By granting the Minister of Health the power to manage individual hospitals, team-building is undermined. Are all of these new powers necessary, or even helpful? We do not believe so.
The Minister of Health can meet his responsibility to oversee the hospital system and to ensure compliance with government policy in a number of ways. The requirement that the ministry approve hospital operating plans, the power of the minister to approve changes to hospital bylaws, the right of government to set funding levels, and the right to appoint a hospital supervisor are some of the ways that government can ensure hospital compliance to government policy, and they do not undermine the ability of hospitals to manage their own affairs.
Bringing Common Sense to Health Care recognized the need to continue strong community involvement in health care and to foster community involvement, promising "to give communities more say in establishing their own local health care priorities, as well as how and where they want health care services to be provided."
0950
Bill 26 in its present form does not foster community involvement. Bill 26 threatens a community's ability to make decisions about health services. The current Public Hospitals Act allows the minister to veto changes to hospital bylaws. We believe the change from the veto power to the power to create hospital bylaws is a significant and unnecessary, perhaps dangerous, new power. Under Bill 26, there are no substantive decision-making powers left exclusively to the local hospital board. All of these may be superseded by decision-making by the Minister of Health. With the power to write bylaws moved from the hospital to Queen's Park, the board becomes a shell. We believe this threatens the voluntary nature of hospital governance which has been the strength of Ontario's hospital system.
At the Ontario Hospital Association, the Minister of Health said: "You have asked the government to affirm its commitment to hospital voluntary trustee governance. Yes, I am doing that today." Bill 26 may threaten that commitment.
Last year, the Progressive Conservative Party noted that "For too long, the public has been a silent partner in important health care decisions, and has had to defer to politicians and administrators to manage Ontario's health care system.... In too many cases, there has been no real consultation with the public before services which people value highly are reduced."
Despite the policy objective of what was at the time termed "true consultation," Bill 26 does not require consultation even on the single most significant reduction of service: the closing of a community's hospital.
We understand the need to restructure Ontario's health care system. We agree that the health system must be restructured. But ultimately there must be public accountability for decisions which may profoundly affect individuals and communities. Under the proposed legislation, an appointed commissioner may close or order the amalgamation of hospitals without public consultation and without the express approval of the Minister of Health. We believe such decisions should not be delegated, and must rest ultimately with the Minister of Health.
In Bringing Common Sense to Health Care, the Progressive Conservative Party identified the real need to ensure the rights of our patients. The paper called for treatment which "recognizes one's privacy, dignity, and individuality." But under Bill 26 this principle is undermined. Simply by using our hospitals, our patients will be seen to have given consent to the disclosure of information about treatments received. Bill 26 threatens the privacy of the patient. A patient's use of the hospital cannot be seen as having freely given consent to the release of personal medical information.
Further, the minister may enter into agreements with others to collect or release such information. Under Bill 26, the minister would not only have the right to release information about the services received, but also could allow others to use such information. The unrestricted right to release patient information from the medical record risks the privacy, dignity and individuality of our patients.
We are given to believe, from reports in the press, that the government intends to amend this section of the bill. The release of information from the medical record tied to the names of individual patients is not necessary for health care system management.
We believe the principles underlying Bill 26, principles which we endorse, may be better supported through a number of amendments. Underlying our suggestions is the belief that broad new powers should only be given to government where they are truly needed.
First, where there are to be significant alterations in hospital operation, such as closure, amalgamation, or major program alterations, hospitals and the local communities should have the opportunity to comment before change is implemented in order to ensure community participation in health care decision-making.
Second, significant alteration in hospital operation should require the concurrence of the Minister of Health in order to ensure public accountability.
Third, language granting the minister power to manage hospitals on a day-to-day operational basis should be amended to provide only those powers necessary to ensure adherence to government policy and the sound local management of the hospital.
Fourth, volunteer hospital boards should be supported, as should the board's rights and responsibilities to establish bylaws and oversee those people they select to manage the hospital.
Lastly, privacy of patients should continue to be protected.
We urge the committee to consider the detailed proposals for amendment made by the Ontario Hospital Association and others.
Thank you, Mr Chair.
The Chair: Thank you, gentlemen. We've got about three minutes or so left per party for questions, beginning with the government.
Mrs Janet Ecker (Durham West): Thank you very much for coming today and putting in a lot of work and making some very excellent suggestions in your brief and submission. If you have any further comments or suggestions, we would certainly encourage you to make sure they are submitted to us.
I'm pleased to see that you recognize the principles of the Common Sense Revolution and the restructuring in health care and what we're trying to achieve here. I also appreciate that you have some concerns and suggestions about how the bill may well be amended.
As you know, the confidentiality area is something that has provoked concern from some individuals. Certainly, the protections for confidentiality that were there before within various legislations we believe are still there, but if there's a way to enhance that, we're prepared to consider that and are indeed working on that.
The other point I would like to make, of course, is that without the sharing of information within the health system -- anonymized, as you mentioned -- we would not be able to have the work of places like the Institute for Clinical Evaluative Sciences, ICES, which as you know has done some remarkably good work in helping hospitals be able to figure out what it is they're doing in what areas and regions of the province. We wouldn't be able to have that kind of good research in the system without some appropriate sharing of information.
If the ministry is to restructure the system -- and you mentioned that the minister has talked about steering, not rowing. The only way one can steer and not row is to be able to give appropriate direction. We've heard from many communities and many hospitals that they want the ministry to be able to make some difficult decisions within their local communities. My region, is one where we went through a local restructuring exercise, but then we needed the ministry to make some decisions and to get on with helping the community restructure. We have heard that message from many areas.
With the appropriate safeguards which you've mentioned -- we've talked about sunsetting, we've talked about changing the minister's ability to influence hospital bylaws so that the bylaw power of hospitals is allowed to be there -- with those appropriate safeguards, do you see areas where communities do need the ability of the ministry to make some decisions, as long as that local consultation is there, as it currently is? There's nothing in Bill 26 that changes that. As long as that is there, is there some way for the ministry to be able to make some of these decisions and get on with the job of restructuring, which the hospital community has told us is very, very urgent?
Mr Rosenbaum: I'll answer that. I think the difficulty first is that there may be some communities in which hospitals will be unwilling to act without there being intense pressure brought to bear. We recognize that. We don't believe this is one of those communities. In fact, we've had a long history of collaborative relationships, one in which we have voluntarily transferred programs and budgets between our institutions in order to rationalize services as much as possible. Nevertheless, we recognize that this is not universally the case.
The problem is that the bill allows for forced changes in programs without the need that there be consultation, and ultimately there's no accountability, or there need not necessarily be accountability. The minister really must stand behind the decision which is made to amalgamate a hospital. Accountability can only be assured through the electoral process, and a commissioner stands outside that process.
1000
So I think there are those two changes which we see as essential to this bill. The first is that hospitals be given an opportunity to comment before the recommendations are implemented, and secondly, where there are major changes, that the minister acknowledge and accept those recommendations, that they not be implemented by a commissioner.
Mrs Lyn McLeod (Fort William): I appreciate your very thorough underscoring of the concerns of the Ontario Hospital Association, in fact the unanimous concerns of everybody except Conservative government members, about the unprecedented and unilateral powers granted to the Minister of Health under this bill. I believe that those concerns are increased by the fact that this bill is all about cutting dollars out of the health care system. It is a finance bill presented by the Minister of Finance on the same day that the Minister of Finance took $1.3 billion out of hospital budgets and about $1.5 billion out of the budget of the Ministry of Health. This is a bill that essentially makes the Minister of Health subservient to the Minister of Finance. I am deeply concerned that as the powers under this bill are exercised, there's going to be a lot more concern with cuts than there is with community, and that's why I believe people are worried.
I would like, however, to ask you to comment today on some powers in the bill in a section that you haven't commented on, recognizing the varied expertise of the people who are here. As you'll be aware, there are powers under this bill which allow the government for the first time to prescribe what is medically necessary and set the terms and conditions under which care can be provided to patients. It also provides the government with the power to deny payment to physicians for care that has already been provided if it's seen to be not medically necessary, and in fact to force physicians to compensate the government for the cost of referrals if referrals were found to be not medically necessary. I wonder if you could comment on what you think that might mean to patient care.
Dr Marshall: While recognizing the necessity for the province to put its fiscal affairs in order and recognizing that health care, along with other sectors of the public purse, must make a contribution to that, and my profession is part of that sector, the powers that the government potentially takes upon itself, and in fact takes upon itself in this bill, allow it to intrude in a pre-emptive way into the relationship between a physician and their patient in a way that pre hoc, not post hoc, may well affect decisions in patient care.
While one does not necessarily anticipate the use of that power, and while one can understand at the end where that power might be used and directed in an extreme circumstance, the very existence of that power causes the relationship and the decision-making of physicians to be made under a particular threat.
To say that in a particular instance that will affect an individual physician's decision is probably not true. But individual decisions are made in a climate, and that climate will gradually change. I think this threat, even if not used, has a potential of having an effect on the way patient care is delivered.
Mr Marchese: Thank you all for a very thoughtful presentation. I want to highlight something that you said that I have observed in the House in the last short while. We were dealing with employment equity in the last couple of months, which has been repealed rather quickly by this government. Mr Clement is here, and in fact he said that bill was very "intrusive"; he used that word. He in fact even said it was very "draconian," and used other words as well, which I'll refrain from saying.
The point is that what you've done today that I've identified is the contradiction between what they say and what they do. On the one hand, they will say: "Employment equity was very draconian. We've got to get rid of the Advocacy Act because it's too intrusive." On the other hand, they introduce a bill, Bill 26, which in effect does that. It's very intrusive, is very draconian, and they find ways to justify it and justify why it is that they must get rid of something that's intrusive in other areas.
Do some of you have a sense of why it is that they can contradict themselves in this way, why it is that they need these draconian powers? Is it really for health-related reasons?
Anyone? Be gentle now. If not, I'll move on to another question. If you think it's too political, I'll move on.
You've made a number of recommendations that I think go beyond simply changing a word or two and then we fix Bill 26. I think if we implemented your recommendations, it would fundamentally alter Bill 26 and I'm not sure they would do that. But I really believe that a lot of what you say needs to be reflected on. I'm not sure quite sure that we're giving enough time to the Conservative members and the policy people who draft these things to consider these amendments in a very thoughtful way. Do you think that they will have enough time to implement some of these changes? Do you believe that we need more consultation or more time in order to be able to give the public and the Conservative members time to be able to properly deal with some of the suggestions that you and others have made?
Mr Rosenbaum: You've invited a question. I'd like to answer a slightly different question and say that we've made it clear that we believe the bill can be improved by amendment. How much time is required I wouldn't speculate. I think the government has at its disposal experts within the various ministries who could address those problems.
I note, for example, Ms Ecker's remarks with regard to confidentiality. Her confidence that the confidentiality of patients will continue to be protected, I think, is a matter of interpretation, looking at the legislation. In that case, it may be a simple modification which is required, making clear that the release of a medical record to groups like ICES doesn't include the names of patients. That's a very simple amendment to the legislation.
As to how much time is required to address these, I don't know. As I say, I think the government has adequate resources to address them.
The Chair: Thank you, gentlemen, for your presentation. We appreciate your interest in our process.
Mrs McLeod: Mr Chairman, I have a question I would like to place on the record for the ministry staff to respond to. I'd like to place the question while there are people present who are involved in psychiatric care and expressed a concern for the confidentiality of records.
This is an issue which comes up on a regular basis. Yesterday in our hearings, Mr Chairman, you'll be aware that in response to a concern about access to records the government members provided an assurance that there was no need to be concerned about access to psychiatric records because the Mental Health Act would supersede the provisions in this bill.
It is our legal opinion, subsequent to that statement being made, that the Mental Health Act can only supersede this bill for patients who are resident in a psychiatric hospital; that for anybody being treated in an outpatient clinic or in a doctor's office, a psychiatrist or a general practitioner's office or in a general hospital, this bill would in fact have force and effect. I would like the ministry to respond and clarify that issue.
The Chair: Before the next presenters come forward, I do need to address something. The basic rules of the committee process are that the audience does not participate. Now I'm prepared to allow you to show your pleasure at the end of a presentation to somebody, but there may be somebody come forward who expresses an opinion you don't agree with. I wouldn't expect you to boo them. I would ask to --
Mr Alvin Curling (Scarborough North): Oh --
The Chair: Mr Curling, I'm in charge of this process, please. I would ask you to please either show your appreciation once at the end of the process or we will have to go by the strict rules of order and that is that there's no audience participation. I'd appreciate your support in that.
Interruption.
The Chair: We've got a couple of options here.
Interruption.
The Chair: Folks, we're in Kingston to listen to the concerns of the people of Kingston. We've got a couple of options. We're here till 1 o'clock. We can listen to people or we can recess the hearings. We've got a couple of choices.
1010
NORTH KINGSTON COMMUNITY HEALTH CENTRE
The Chair: The next group is the North Kingston Community Health Centre, represented by Tanya Beeler and Charlotte Rosenbaum. Good morning and welcome to our committee.
Ms Tanya Beeler: Good morning. I am here as president of the board of directors of the North Kingston Community Health Centre. With me is Charlotte Rosenbaum, the centre's executive director.
The North Kingston Community Health Centre is a primary health care facility which serves the residents in the northern part of the city of Kingston. This area includes a large senior population, as well as the highest number of children in the city. The community health centre was founded because community residents and health care professionals demonstrated to government the higher burden of illness in this area and the need for primary health services.
Community health centres are prime examples of organizations which are flexible and responsive to a variety of needs in the community. They are organizations which focus on individual and community strengths rather than weaknesses, and are fully accountable to the communities they serve and their funding bodies. They incorporate a team approach, effectively using a range of health professionals. All staff members working in community health centres, including physicians, are paid on salary.
We are proud of the many innovations in health service and health promotion in our community. Through intensive community work we have been able to develop programs and services which are needed by our community, and to move beyond the direct provision of services to the larger problems which affect people's health. We believe in fostering self-reliance and supporting individuals and communities to take responsibility for health solutions.
Volunteerism is the lifeblood of many organizations across Canada, and many volunteers contribute their time and energy at the community health centre. Most importantly, the community health centre is governed by a volunteer board of directors which provides a link between professionals, the local residents and ministry funders to ensure high quality, responsiveness and accountability.
The North Kingston Community Health Centre is a member of the Association of Ontario Health Centres and strongly endorses the submission made by that body to this committee. Without repeating too much of what has been already stated, we would like to respond from a local perspective to some of the provisions in Bill 26.
Before voicing our concerns, however, we would like to put them in the context of our general support for reform of the health care system as stated in the Progressive Conservative document Bringing Common Sense to Health Care and in sections of the omnibus bill. In particular, we would like to express our support for the addressing of maldistribution of physician services; the rationalization and restructuring of the hospital system; alternatives to the fee-for-service system of physician remuneration; the emphasis on consumer and provider input; and the upholding of the principles of the Canada Health Act.
Indeed, our concerns in Bill 26 stem from areas where there seems, in our opinion, to be discrepancies between stated principles and new or amended legislation.
As we understand the bill, it provides for a range of facilities such as community health centres to be deemed as independent health facilities. It also allows for the minister's discretion to specify persons who may send in proposals for a licence to establish and operate an independent health facility. The bill eliminates priority to non-profit, Canadian-based health care services.
The high standards of quality of care set by Canadian non-profit health services should be the yardstick by which proposals are measured so that proposals professing initial cost savings are not translated into poorer quality or transfer of costs to consumers.
We are concerned that the proposed changes to the legislation will make it possible to narrow the selection process and eliminate fair opportunities to the public to tender for independent health facilities licences and that the principles of quality in our Canadian system may be undermined.
We are aware of the importance of swift and effective action to preserve the best of our health care system and eliminate waste and ineffectiveness. The government has committed to involvement of the public in health care decision-making and to creating opportunities for health professionals to provide innovative ideas from the front line.
Provisions in Bill 26 do not require such a process and make no allowances for input from either consumers or health professionals in key decision-making. Although we feel involvement of consumers and health professionals at all stages of planning is essential, the current bill does not even allow for a system of appeal once government decisions regarding hospital restructuring have been made.
We are concerned, along with our hospitals, about the proposed limitations put on boards of directors which could reduce their powers to make key decisions on a local level. These volunteer boards of directors represent a connection to health services and to government funders for the entire community. They engender a sense of caring and ownership for local institutions.
We are also fully aware that this sense of ownership can make restructuring and reform difficult at times, but we believe that communities which are given the opportunity to develop better local health care services can meet this challenge.
The Minister of Health currently has power to set health care policy and priorities, to fund or not to fund services and programs, to reduce budgets, veto hospital bylaws and ensure that systems for accountability and management are in place.
We strongly support the minister's role in determining mandates and ensuring compliance in a time-efficient manner. Although grateful for this opportunity to comment on a bill with such far-reaching implications, we are opposed to lengthy consultations which can become battlegrounds for interest groups to maintain or increase their turf.
Our concern is the sweeping powers in the bill which allow the minister to act in the public interest without any guidelines as to how this may be determined and to transfer powers to an investigator who may assume all of the board of directors' authority and responsibility.
Ironically, our ability to participate in decisions about our own health care may have more of an effect on our health than the actual services we receive. Studies have shown that people who feel they have control over their lives and have a strong commitment and involvement in their communities have better health outcomes.
For these reasons, it is extremely important that the role of volunteerism and community input is not lost from our health care services. If extraordinary powers are needed for extraordinary times, people must fully understand the nature and purpose of these powers and at the very least have an appeal process available.
Primary health care typically involves primary prevention and secondary prevention. Primary prevention means taking measures to prevent an illness or condition before it occurs; for example, screening for diseases, immunization, healthy lifestyle practices. Secondary prevention involves the treatment of an illness or a condition once it has occurred to prevent it from getting worse. It may involve direct treatment such as medications coupled with lifestyle changes which improve health.
An example of secondary prevention in primary care is hypertension management. A person diagnosed with high blood pressure is at risk for coronary disease and stroke. A family physician or nurse practitioner can assist a patient to manage their hypertension effectively with proper medication, diet and exercise.
The savings achieved through primary care by the out-of-hospital management of thousands of patients and conditions has not been adequately measured. Yet the high risk for hospitalization for many people, particularly seniors, if these medications were not available, translates into much higher costs and unnecessary human suffering.
We are concerned that the proposed changes to the Ontario Drug Benefit Act which will require copayments from eligible persons "to bear some of the costs of receiving drug benefits" put undue hardship on many and may result in a false economy.
Seniors may have to choose between medications or proper nutrition, leading to irregular use of needed medications and unbalanced nutrition. Parents may choose to forego their own needed medications to ensure they will be able to cover costs for their children. Individuals with chronic conditions with significant drug costs may require more frequent use of institutions.
1020
In north Kingston, 96% of seniors have family incomes of less than $20,000 per year and approximately two thirds live in rental accommodations. A senior with a heart condition could be taking three medications on a regular basis. The combined deductible and dispensing fees would have a significant influence on annual income after costs of living are paid.
Seniors in this country are very proud and resilient. Many have lived through the Great Depression and a world war. It is our experience that they will do without before they will admit they can't afford something. A senior on a low fixed income and in poor health will be making compromises every single day on what is absolutely essential and what can be put off.
As representatives of a primary care organization, our job is to keep seniors like this as healthy as possible and avoid hospitalization. This added burden to seniors with low fixed incomes could make this task a lot more difficult to achieve. Maintaining individuals in the community through proper medications is a real economy which should not be overlooked or compromised.
We are also concerned that all drug products that are medically necessary and efficacious are listed as benefits and that price is not a determining factor for their inclusion. We also urge that if the bill makes changes to allow the minister to negotiate price directly with the manufacturers, the public is informed through a clearly stated process of the substance and basis for these decisions.
Primary health care focuses on the prevention and early detection of illness to prevent further damage. We fear patients will be reluctant to come for care and discuss problems such as substance abuse and sexually transmitted disease for fear of disclosure. They may fail to receive needed help before the condition becomes chronic and also poses a threat to public health.
We see patients as active participants in their health care, not as passive recipients. Health care providers enter into relationships with their patients which are built on trust and mutual respect.
Each of us in this room has entered into this type of relationship with a health professional. This relationship may have been positive and may have not been. But in each case, we enter into this relationship on the tacit understanding that the information we disclose shall be used for medical purposes only in the process of our care and treatment.
Each of us has shared information with a health care professional which we would be deeply concerned about being shared outside of medical necessity.
We are concerned that provisions in the bill allow for what appears to be the unrestricted disclosure and release of personal medical information if the minister or general manager deems it necessary for management of delivery of the health care system or "for any other purposes as may be prescribed."
Further, it allows the government to disclose personal information to any party it enters into agreement with. We are deeply concerned about the release of information on this basis without any protection for individual right to privacy.
These proposed changes, which so directly affect the individual's right to privacy, dignity and care without discrimination, seem in direct contradiction to the government's commitment to a health care bill of rights and out of step with the spirit of the Common Sense Revolution.
We have highlighted a few of the concerns which were apparent to us from a local perspective. Although realizing the importance of haste in reform of the health care system, it is imperative that the principles set out by the government not be set aside for expediency's sake.
In light of the government's principles relating to fairness, public involvement in health care and protection of individual right to privacy, we recommend that government ensure that these principles are not compromised or undermined by any provisions in Bill 26.
We would like to be assured that the importance of the autonomy and accountability of board of directors is respected and maintained; that the need for public accountability and informed community input into health care decisions is recognized as essential and healthy; that the potential threat to individual privacy through unqualified release of individually identifiable medical information is eliminated; that medications remain accessible to those most vulnerable to disease and disability and that limited cost savings at one end of the health care spectrum do not translate into greater costs at the other end.
The board of the North Kingston Community Health Centre thanks the committee for giving us this opportunity to present our views and hope that they will be constructive.
Mr Frank Miclash (Kenora): Thank you very much for your presentation. I think we all know how important voluntarism is in the health care field. I'm looking for the impacts this bill will have on the quality of care that you, as an organization, provide to your patients or the people you serve. If you could expand a little bit on where certain aspects of the bill will affect that quality of care, I'd appreciate it.
Mrs Charlotte Rosenbaum: It's hard to say how directly it will affect it. As the previous speaker said, health care decisions and health care are provided in an atmosphere. If providers feel they are viewed as people who are working against the system rather than as part of the system, and if patients feel they don't have protection for the kinds of information they release, eventually it's going to erode that relationship. Particularly at the health care centre, we try very much to have patients become more active in their own health care, and I think some of the provisions in this bill will actually be a deterrent to that, that people will pull back.
Mrs McLeod: One of my frustrations with this bill is that it touches on so many areas and any one of them needs individual hearings so we can look at the impact of it. I appreciate your touching on a number of them including the access to information, and the irony that the copayment not only will be a penalty for those who have to pay it but they end up being more costly for the government rather than bringing in any real revenue. You touched on one that rarely comes up, and it's rather mysterious that the government wants to open new independent health care facilities without even a request for proposals.
I'm going to ask you just one very specific question on the whole idea of comprehensive health care, because that's what you're involved in in a community. Given the past history, I think 1973, when there was a major deinstitutionalization of psychiatric hospitals and we were supposed to provide community care, and we're still, 22 years later, trying to provide community care, are you concerned that cuts will be made to hospitals, that there will be a loss of hospital service in the restructuring process without the dollars being made available to the community? Do you feel that you need the reassurance, as a community, that the dollars that are saved will come back into the region and the community to be used for health care here?
Mrs Rosenblaum: In all fairness to the present government, every other government has promised that and never delivered it. We're kind of hoping this government will.
Mr Marchese: Thank you for your presentation. I want to ask you a question in relation to what you said about your concern over long consultations and that this might give an opportunity to interest groups to take the process over. I'm more or less paraphrasing what you were saying. I'm concerned about that, because I view you as an interest group, as I do all the other presenters, and I think all these interest groups that are coming today, that would like to present today, are important interest groups in the process, because they all have something to say with respect to their respective disciplines. I don't see interest groups as a negative. I see interest groups as a positive thing and thank God they're here.
Did you have something in mind as to who these interest groups might be other than the people who are here?
Ms Beeler: It certainly wasn't my intention to imply that interest groups shouldn't be involved. Obviously we are here today. I think what there often tends to be -- and I've been involved in various things like this -- is when some people are allowed to speak and some people are not it almost forces interest groups to be somewhat territorial and it can be a divisive thing within the community.
Mr Marchese: Right. That's the point we're making with respect to who can speak and who cannot. If you don't give adequate time to people to be able to be properly consulted and to have a say, it could happen that those who are quick on the mark, who have a sense of what to do and what to say, will be the ones who will be heard as opposed to the others. So the point of it is to make sure that there's adequate time for everybody to be able to have a say, because all of us are affected by this bill.
Just to move on to another question, you talked about the issue of copayments, more commonly known as user fees, and you talked about the Ontario Drug Benefit Act and the changes to that and the effect it would have on seniors. Some seniors take not only three drugs potentially but up to 10, we're told by different users in the health field, so the expenditures can be great.
But if you take that in isolation of all the other user fees that are about to be imposed through the tools kit that this government has given the municipalities as they download, then municipalities will impose user fees, doctors and hospitals will do that, the independent health facilities will do that, and then of course we have the drug plan.
If you take them all into account, that puts a greater burden on the seniors other than simply the point of user fees on the drugs. I'm assuming that if you take that into account, it will have a devastating on seniors in particular. Do you not agree?
Ms Beeler: Yes, added user fees will certainly have an impact on people, particularly seniors on low and fixed incomes. There's no question about that.
1030
Mr E.J. Douglas Rollins (Quinte): Thanks to you people for being here today. It's nice to see people like yourselves who do a lot of volunteerism and work with that. This government is certainly complimentary to people who do volunteer. You stated that past governments haven't followed through on their wishes and the hope that we can.
Interjection.
Mr Rollins: Well, there may be a change afoot, you know. Things have happened that way.
We are working under the Canada Health Act and we try to stay under that with some of the restructurings that have to go on. I know it's not an easy situation to be in. We have to be in position where we may have to make some decisions of closing some hospitals and things of that nature, and also putting some of those services back out into the community, out of the hospital.
I think with some of the things, like dialysis, that we're putting out into the communities, that are reinvesting those moneys that are being put out, those are the types of things that have to be followed up on and allow customers, you might say, or the people of Ontario the privilege of having that facility a little bit closer to them.
Regarding your copayment, we do realize that there is some concerns with people on low income, of that nature, and I think it does not fall completely on deaf ears. It is one of those kinds of things we have to take a look at. On the other hand, we have to be able, somehow or another, to reinvest our dollars in the health care system to make sure we get the best bang for our buck that we have. I think without exception, hearing many, many presentations, there's nobody who has come to the table, or who hasn't come to the table, and said it's completely right and perfect at the present time.
I don't perceive the things that we're going to do as being all right and perfect, but I do believe that it's a start in a direction that we can make some changes and make them for the better of not only people like yourselves but also everybody in the province of Ontario. I think that's one of the things we have to follow.
Licensing of these places: We certainly have to have the utmost of quality, top-notch, best-possible care for the people we represent. On behalf of the government, we can assure you that's the input we're going to make sure happens. Thanks for coming. We appreciate it.
The Chair: Thank you very much. We appreciate your presentation and your interest in our process.
Mr Miclash: Mr Chairman, we have had yet another amendment suggested. I would like to make a motion that at this time we ask that those amendments that have been referred to or suggested be tabled so that we can take a look at them, so that we can move on in our hearings, knowing what the government has in mind. We just had a member of the Conservative Party suggest there was yet another amendment that we have yet to have access to, and I would certainly like the tabling of these amendments as we go along.
The Chair: Is that in the form of a motion?
Mr Miclash: Yes.
The Chair: Okay. We do have people waiting to make presentations. We didn't come here to argue among ourselves. We came to listen to the input from the people of Kingston. Can I have all-party consent to discuss this when the presentations are over? Everybody agree with that? Okay.
KINGSTON AIDS PROJECT
The Chair: The next presenters are Evelyn King and Paul Waltenberry of the Kingston AIDS Project. Welcome this morning to our committee.
Ms Evelyn King: Good morning. First I would like to thank the opposition parties for their stance against Bill 26 and advocating for public hearings.
Mr Miclash: Yes. Alvin.
Ms King: Yes, especially. I believe you prevented the ramming through of this undemocratic piece of legislation. We now have a democratic process which is unfamiliar to this government. It saddens me as a citizen of Ontario that these hearings were forced upon the Progressive Conservatives rather than being implemented by them. It reinforces my opinion that the Tories have declared war on the middle class, the poor, disabled and seniors of this province in order that the wealthy and business community can benefit.
During the election campaign Mike Harris made many promises. He provided hope for many when he promised to create 725,000 jobs. To date, we have only witnessed job losses. He also stated that he would not cut health care. This bill certainly invalidates that statement.
Hospital closures, staffing cutbacks and the emigration of doctors to other provinces or countries can only hurt the health care criteria of Ontario. The waiting lists for specialized tests and surgeries are currently too long. If so much money is taken out of the current structure of health care, how can it be more effective? The implementation of user fees will cause financial difficulties for seniors and the disabled. Most are on limited incomes and a vast majority must take multiple medications. Families with children will also be affected if there is a long-term illness or a disabled child. The new powers allocated to the municipalities through Bill 26 will also place an added expenditure on low-income Ontarians when user fees are implemented.
This government has been getting a lot of mileage from the statement, "We are spending $1 million more an hour than we take in." This from a government that has not yet produced a budget. We all agree the deficit must be lowered, but I have a problem with the continual attack against the less fortunate of our society. It was not welfare recipients or users of social programs that created the debt. They do not live a profitable life, as suggested.
The real beneficiaries are the large corporations and the rich who have been subsidized for years through tax deferrals and tax expenditures. A government should require our wealthy and business community to carry their fair share of the tax burden. I can only believe that this government has an agenda, and that is to create a tax-free business community at the expense of the low- and middle-class citizens of Ontario. There is a great deal of pain mushrooming through this province. I find it hard to fathom that the Tories cannot see or hear this. Why are there so many demonstrations and why is Queen's Park like a fortress? I have never seen Ontario in this state.
Another area of concern for me is the ministers in high-profile positions with no previous experience. How can critical decisions be made without consultation? You are dealing with the lives and livelihood of people, not commodities. A case in point is the decision to remove the rent-geared-to-income program. In order to maintain affordable housing, many seniors, disabled and families rely on this program.
How many people will become homeless because of this decision? Of course it is stated that something will replace it, but my confidence level is not high. With rent controls being eliminated, I envision landlords rubbing their hands in glee. The private sector will not provide affordable housing because they will not make a profit. In Kingston the vacancy rate is rising, yet the applications for subsidized non-profit and co-op housing grow daily.
I realize I have strayed from the health issue, but I believe these issues are all related. Good health is dependent on the security of employment and affordable housing.
Bill 26 opens the doors for all types of abuse by the government. This bill will allow access to my personal health records, which I really resent, and I'm sure others do in the province. Bill 26 will create a multi-tiered health care system in which only the rich are guaranteed full access. The Minister of Health is being granted too much power by this bill. Where in a democratic society does an elected politician warrant such dictatorial powers?
On these points alone my suggestion is to scrap Bill 26. The omnibus bill is a contradiction to the Tories' campaign promises and it will create havoc in Ontario.
1040
Mr Paul Waltenberry: My name is Paul Waltenberry, and I'm a community worker with the Kingston AIDS Project. When I was first asked by Evelyn to come before the committee, I contacted many service organizations across Ontario on what their reflection would be if this bill was passed. Here is one of the things they said: "If this bill is put forward and passed, it will have enormous repercussions for people living with HIV/AIDS in this province and especially for us in the Kingston area."
I would first like to address the issue of facility pay. Many of the individuals who are living with this disease cannot afford any type of group or private insurance. Furthermore, many people who are living with HIV/AIDS are on a disability and fixed income. Therefore, any further fees will force our consumers to live further below the standard they are forced to live with now.
Another section of Bill 26 will allow the minister to have unilateral powers over patients' files and the collection and disclosure of information that is presently confidential. In Canada today there are approximately 70,000 individuals who are living with HIV and AIDS; 41% of that number live in Ontario. Those are individuals who have come forward to be tested. If this bill is passed, individuals who may suspect that they have been put at risk of contracting HIV will not, and I repeat "will not," come forward to be tested. There are reasons why. Please let me take a moment to explain.
Discrimination is one of the most feared forces that someone living with this virus experiences. People living with AIDS face an inordinate amount of discrimination directly or indirectly every day of their lives. Although it is illegal in Ontario to discriminate against people living with HIV/AIDS under the Human Rights Code, we hear and have witnessed stories of ignorance, fear, denial and hatred every day.
People have been denied such necessities as social and medical services, insurance, employment, children and family support because of their HIV status. If this bill is passed, then everything that AIDS service organizations across this province have been working towards will be non-existent. In Ontario today the availability of non-discriminatory medical services should be seen as a national shame, simply because someone has contracted an illness which is spreading faster than our ability and willingness to deal with it. This should never have happened, but our collective denial and active discrimination by this government have allowed such a situation to flourish.
If this bill is passed, it will allow the government to deny its collective agreement to protect the rights of every citizen of this province, including people living with HIV/AIDS. If this government refuses to protect the privacy and continues ahead with the power to access confidential files of patients and to disclose the information that is contained therein, it will have enormous repercussions. I urge you to protect the right to privacy for everyone in Ontario, especially everyone living with this terrible virus. You cannot allow this act to be passed in its present form.
Another area of concern is the government's right to delegate and authorize which patient is allowed to receive treatment or care for their illnesses. People living with AIDS face many opportunistic infections that are directly related to the virus. These infections and treatments are sometimes very costly, but some have been known to prolong or improve the quality of life for somebody who's living with HIV/AIDS for a period of time.
What right does this government have telling someone that they do not qualify for various medical services, not even being a doctor or having insight into the individual's illness? But based around the almighty dollar, this bill will deny the people of this province their basic human right to medical services.
In consultation with other AIDS service organizations across Ontario, we fear that if this bill is passed, discrimination will also play a large part in this government's decisions to approve or disapprove various treatments that may be costly and because PHAs, people living with HIV/AIDS, face discrimination at every turn, this bill will only reinforce that.
Many of our consumers fear that the impact of this legislation being passed by this present government will allow politicians to cater to a two-tiered system of health care, the individuals of this province who are able to afford high costs of treatment and people who are financially not able to afford treatment. Therefore, the quality of medical care that is supposed to be afforded to everyone in Ontario will no longer be available.
Services that are already insured are at risk of being eliminated by this bill. Many of the treatments and medications that are now available to people living with AIDS are still in the experimental stages. This bill will eliminate various services already insured through the Ontario drug benefit plan. Therefore, people living with AIDS, most of whom are on a fixed income, will not be able to afford these treatments and medical services. People will get sick and, not being able to afford the medical necessities of life, will die quickly. Passing this bill in its present form constitutes abuse and will enable this government to regulate who has the right to live or die. As an advocate for persons living with HIV and AIDS, I strongly urge this government to rethink its decision and regulate and control our health care system.
It has always been my understanding as a person living in a civilized and democratic society that regardless of which party is elected to lead this province and regardless of the individuals who chose to elect this party, this government is here to represent every citizen of Ontario and not a select few who can afford to be a part of this present government.
Mr Marchese: Thank you for your presentation. I want to refer to Mr McCaskell, who was from AIDS Action Now and made some interesting comments on the issue of privacy as well. He said:
"I think there are two levels to do with privacy. There's a level of principle, that people have the right to their privacy, and I think everybody understands that. But I think that the level we're dealing with here is something which I wouldn't say is more serious but is serious in a different way, because what we're talking about is what lengths people will go to to preserve their privacy and how that can affect public health.
"I know of people who were working, had an insurance program, and when they were diagnosed with AIDS and HIV bought their own drugs rather than put those drugs through their insurance program because they didn't want people in their office or even in the insurance company to know what they were suffering from since the drugs they had would be AIDS-specific."
And he goes on to talk about the implications of that. He says: "We know that once people test, their behaviour in terms of responsible activity changes dramatically. But people who think they may be infected but don't really know for sure can always talk themselves into not following safer sex guidelines."
Part of his concern with respect to having medical records made public in ways that we've never understood before has this potential danger for us all in terms of the lengths people will go to to protect their privacy. You said very much the same. Do you have any comment with respect to what Tim was saying?
Mr Waltenberry: Personally, from my experience, from the people we deal with and the consumers we deal with in our area -- we serve a 100-mile catchment area here in Kingston -- many of the people who get tested early and are HIV-positive tend to lead a life of not having sex. That's the bottom line.
If this bill is passed and the information is made public and the disclosure that people are living with AIDS is made public, people will tend not to go forward to get tested. Therefore, after a period of time they will continue with the exact kind of lifestyle they're already leading. This bill and this act will put other people at risk.
Mr Marchese: One of the things that we in opposition, and indeed the public, fear most is the tremendous powers this bill gives to cabinet, and the restructuring commissioner is another immediate example. What happens when we do that is, we make our politicians, or an agent who is given that power, unaccountable. If they have such powers, the point of it is, how do we make them accountable and under what process?
Part of what we did in opposition was to force the government, through the introduction of Bill 26, to be made accountable for the things that it is introducing. What we wanted is people to be able to say, "We want to know what's contained in this bill, we want access to that information and then we want to be able to respond to it." Do you think the people you've talked to have had enough time to review what's contained in this bill, to have a sense of how it might affect them, particularly or generally?
Mr Waltenberry: Not at all, and I'm sure that everybody who's come up here to speak and everybody who has not been given the chance to speak or address this committee or any other committee around this bill -- one of the things that this government is doing is pushing this bill through so fast, and it is not releasing all the information to the general public so that people can respond to this bill, that when this bill is passed, the unilateral powers that this government and this minister will have will be catastrophic to the people whom this bill affects.
Mrs Helen Johns (Huron): Thank you for your presentation this morning. I'm sure it will come as no surprise to you that some of your premises I disagree with.
We believe we offered more hours of hearings than were eventually agreed upon by all the parties. We offered 360 hours, and 300 hours is what we are doing now, so we feel that we did try to get as many hours of public consultation as possible. We are listening to what people have to say, we have said that we will look at changes. I think this process is doing what we wanted it to do, what we all want to do as Ontarians, which is to make comments on a bill.
From my perspective, health care is the most important part of what we have in Ontario. We have guaranteed that $17.4 billion will be in the health care system at the end of the four years of our government, but we never promised that the status quo would be maintained. I personally don't want the status quo to be maintained; I want the system to be made better. There is disease that is continually evolving; there's health care that we need to change to make it better and more effective for the people of Ontario. The health care system has to meet the changing needs of the people of Ontario.
I don't think that's more obvious than in the field of AIDS. The minister has said that he has prioritized AIDS, both the commitment to AIDS resources and the financing of the search for a cure for AIDS. It's important to move funds from other areas to be able to work on new and important differences that are happening in the health care field. We believe that's what this bill is about: managing the health care so that we can bring it to areas such as AIDS.
With respect to the allocation of dollars, I think one of the most important areas for AIDS patients is that drugs are changing very quickly. In effect, the breath and livelihood of AIDS is new drugs coming out to find cures for your disease. In the past, governments have had to take drugs off the drug formulary to be able to add new ones that might be able to help AIDS patients, cancer patients, new diseases. If we don't change --
Interruption.
The Chair: Excuse me, Mrs Johns. We're either going to run this hearing with no participation from the audience or we're going to recess it. We've have four other groups we want to hear from --
Interruption.
The Chair: I'm sorry, the committee has been doing this the same way for six different cities; we'll do it the same way in Kingston.
Interruption.
The Chair: We're going to have a five-minute recess.
The committee recessed from 1054 to 1100.
The Chair: If anybody's interested in the rest of the proceedings, we'll reconvene.
Mrs Johns: New technologies are being found for AIDS. In the past they've taken drugs off the drug formulary because there's been a finite set of resources. How do we continue to provide new technologies that are being found for AIDS patients with this finite set of resources we have if we don't make reallocations within the health care system?
Mr Waltenberry: Number one, what right does this government have to regulate a treatment that may improve the quality of life for somebody who has nothing to look forward to but death?
Mrs Johns: That's what we're trying to do by putting the drugs on the formulary.
Mr Waltenberry: But what you're trying to do and what this government is trying to do by passing this bill is to have unilateral power over the health care system in Ontario to regulate who gets treated and who doesn't.
Mrs Johns: I disagree with that.
Mr Gerretsen: First of all, I'd just like to respond very quickly. In the Common Sense Revolution it specifically states, heavily underlined in black, "No cuts to health care and no user fees for health care." To state that somehow at the end of the five-year period we're going to spend the same amount as we are right now, but that somehow in the middle there can be a trough in the funding for health care, is just intellectually dishonest.
What's really funnelling this whole thing is the tax cut. We're talking about a 30% tax cut. My question is very specific to you. The tax cut will amount to $5 billion in a couple of years, once it's implemented. We have a deficit problem in the province of Ontario and we have to cut out $10 billion. With the tax cut we have to cut out $15 billion, though. That means that the amount that has to be cut in the various areas is about twice as bad as it ever needed to be.
My question is this: Are any of the people you serve in one way or another going to benefit from a tax cut?
Ms King: Personally, I'm not. I live on $11,000 a year. I know I'm not going to get anything from the government, and most people I know who are on low incomes will not benefit from a tax break. The only people it benefits is the rich.
Mr Curling: Let me say to you that I want to commend you for your presentation and the excellent presentations that I've heard here in Kingston. Listening to the government actually lecturing you instead of consulting with groups that are coming forward -- as a matter of fact, this bill would have been law on December 14, and they're thanking you for coming forward and bringing amendments forward. We have to make sure that they don't ram this thing through and that democracy is alive and well, and we want to say thank you for making this kind of presentation.
Mr Wilson, the minister, said if you need drugs and you can't afford them, you must go and barter with the pharmacist. Do you feel this is an appropriate way for someone to conduct their life with respect to drugs?
Mr Waltenberry: Presently, every drug that somebody living with AIDS is on is in an experimental stage. There's a course of treatment that is outlined once somebody is diagnosed HIV-positive that is put forward by the attending physician. It should not lie in the hands of patients to go and barter for medication that could improve the quality of life that they need to live.
Mr Curling: The government has labelled people like yourselves special-interest groups.
Mr Waltenberry: You're damned right I'm a special-interest group, and with 70,000 people living in Canada who are infected with HIV and AIDS who have gone forward to get tested, and 41% of that number who live in Ontario, those are individuals who have opted to come forward and expose their status through getting tested. If our government refuses to protect the privacy and to protect the treatments that are afforded people living with AIDS, that number will quadruple and people will not come forward and they will be in a chronic stage of illness before they come forward to be treated, when they're put in hospital; then the cost of hospitalization will skyrocket; then this government will go forward and say, "Oh my God, what did we do?"
The Chair: Thank you very much for your presentation. We appreciate your interest in our process.
CANADIAN ASSOCIATION OF CHAIN DRUG STORES
The Chair: The next group is the Canadian Association of Chain Drug Stores, represented by Rochelle Stenzler, Sherry Porter, Syd Shrott and Terry Creighton. Good morning and welcome to our committee.
Ms Rochelle Stenzler: Good morning. The Canadian Association of Chain Drug Stores, CACDS, is pleased to offer the committee its view on the implications of Bill 26 for the Ontario drug benefit program. My name is Rochelle Stenzler. I am the chairman of CACDS and in my day job the president of Pharma Plus Drugmart. With me today are Sherry Porter, president and CEO of CACDS; Syd Shrott, a CACDS board member and owner and vice-president of operations, Medical Pharmacies Ltd; and Terry Creighton, president of corporate relations, Shoppers Drug Mart, a member CACDS company.
CACDS represents traditional retail chain pharmacy as well as mass merchandisers and grocery chains with in-store dispensaries. A full list of our members is attached at the end of the presentation. In this province, our membership accounts for 836 stores employing approximately 16,000 Ontarians. Let me begin by saying that CACDS believes that the current system works well in providing drug coverage for all seniors and social assistance recipients in Ontario. However, CACDS understands the need for cost reductions and future controls within the Ontario drug benefit program. All partners in the delivery of drugs in Ontario -- manufacturers, distributors, retailers, governments and patients -- must share responsibility for controlling costs in order to deliver a sustainable drug benefit program which can maintain its widely recognized reputation for quality.
Bill 26 will make major changes to the Ontario drug benefit program. These changes fall into many areas. However, for purposes of today's presentation, I will focus primarily on two issues: copayments and deductibles, and pricing disclosure.
Today in Ontario, anyone who is over 65 or receiving social assistance or living in a long-term-care facility receives their prescription drugs free of charge. Currently, when an ODB patient presents a prescription in one of our member stores, the pharmacist fills the prescription and the patient does not pay. Instead, the pharmacist is reimbursed by the government through an electronic network.
The reimbursement is made up of two different components: first, the drug costs, which are regulated by the Ministry of Health. The reimbursed cost is equal to the best available price as determined by the Ministry of Health, plus an additional charge of up to 10% for distribution expenses. The second component is a professional fee of $6.11. For this $6.11 the services performed by the pharmacist and the pharmacy staff include the following: the actual dispensing of the drug, which includes repackaging and labelling; checking for drug and/or food interactions or reactions; checking dosage and/or day's supply; counselling on usage and side-effects; substituting generic products where appropriate; compliance checking for early, late or missed refills; and checking for double doctoring or polypharmacy where possible. in addition, the $6.11 covers the pharmacist's overhead and operating costs.
1110
Bill 26 introduces patient cost-sharing into the system through a series of copayments and deductibles. Copayments will be made by two classes of patients. The first will be social assistance recipients, residents of nursing homes, single seniors with incomes of less $16,000 per year and families of seniors with less than $24,000 per year. These Ontarians will pay $2 each on each prescription filled. The second class encompasses eligible single seniors with incomes of more $16,000 per year and eligible families with incomes of more than $24,000 per year. This group will pay in full for the first $100 worth of their prescription costs each year and then pay, as well, up to $6.11 per prescription.
In the economic statement, the government's stated savings through these copayments and deductibles are $225 million per year. Based on ODB data and our best estimates, this breaks down as follows: For social assistance recipients, those living in nursing homes and low-income seniors, the $2 copayment will generate approximately $46 million. For seniors over the income threshold, the $100 deductible and the $6.11 copayment will generate approximately $179 million.
CACDS accepts the ministry's rationale for copayments. We understand and fully support the minister's intention to raise consumer awareness of the cost and the value of the benefit received and for the patient to share in some measure in the achievement of necessary cost savings. However, we are concerned about the structure of the copayments in Bill 26. Specifically, we wish to raise some very important questions about the $6.11 copayment and the $100 deductible for ODB-eligible Ontarians earning more than $16,000 per year.
We are concerned because the amount of money those seniors must pay on average will be high -- according to our calculations, in excess of $230 per person, per annum. Moreover, there is no upper limit. Patients who have greater-than-average drug needs will be facing prescription costs into the hundreds of dollars. The ministry's own estimates indicate that at least 10% of seniors will pay $412 per year or more for their prescription needs.
The ideal copayment program should build in disincentives against program overuse by patients, but without unfairly penalizing patients with high medication needs. The ODB's quality, fairness, equity and accessibility will be severely compromised under Bill 26.
We are worried about other aspects of this differential copayment and deductible system. When a patient presents a prescription, the electronic network will inform the pharmacist whether the patient is a $2 person or $6.11 person. I think you'll agree that this significantly compromises the patient's privacy, as well as creating a difficult situation, as pharmacists are forced to explain to patients, many of whom are elderly, why there is a differentiation.
Let's be clear about the administrative burden this will create. Maintaining running totals against a deductible is a complex business which no computer network performs anywhere near perfectly. When a consumer wishes to contest a private insurance network's tally, one has to fill out a paper claim, attach previous receipts and send it in for processing by hand. Is the ODB ready for this challenge? Are consumers? Does the government want to start maintaining digital and paper tallies for hundreds of thousands of ODB recipients?
As we said earlier, we accept the ministry's rationale for the patient cost-sharing concept. We believe that cost-sharing in general will be a deterrent to utilization. That is why we recommend that the government make the $2 copayment mandatory, so that all ODB recipients, regardless of income, take some responsibility for usage levels and the system's costs. The government of Alberta has taken this approach with a mandatory copay for all prescriptions.
We do not believe that the $6.11 copayment and $100 deductible for those earning more than $16,000 is a sound initiative. As an alternative, we would therefore propose the following cost-sharing system, which will achieve or exceed the government's cost-saving targets.
As stated, we recommend a mandatory $2 copayment on all ODB prescriptions filled. In addition, and this is our second key recommendation, for those earning more than the income threshold, we recommend a premium-based insurance program instead of ODB coverage with a copay and a deductible.
The plan is simple. An eligible patient could purchase insurance at a flat annual rate and be enrolled in the ODB program. The system we're proposing is similar to purchasing dental insurance. Once the recipient pays the premium, he or she would be covered for all prescriptions and would make the $2 copayment on each.
Our calculations indicate this premium would be approximately $160 to $180 annually or $13 to $15 per month. It should be noted that this figure is comparable to the ministry's own estimates that 50% of the seniors will pay approximately $173 per year under Bill 26.
There is a similar program operating in New Brunswick today, although the funding mechanism is slightly different. It was successfully implemented in the summer of 1993 and has saved the government 37.5% of its previous drug program costs.
There are significant advantages to our suggested premium-based system over the $100 deductible/$6.11 copay program as proposed in Bill 26: It will make eligibility tracking easier and eliminate complicated billing disputes between ODB recipients and the government; it does not distinguish classes of patients at the cash register, so it doesn't raise any privacy issues; it is fairer and more equitable because it doesn't penalize patients with above-average medication needs; and for those who choose not to enrol, there is still a safety net against catastrophic need through the Trillium drug program, or they would have the ability to enrol at any time should the need arise.
Two other central cost control problems in ODB need to be addressed: overutilization and non-compliance. We commend the ministry for limiting in Bill 26 the quantities on prescriptions from 250 days to a new limit of 100 days' supply. Although this was done for economic reasons, it will prove to be of major benefit in improved health outcomes. We strongly urge the government to maintain this initiative.
On January 5, 1996, members of CACDS attended a meeting with ODB officials where our second major concern, pricing disclosure, was discussed. As you know, this issue is not specifically covered in Bill 26. None the less, we understand that consideration is being given to requiring the pharmacist to detail the cost components of any and all prescriptions, not just ODB ones. Currently, pharmacies are required to disclose on their receipts the cost of the drug and the professional fee. Were such a measure to be adopted, all inputs of a prescription's cost, including the professional fee, any markup and the actual cost of the medication itself, would be detailed on the prescription receipt.
We are confused and surprised that this government would consider such a measure. There is at this time absolutely no product or service in Canada for which such disclosure is required. Are gas companies, which are provincially regulated, forced to detail the cost of exploration, production, transmission, distribution and maintenance on the bills they send to consumers? Are doctors, when billing OHIP, required to list the input costs of running their office, their staff, computers, supplies, medical training and undergraduate education on their claim?
On top of that, the pricing information would (a) be impossible to set an objective standard for, (b) be next to useless in making comparisons, and (c) be totally useless information for consumers, who are interested solely in the total prescription cost.
Does the government intend to carry this step to its logical conclusion, which is requiring that the input costs and markups of the drugs themselves be listed? We don't think so, which begs the question: Why would our input costs be disclosed on the receipt?
In Bill 26, the ministry has made a point of deregulating the private market. We find it amazing that this same government might in the same breath impose a significant, unfair and onerous regulatory burden on the same market it seeks to deregulate. Therefore, we recommend that there be no changes to the disclosure of pricing information on a prescription receipt.
In conclusion, members of the committee, we have before us a complex and challenging piece of legislation which deals in part with a complex and challenging issue -- ODB reform. Let me sum up CACDS's position on the issues at hand:
We are in favour of a more cost-efficient drug benefit program.
We accept the ministry's rationale for patient cost-sharing and believe all parties in the delivery of drugs must share in it.
We understand and accept the rationale that the $2 copayment which is in Bill 26 is limited to lower-income recipients, but we believe it should be made mandatory for all ODB prescriptions regardless of the patient's income.
We recommend that for ODB recipients with greater incomes, the government replace the $100 deductible/$6.11 copayment with a premium-based system, not unlike New Brunswick's.
We recommend that there be no changes to the disclosure of pricing information on a prescription receipt.
Together, working with all the partners in the pharmacy care system, we believe we can build a strong, sustainable ODB program for the Ontarians who need it.
1120
Mr Clement: Thank you for your presentation. It was very well-thought-out, from my perspective anyway.
I take comfort in your conditional support of the government's direction in this area, to try to inject some accountability into the system rather than what we have right now, which not only is costing the taxpayers but there are also problems in terms of health care delivery. We've heard a number of deputants talk about the overprescribing that occurs with our seniors in our society. If there is a way to try to curtail that through some accountability in the system, is that something you're looking forward to as well?
Ms Sherry Porter: Yes, we are in a province that has a situation where the seniors are overprescribed compared to the other provinces in this country.
Mr Clement: You raised the issue of privacy, and you've got some very good suggestions on how to balance the need for some accountability with the privacy concerns, which is something that when one is in government one always has to grapple with. I'm not saying we've perfected it in our legislation.
To broaden the issue a bit further, because we've had some very emotional presentations already in Kingston this morning about confidentiality and privacy that -- if I can say editorially, sometimes these generate more heat than light. My reading of the legislation, and I'm wondering whether you can comment on this, is that if you look at the deemed-to-disclose provisions found in schedule H -- you may not be too familiar with them -- a patient is deemed to disclose certain chunks of information about his or her record. That was in the old legislation as well. In the new legislation you're deemed to disclose, not generally, for whatever purpose, but for a set of four purposes in the legislation. My theory, and it's my personal opinion, is that that is more strict, more focused, less broad than the old legislation. If that is a correct interpretation, and if there is some way we can build in some specific curtailments to general disclosure, which I agree should not be the case and I don't think it is the case in the legislation -- if we can further specify that and calibrate that, would that go some ways to alleviate your concerns?
Ms Stenzler: We recognize that you've introduced certain elements that you may believe will do that, but as a retailer let me describe for you what will happen in the real world. You will have two customers standing to pick up a prescription who are both ODB patients. The computer will tell the pharmacist that this is a $2 person or a $6.11 person; that's really what this boils down to. You will have them both standing at the cash register and you'll say, "Mrs Smith, your prescription is $2," and she'll know that her friend next to her, Mrs Doe, is also a senior and she'll hear her being told, "Your prescription is $6.11." You then have two elderly people saying, "Why am I different from her?" I think it's utter chaos. I've restricted it to two people standing there; you have hordes of people at a checkout sometimes.
Mrs McLeod: We've heard all week that Mr Clement keeps wanting to use his personal opinion to reassure himself that the law does not do what the law clearly does in terms of an invasion of privacy. The privacy commissioner has made it very clear that this act does in fact open new access to patient records, with the Ontario drug benefit plan administration of the copayment, with the independent health facilities and with access to records in physicians' offices.
I also find it amazing that Mr Clement can take comfort from a presentation that has said the copayment in this law is both unfair and unworkable. I appreciate the fact that this group has taken the time to present a potentially viable alternative. I don't know whether I would subscribe to it, but at least it's an alternative that has some greater potential for fairness, and it's exactly the reason this law should not be going ahead. This is the kind of issue that needs further consideration.
You did not touch on one issue I'd like you to address, and that's the whole question of deregulation. I'm almost a little hesitant to put it on the table; I see you groaning a bit. Ms Lankin and I shared a frustration yesterday in Ottawa because every presentation we've had has suggested something different about what deregulation will do to the price of drugs. We think, how can you just deregulate the price of drugs when nobody, least of all the government, has any idea what it will do to the price of drugs? We know at the very least that there may be a temporary increase; the Ministry of Health has said potentially 15% initially. We know the Minister of Health believes there will be different drug prices in different pharmacies and different communities. We've heard concern that chain pharmacies, for example, may be able to reduce the price of drugs because of the volume they do, but in small communities drug prices may be higher. We certainly don't think people who are sick or who have sick kids can go from pharmacy to pharmacy bartering for the best drug price. I, with some hesitation, ask you to comment.
Ms Porter: And with some hesitation we'll answer. You've mentioned many of the concerns we raised. We obviously would have liked to have addressed this issue, but when we tried to get information on what exactly was meant by the deregulation, we really weren't clear on what it did mean. Within our own membership we had varying reasons and results of what this could mean, and that was all based on the fact that we didn't have adequate input. We felt that if we didn't have the right information, we really shouldn't address it at all. We're hoping we do get clarification on this very soon.
Mrs McLeod: It's odd that the government, wanting to make this law, didn't have enough information, but I appreciate your hesitation.
Mr Marchese: I'm not sure I agree necessarily with the position you take that we should simply have a charge of $2 for everybody and that might be more fair to everyone. On the whole, I take the position that it's unfair to most, particularly those who have very little to begin with. We know from statistics that seniors are on the whole quite poor, so when you impose that fee you're not helping them any. I'm not sure seniors are the abusers with respect to drugs or whether the abuse lies somewhere else. To impose the fees, to impose the abuse, on those seniors I think is wrong.
When you add these fees to those seniors, and additional user fees this government will impose through this bill -- municipalities will impose user fees, and many are looking forward to it, hospitals, doctors, independent health facilities and the drug plan -- when you add it all up, we've got a problem. Some seniors will pay a hell of a lot. I'm very concerned about that fee and other user fees. Does anyone have a comment?
Ms Terry Creighton: I think I could respond to that one. Clearly, we think the current system is the fairest and the best for everyone in Ontario because it's free, but we're responding to the fact that the government has made it extremely clear that it wants to impose some sort of cost-sharing system. We're saying that if you're going to design a cost-sharing system, you have to do so with a very delicate balance. On one hand you want to put deterrents in place so that the system won't be overused, and on the other hand you want to make sure that people who have really high medication needs, those who need the program the most, are not penalized because of that.
We're saying put a nominal copayment in place, make it mandatory across the board so you do get the benefit of driving down utilization, where seniors will participate in the decisions their doctors make on what they're prescribed, but on the other hand make it fairer so that people who really need the system get the benefits of it as well.
Mr Marchese: I appreciate the position you're taking vis-à-vis what this government is trying to do. On the whole, I just don't agree with them or the position you're advancing, although you're trying to moderate, I suspect, in your own way the effects it might have on some people.
Mr Clement talks about privacy. I'm not sure whether you might have a comment. I was reading through Hansard the other day, and he was saying that the old section is broader than the new section in terms of its scope. The privacy commissioner, including Dr Cavoukian, who was with them, talked about that particular part and said the following:
"What we should draw to your attention is that the previous legislation as well was very problematic from a privacy perspective. It is for that reason that the commissioner has met with the ministers of Health over time and recommended that specific privacy legislation for health care records be developed because of the problems with existing legislation. So it's not that you begin from a place that is satisfactory for the protection of medical records."
In other words, he was saying we had a problem in the past and this particular section is going to complicate it even more.
1130
Ms Porter: I don't think we're probably talking the same thing here. What we're really concerned with is the privacy of the patient within the dispensary, and I think it's a little bit of a different scenario.
The Chair: Thank you, folks. We appreciate your presentation and your interest in our process.
HASTINGS AND PRINCE EDWARD COUNCIL ON AGING
The Chair: Our next presenter is Dr Margaret Cahoon from the Hastings and Prince Edward Council on Aging. Good morning, doctor, and welcome to our committee.
Dr Margaret Cahoon: Honourable Chairman and members, on behalf of the Hastings and Prince Edward Council on Aging, I thank you for providing us with the opportunity to share our views concerning Bill 26.
The Hastings and Prince Edward Council on Aging is a non-profit charitable organization by seniors for seniors. Its mandate is to enhance the quality of life of older adults in order that each person shall have the opportunity to achieve full potential both in enjoying life and contributing to it. The majority of the board of directors consists of seniors, to facilitate their full participation in policy and program decisions. To provide a close working relationship with the current needs of seniors, representatives of service agencies give tremendous support to the seniors. The structure, objectives and some of the major accomplishments are presented in appendix 1 in the copy which has just been handed out to you.
Of the total population of the two counties in 1991, 15% was 65 years or more, compared with 12% for the eastern Ontario region and the province as a whole. In fact, in Prince Edward county it's over 17%. This percentage is the second highest in Ontario to Victoria county. Close to 25% of the population of the two counties are over 55 years of age. Both counties attract people who are retired or planning to retire. Most property sells to "move-ins" or "move-backs." Since both counties are major tourist areas, summer visitors increase the population and place heavy pressures on emergency and health services.
Many of our seniors lived through one if not two world wars and the Depression of the 1930s. They remember the widespread unemployment, poverty and homelessness of the Depression years, the devastation of critical illness and the almost total absence of economic security and care in old age. They were the generation that supported the development of comprehensive and universal government programs for health care, unemployment benefits, affordable education, pensions and the social safety network that has characterized Canada as a caring society, recognized as one of the best places in the world to live.
Seniors recognize the need for reducing the deficit and for economic reforms probably better than any other generational group. According to Revenue Canada statistics of April 26, 1995, four seniors out of every 10 are living on less than $11,000 a year single, or slightly less than $17,000 a year married. Seniors are among the first to acknowledge waste and inefficiencies in our health care services, and they want stricter control. There's probably no generation in our society as supportive of sound economic measures. Seniors had to pinch the pennies as they came up the years.
The next part is the concerns we have about the restructuring.
Some of the proposed changes in Bill 26 are threatening universal health care. It may be time to revise the Ministry of Health Act, as seniors are aware that governments change and Ministers of Health change. Can the proposed powers be trusted to this government and to its successors?
Bill 26 proposes the replacement of the Ontario Council of Health by a Health Services Restructuring Commission. What is its authority? What are the qualifications for membership? What are its functions? Is it assumed that restructuring will be an ongoing process?
With respect to hospital mergers and closures, many seniors and their families shared in the development and maintenance of small rural hospitals before there was any government support. They are still supportive, as evidenced by the foundation funds that have been developed for expansion and improvements. While seniors can understand the concept of merger with other hospitals in matters of purchasing at a better price based on quantity, they're shocked by the removal of the hospital kitchens and the provision of "airline" food in areas where there is an abundance of fresh foods. They can also understand the cost savings of laundry sharing, but are concerned about the loss of employment of kitchen and laundry staff workers in the rural areas. What other jobs are there for them?
Seniors can accept reduction in the administrative areas of their local hospitals, but they want protection of those who provide direct care. They want and expect qualified staff rather than replacement by technologists and technicians. They do not expect their local hospital to provide levels of specialty care, and they count on transfer to more sophisticated health care centres, such as in Kingston, but they recognize that much of the family health care can be provided in the local hospital. Seniors, when ill, want to be in their local hospital, where they can be visited by family and friends.
The proposed distance between hospitals of 40-odd kilometres is unrealistic. The distance of the catchment area is the only sensible consideration. Moreover, the road conditions, the weather conditions and other factors have to be considered.
According to the Ontario Hospital Association, only 7% of hospital expenditures goes to the small rural hospitals.
One of the major concerns at the moment is what will happen to the foundation funds that have been accumulated in the case of merger or closure. You won't find it's given over to the government very easily.
With respect to medical services, Bill 26 seems to be declaring war on the medical profession. The proposed legislation threatens the ability of physicians to provide care by setting fees for services, paying variable rates for the same services, and ordering repayments by the doctor for services considered retrospectively to be unnecessary. The power to decide which doctors can have hospital appointments and to revoke their privileges without recourse or compensation is almost unbelievable. I should point out at this point that I am not a physician, but I have worked with them for over 50 years. Similarly, the decision as to where one can practise is unrealistic. The Ministry of Health might recall the experiences of the theological colleges when they sent new graduates to underserviced areas for a two-year period and found that they left on the exact anniversary.
Seniors have great loyalty to their family physicians. They are disturbed by the implication that doctors are cheating OHIP. They can accept that there may be a very few who are greedy, but they resent the idea that government control of all of them is necessary.
In some areas in Hastings county, there are family physicians who do not have hospital appointments. This situation results in double doctoring, as patients have to be referred to a physician with such privileges in a hospital if they need hospitalization. It's difficult in both counties for the move-in or the move-back to find a family physician. Undoubtedly, this is one factor in the abuse of emergency departments. In some areas, there is already a reduction of services. Some practitioners want to take on only young families. Unless some compromises with the medical profession can be achieved, there will be a greater exodus of physicians from Ontario and greater difficulty in accessing quality medical services. Health care services are in very large degree dependent upon medical services.
With respect to the confidentiality of medical records, the proposed amendment to the Health Insurance Act and the Health Care Accessibility Act will give the Minister of Health or an appointed inspector power to go into any health care facility and examine, copy, remove and disclose confidential records. Although the Minister of Health has assured us that this amendment will be changed, what protection will be provided for the security of personal, private records? If seniors fear that their records cannot be secured, they may withhold information which could be critical for their care. Physicians may also feel threatened by the intrusion into privacy and confidentiality of communications with patients. Records may be edited to prevent leaks of vital information. Are there not more ethical means of achieving the information that's required? To whom do these medical records belong? Would confidentiality be better controlled if they were the property of the patient and/or family, as they are in some other provinces?
1140
With respect to copayments, "no user fees" has been replaced by "copayments." Is the difference inherent in the amount that can be shifted to the consumer? Are there plans for a two-tier system of care such as that in Alberta, which is being penalized for contravening the Canada Health Act? Changes in schedule F, Health Services Restructuring, make it easier to charge facility fees.
We have just heard the details about the amendments to the Ontario Drug Benefit Act. I was on the reform circuit three or four years ago, and I think we should be reminded that Ontario's seniors use 5.7 prescription drugs and 3.2 over-the-counter medications per day, a total of 8.9 medications, according to the Lowy report. If you count that up times $2 in addition to the $100 -- I'm not going to repeat all that was said in the previous presentation, but it's written here in this text. It's absolutely ridiculous to suggest that seniors shop for lower prices. If they're ill, they do well to get to a drugstore, if there is one available.
Just a couple of weeks ago I heard at the counter in my local drugstore a conversation about the Trillium drug plan that revealed income, and I was quite disturbed about it. One thing the ministry should do is make space accessible to the druggist to talk to the patient confidentially, because it was very clear to me, and to everybody who was shopping in that little drugstore, what the situation was. I don't think it's fair; we don't want a we-and-them situation.
I started in the health field before there was any of our present structure, and I saw how pitiful the situation was and how desperate it was. When I first went into community health, I did everything but steal to get enough to help mothers meet the needs of their children. If it hadn't been for the Red Cross, the Salvation Army and the Catholic Women's League, I don't know how people would have managed in the latter days of the war.
The drug program secretariat studied the use of user fees extensively, about four years ago probably, but concluded that the cost of collection might outweigh any savings and that it could bankrupt the small, independent pharmacies on which many clients depend. The presentations from some of the small pharmacies were really very shaking. I was disturbed by it when they told what the situation was in keeping the shop open.
It must not be forgotten that very large numbers of drugs and pharmaceuticals have already been delisted from coverage under the drug benefit program. Seniors are already having to pay for essential medications such as asthma drugs and calcium supplements. When we talk about $2 a prescription, what if a family has four or five children with asthma? The cost of the inhalers and the drugs, times $2 -- they're not all going to get them. It's only the worst that are going to be filled. When I started in community health, people were collecting prescriptions they couldn't get filled, and the only way I got the urgent ones filled for them was to get a service club to pay for them. We can't go back to that.
Bill 26 allows for the deregulation of drug prices, and I agree with the former speakers that I don't think we know what this means. The prices may skyrocket.
With the implementation of these copayments, will seniors be forced to choose between medications and food or other essentials? We have had reports just recently of some of the seniors buying cat food again, that don't have a cat. That happened 50 years ago. Do we want it to happen again?
Changes in the Health Insurance Act and the Health Care Accessibility Act mean that hospitals can charge user fees for anything not covered by the Canada Health Act that is not medically necessary. Patients on a waiting list for a nursing home or chronic care hospital may be charged about $37 a day. What happens to the patients who cannot be transferred because of the required level of care? I ended my professional career as the Rosenstadt professor of health research at Sunnybrook Medical Centre, and we had patients who were there over a year, from the trauma unit, that no institution would accept. They didn't have $37 a day to pay anybody. North York hospital was in the same situation. And we're closing hospital beds?
Again I ask, will the implementation of copayments incur more for cost than you're going to save? Saskatchewan introduced user fees in 1968 but found there was no reduction in health costs. With regard to privatization, it appears the government is advocating privatization of ownership and delivery of health care services. There's no evidence that privatization will do anything other than make profit for the owners.
The government may believe that services could be acquired more cheaply, but what about quality? To make a profit, the owners have to reduce to the minimum. Are Ontario seniors ready to accept lower standards of care? Privatization really means Americanization of our health care services, and they can't handle their own.
There's a critical issue inherent in the proposed expansion of the renal dialysis program in this province which I'd like to commend very highly, but every member of the Legislature and every member of the Ministry of Health should read the article by Kirk Eichenwald entitled Death and Deficiency in Kidney Treatment, in the New York Times of December 4, 1995. I'll just quote a bit of it:
"Two hours into the medical treatment that was cleansing her blood, Sue Ellen Coffin screamed, pulled at her hair and vomited.
"Pandemonium spread at the Albuquerque Kidney Center as Mrs Coffin's screams were followed by those of five other people in intense, unexpected pain. The nurses on duty shut off kidney dialysis machines.... Most of the patients recovered but Mrs Coffin died within six hours.
"The terrifying episode 15 months ago was attributed to human error: A technician had thrown a switch to rinse the dialysis machines while patients were hooked up to them. The rinse, rather than the appropriate blood-cleansing solution, had been sent into their bloodstreams, causing a breakdown...."
Government investigations revealed actions by the company, the largest in the States, National Medicare, that led to the deficient care:
-- Shifting the duties of doctors and registered nurses to lesser-trained and poorly supervised technicians and medical staff.
-- Allowing the use of outdated, poorly maintained equipment.
-- Manufacturing equipment that has not met federal standards.
-- Keeping patients on dialysis for too little time.
-- Re-using disposable equipment that manufacturers, including for many years a division of National Medical itself, recommended be used only once.
-- Deviating federal money that could be spent on patient care to enrich its doctors for little work and to finance other businesses.
We do not need expansion of renal dialysis by American firms. An excellent model has been developed by the Kingston General Hospital in a satellite in Belleville, Ontario, and I think when you're looking at that situation, it should be examined.
1150
Since the signing of NAFTA, American heath care insurers, suppliers and management consultants are working hard to take control of the Canadian for-profit market. I'm not going to read all of pages 9 and 10, but point out the amount of money that is going out of Canada to these American firms. They haven't been able to demonstrate for at least 40 years that they could handle the situation in the States, and yet we're paying millions of dollars for them to plan the restructuring of our health care system and our social network.
What is the matter with us? All of our medical schools are in a position to have staff who are very competent researchers. You can give far less money to them to help the restructuring than these people are charging. I'm thoroughly disgusted with this situation.
I did my doctorate at the University of Michigan and I learned a lot that was not on the curriculum, as well as some that was. Many of the people will tell you that the health care system in the States is steadily getting worse and that it's a political situation rather than a situation with respect to care.
Vigilance is also necessary with Canadian for-profit firms. Even these have proven embarrassing to previous and current governments. Few may remember the Brown escapade in homes for emotionally disturbed adolescents, but many may have seen The 5th Estate's recent program on the aversion therapy of brain-injured Ontarians, where the director and owner was a graduate in physical and health education, not in psychiatry or psychology.
It's important to provide care in this province, but quality care is the bottom line. With the numbers who have lost positions in restructuring, it should be possible to develop exceptionally good not-for-profit facilities. It's a myth to believe that not-for-profit is more expensive in the long run. Moreover, there's no incentive in for-profit firms to do the research that undergirds non-profit services.
With respect to the context, welfare recipients are being told to get help from their families. Intergenerational pressures may result in seniors trying to share with unemployed sons and daughters, their grandchildren and even their great-grandchildren. Adult children and grandchildren are having to return home to their parents. Other seniors have families living hundreds of miles away and they hesitate to alarm them even when there's desperate need.
The primarily agricultural nature of the areas, many of which are on marginal farm land, are consistent with expectations which were never very high. There are more unpaid real estate taxes in some of the communities than has ever been experienced in the past, and there are more places having to be sold by power of sale. One man who did income tax returns for seniors through Community Care last April reported that he had no idea that so many people could live on so little.
Lack of transportation in the rural areas of both counties is another related problem. The proposal to remove rent controls may mean that some of the seniors will have to move farther from their necessary services.
Seniors who have been hospitalized are being sent home sooner and sicker. I heard what the young doctor said yesterday in Ottawa and I thoroughly agree with him: We have to have continuity of care. Discharge on Friday may mean that there is no one to help the family until at least the following Tuesday. That's not good enough, particularly when some of them are going home almost the next day, if not that day.
I have a few commonsense suggestions. One of the first is to get rid of the extra numbers of health cards that we've got in this province. It's estimated that maybe there are 50% more than the population. How much of the wastage do you think is coming from that? There is experience in Quebec, for some period now, and there is a project in Alberta using a smart card. It would provide information in emergency departments and in doctors' offices that could drastically reduce the number of tests and medications.
It would also give the emergency departments and doctors's offices help in reducing the pressures for medications by drug addicts. They would soon learn that they couldn't acquire their supply that way. It can control double-doctoring to a large extent. All of the seniors had an identification card during the Second World War and it didn't do us one bit of harm, and I suspect in fact that a smart card might be a real comfort to seniors in knowing that there was immediate information available.
Is it now time that the patient's medical records become the property of the patient and family rather than the physician or institution? With the mobility of people today, it may be advisable for the patient to accept responsibility, although copies could be held by the physician and the institutions most frequently used. But I lost many years of mine just through the death of a physician in Toronto recently.
Drug record books are now available for patients. These could be combined with a medical record book to be signed by the physician. Phone follow-up of visits by OHIP have been made to check on medical billings, but so often the delay is so great that people can't really remember whether they were there on a particular day. If a simple printout of the billing was given to the patient, there would be much better evidence. Moreover, awareness of the costs might make the patient think about the need for the visit.
The Ontario government should pressure the federal government to repeal Bill C-91, the drug patent legislation. This legislation is one of the major causes of increasing drug costs.
If it has not already been legislated in Ontario, and I'm not quite sure about this, it should become mandatory to dispense generic drugs, where available, unless there are exceptional circumstances which would prohibit these instead of the more expensive brand-name drugs.
The family physician study in Hastings and Prince Edward counties is an important base for finding out how doctors use their time and what activities are included in practice. This study by the Hastings and Prince Edward Counties District Health Council, in partnership with the department of family medicine at Queen's, is supported by the Ontario Medical Association and the Ontario College of Family Physicians. A preliminary report is expected by late spring.
The most cost-effective measure is health education. Often seniors do not understand what they're told. Many were raised in an era when you seldom asked questions of the doctor. Today, it's important that patients understand what is wrong and what to do about it. The pharmacists have begun to provide medication education through a variety of media, as well as counselling. Seniors would probably use physician visits and emergency departments less if they had more accurate and authoritative information. Most seniors have no idea that the cost of a visit to the emergency department is much greater than a visit to the physician's office. These are things that I'm sure would influence activity.
About 20% of hospital admissions of seniors are related to drug interactions. On December 27, 1995, the federal Minister of Health approved a New Horizons grant to the Hastings and Prince Edward Council on Aging of over $50,000 for an educational project, Medication Risks of Rural Seniors. I won't read you all the objectives, but they're in this report.
Another pilot project of the Hastings and Prince Edward Council on Aging: This one I'm speaking of is cosponsored with the women's institutes of the area and with the United Senior Citizens of Ontario, Zone 18. This latter one -- I'm running over time I realize -- is entitled Healthy Living on Less and it's directed to the development of mutual support groups in a least eight communities in the two counties.
These will be consumer-driven groups to help people live on less in their communities. Some or all of these groups may result in a skills exchange in which people may volunteer to help those who need assistance in exchange for something the recipients can do for them. A long-range outcome will be the empowerment of the members of these groups -- the sense of achievement, self-esteem and security. These groups should enhance intergenerational relationships as some of them will involve younger people in their activities. They're directed to helping people remain in their own homes as long as possible, which is what most of them want above almost anything else.
In closing, let us not forget that change has to involve people, and change too vast made too quickly breeds resentment and resistance. People have to be involved if they're to accept change. Remember that the five principles of the Canada Health Act must be maintained: universal coverage, accessibility, portability, comprehensive coverage, and non-profit public administration. Our seniors and their families expect services that uphold these criteria.
The Chair: Thank you for an excellent presentation. It was exactly 30 minutes long, so your command of the time was very good too. We appreciate your interest in our process.
1200
KINGSTON AND DISTRICT LABOUR COUNCIL
The Chair: Our next group is the Kingston and District Labour Council, represented by Charlie Stock, the president; Gavin Anderson; and Vince Maloney. Good afternoon and welcome to our committee.
Mr Charlie Stock: I'm president of the Kingston and District Labour Council. Joining me, as has been announced, are Gavin Anderson and Vince Maloney, members of the labour council. We'll be making comments around Bill 26. With that, I'll turn the microphone over to Gavin.
Mr Gavin Anderson: Good afternoon. I'd like to start by thanking again the members of the two opposition parties for fighting to create this slim opportunity for participation in our democratic process, particularly Mr Curling. It's important to acknowledge that were it not for his act of protest, Bill 26 would quite likely already be law, and without the 100-odd corrections and amendments that apparently have already been considered and accepted.
I'd like to begin my actual presentation by sharing something that both my grandfathers taught me long ago, when common sense was much more than a hollow political slogan. Each of these honest, hardworking men, both now long-deceased but very much alive in my memory, made their living with their hands. Each kept a toolbox filled with chisels and measures, screwdrivers and dozens of other wondrous gadgets and utensils that fascinated me as a young boy. I'm proud to say that several of those tools now occupy my own toolbox and in my home I have several of the beautiful and durable products these two gentlemen created with those tools. What these two men taught me is that you can learn a lot about a person by the state of their toolbox.
Bill 26 has been referred to as Mike Harris's toolbox. It supposedly contains the tools he needs to carry out his agenda for Ontario. I have looked through this toolbox as best I can, and I find no builder's tools. There is nothing in this box that can be used to put anything together, nothing that measures with precision, nothing that can join or smooth, no glue, nails or fasteners of any sort. Mike Harris's toolbox contains nothing but sledgehammers and axes and crowbars. Bill 26 is the toolbox of a demolition man. The 200 pages of text and the 2,000 pages of addenda in the bill form a wrecking ball. It is clear that Mike Harris is intent on smashing that which people of real talent, of courage and vision, have put together over a period of generations, particularly in the health sector.
A case in point: I'm a social worker and family therapist at Beechgrove Children's Centre. Beechgrove is a children's mental health centre serving families across six counties of eastern Ontario, from Carleton Place to Trenton, from Cardinal to Bancroft. As a direct result of budget cuts to our agency, we have just been forced to close referrals to our behavioural paediatric program effective January 1, and in three months the program will be entirely shut down. Our BP program, as it is known, is the only service in our huge catchment area that assesses and treats children suffering from a combination of emotional and medical problems, problems like enuresis, encopresis and many of the learning disabilities, including attention deficit disorder and hyperactivity.
Next on the hit list are our residential facilities, two of the finest clinical programs of their type in the province. At Beechgrove, we wonder and we worry about how many of our young clients, none of them criminals, all of them in need of treatment, will be consigned to boot camps for want of appropriate clinical placements. Both the BP and residential programs have waiting lists. Most on those lists may now wait forever. Children and their families are suffering now. If these children are ever going to grow up to be contributing members of our society, they need help right now. Without help, they will not be able to work and be productive, they will not be able to raise their own children to be healthy or productive members of our communities. Cutting these programs to children is not common sense, it's nonsense.
In terms of Bill 26 and its impact on our health sector, I will not attempt a precise critique in the brief time allowed today. The bill is too large for that, and by the sound of it, its authors are already admitting that much of it is flawed and will have to be reworked and rewritten. I have no way of knowing what the government side has already decided to scrap. The problem I will focus on is the bill's entire focus.
The process used to ram this thing through is the strategy of the bully: no valid consultation, no attempt to find common ground, no commitment to creating real solutions to complex problems by building on the strengths of one of the finest health care systems in the world. The biggest concern the Kingston and District Labour Council has relates to the enormous assignment of authority to the Minister of Health and various commissioners, especially in schedule F on the health services restructuring.
There is no concurrent assignment of accountability. Authority without accountability is a classic prescription for irresponsibility. Irresponsible government is not in anyone's interest, let alone those who rely on the system. This being the case, the Kingston and District Labour Council cannot offer suggestions or recommendations that will bring Bill 26 up to any acceptable standards. It is a massive, fundamentally flawed piece of legislation, abysmally drafted and abusively presented. The only thing to do with this wrecking ball of a bill is to melt it down and start over, this time forging a new set of tools, constructive tools designed to fix and repair rather than demolish and destroy.
My grandfather Darrah used to say that even a stopped clock was right twice a day. I spent a day reading this bill, and let me tell you, the sponsors of this bill cannot even make that claim.
Mr Vince Maloney: Mr Chairman and members of the committee, I have been retired for several years, but there does exist in Canada and in the United States an organization known as SOAR. That stands for Steelworkers Organization of Active Retirees. While I may be a little inactive, I have the privilege of being president of chapter 16. We have the potential in Kingston and Gananoque and Napanee, having had several plants represented by Steelworkers, to have an organization membership of well over 1,000, but we haven't attained that yet. The reason for SOAR's existence is to be vigilant and to be able to intervene on behalf of seniors when governments do something sleazy and sneaky like you fellows are doing right now.
You have in your possession a response to Bill 26 that was presented by the Ontario Coalition of Senior Citizens' Organizations on December 19. Our organization endorses that document completely. However, I wanted to introduce a few personal thoughts.
1210
What a difference. Before the previous government introduced changes in legislation, there were province-wide hearings with full encouragement for public input, both pro and con.
Winston Churchill, at the beginning of the Cold War, coined the term Iron Curtain. Later, Communist China introduced what became known as the Bamboo Curtain. Now in Ontario we have the Wooden or Board Fence Curtain. Whereas the previous government invited and welcomed healthy discussion and debate, the present Tory gang attempted to impose the tyranny of a massive majority through the underhanded process -- I had "slimy" there, but that might be unparliamentary so I won't use it -- of introducing Bill 26 in concert with the budget lockup, and further hoped that the public would be thinking of Christmas shopping and other everyday concerns and would not notice the dastardly deed until too late.
Only by the fact that the opposition parties created a knothole in that board fence, we're now getting a very limited peek, and what we see we don't like. As a senior who remembers the not-so-good old days before medicare, I remember my grandmother dying at home after a series of strokes, with no professional care of any kind and the doctor only coming to declare, "Yes, she's in fact dead." Likewise, my father passed away in 1948 at home -- no medical plan and no money to pay hospital and doctor bills. My mother, who was two years younger, was accepted years before in Blue Cross, now Liberty Health. They had refused coverage to my father because he was two years older. One wonders what "liberty" is contained in this policy now of Liberty Health, formerly Blue Cross. It's the same measure my father had. Their motto and all other private, for-profit plans should be "Profit from Misery."
In my own experience, the doctor who had attended my birth at home was selling his practice in Odessa and approached me because he'd never been paid and wanted to get the account settled. I can make the unique claim that I paid for my own delivery after I was 21 years old.
Likewise, the collusion of the Liberal and Tory parties in passing the current drug patent legislation through the effective lobbying of Judy Erola, former national Minister of Health and Welfare under Trudeau, shows how the two old parties are all but handmaidens of big business. After all, where do they derive their financial contributions from? They are not about to bite the hand that feeds them.
Do any of the current government members recall the demise of the federal Tories? Don't forget that the people who voted you in will have another vote, with the opportunity to give you as many seats in Ontario as the federal Tories presently enjoy. Grey Power will be there, along with our Geritol, unless we die from the lack of health care. In the meantime, I suggest you start looking for a job. You're going to need it the day after the next election. The boys on Bay Street might offer you something, but they don't usually reward losers. Thank you.
Mr Stock: Let me close by saying the Ontario government is displaying a very callous disregard and attitude towards the citizens of our community, and indeed the province, by denying a proper amount of time and consideration regarding Bill 26.
Bill 26 represents a clear and ongoing decision on the part of this government to exclude the possibility for public debate and consultation on essential value questions for the society we live in. The Kingston and District Labour Council requests the government to suspend the current time frame for Bill 26. We ask for the legislation to be placed into its component parts and that a proper amount of time and energy be given to an analysis and impact study, along with public consultation. The government has recognized to a limited degree the massive size and diversity of the omnibus bill by splitting the committee into two segments, which are health and non-health.
At the opening this morning we heard there were going to be over 750 representations in regard to Bill 26 and that that should be an adequate and proper consultation process. I would suggest, for anybody in this room and for the members of the committee who are fully aware, around this table, that when you have a bill that's over 200 pages thick, and you have a compendium of over 2,000 pages that goes with it, and you're allowing 300 hours of public hearings, certainly isn't proper. That doesn't allow seven minutes per page to digest, let alone try to swallow.
When you turn around and mix the health act, your municipality act, the Highway Traffic Act and everything else that you're doing here, and try to put it across as if that is proper input, we're here to tell you that you're wrong. We totally disagree, and there are a lot more people from our area and across this province who are on our side than I feel are on your side of this argument.
We join with the opposition in requesting the government to start over in regard to Bill 26. After all, the citizens of Ontario deserve fairness, not borderline democracy. Thank you very much.
Mr Gerretsen: Charlie, you missed a few other acts as well: The pension act, for example, is going to take about $400 million away from people who have rightfully earned that; the Mining Act that's in here; the natural resources act; the Corporations Tax Act; the Public Service Pension Act. This is a huge bill, as you've already stated.
The 360 hours, by the way, that we heard about earlier for public hearings were all to be in Toronto. There were three committees to sit at the same time, from 9 am until midnight. This is the best we could do. We could only get half a day here in Kingston. Yet, I've been in the hearings on the other side of the committee, the whole week all over the province, and I've never seen in any other city as many people as have come out here today. It just shows you that more hearings are needed.
If there's one thing that I disagree with my friend Vince over here, it's the fact that he's no longer active. I would never say that about somebody who's done as much for the community as you have in one way or another.
You and I know that at the municipal level what makes the process work is public consultation and public hearings. You've been allowed to make a presentation, we're given four minutes to respond per caucus and this is regarded as consultation. I don't regard it as consultation. What are your comments on that, Vince?
Mr Maloney: I think the fundamental tenet of any democracy is adequate two-way conversation -- open disagreement, yes, but consensus and finally arriving at something that both can live with and that's going to be better than what the situation was before. They tried to sneak this through before Christmas without any consultation. I think they deserve the "Heil" salute.
The Chair: I find that behaviour absolutely offensive, sir, and I will not tolerate any more of it.
1220
Mr Stock: Can I just interject, because my name was mentioned in the question too. Excuse me.
The Chair: To the government. Mr Rollins.
Mr Rollins: Thank you, gentlemen, for coming out with your ideas. I don't think this bill was put together in 330 hours. It may not be known to you how many ministers and how many of these people have met with other deputations before forming this legislation. This legislation wasn't formed by the wishes of Jim Wilson in a closed-door meeting. He had meetings with many community-involvement people who were partakers of this.
Mr Gerretsen: But they were all closed-door.
Mr Rollins: Now, come on. Like the business community he was involved with; he met with over 200 doctors in Hamilton. I know that for a fact. Those are the kinds of things, and he put together, with the recommendations of these people, that the system we've got is not working. We cannot afford to keep on going and paying the type of dollar that we are in our health care system and still be able to support, as people here with different groups wanted, some new money spent on the development of new drugs and put forth. We've got to make the savings within the system. It's not an endless bank. Some of you people, it's very nice to sit there and say --
Mr Anderson: What about the $5 billion? If that's a question, I'll step in and answer: You've found $5 billion to put back in the pockets of the most wealthy people in the province. That's a start. Does Doug Gilmour really need a quarter-of-a-million-dollar tax rebate? I look at the agency that I work for, with a budget of less than $6 million. That's the tax saving you're giving the Toronto Blue Jays alone. So if you want the money, the money is there. Don't say that it's a question of not having the money. It's a question of priorities and commitment, and you've lost your commitment.
Mr Rollins: No, we have not.
Mr Anderson: You have no commitment to the emotional or physical health of the people of Ontario. You're quite satisfied that the most wealthy people can purchase that service. You don't care about the common people of Ontario.
Mr Rollins: Yes, we do care about the common people of Ontario.
Mr Anderson: Where's the evidence? Bill 26 speaks against that.
Mr Rollins: The evidence was on June 8, sir.
Mr Anderson: No. You cannot interpret June 8 as a mandate to take apart this province. You had no mandate to do that.
Mr Marchese: I apologize for missing part of the presentation. I went outside to support the people who are holding a vigil outside. I understand some of you didn't have an opportunity to answer one of the questions. So, Mr Stock, rather than asking a question, I'd like to give you the time to respond to a previous question that was asked to you and to the other speaker beside you, if you would like to make other comments.
Mr Stock: Thanks, Rosario. I was going to say to John and to the rest of the people, about one of the comments that was made, that this government has never seen this type of reaction by the people here. I'd just like to tell the current government that you haven't seen anything yet. You may win the day, but by the time this is over you'll remember your trip to Kingston. You'll remember your tour of this province, because the people have good memories and the people are not going to tolerate. This is absolute nonsense and has nothing to do with common sense. As my colleague Gavin has said, there are other ways to do it. If you had open minds, instead of closed minds and mean practices, you'd be considering that in a better fashion.
Some of us have been around a long time, dealing with legislative hearings such as this. I have never, and nobody here who's been around this table has ever, seen anything like this. To insinuate that this is a fair process is absolute nonsense. If that isn't acceptable to you people, that's too bad. You'll take the results the next election. Thank you.
ONTARIO PUBLIC SERVICE EMPLOYEES UNION
The Chair: The next presenters are the Ontario Public Service Employees Union, represented by Mr Warren Thomas, a member of the OPSEU executive board. Welcome to our committee hearings.
Mr Warren Thomas: My name is Smokey Thomas. I work at Kingston Psychiatric Hospital as a psychiatric nursing assistant. I'm also an executive board member on the Ontario Public Service Employees Union. Our democratic union currently represents 105,000 members provincially -- whom, by the way, the government's trying to force out on the streets -- over 5,000 locally, and locally we have over 2,000 workers actually working in the health care sector.
Province-wide, 20,000 of our members work in the health sector in hospitals, community agencies, long-term-care facilities, public laboratories and as ambulance attendants. These people will certainly be profoundly affected by this bill.
OPSEU welcomes this opportunity to present our concerns about Bill 26, the Savings and Restructuring Act, 1995. I too would like to join in in thanking the opposition parties, and in particular Mr Curling, for their dramatic actions in stalling the government. I believe it's a page right out of a labour movement, a good shop floor democratic action: "Down tools and stop the process."
As well, we appreciate that he opposition actions were born out of the same frustration and anger that we as citizens feel. Everyone who's had the opportunity to review this bill is frustrated, angry -- furious, in fact -- over the proposed changes and the actions of a deceitful government.
This government has shown blatant disrespect for the public and for democracy in assuming that they could ram this huge omnibus bill through. Simply put, they're moving too fast even for fascists. Their actions insult the intelligence of the Ontario public and are clearly worthy of contempt. I could rail on for two or three hours about this bill, but you have our written submission. I think I'd rather focus on the way forward as a community.
In your package you have two proposals. One is called option K. Option K, simply put, is a proposal from OPSEU members and our union to create a greater Kingston public services task force strictly to look at provincial government services directly provided.
We propose membership from the business community, labour, political -- all three levels of government -- public sector, institutional CEOs, and -- I know they get offended at this -- interest groups on an as-needed basis.
We would see the membership on a central steering committee consisting of the president of the chamber of commerce and two other representatives from the business community chosen by the business community.
From labour I would suggest someone from the public sector, perhaps myself -- I'm a board member with OPSEU -- someone from the labour council -- in my mind it would be Charlie -- and a representative from the Public Service Alliance of Canada, the other large federal union in the area.
In my view, political representation is absolutely essential. It would not necessarily have to be the local MPs or MPPs in person at every meeting, but they could send a representative. I would see the mayor and reeves of the surrounding townships or their delegates as essential members as well.
It's been my experience that on an issue-by-issue basis, other groups should have representation on subcommittees depending on what is being looked at. For example, if we were to look at health care we could consider forming a subcommittee with representation from the district health council, hospitals, health sciences complex, medical faculty at Queen's, business and labour. A steering committee could mirror the current CFB task force with additional representation from business in the provincial level to round that body out.
This committee could be mandated to explore service sharing arrangements, program sharing arrangements, joint cost-saving arrangements, revenue-generating arrangements and improved efficiencies within the provincial public sector in the Kingston area. This committee would seek public input into its proposals. This committee would make recommendations to the appropriate level of government within one year of its establishment.
If as a community we're able to bring these groups together in a non-partisan forum, I believe we'll be able to establish Kingston as a desirable place for both the government and the private sector to locate in. I believe our future prosperity depends in large part on our ability to work together.
The second proposal is for community forums. The current Ontario government continues to impose severe budget and service cuts, it continues to ignore the democratic process and refuses to facilitate meaningful public debate, consultation and input. To correct this injustice, we would propose a series of town hall meetings to allow for a real public debate, consultation and input. I had suggested that these meetings be on Thursday evenings. They could be Saturday morning, Sunday afternoon, whatever works for everybody, but we would suggest that at least five town hall meetings be held.
We would suggest the following topics, and not necessarily in this order or all these topics, or the list could be expanded: Bill 26, health care, education, social services, and the Ontario public service restructuring.
In our view it would be absolutely essential that our two area MPPs clear each Thursday evening for the five weeks or five meetings, whatever, to be panel members. That means where I live, in Frontenac-Addington, we'd actually have to be able to liaise Bill Vankoughnet, see him there and have him speak. OPSEU would be willing to sponsor these events.
We would not control that process; we would simply facilitate the venue, and we would suggest that a three-person committee arrange for the appropriate panel members and moderators. We would suggest that the committee consist of one staff person from Mr Gerretsen's office, one staff person from Mr Vankoughnet's office and one member of our local community agreeable to the parties. We have a lot of local community leaders who would be seen as non-partisan and would be seen as fair and just.
1230
We believe that these forums would provide our community with the opportunity to express concerns and, just as importantly, offer alternatives. Of equal importance, our political and community leaders would receive input that would allow for more compassionate and informed decision-making during these difficult times. I'm going on the assumption that all MPPs get to have a say in the House and get to be part of the political decision-making process. I would certainly be happy to discuss that at greater length with anyone interested.
That, Mr Carroll, is definitely a sincere offer. We have had many public forums in the Kingston area in the past, and I think the information that comes out and the level of cooperation it builds in this community in particular are very beneficial. With that I think I could probably sit. It's hard to top what Vince said, what Charlie said and what Gavin said, so even though it gives the Tories more time for questions, I'll turn it over for questions.
Mr Marchese: One of the comments that was made by one of the Conservative MPPs, Mrs Johns, was I believe, "This is the process we wanted." I'm not sure this is the process they wanted or what they want. What they wanted to do was to pass Bill 26 very quickly before December 14, and if it wasn't for the effort we made in opposition, that's what they would have had. They would have had no consultation whatsoever. This would bypass the normal processes of a democracy, where people have an understanding of what's being proposed, an opportunity to debate it and of course, based on that, get some changes to the proposed bill. This is not the process they wanted, for the benefit of those who are here. We forced this process on them and we're happy that you're here, along with all the other interest groups. I'm happy to say that I support interest groups because they all have something to say and there is something that we need to hear from all of them.
Another deputant, and I thought it was Dr Cahoon, said people have to be involved if they are to accept changes. That's a statement that I think everybody would support. How can anybody support any particular aspect of any bill without being involved in it? Do you have a comment on that?
Mr Thomas: Frankly, I couldn't agree more. In fact, the previous government, on bills that went through, sat without getting in a gabble, jumping up or calling a recess like crybabies. They sat, listened to criticism, took the input, and you could actually see where your input, if it was valid and legitimate, changed what would happen.
As a community, Kingston is in store for a massive cut; all three levels of government are going to cut back. It's going to create enormous unemployment; it's going to create enormous hardship; it's going to put more people, from where I work at the psychiatric hospital, living in untenable living conditions, more welfare people on the street.
If there is a meaningful opportunity for people to come out, at least get it off your chest and say what's on your mind. You might be able to avoid riots -- what they call riots -- those types of demonstrations. If you don't have that, unrest grows, and then if Harris ever comes back to town, God help him. God help him if he ever comes back here, but that's what happens.
So I couldn't agree more, Mr Marchese. You've got to have public input, and that's from everybody. Why is it that the average citizen is excluded? I got here by virtue of being an executive board member of my union. I'm really pleased that there were some community groups here and other groups. But I would agree wholeheartedly with the motion this morning: Break it up; have the extensive consultations. They don't need this stuff overnight. It's not about money, it's not about the deficit; it's about political expediency and a political agenda.
Mr Marchese: Let me ask you another related question, Warren. One of the things this government prides itself on is that they don't want to be intrusive, that they want to get out of the way and let the private sector do the job right and just let every agency do the job right. That's what they say. What they've taken upon themselves through this piece of legislation is they've given themselves tremendous powers to do what they want. What is it that they want, in your opinion? Why is it that they're giving themselves such powers and at the same time saying they want to get out of people's hair?
Mr Thomas: Okay, this is my personal opinion. I don't believe they're interested in re-election. I believe they're interested in moving a business agenda forward. They can't be interested in re-election.
Mr Marchese: I hope you're right.
Mr Thomas: What they're attempting to do, in my view, is pull back control to about four or five people. That's not democratic. I mean, democratic is defined as majority consent to minority rule, but how do you define a minority? It's not five people in this province; it's the House of elected representatives, everybody we send into that House to represent us.
I work for the provincial government. I deal with regional directors, deputy ministers, everything else. The deputy ministers know what's going on. From that level on down, everybody's in the dark. You tell me that's democracy, you tell me that somehow there is not some other kind of sinister agenda, and I won't believe you, because there is, in my view, a sinister agenda. American health care is coming to Canada.
I'll give you a couple of quick examples. They privatized the lab where I work. It now costs the taxpayers 35% more than it used to. Whenever you introduce the profit margin, costs go up. The last government did a detailed study of contracting out, and I think we're moving towards contracting a lot of stuff back in, taking it back into the public purse where it rightfully belongs.
Working people and unions have a lot of good ideas about how to save this government money. But try to get this particular government -- the most offensive thing I find as a union representative is that right in their Common Sense Revolution they say that OPSEU has a lot of great ideas and they will work closely with us, but Mike Harris has yet to meet with the president of our union. Now, if you were the CEO of a large corporation that employed 65,000 people directly, and you're union, right, wouldn't you think at some juncture you'd meet with the union president?
Mr Marchese: At some point.
Mr Thomas: Exactly. They're making very provocative actions: training scabs over at OHIP downtown here in the event of a lockout or a strike. They're training scabs, and yet they sit at the bargaining table and say, "We'll honour the essential services agreements." They give out misinformation. In fact, in my opinion, they downright lie most of the time.
Mr Marchese: They wouldn't do that.
Mr Thomas: I think they're looking to dismantle government to the extent that it serves their business partners, and that's the large multinational corporations. Not small business, not medium business -- it's the large multinationals that take all their money and invest it offshore. That is, I think, the real agenda here.
Mrs Ecker: Thank you, Mr Thomas, for coming forward. It's good to welcome you for your second opportunity at the hearing table. I won't ask you the same questions we asked you in Toronto when you were there.
I'd like to thank you for, one, putting forward an excellent suggestion about town hall meetings. I'm quite prepared, as an individual, to attend them. I know I speak on behalf of my colleagues, and many of us in the Legislature have continued during December and January to have town hall meetings.
As a matter of fact, I have a series of meetings tomorrow with members of my community to hear input. I know some of my colleagues are still continuing to door-knock on a regular basis to talk to people one on one about what we're doing and the need for restructuring. I certainly have no problems with continuing these kinds of dialogues with people, as we have since June 8 and as we will continue after, on this thing as well.
1240
The other thing, just in terms of some comments made about who got to be on the lists and everything, because there was an oversubscribing of individuals wanting to come forward, all three parties had an opportunity to make choices about who they would like to have on their list to come forward.
Interjection.
Mrs Ecker: Hey, I'll leave my opposition colleagues to claim that. Mr Thomas, actually what would be about the average salary of your membership?
Mr Thomas: In OPSEU? On average probably $30,000, low $30,000, $31,000, $32,000 range.
Mrs Ecker: About 66% of the population is about that income level, and I think it's worth noting that 66% of the population will benefit from a tax cut. I think that's an important measure to mention.
Mr Thomas: Is that a question?
Mrs Ecker: Well, it's a statement of fact, but you can respond certainly.
Mr Thomas: Nobody is going to like this response. Regrettably speaking, I think people might actually support that tax cut because we're going to need every damned penny we can get to cover off the user fees and everything else that you're stripping away. You may find working people saying, "It might be only $100 a year but damn, I'm going to need it to put my kid in soccer, because the township just raised it, and my property taxes just went through the roof, so do I walk on the mortgage and lose all my equity?" You're forcing Ontarians to, perhaps unwittingly and unwantedly, subscribe to that tax cut. But personally I'm opposed to it.
How can you justify in any rational kind of mind that you're going to keep borrowing money to give a tax break and hope that it somehow gets pumped back into the economy?
Mrs Ecker: But we're not going to be doing that, sir, and one of the things I've heard from workers --
Mr Thomas: We are. How can you say that?
Interjection.
Mrs Ecker: Excuse me, Mr Gerretsen. One of the things that I've heard from many of the workers in my own riding is that they want a tax break. After 65 tax increases over the last 10 years they want, and I think they deserve, a tax break, because there are a lot of people who are working very hard out there over the last several years through two recessions to put food on the table for their kids and a roof over their heads, and I think those taxpayers deserve a break. I think they deserve a break.
Mr Thomas: Could I ask you a question then? Could you somehow explain to me -- you made a promise of creating 725,000 jobs. In OPSEU alone you're going to eliminate 14,300 just out of the 65,000. The broader public service sector transfer payment agencies I think were given to understand -- I don't know what -- I guess a phenomenal 50,000 jobs. In Kingston alone, just in the OPS, Ontario public service -- I get paid from corpay in Toronto -- people like that that get paid, regional directors of council are saying it's 1,000 jobs. Excuse me, I won't be paying anything into the system when I'm gone. I'll be one of those people.
I can't understand how you can say to welfare people, "Get off welfare, get a job," and then say to the public sector: "To hell with you. You're the scapegoat. You're the whipping post. We're going to lay you off. Go on welfare." How can you say that? I have no shame in saying I want to work for a living --
Mrs Ecker: Mr Thomas, I'd like to answer that.
Mr Thomas: -- none whatsoever.
Mr Clement: She'd like to answer that.
Mr Thomas: Sure. Go ahead. I'm curious.
Mrs Ecker: I agree that a good-paying and a decent job is what everybody wants for their family. But I would suggest that if government spending gave us all the jobs, we'd all have at least two. The difficulty is that some of these jobs are being paid for by borrowed money to foreign moneylenders. Quite frankly, I'd rather have the money going to my health care system than to foreign moneylenders.
Mr Thomas: If you're saying you're going to make all these cuts and put it to the deficit, Ontarians might actually swallow that. But you're not. You're still giving a tax break before you balance the books.
Mrs Ecker: I can only speak for my riding, but we had 16 all-candidates debates in my riding where we talked in great detail about where the money would go, what it would mean for the impact on cuts. We had lots of meetings and discussions about it, and the people -- and I can only speak for my riding -- chose the plan that we put forward. So that's what we told the people --
Mr Thomas: Can I ask you to do --
Mrs Ecker: Just a minute. That's what we told the people of Ontario we would do. We were elected to do that mandate, so that's what we are attempting to achieve here. We believe there should be a balanced budget so we can all stop paying $1 million more an hour than what we spend.
Mr Thomas: Can I ask you to do something for me then? As one of your employees, as a citizen of this province -- two things actually: Phone Bill Vankoughnet. Tell him he's going to sit on these panels. All right? Tell him that when the media calls him or a concerned constituent calls him, he'll actually call them back, and we will see him once in a while. All right? And before you say to me and my wife, who works for the government, "We're going to put you both out of work and you're going to lose everything you worked for" -- because, guess what, I earn my money working for you. I earn my money.
Mrs Ecker: You don't work for us; you work for them.
Mr Thomas: No, you're my boss. The last government didn't get that either. You're my boss; you're the government in power. We negotiate with you. This government can never understand that.
Mrs Ecker: I have no further questions.
Mr Thomas: I don't negotiate with the taxpayers. I negotiate with you.
Mr Miclash: Thank you for your presentation. We've talked a lot about Bill 26 and the hearings that are going on today and the hearings that are going on across the province. Earlier, one of my Conservative colleagues alluded to the fact that there were groups that were actually consulted on the drafting of Bill 26. Were you, or do you know of any group that was consulted on the drafting of this piece of legislation?
Mr Thomas: I don't believe the labour movement as a whole was. I know OPSEU certainly wasn't and I know I certainly wasn't consulted. I've been at meetings of our membership of over 400 and 500 people; one had a couple of thousand. We ask the question, "Has anybody in this room even been phoned by one of those polling companies that say they have 50% in the polls?" No one ever puts their hand up. We ask the question, "Has anybody ever been consulted?" Nobody puts their hand up.
We have a strange kind of situation in being a government employee; there's a thing called the joint cost savings committee which is sitting, which was struck under the social contract, and my only bitch about the social contract was, you can't legislate cooperation. Certainly we had our disagreements over process and everything else.
They're making the pretence of keeping this process alive. They say that 80% of the cuts are decided, but they won't tell anybody. They'll give it to one person in my union and make them sign a confidentiality agreement so they can't tell anybody. How does that benefit anybody? How does that benefit the 1,000 people in Kingston who probably will lose their jobs in terms of us going forward and saying: "Let's look for some real alternatives. Let's look for some cost savings. There are opportunities"? But they don't consult with anybody.
I asked the question the last time, "Name me one person, one group, one union you consulted with," and they couldn't answer it, if you remember that.
Mr Miclash: I've been asking the same question as we've travelled across the province and finding the answer to be exactly what you've told me. Mr Gerretsen.
Mr Gerretsen: First of all, the one thing that the Conservative members just don't get, and I've raised this matter at least a dozen times in the House, is that the tax cut -- their own financial statement of November 29 clearly indicates that the debt of this province is going to go from $95 billion to $120 billion, according to their own figures, by the year 1999, which is roughly the amount of money that will be paid back in the tax cut.
If you just forgot about the tax cut and at least put it towards deficit reduction etc, we wouldn't have half the cuts we're talking about right now -- that's number one -- and at least we wouldn't --
Mr Thomas: Hear, hear.
Mr Gerretsen: As far as the savings that the tax cut will give, and this again is according to the Common Sense Revolution, not something I dreamt up, it's about $425 for a person making $25,000 and about 900-and-some-odd dollars for a person making $50,000, but it's something like $5,000 for a guy making over $100,000.
For anybody to suggest that the rich, the well-off -- and I include myself in that group -- aren't going to get a better cut than somebody else is absolute nonsense. They don't know anything about how our taxation system works, which is basically a progressive system: the more you earn, the more you pay, and therefore if you cut it, you're going to get a bigger slice, a bigger cut.
Mrs Ecker: Don't forget the fair share levy on the health system, Mr Gerretsen.
Mr Gerretsen: It's very little. Look at your own figures.
Mr Thomas: You're too charitable, Mr Gerretsen. I'll say this --
Mr Gerretsen: I'm always charitable.
Mr Thomas: You could be a little more forthright with them.
Mr Gerretsen: I try to.
Mr Thomas: It's the old adage: the rich get richer, the poor get poorer. The middle class in Ontario, and particularly in Kingston, quite frankly was produced in large part by the government. I came out the north end of town; I came out of not abject poverty, I wasn't as bad off as some people, but I got a decent government job. I'll tell you how I got that job. I had to shake this guy's hand and say, "My daddy's a Tory, my granddaddy was a Tory, and I'm a Tory and I'll always be a Tory." I lied. But that's how I got the job, John.
I've gone to educationals not sponsored by unions on all this financial stuff and what's really happening here, and it has got nothing to do with the deficit, nothing. It's got to do with making rich people richer. What is it, 1% of society controls 80% of the wealth in Canada. So who really benefits?
Mr Gerretsen: The other thing that the members of the committee ought to realize is that one out of every two wage packages in the Kingston area comes out of the broader public sector, and the cutbacks both federally -- and I'll take the responsibility for that, as a party member -- and provincially are going to mean the loss of -- I try to be fair to everybody; I'm not perfect either; I'll be the first to admit it -- it's going to cost this community over 1,800 jobs, as indicated in a Whig-Standard report just recently.
Kingston has always been a very stable community, but 1,800 jobs lost in this area is going to have a tremendous impact. You're talking about almost $83-million cutbacks by various organizations and by various government levels etc. By the way, I think your idea of these town hall meetings is a great one. The CFB Kingston study in which you and management and the local community were greatly involved was a great push in that area, and I'll certainly play whatever role I can to make it happen in this area as well. I'll even speak to Bill Vankoughnet and ask him to come.
Mr Mario Sergio (Yorkview): I won't ask any questions. I have enjoyed very much the presentations this morning, every one of them. We do have Bill 26 now, and I wish we didn't have Bill 26 to deal with. But let me say that when Bill 26 was introduced in the House the Premier didn't know its content; Mr Eves, the Finance minister, didn't know its content; no minister knew the content of Bill 26 and, with all due respect, no other member of the House, that side or this side, because nobody had received the package. No one. So I can sympathize with everyone who has been attending presentations in various parts of our province, showing major concerns. We have heard from "drastic" to all kinds of other names that the bill has been called.
My problem with it is this: I'm saying to the members from the other side that when they get back to caucus in Toronto, they will have less than a week to absorb everything they have heard throughout the province. They will have a number of amendments, both from their side and this side here, and I just can't see ramming through an amended bill when no one fully understands the impact as it is now, with all the various amendments they will have to deal with, which means they want to push an amended bill, if you will.
I have to say there are good financial reasons why they want to push it through. It's not solely because of an ideology; I think there are big dollars attached to it. They want to have this approved as quickly as possible, so they can put in place, implement some of the things they are saying they want to do, so they can raise some of the big money this government needs. There's a financial attachment to Bill 26.
My final comment is this: Most of the ministers didn't know when we posed questions in the House how to answer even for their own particular department. They absolutely did not know the content of the bill and they still don't because it's very complex.
Mr Thomas: My half-hour is not up, by the way; it's not 1 pm. I might make one comment on that. If they go back and a week later they ram through -- first off, they shouldn't amend anything; they should just scrap it. Go back to the drawing board and start over -- that's our official position -- and engage in real and meaningful consultation with the people of Ontario. They did not get the mandate they claim to have when they got elected, and when they got elected they got elected to represent all citizens of Ontario. They're not doing that.
The Chair: Thank you very much, Mr Thomas.
Mr Thomas: Excuse me.
The Chair: The meeting is recessed.
Mr Thomas: Excuse me, Jack. Don't interrupt me again.
The Chair: The meeting is recessed until Peterborough.
The committee recessed at 1254 and resumed at 1701 in the Ramada Inn, Peterborough.
The Chair: Good evening, everyone. First of all, welcome to our committee hearings. We're happy to be here in Peterborough. I do want to throw in a plug here. This is my home city. Most of you here probably don't know me, but I was born and raised in Peterborough, and it's nice to be back home.
We've added the extra space. Unfortunately, the sound system isn't quite adequate, probably, to handle that extra space, so we're going to have to maybe be particularly quiet just so that we can hear.
We've got eight presenters, I believe, tonight. Because of the rules that the committee is operating under, rules that are set by the Legislature, we are not allowed to sit past 9 o'clock. We have eight presenters, a half an hour each, from 5 to 9. I would like them all to have their time, so we will go through this as expeditiously as possible. The dialogue is between the presenters and the people at the table. Any of the committee members would be happy to discuss anything with you, on a one-on-one basis, after we finish. I would hope we can get through this in a nice, friendly sort of way, because there certainly are different opinions available.
We have a motion that was presented in Kingston. Because of a couple of technical difficulties there, we didn't get around to dealing with it. It's a short motion. Can I get all-party agreement to just spend a minute, a quick statement on it and then call the vote so we don't impede on presenters' time? Okay. Mr Miclash.
Mr Miclash: What we've seen earlier today, as in the past, is that we have a good number of amendments that are going to be required in terms of this legislation. For people who are unfamiliar with amendments, they will come from all three parties, whether it be the governing party, the NDP or ourselves, the Liberals. I guess what we're looking for and what I believe was a commitment of the minister was that some of the government amendments that are being worked on we would like to see tabled at the present time. Should we have those amendments in hand, we would know where portions of this bill will be going for further discussion, for further hearings. I just think it's a very important fact that if we could see the amendments that the government is going to table when the legislation goes back to clause-by-clause, it would make the process much easier.
Mr Marchese: I certainly support that motion. It would be very helpful, if they have a sense of what those amendments are, to present them to us, because then we would not be repeating the same questions to the presenters. The presenters would know in advance, because we would know and would let them know, so that they would be able to adapt those points they have and speak to other issues so that we wouldn't have to reiterate that.
I'm not sure they have amendments, other than alluding to the fact that they will make amendments. Perhaps that's the case. We simply argue in support of what Mr Miclash is saying, that if they have them, we would like to see them.
Mr Clement: I can confirm to Mr Miclash that we don't have any wording of any amendments to date. We're taking this process seriously. We want to hear from as many people as possible before we finalize amendments, so I don't want to short-circuit the process tabling what we think is the etched-in-stone version of the bill without hearing from, say, Peterborough or Windsor next week or what have you. I can assure the member that we don't have amendments that we've got in our back pocket. There are no amendments that have been worded. I think we all have our individual views perhaps, but they haven't been coalesced. I might add that the Liberal caucus in its press release this morning indicated that your amendments will not be ready until the first week of clause-by-clause, so I think that seems to be the trend on this committee.
The Chair: All those in favour of the motion? All those opposed? The motion is defeated.
You've just probably seen something very historical: three politicians actually speak for one minute each. I guarantee you, it won't happen again this evening.
PETERBOROUGH COMMUNITY PHYSICIANS
The Chair: The first group to present to us tonight is the Peterborough Community Physicians, represented by Dr Paul Leger. Welcome to our committee. You have a half-hour of our time to use as you see fit. Questions, should you allow time for them, would begin with the government and the question time would be shared evenly. The floor is yours, sir.
Dr Paul Leger: Mr Chair, I have a prepared document which I'd like to read from and guide my comments, and thus your questions, from that. I'd like to first of all thank the committee for allowing this opportunity to address the concerns that Peterborough Community Physicians has with regard to the effects that Bill 26 will have on quality of care and delivery of health care in this community and across the province.
There are five major areas of concern that I'd first like to address with regard to Bill 26: (1) Government violation of legal contracts represented in this legislation, (2) violation of the democratic principle of fair representation, (3) violation of patient confidentiality, (4) unfettered ministry involvement in health care management, and (5) concerns about who assumes responsibility for patient welfare and care. I'll elaborate on those.
Concern 1: Schedule I allows the government to unilaterally break legal contracts approved in legislation. Under schedule I, previously negotiated contracts with the Ontario Medical Association are designated. This means government's legal contractual commitments will not be fulfilled; physicians' obligations have been.
Concern 2: Patient confidentiality of personal information is violated in this bill. Under schedule H, part I, section 33, inspectors can enter any medical practice and review any patient file. Schedule H, part I, sections 2 and 21 allows publication of any personal information that the minister wishes. Schedule H, part I, section 21 states that when a person obtains an insured service, it means they automatically give consent to the release of personal information, and schedule H, part I, section 21 is the section whereby the government is not legally liable for the consequence of violation of patient confidentiality.
Concern 3: There is loss of fair process and the democratic principle of right to fair representation is violated. Schedule H, part I, section 6 states that appeals of ministry decisions, based on the discretionary criteria which I will elaborate on further below -- when these decisions are made against the practitioner, they're to be reviewed by the Medical Review Committee, whose terms of reference and appointment are determined by the minister. Then under schedule H, part I, section 27, there can be no legal action for compensation for the result of these decisions. In other words, if the minister decides to take away a licence, change the services that a physician can provide, they will be removed and there is no recourse for the individual.
1710
Concern 4: The ministry is given complete power in schedule H, part I, to micromanage all aspects of physician services. I will enumerate these:
(a) There is unilateral determination of physician eligibility. Under section 26, the manager of OHIP can establish the eligibility of any practitioner by any prescribed criteria.
(b) In section 19, the minister can arbitrarily determine contributions or fees that practitioners or health facilities respectively would reimburse back to OHIP. The minister can, as well, set arbitrary thresholds under section 11 and everything billed above that is not paid. Again, these are arbitrary figures.
(c) In section 11, the minister can set a fee value at nil. I will review these concerns below.
(d) Differential fee schedules can be created which can vary from one practitioner to another and the ministry can determine what the appropriate and arbitrary criteria are.
(e) Where an established practitioner may practise could be determined by setting fees by any prescribed criteria if those criteria were based on geographic distribution.
(f) The ministry prescribes what constitutes an insured service, constitutes a necessary service or what proves the service provided equals the service billed.
(g) All the above concerns with regard to the discretionary and unilateral approach recur in schedule F in application to independent health facilities, and as the minister can designate any physician as such a facility, they would apply to the physician. This is under schedule F, part IV, section 20.
The increase of the control and involvement of government is counter to the stated goal of this government to decrease governmental load.
Concern 5: Physicians have always had the responsibility of patient management and outcome. However, under this bill the ministry will have total control to allocate service provision. Is the ministry prepared to take responsibility for patient outcome? In addition, physicians, who are the main advocates of quality care, can be completely removed from the management process in health care.
I'd like to go on to address effects on health care delivery. Patients will be reluctant to disclose personal information, and thus diagnosis and treatment will be compromised. For instance, 15% to 20% of people will have psychiatric illness in their lifetime. Physician access to full personal information is essential for proper treatment of all medical disorders, including psychiatric illness.
A threat of arbitrary bureaucratic evaluation on every service and a fear of uncontestable, punitive action, will lead away from a focus on provision of service and towards a focus to get prior authorization and to make minute documentation for every service performed. Decreased efficiency and productivity, delayed service provision and decreased service provision will result.
There will be significant problems as a result of unilateral ministry management for all service delivery. The prior experience of this community with regard to the underserviced designation process, and the setting of a service at nil, serve as examples of how this unilateral and, I would say, uninformed -- in the sense that physicians and not bureaucrats provide patient care -- control will impact on health care.
Last year, this community applied to OHIP to be designated as an underserviced area. We'd experienced several years of inability to attract enough family physicians to this area. We'd established a waiting list of some 3,000 to 5,000 people without a family physician. Our medical society did a census of active family physicians and found that the current population-to-physician ratio was approximately 1,700 to 1, which was within the criteria to be designated as underserviced. The ministry determined by their figures that the ratio was 1,100 to 1, which is below the average expected for a family physician. The ministry would not release the information on how they arrived at this figure despite repeated requests. To this day, we are still underserviced, with a large population that has no primary care physician. My office and many others get requests daily from people with no family physician requesting we take them on as patients and we are unable to comply.
With regard to setting a fee at nil, a lack of appreciation of consequence is evident. I'd remind you this is one of the provisions within the legislation. There are two scenarios for setting a fee at nil. The first is if the service is currently not an insured service and is billed to the patient directly as a non-insured benefit. This is usually telephone advice or telephone prescription renewal. If this service was put in the fee schedule payable at nil, more office visits billed to the system will be the result as the patients would not get that service over the phone. This will cost the system more than what is currently in place, and the volume of additional service will not really be able to be accommodated.
The second scenario is that if a service is currently in the fee schedule it could be reduced to zero payment. If this service were, say, abortion, as there would be no payment for it, there would be decreased availability for this particular service. For any service rated at zero, it actually costs the physician or hospital to provide it about 50% of the current payment in overhead costs.
Likewise, if psychotherapy codes for family doctors were zero-rated, in communities like Peterborough where there is currently a shortage of psychiatric services there would be a crisis, as family physicians are providing the bulk of primary care for psychiatry in this community.
An inevitable consequence of all the above discussion is going to be extreme demoralization of physicians, as the ability to provide needed service is eroded in a system which will be perceived to be arbitrary and punitive towards physicians. One result will be a progressive exodus of new trainees, primary care providers and specialists out of the province. This community has already seen many physicians leave, with many patients left with no primary care physicians.
Potential solutions: Schedule I should be cancelled and meaningful and constructive negotiations with physicians entered to obtain workable and democratic solutions. Physicians wish to be part of the solution, not blamed for the problems.
If this legislation is to go forward, significant changes should be made to the arbitrary and unilateral powers the ministry would have. For instance, the ability of the ministry to set arbitrary fee schedules, fees or contributions payable back to the ministry and arbitrary thresholds should be deleted. Criteria for ministry standards to determine appropriate and necessary services, fee schedule variance and physician eligibility should either, at the minimum, be set by a panel equal in representation by physicians and government, or simply be deleted. An independent and objective appeal panel should be stipulated within the legislation. Physicians should be allowed the right to have legal recourse to the process in addition to an objective review panel.
The right to physician-patient confidentiality has to be protected. The power of inspectors to remove patient information from a place of storage and the right of the minister to publish personal information should be stricken.
One goal of this legislation was reputed to be cost saving in health care delivery. The size of the bureaucracy required to police and administer it alone would preclude this goal. The inefficiencies of bureaucratic micromanagement are going to increase cost and decrease service provision.
There are significant cost-saving issues not addressed in this bill, such as getting rid of the several million fraudulent health care cards or adopting primary care service plans such as proposed by the Canadian College of Family Physicians, which provides incentives for both service providers and patients to be cost-effective. Information on primary care plans is available at the OMA, and the OMA awaits discussion on this issue.
Fundamentally, there are restrictions to cost cutting, and the system is already thin after five years of cuts -- and there have been five years of cuts. Utilization increases are driven by increasing and expensive new diagnostic and treatment modalities, as well as increasing patient demand for service. The latter at least needs to be addressed, and the abovementioned model provides incentives for patients to be cost conscious.
1720
I have detailed areas of schedules H and I that raise particular concerns. Schedule F also contains many problems not possible to detail here. The time allowed to amend this bill is far too short for a bill whose breadth is so immense. More time is required for meaningful evaluation and amendment. The sections pertaining to health care should be pulled out and dealt with individually. Physicians would welcome open discussion.
In any event, there should be a sunset clause inserted that would come into effect within two years. This would at least allow a re-evaluation of whether the goal of providing all Ontarians with cost-effective, comprehensive health care is being met.
I thank you for your time and attention. I anticipate your questions.
Mr Clement: Thank you for a very worthwhile presentation. I think I can speak for all of us on the government side that you've added into your presentation some constructive suggestions, and we can certainly undertake to look at those with an open mind.
I wanted to probe just a bit on some of the items you have discussed. It will come as no surprise to other committee members that I wish to discuss disclosure and confidentiality. There is some misunderstanding, which I suppose is partially the government's inability to get its message out, but also there's some myth-making going on about what is actually in the provisions.
For instance, with respect to inspectors, as I think you would know, under the old act, inspectors had the right to enter a doctor's place of work and have access to material. No one could obstruct the inspector from doing his or her responsibilities. I acknowledge, and you make reference to, the fact that the inspector, under the new legislation, is given the power to remove documents for the sole purpose of photocopying those documents and then returning them, not without notice. Do you see that as unduly broad even in that circumstance, sir?
Dr Leger: There are two issues. The first issue is the criteria by which the inspectors enter the practice. In this situation, there are what will be perceived to be arbitrary, unilateral, broad-based criteria, with no criteria stipulated in the legislation, for these people to come into practices. They can do so under any pretext and remove any patient information.
The second issue is that when they copy it, that information is now gone from the physician's office. The real difficulty I have, that I think everyone has, is that this information can be published by the minister for whatever purpose the minister deems appropriate. That is provided for within the legislation.
Mr Clement: I gather what you would like to see -- I'm fishing for amendments, I guess. The purpose of this section, quite frankly, is to root out some fraud and misuse in the system. I'm not saying it's endemic in doctors' lives, but obviously a fraudulent dollar is a misspent dollar when we've got so many crying needs in the health care system. If there is some connection between what the inspector is doing with that purpose, would that satisfy you?
Dr Leger: In my section where I dealt with potential solutions, I recommended that the criteria whereby services are deemed to be inappropriate, unnecessary or otherwise fraudulent, by your terminology, should be established by objective criteria. That is fundamental to the process.
Mr Clement: I think the college is working on that as we speak.
Let me just talk about underservicing. We just returned from northeast and northwestern Ontario where that was obviously a very cogent issue among your colleagues and the community as well. I understand your concerns about the powers to deal with that.
Previous governments -- Liberal and NDP governments before us and PC ones in the distant past -- have tried to deal with underservicing for perhaps two decades. The chart that was part of your presentation shows that even prior to the 1995 election, we've had a bit of a problem here which good-faith discussions between NDP and Liberal governments and the OMA have failed to solve. Am I wrong in wanting, on behalf of our communities in Ontario and on behalf of Peterborough, to try to solve this a bit more forcefully, shall we say? Is that an invalid consideration?
Dr Leger: You prefaced your remarks by referring to previous discussions and contractual arrangements. I really don't have the space to address those and I would refer those back to people who are more knowledgeable than myself. What I do know is that at this time there is a proposal before the government from the OMA, in conjunction with PAIRO, to address the underserviced area issue in a cost-neutral fashion.
Mrs McLeod: I regret having to begin again by dealing with the issue of access to information. Unfortunately, Mr Clement keeps trying to make his personal opinions the view of the government, and make the legislation what he would like it to be. I thought the government's message was delivered by the Minister of Health, who has said quite clearly and quite publicly that there will be amendments to the access to information because the privacy commissioner has said that this is a grave violation of individual privacy.
In addition to the changes in terms of being able to take patients' records out of doctors' offices, copy them, disclose them, and to the fact that there is no penalty of any kind to the Minister of Health, the general manager of OHIP or any staff member or any other individual for inappropriate use of that material, there is also the very straightforward fact, Mr Clement, that one of the differences here is that up until now the only people who had access to a physician's records in the office were inspectors who were working under the Medical Review Committee of the College of Physicians and Surgeons, and that is a huge and significant change.
Dr Leger: Thank you for clarifying that.
Mrs McLeod: We have to do it quite regularly, which is why I felt the need to do it again. We thought this was one area where we'd made some gains, and he keeps setting us back.
You've presented very thoroughly a complex piece of legislation, including the dangers of many parts of this legislation coming between a patient and a physician. We're hearing in other communities that there are already concerns leading to physicians second-guessing their decisions about testing and so on. I won't take you into that area, in the interests of time.
I do want to talk a little about the underserviced area issue, because I've been coming into Peterborough long enough to know how long Peterborough has struggled to get recognition as an underserviced area. I would suggest to Mr Clement that there are some models that help in underserviced areas, and all Peterborough has been asking for for years is an agreement from the Ministry of Health that it can use the incentive programs under the underserviced area program. I know the Peterborough frustration.
We were in Sudbury the other day. They've had trouble getting recognition as underserviced in some areas. The Ministry of Health statistics included three physicians who were dead and one retired physician who gave flu shots to his neighbours as full-time practising physicians.
This act is incredible in what it does to allow the ministry to determine what physicians will be eligible to practise, to set quotas for every community, and if there are more people than will fill a quota -- should we be so lucky -- the ministry will be able to set the regulations as to who gets chosen to come to a community.
But you've raised the issue of this bill getting in the way of even being able to recruit. The minister's answer to the problem of recruitment of physicians in northern Ontario and in rural Ontario has been to say, "Let's put in place billing numbers" -- a coercive method -- "but we won't use it unless we have to." Across northern Ontario we heard: "It won't work. Coercion will drive people out, and that, combined with the other measures in Bill 26, will make the problem more difficult." Is that your concern as well?
Dr Leger: You've covered a lot of ground.
Mrs McLeod: I did.
Dr Leger: According to our calculations, the way the ministry derived the figures for our area, we assume we have some dead practising physicians here as well -- none of them in this room.
Mrs McLeod: If they were, they'd count for two on the ministry list.
Dr Leger: I agree essentially with what you're saying, that this idea of trying to coerce physicians into a model of management is not going to work. We've been working very hard for the last five, six years to provide services. For instance, in Peterborough we're working with half the number of hospital beds that we did seven years ago. We've been working under very adverse circumstances and trying to do the best we can.
Trying to coerce people who are doing the maximum effort they can do is only going to have a rebound effect. There has been a progressive exodus of physicians out of this province. A statistic I heard recently was that 50% of the graduating class of the U of T family practice program went to the States. Now, not only are we paying this education cost, we're losing all our human resources.
1730
Mr Marchese: Dr Leger, thank you for your presentation. I have three or four quick questions, if the answers are equally short. One of the stated objectives of the government in presenting Bill 26 is that it would help to deal with our deficit problems. Is there anything dealing with doctors in general here that helps the government to deal with the deficit?
Dr Leger: I can see no way in which this legislation is going to achieve a goal of cost saving. In fact, I would perceive that there would be cost increments required for the bureaucratic administration of this legislation.
Mr Marchese: The other stated objective is that they're trying to deliver a better health care system in order to be able to take care of our population. Much of what you've said is very critical. Is there anything that you have read in relation to the medical profession that helps to deliver a better medical model or better health care system for our population?
Dr Leger: Yes. I did make reference to the primary care models that are available. The college of family practice is a model, for instance, which would in its implication make both service providers -- physicians -- and patients liable and responsible for costs incurred. So there are primary care models that are available now that would actually help with cost control and cost reduction.
Mr Marchese: But in terms of what they have presented to us here in this bill, is there anything there that you think is good for a good health care system in Ontario, to make it better? Be kind now.
Dr Leger: There is an intent behind the legislation. If one had a magnanimous autocrat, one could perceive that this legislation could be beneficial. But in the practical realities of administration of such a complex document, no. I can't find, for instance, areas where I would perceive there would be cost saving. You're asking me questions that are -- I'm a family physician, practising full-time in this area.
Mr Marchese: The questions are related to your field. Is there anything in this bill, of which part you've read -- you may not have read the whole thing.
Dr Leger: I read it.
Mr Marchese: Is there anything in this you like?
Dr Leger: One third of it I did not understand fully because of the complexity of the documentation requiring full and complete knowledge of many other pieces of legislation. The parts relating to health care were difficult. I don't have the expertise, but I was concerned about sections relating to the environmental concerns with mining and I had some concerns with the way in which the Corporations Act was being changed, but I did not fully understand the impact.
Mr Marchese: If there is one third that you didn't understand as a medical doctor, can you imagine what the rest of the population would think about this document? It would be complicated, wouldn't you say?
Dr Leger: Yes, I can.
The Chair: Thank you, doctor. We appreciate your presentation and your interest in the process.
ONTARIO SOCIETY OF OBSTETRICIANS AND GYNAECOLOGISTS
ONTARIO MEDICAL ASSOCIATION, SECTION OF OBSTETRICS AND GYNAECOLOGY
The Chair: Our next presenters are from the Ontario Society of Obstetricians and Gynaecologists. Welcome, gentlemen, and introduce yourselves.
Dr Richard Johnston: Thank you very much for the opportunity to present this afternoon. On my right is Dr Marshall Redhill, secretary-treasurer of our section of Obstetrics and Gynaecology of the Ontario Medical Association. On my left is Dr Robert Kinch, former professor at McGill and Western Ontario, an executive vice-president of the Canadian Society of Obstetrics and Gynaecology. Dr Kinch won't be speaking this afternoon.
I will open and Dr Redhill will follow. As mentioned, I am chairman of our section of 600 obstetricians and gynaecologists in the province. The obstetrical and gynaecological care in this province has historically been of the very highest calibre. Comparing any number of statistics regarding outcome, both in obstetrics and gynaecology, it is clear that patients in Ontario have received the very best in care.
More recently, within the past 10 years, with further and more drastic government intervention, careers in obstetrics and gynaecology and the practice itself seem to be under major stress. We are very concerned that not only areas of northern Ontario, but areas of central and southern Ontario may well become underserviced in obstetrics and gynaecology in the very near future. Bill 26 may make the latter possibility a reality in 1996.
It has become in the past few years more and more difficult, with rising litigation and malpractice premiums, to encourage young people to enter the area of obstetrics. This obviously impacts on manpower and the ability to provide first-class obstetrical service not only in large urban centres but in smaller central regional and northern regional areas. The very difficult physical and mental challenges of obstetrics occurring 24 hours a day, seven days a week, have diminished the interest of many competent young medical graduates who have now sought careers in other areas and other locales, read "south."
Bill 26 will eliminate the membership subsidy for malpractice, which was introduced by the Liberal provincial government in 1987 in lieu of a fee increase. If this current legislation passes, obstetricians will be paying $2,000 per month for 1996, and there's every reason to think that in 1997 and thereafter, these fees will continue to increase. With the base fee per delivery of $245 and the average obstetrician in Ontario delivering only approximately 160 babies per year, it is very clear that for obvious economic and business reasons, many obstetricians will simply no longer be in the obstetrical business. Currently, one would have to deliver 90 babies, approximately, simply to pay our malpractice fee.
There are currently 600 ob-gyns in this province, with only 500 actually doing full- or part-time obstetrics. Of the 500, only 400 carry a balanced obstetrics and gynaecology practice. Of the 400, a small per cent in university centres practise full-time obstetrics.
There are approximately 140,000 babies born each year in this province, and approximately 20% to 40% of these patients are considered at high risk, requiring specialists' care. Other patients simply choose to be delivered and cared for by specialists where available, while others will seek out family doctors or midwives.
Whether or not patients are delivered by family doctors, midwives or obstetricians, patients have very high expectations of their obstetrical provider. The cornerstone in the obstetrical team is in fact the obstetrician. We recognize the very important role that other physicians, anaesthetists, paediatricians, obstetrical nurses, geneticists and midwives play during the course of a pregnancy, but obviously the pivotal, or buck-stops-here, individual can ultimately be the obstetrician. Clearly, our malpractice membership fees and premiums substantiate this as we are paying a fee shared by no other medical group in this province.
At an emergency meeting of our section just this past Sunday, January 7, a question was asked with regard to continuation of obstetrical practice if no changes were made with regard to Bill 26 and our malpractice situation. It appeared that approximately one third of the physicians present were very seriously considering alternative practice patterns. It is ironic that never before have the obstetricians in this province been so galvanized and unified in their response to legislation and what appears to many physicians and patients to be the equivalent of the War Measures Act for health care.
The overwhelming powers entrusted to government in this legislation is beyond the scope of our presentation, and our focus today is simply in regard to our concern that there is a very real threat to the continuation of high-quality obstetrical care for patients in this province.
1740
We do not understand the virtually unlimited powers enshrined in this document to the Minister of Health. We do not recognize that there is a major crisis in health care warranting such intervention and legislation. Pregnant patients, their complications and newborns are not a doctor-driven situation. We are tired of hearing from various sources about the latter aspects of health care economics.
Everyone in this room and every physician and health care worker in this province recognizes and encourages the need for many changes in health care. No current medical formula, including Bill 26, is perfect.
We agree that there are changes needed within the OMA's structuring and fee schedule, as well as the approach and incentive for rural remote areas of this province, including the provision of obstetrical services in these very places.
In a number of areas of this province obstetricians carry a very high obstetrical load, and any concept of capping these individuals will have dire repercussions for patients in those areas.
Women's health care deserves a better deal from this government.
Furthermore, the current message in the past 10 years, but precipitated more so by way of Bill 26, is a message to medical students and residents: Why would anyone in their right mind consider a career in obstetrics in Ontario?
The maintenance and continuation of high-quality obstetrical care is only possible by the infusion of talented, bright young people, and we are very concerned that obstetrics as a choice will not be on the short list of any young graduate. If it is on their short list, it may be south of the border where many vacancies still exist throughout virtually every state.
Canadian obstetricians are recognized in the United States as a high-quality, guaranteed product. Our undergraduate and postgraduate training is of the highest order. Many Canadian obstetricians occupy university appointments and chair several of the major departments at university centres in the States.
While the emigration for Canadian doctors is listed and reported as only about 2% a year, a disproportion of this emigration is in fact obstetricians. The province cannot afford to lose these highly trained, well-qualified young Canadians.
Our membership and constituents have spoken to us very clearly. Regardless of our leadership, they are very angered and will be making decisions independently as to their continuing decision and choices regarding obstetrical care.
That's the end of my brief. Dr Redhill has a few comments as well. Then the three of us will be prepared to answer questions.
Dr Marshall Redhill: Mr Chairman, ladies and gentlemen of the committee, I thank you for the opportunity of addressing you today. On behalf of the section of obstetrics and gynaecology, I'd like to communicate with you the potential crisis that could arise in the delivery of obstetrical care in the province of Ontario if this government's current agenda, particularly in regard to withdrawal of assistance to the province's obstetricians with their malpractice dues, is implemented.
I want to assure you that the obstetricians of the province are committed to provide excellence in obstetrical care to the women and newborns of Ontario. On the other hand, we are very seriously worried about the safe delivery of newborns in the province if it becomes practically impossible to maintain a high level of specialist service to continue that service in many areas because of the economic impact of the withdrawal of the assistance with the Canadian Medical Protective Association coverage.
The membership of our section is concerned that your government may not have been properly informed of the net effect of this decision and the way in which that decision may, and indeed we believe will of necessity, impair the quality of care to the women and children we serve.
There are, as my colleague's just told you, approximately 500 practising obstetricians in the province who are involved in the delivery of approximately 125,000 babies annually. Now, Dick probably has more updated statistics and says 140,000. As you may also be aware, due to the Ontario coroners' recommendations, every provincial hospital is currently advised, for public safety reasons, to have an obstetrician on call, even if a family doctor and/or midwife is available to do uncomplicated deliveries, on the staff of that hospital if obstetrics is practised in that hospital.
Needless to say, obstetricians must have malpractice insurance to have hospital privileges to perform obstetrics, even if they are only to be on call for complicated deliveries. Quite frankly, net compensation to an obstetrician for an ordinary labour and delivery, which would average somewhere between six and 10 hours of labour -- but there are outside those parameters many women who'd go shorter or longer -- if this decision is implemented, will be -- are you ready? -- $34.90. Please do not think that I'm either exaggerating or overreacting. This is a fact which on its face should indicate to you that many obstetricians simply will not and cannot continue in obstetrics. The average obstetrical caseload for specialists in this province is about 160 deliveries per year. A little later in this presentation, I'll explain to you in detail how I arrived at this figure.
The section of obstetrics and gynaecology is turning to you in good faith and with a genuine concern for the people of the province of Ontario who have elected this Conservative government into power. We want very much to continue to give women and newborns of this province the excellent and superior care that they not only are accustomed to but, we believe, are entitled to expect from us. We need your help in achieving this. We know that you do not think that obstetricians are creating work for themselves by overutilizing the health care system and we are reasonably confident that within the current government there is a will to maintain the excellence in health care to which Ontario is accustomed.
The CMPA rebate was brought into effect in 1987. It was in lieu of a fee increase in the schedule of benefits for physicians after several years of very minuscule, if any, increase in fees for remuneration of doctors. The "reserve" fund, which has attracted a great deal of attention from the ministry and the press, is the result of good actuarial practice on the part of the Canadian Medical Protective Association. It is in reserve for the entire national picture of Canada rather than just the province of Ontario; it's national. In comparison with the massive unfunded liability of the Workers' Compensation Board and problems with the Canada pension plan, the lawyers' compensation fund and failing insurance companies, the CMPA's reserve fund should be applauded rather than criticized. The increase in premiums over the past several years is due to an increase in court awards, 50% of which is returned to the public coffers via OHIP for subrogated interest.
I'd like now to make you aware of some facts, and I apologize for not having enough copies of this made.
Fact: Obviously, obstetricians do not overutilize the health care system. The birth rate is not driven by obstetricians. Otherwise, we'd all be hauled before the College of Physicians and Surgeons of Ontario. Besides which, we're all too damn tired.
Fact: There are 500 practising obstetrical specialists in the province and, as I said before, 125,000 babies are delivered annually in Ontario, either directly or indirectly by obstetricians.
Fact: Due to coroners' recommendations for patient safety, every Ontario hospital that has an obstetrical unit must have an obstetrician on call even if a family doctor or a midwife is also on staff.
Fact: Hospital bylaws and standards of practice require that obstetricians handle high-risk pregnancies.
Fact: In 1986, 10 years ago, malpractice insurance for obstetricians and gynaecologists was $4,900, of which $1,400 was ascribed for the obstetrical delivery portion of the practice. Today, that fee is now $24,036, of which $12,924 is assigned to the obstetrical portion for deliveries. This represents an increased burden of $11,524 over the base year of 1986 and is the financial burden that we will have to carry if this portion of the bill is passed. This represents $72 per obstetrical delivery that I do, based on an average caseload of 160 deliveries per annum.
Fact: In 1996, malpractice insurance for family physicians is $4,332 and for midwives, $4,500.
Fact: In 1986, 10 years ago, obstetricians in Ontario were paid $210.30 by OHIP for an ordinary, uncomplicated labour and delivery. Time, on average, as I alluded to before, is between six and 10 hours.
Fact: In 1996, obstetricians are paid $34.40 more, for $244.70 for the same uncomplicated delivery.
1750
Fact: From this $244.70 payment to the obstetrician the following are our costs of performing that delivery: 10% clawback for overutilization of the system, which will now in the new legislation be called "contribution"; $72 CMPA insurance, as I've indicated previously; a 10% contemplated decrease in the threshold that we are allowed to bill; 40% office overhead, and 53% income tax.
Fact: The net compensation after all of these deductions for a delivery, representing somewhere between six and 10 hours of labour, both on behalf of the patient and on behalf of the doctor labouring, is $34.90 with an average of less than $6 per hour net take-home pay.
Fact: If all prenatal visits, post-partum care in the hospital and postnatal checkup at six weeks in the doctor's office are factored in for a straightforward, uncomplicated pregnancy labour and delivery, the gross pay is approximately, for the entire nine months, or nine yards, $570, and this works out to a net return, after all those abovenoted deductions, $110.
Fact: Without the government's assistance with malpractice fees, the compensation to obstetricians to supervise childbirth will make it economically impractical for some obstetricians to continue to practise obstetrics.
Fact: New midwives entering the profession are paid $55,000 per annum, with government increasing $2,000 per annum for each year of seniority or grandfathering -- that somehow sticks in my throat; it should be grandmothering -- to a maximum of $77,000.
Fact: Two midwives are required to attend together 80 deliveries per annum.
Fact: The gross compensation for a midwife to do a straightforward, uncomplicated patient's prenatal care, labour, delivery, post-partum care and newborn care therefore varies between $1,375 for the lowest-paid midwife to $1,925 for the most senior midwife.
Fact: The government pays for the midwives their drug, dental and extended health care, and also makes a contribution to their retirement savings plan. Their malpractice insurance of $4,500 per annum is also paid by the government. Their office expenses are completely paid for, as well as their mileage and cellular phones.
Fact: The only expenses which a midwife is faced with paying are her college and midwife association fees. In addition, of course, she too has to pay income tax.
Fact: Enrolment in medical schools and postgraduate residency training programs is reduced by government fiat. More graduates are writing their American board exams at the same time as they write their Canadian fellowship exams preparatory to job hunting in the United States. And as my colleague has indicated, Canadian graduates in the specialties are very attractive in the States.
Fact: This resultant loss of future specialists will threaten research and academic excellence for years and years to come.
As a result of our serious concern about this constellation of facts, the section of obstetrics and gynaecology at the emergency meeting last Sunday passed the following motion which was carried unanimously:
"Whereas the Ontario Medical Association Section of Obstetrics and Gynaecology's mission is to continue to provide excellence in obstetrical care in Ontario, and whereas 500 obstetricians are currently responsible, either directly or indirectly, for the safe delivery of 125,000 babies each year;
"And whereas the government's Bill 26 Savings and Restructuring Act, by its draconian provisions, demonstrates gender insensitivity to the women and newborns of this province,"
The section voted "to inform an alert government to the fact that in the absence of a responsible amendment to the act directly impacting obstetrical service and delivery, a serious crisis in obstetrical care will be created within the year as a result of the forced retirement of significant numbers of specialists from the profession who will be unable to reasonably pay their CMPA obstetric malpractice fees on the basis of the current fee schedule."
In addition, because we cannot be held responsible for utilization levels in obstetrics, a further motion was unanimously carried, and this motion read: "The threshold for obstetrical codes be eliminated."
Interruption.
Dr Redhill: If that's my wife, I'm busy.
Mrs Ecker: It's one of your patients.
Dr Johnston: Somebody's fully dilated, Marshall.
Dr Redhill: Somebody's obviously fully delighted.
All of which is respectfully submitted. Thank you so much for your time and I'd be pleased to answer any of your questions, as would my colleagues.
Mrs McLeod: That was such a compelling presentation that you feel as though no more should have to be said and the Minister of Health should simply revisit this issue immediately.
I'm going to stay with it because, first of all, we don't often have obstetricians coming and presenting that case to this committee and, secondly, because I think this is one of the areas in which there is the potential for an immediate crisis even before passage of the bill.
I have, a combined conflict of interest. The first is that I want my daughter's obstetrician to stay in practice long enough to deliver my first grandchild next month, and the other is that I confess to a personal conflict because my husband has been a family practitioner for 30-some years in a northern community doing obstetrics. He thinks he should get to the point where he stops so he can guarantee a full night's sleep, but he loves it. He's delivering the babies of the babies he delivered. He wants to stay doing it, and he will not because he would actually have to pay for the privilege of delivering those babies. That is a terribly sad situation and indeed, combined with the potential withdrawal of services by obstetricians, does constitute a pending crisis.
The Minister of Health has given some indication that he may revisit this issue for family doctors who do obstetrics. You've made it clear he must also deal with it for obstetricians, but I would ask you to comment. If there was a withdrawal, not only by obstetricians but of family doctors in this area who may do obstetrics, what effect would that have on access to obstetrical care?
Dr Redhill: Before I reply, I must tell you there is not going to be a withdrawal of service. This will be a natural effect for obstetricians who are approaching the long-in-the-tooth situation where instead of retiring at 65 or 67 are going to quit at 62 and 63 and say: "To heck with it. I just can't take this any more." This is a natural result of this sort of economic reality. It will not be a withdrawal of services. There will be doctors who will continue to do obstetrics, and I too am now a grandfather of many children whom I delivered originally.
The impact on obstetrics is plain and clear to see. There are going to be less practitioners to deliver more babies. There are not going to be enough midwives to fill the roles. There are not going to be enough women in the province who are going to choose midwives over either family physicians or specialists. It's just not that popular or large a demand. When you increase the volume that tired, old obstetricians have to deliver, you decrease the care and increase the risk. That is not satisfactory.
Mr Marchese: I have a general question. A previous group this morning in Kingston made this comment where they said, "The role of government is to set policy standards and objectives and the role of medical institutions generally is to manage and administer the system." With Bill 26, what it does at least is to confuse those roles where in fact the government is assuming the role of managing the system, and it presents a problem.
In terms of what's contained in here, I suspect some of you have in your mind that the New Democrats would have been capable of doing something like this --
Dr Redhill: How perceptive.
Mr Marchese: -- but we didn't do it. I knew I could assume some things and be quite correct.
They say on the other side that: "We got rid of the Advocacy Act because it's too intrusive. We got rid of employment equity because it was too intrusive and draconian. But we now have a bill that we need. We need this Bill 26," which is very draconian and very intrusive, but they don't think that's a problem. In your view, is this necessary, what they are presenting to us? Does it help to solve the deficit? Does it make our health care system any better?
Dr Redhill: The brief answer generally is no.
Dr Johnston: And we agree.
Dr Redhill: The College of Physicians and Surgeons has the role to supervise and deal with physicians who abuse their role or are fraudulent. Without being pejorative, this bill criminalizes physicians even more so than previous governments have had a tendency to do. My sense of this bill is that this has been drafted by a Conservative, small business government with a left-wing agenda in a right-wing fashion. Did I leave anybody out?
1800
Mrs Ecker: I'm a bit speechless after that description of what you believe is happening, but I would like to thank you very much for coming here and taking the time from what I know is a very busy schedule to bring forward your concerns and your suggestions. You mentioned the Medical Review Committee under the CPSO in terms of its powers to be able to look at inappropriate or misused billings or whatever in the system.
One of the concerns the college has been telegraphing for several years now is that this system is not working, that it's costing physicians and the college, your fees to the college, an outrageous amount of money for the time -- two, three, four and five years -- to get through. When they do find someone, they have not been able to get the paybacks from someone who is actually doing something inappropriate.
They've been suggesting very strongly for some time to previous governments that amendments need to be made, that the system needs to be streamlined, improved, enhanced. Would it be more appropriate if the role to continue to look at the inappropriate billing were to be placed with CPSO with an enhanced, streamlined, more effective Medical Review Committee, where there is a committee of public representation and physician representation which will look at the patient files and the information to make that decision whether or not the medical necessity or the billing has been inappropriate?
Dr Redhill: Janet, you've worked with the College of Physicians and Surgeons. You are more familiar with the machinations of the college than perhaps anybody else in this room. It sounds like you're reinventing the wheel; it already exists.
Mrs Ecker: But they're saying it's not working, though. The college is saying the current system does not work. They say it needs to be changed.
Dr Redhill: Why, because they haven't got 25% of doctors in jail? Maybe there aren't 25% of doctors who are crooks.
Mrs Ecker: Well, if there are, we should be doing something about it. I don't think the percentage is that high, quite frankly, sir.
Dr Redhill: This legislation suggests and has sections in it that keep repeating again and again "inappropriate billing" and "fraudulent use" and "misrepresentation." Nowhere in this bill is the misuse or abuse of the system by the public, and health card fraud, addressed, nowhere.
Mrs Ecker: Mr Wilson has said very much that, one, smart card technology and stuff to go after that is certainly a priority. Secondly, the only way we're going to get after what you as physicians describe as double doctoring -- we know, for example, that in one month 7,000 people went to see more than five GPs in one month, which you think is pretty excessive. The only way to get at that is to have information within the system. I certainly support that because that is money that should be there for front-line services that are needed.
The Chair: Doctors, thank you very much for your presentation. We appreciate the time you've taken to be with us tonight.
NORTHUMBERLAND COALITION AGAINST POVERTY
The Chair: Our next presenters are the Northumberland Coalition Against Poverty, represented by Carolyn Blaind, a member, and Pat Gardner, a member. Good evening and welcome to our committee.
Ms Carolyn Blaind: Our presentation starts out by saying, "Good afternoon." I will begin by saying, "Good evening" instead, and thank you for the opportunity to present to the committee. We are here today representing Northumberland Coalition Against Poverty, a coalition of low-income people in Northumberland county.
Our members include people on social assistance, disability pensions, workers' compensation and people working for low wages. Our activities include speaking out to our elected representatives about issues that concern us, as Dr Galt can tell you. Our presentation is intended to address our specific concerns about Bill 26 with regard to the health sections of the bill. Before we address our itemized concerns, we would like to provide you with some summary information on the determinants of health.
For many years, governments, health care providers and consumers have been involved in studies, consultations and research in an attempt to define health and wellbeing, to predict the determinants of health and to assess the impact of poor health on individuals, families, communities and nations. From these initiatives, numerous reports and statistics have shown us that there is a direct correlation between income and good health or bad health.
Healthy people are those who have the necessary resources for health, one of which is adequate income. With an adequate income, people's opportunities to participate and create healthy communities and societies increase. High levels of health are a means to sustaining independence as individuals, communities and nations. There are no wealthy countries in the world without a high level of health.
To achieve and maintain good health and to decrease costs in health care, we need to foster strong supportive families and communities and to provide accessible, affordable and appropriate services for everyone.
For low-income individuals and families and those who must rely on publicly funded services, the capacity to provide healthy environments for families is being diminished by policies and legislation that have a negative impact.
Ms Pat Gardner: This brings us to this legislation, Bill 26. Under this bill, amendments to the Ontario drug benefit plan permit the introduction of user fees, copayments and deductibles for seniors, social assistance recipients and persons with disabilities. Many of those who must rely on this plan have already been hit with a 22% decrease in income and cannot afford user fees and deductibles. Once rent and utilities are paid, there is barely enough left to purchase food. The food budget is the only place left to cut spending and will now be further depleted when families are required to pay user fees for medication. This means the difference between providing adequate nutrition or necessary medication. There is no choice here. Proper nutrition, also being a determinant of health, will be sacrificed.
Further, under amendments to the Ontario drug benefit plan, the government will no longer pay the difference between generic and brand-name costs for no-substitution claims. We interpret this to mean that if a generic drug is not available or suitable, the individual must pay the difference. Because prices will now be set by the manufacturer and Ontario becomes the only province that does not regulate drug prices, we are concerned that costs to those individuals who can least afford it will increase.
We are aware that we face increased costs to the Ontario drug benefit plan, but not because of overuse of the plan, rather because of overprescribing and federal legislation, Bill C-91, that extended patent protection that delays the introduction of generic drugs that are less expensive.
We feel strongly that low-income people should not be made to bear the burden of such irresponsible legislation at the hands of government. With regard to Bill 26, the Common Sense Revolution clearly stated, and I quote, "Under this plan, there will be no new user fees." This promise has clearly been broken to fulfil an election promise of a 30% tax cut that will have no positive outcome for the poor, seniors or persons with disabilities. We urge the government to amend the legislation so that no new user fees for health care will be implemented.
Finally, we are deeply concerned that this bill will permit astronomical powers to the Minister of Health to define what is a medically necessary service, to permit hospitals to charge user fees and to dictate to doctors where, when and how they can practice medicine. For partners to work well together, we need to know our limitations. In areas where there is no expertise, we must rely on those with the scope of knowledge to provide us with the best information on how to do the best job. The government should stay out of the operating room of health.
1810
We wish at this time to voice our concerns about the fact that Bill 26 gives the Ministry of Health unlimited access to the private medical records of the citizens of Ontario. We are concerned that the information in our private records could be used as a basis for discrimination once the minister is given the power to define what a medically necessary service is. We are also disturbed that there is absolutely no guarantee that our confidential medical files will not end up in the wrong hands.
Finally, we would like to inform the committee that low-income people are fed up with being labelled the deficit-causing problem of this province. A reduction in the deficit cannot and should not even be attempted on the backs of the poor, seniors and persons with disabilities. Bill 26 attempts this. We optimistically believe, now the members are familiar with the negative impact this will have on all sectors of society, that should Bill 26 go to a free vote in the Legislature, it will not pass.
We thank you for listening to our presentation and will be happy to respond to questions.
Mr Marchese: Thank you for the presentation. One of the things you mentioned that I agree with you on is with respect to the user fee in the Ontario drug benefit plan and how that will affect seniors and low-income people in general. We tend to forget -- perhaps not; I'm sure you would have included it if we were speaking generally: The tools this government is giving municipalities will mean municipalities will impose user fees as well on a wide range of things we may not yet know, but if you can think of it, they'll probably introduce it. So municipalities are likely to introduce fees; hospitals and doctors; independent health facilities; the drug plan. My feeling is that when you add it all up, and I'm not sure they've added it all up, the low-income people and seniors will be hurt very seriously. Is that your view?
Ms Gardner: Definitely. As a matter of fact, one of our concerns is that a lot of the user fees that will be imposed by municipalities will be fees for things that are necessities, where we won't have a choice, where we'll have to use these services, such as garbage collection. That's a good example. We might be forced to pay $1 a week or $1 a bag for garbage to dispose of our garbage, and that's something we can't do without.
When you add up the fact that 21.6% was taken off the allowance that social assistance recipients receive for their rent, 21.6% was removed from the amount they receive for their other necessities including groceries, and you top that off with the fact that our rents didn't go down by 21.6% so we have to take that out of our food budget, and then add to that the user fees for drugs, which are a necessity, and any municipal user fees that are levied, that creates a lot of problems for people in our situation.
Mr Marchese: One of the concerns we had as opposition members was that this government had not intended to consult the communities in Ontario. They wanted to pass this legislation before December 14. That would not have been a process. It would not have been democratic. It would not have allowed any scrutiny whatsoever with respect to this bill and what we are all now engaged in. The tactics we engaged in allows us the opportunity to get some media attention and force the government, obviously, to do this.
Do you feel, in spite of that, that you've had enough time to review this document? I'm not sure whether you've seen it, read it, parts of it, the whole bill or not. Do you think you've had enough time to be able to review the effects it has on the people you serve on a daily basis?
Ms Gardner: Just speaking for ourselves, we've only been able to have the chance to see a synopsis of the bill. We have not actually been able to see the entire text of the bill, because obviously, as you know, it's quite a few pages of paper and it costs quite a bit of money to get your hands on a copy of it. Obviously, we don't have the kind of funds to be able to get a copy of the bill. I think a bill that size and of that scope requires a lot of scrutiny before you can make a really educated decision on it, but from what we can see in the bill, there are a lot of things in there that will hurt low-income people and seniors and disabled people.
Ms Blaind: We are also of the view, if our understanding is correct, that under this new bill cabinet will be given astronomical powers to pass things without debate or public consultation. We've come up with a little theme around that, that being that if you don't tell the public what you're doing, the public can't tell you what you're doing wrong. We're very much opposed to the whole process of this bill.
Mr Marchese: One doctor, in the previous submission this morning, said that people have to be involved if they are to accept change, or that if we're going to have good change, if people are not involved that change is likely not to be very effective. I agree with your remarks.
You alluded to the income tax cut. You serve people who, generally speaking, are low-income people. We understand that the income tax cut a low-income person will get is very, very little, and these are the people who normally would spend. We estimate that 60% of the income tax cut is likely to go to the top 10 percentile of the population. We think those people who are going to benefit from the income tax cut are the wealthiest citizens of Ontario, who are not likely to spend, who are not likely therefore to kick the economy into shape. We think this will benefit the very wealthy and will hurt as a result of taking money out of other areas to service this income tax cut. Have you done some thinking in this area?
Ms Blaind: Definitely we have. As a matter of fact, one of the first things we discussed at our meetings when we heard there were going to be these 21.6% cuts was the fact that this money that's coming out of people's welfare cheques is coming out of the local economy. Everyone who is on social assistance spends all their money each month; they put it right back into the economy at the grocery store, at clothing stores, just to buy the necessities of life they need every month. This money has now been taken out of the economy, and that effect will be increased when more money is taken out of the economy to pay municipal user fees and drug fees. We have definitely looked into that.
Mrs Johns: I'd like to thank you for your presentation and for your information about the poor you represent in Northumberland.
I'd like to say that I don't believe this government -- and you know Dr Galt, so you know well that this government isn't an uncaring, unthinking group -- is blaming the poor for the financial situation of this province. The interest the province is paying on the deficit is leading the province to be unable to pay for things we have had in the past. The province must be healthy for individuals to be healthy, for us to maintain a healthy health care system. We're trying very hard to allocate money to be able to have a healthy health care system, that we may all use it.
I wanted to talk about the drug benefit program and the user fee. What has happened in the past is that other governments have had to take drugs off the formulary or the list that would be covered by the government, to be able to put others on it or to maintain a standard so we could live within the health care budget for drugs. This government is fairly concerned about that and we're looking for ways to control this program so we can put more drugs on it, because new drugs are becoming available all the time that we would like to put on to this formulary. If you don't think a copayment fee is the right way to go, have you got any suggestions about what you think we should do?
Ms Blaind: First of all, overprescribing is a problem, definitely a problem. In terms of some of the things that were delisted by the previous government, having worked with the population who are clients of that program, there were many medications that were not necessary, were contraindicated, medications that were prescribed over the phone before an individual had seen a physician. These are some of the things you want to be looking into. Nobody that I know of in Ontario, with the exception of someone holding a medical licence, prescribes their own medication, so you don't blame the individual for the overprescribing of the drug, you don't blame the individual who's the recipient of that medication because we have exorbitant drug fees from the Ontario drug benefit plan; you look to cause and effect. A copayment is like a tax on people who don't prescribe these medications for themselves, who can't afford them. I think you want to back up a little and look at why it got there.
1820
Mrs Johns: You say at the bottom of page 3, "Further, under amendments to the Ontario drug benefit plan the government will no longer pay the difference between generic and brand-name costs for no-substitution claims." We heard from a couple of groups that approximately 6% of people can't take a specific drug -- it would depend on the drug, obviously. We had a definition from one of the groups in the past week that 6% couldn't take a substitute product. They felt that in terms of the "no substitution," we should make an exception for that 6% and ask everyone else to take the cheapest drug available in the system, if it's generic. Do you agree with that philosophy?
Ms Blaind: I think it's an individual thing. Having worked in the system, I question that 6%; that sounds rather low. In some cases generic drugs use fillers, and if you have an individual plan of treatment for someone using the Ontario drug benefit plan who has a chronic illness or disease, you need to look at that whole plan of treatment and maybe that whole plan of drug therapy. If you look at the generic drug, on its own it might be fine, but if there are other medications where a generic drug is contraindicated, there has to be a substitution for that. Otherwise, you're looking at increased health costs and this individual ends up back in the emergency room because their drugs didn't interact well.
Mrs Johns: Can I just paraphrase, and you can say if this is what you're saying.
Ms Blaind: I'll tell you if that's what I said.
Mrs Johns: I don't want to put words in your mouth. You're saying that if we allow the cheapest product unless there's some problem with the person's health, that would be all right with you; if there truly was some reason a person would react, we should change the "no substitution."
Ms Blaind: If a generic drug is available and it'll do the job, yes. Our members don't have any problem with that. Generics have enabled individuals to access medication that's a whole lot cheaper -- and not just on the Ontario drug benefit plan. I'll give you a good example. Tagamet, when it first came out, was a brand-name product, and when the generic drug ranitidine was introduced, there was a difference of $40 in price per prescription. The problem we have now -- again it goes back to cause and effect -- is that C-91 interfered, gave patent protection to brand-name companies, so we're not going to have the generic drugs available. That also has to be considered. We can't just give a blanket statement saying, "Anybody in the Ontario drug benefit plan has to have a generic drug." You have to look at the federal legislation.
Mr Miclash: Thank you very much for your presentation. I must say I'm a little blown away by the comments made by Mrs Johns regarding a caring government when we take a look at the care this government has given us in withdrawing $1.5 billion out of our health care, the caring government that tried to ram this bill through before December 14 with no public input at all, public input for which we had to literally hold the Legislature hostage and which we finally got, which puts us here this evening. We must remember that this is a finance bill, a finance bill to ensure that Mike Harris gets his 30% tax reduction to the rich. That's the way we see it.
I go back to the presenters and ask, do you know of any input into the drafting of Bill 26, or were you involved in any input in the drafting of this piece of legislation?
Ms Gardner: No, we certainly were not. As a matter of fact, another group in our area with which we are acquainted did want to have some input. They were quite willing to have their own input, and were turned down.
Ms Blaind: Do you mean prior to the introduction of the legislation?
Mr Miclash: That's right.
Ms Blaind: There was no consultation that we know of around that, and I fully believe that a lot of the members didn't know what was in this bill either. Send it to a free vote, now that they know.
Mr Miclash: I appreciate that comment. I've asked that question as we've moved around the province and haven't yet found a group or individual who knows of anyone who helped in the drafting of this legislation.
Mrs McLeod: There are a lot of reasons we're glad this did not become law on December 14 or December 23, as the government had wanted. One is that we keep having hints from the government that there may be changes now it's begun to realize the impact of this bill.
For the record, Mr Chair, we've just had some indication of another potential change, that there would be a process for substitution where a particular generic drug is not an appropriate treatment. I hope we are going to see in place at least some process for exception when we finally see amendments.
You've touched on two areas in terms of changes to the drug benefit plan. I want to come back to one you touched very lightly, and that's the deregulation of drug prices. Obviously, there's a concern about copayment for those on the Ontario drug benefit plan, and if we have time I'll ask you to expand on that, but this deregulation issue affects every low-income earner who is not on the plan.
We've become very frustrated over the course of the week, because every presenter has had a different view of what this might do to prices of drugs. One thing that has become clear is that it's most likely to cause higher prices of drugs in smaller communities where there's less competition.
The Minister of Health before Christmas had said the way it might bring down prices is that the big pharmacies, the chain pharmacies, may drop their price, because they do a big volume. The chain pharmacies presented to us this morning and said they were not commenting on deregulation because they had no idea what it would do to prices.
One thing the Minister of Health has said is that there will be differences in prices for drugs from one pharmacy to another and that people should barter to get the best drugs. I'd like you to comment on how feasible you think it is for the people you're working with, to think of a single mom with a sick kid going out and trying to get the best price for the drug for that child.
Ms Gardner: As a single mother myself, I'd have to say that first of all, when you live in a small town you have a very small choice of pharmacies to go to. Second, when you have a drug card, you take it in whenever you have your first prescription that month and put it into that pharmacy, and it's quite a hassle to go to a second pharmacy and get them to call the first pharmacy and verify that you have put your drug card in there. It's a lot of hassle when you're driving a sick child around town, going to this pharmacy and that pharmacy and having to go up to the pharmacist and say: "How much are you charging for this drug? How much would you charge me if I gave you this prescription?" I'm sure it's not fun for the pharmacist either, who is usually busy and has a lot of things to do. He doesn't want to have to go running to the back and check and see how much he's going to charge you for that drug when he's got 15 other prescriptions to fill.
Mrs McLeod: Copayment: Let's look at the effect on particularly a disabled individual and a psychiatrically disabled individual. We've been told that somebody with a psychiatric disability might be on as many as four to five prescriptions, that they are filled in small volumes, for obvious reasons, so they may have to have those prescriptions filled on a weekly basis, so at a minimum, with a copayment of $2, that individual might be paying $10 a week or $40 a month to have those prescriptions filled. Given the people you work with, you have a sense of the face of poverty in your community. What does $40 a month mean to a psychiatrically disabled individual on a disability allowance?
Ms Blaind: They're not going to take their medication, because they're going to have to choose whether they eat or whether they take their medication.
The Chair: Thank you, ladies. We appreciate your interest in our process and your presentation.
ONTARIO PUBLIC SERVICE EMPLOYEES UNION, REGION 3
The Chair: The next presenter is from the Ontario Public Service Employees Union, Region 3. Good evening, and welcome to our committee. Identify yourselves so Hansard has a record of it, please.
Ms Bonnie-Lee Baker: I'm Bonnie-Lee Baker from OPSEU Local 345.
Ms Annemarie Powell: I'm Annemarie Powell, provincial health lab employee. That's OPSEU Local 339.
Mr Thomas Veitch: I'm Thomas Veitch. I'm president of the Peterborough and District Labour Council.
Ms Baker: Our country's health care has always been the envy of other countries. This bill destroys everything Canada stands for: freedom to choose, the choice to make a decision to be someone who can make a difference in your profession. Privacy and confidentiality between a patient and their doctor will be eliminated by this bill. Doctors' hands will be tied as to where they can live, what tests and medications they order, and they will be forced to share with a non-medical, unqualified person in the government patients' records.
1830
The government can appoint a supervisor who can close a hospital or force them to form a corporation with another hospital without considering the consequences that could happen to patients. Also, more people will become unemployed with the closing of hospitals and other services. User fees will allow only the patients who are financially stable to have the best health care, where the less fortunate will not.
Ontario is very fortunate to have doctors that are caring, well-educated human beings, who will become powerless to treat their patients how, when and where they need to if this bill becomes law. Simply put, this bill is a dictatorship that Canadians have fought long and hard against for years.
The one thing I have not read or heard is how actual patient care will be affected. It is a sorry day when doctors and health care workers have to implore the politicians to allow them to provide the health care they have been trained to do without asking permission of the government and to ask that user fees not be forced upon the patients that are the less fortunate.
Ms Powell: I am here representing the provincial health laboratories of Ontario as well as my union, OPSEU. I'm proud of both those things and I feel this Bill 26 is threatening both those things. I'm a very fortunate person in that I chose a caring profession, and I continue to practise that profession and I want to continue to practise that profession. I'm also a believer in unions because I believe in a decent wage for a decent day's work and I believe in a decent standard of living for the people of this province and, as a matter of fact, for the people of the world, if it's possible. I'm an idealist, but that's fine. It makes my life good.
The provincial health labs have been around for a lot of years. We've filled different roles, whatever was required of us. At the present time we are mainly fighting infectious disease. We're the front-line workers on that. We're the experts in TB; we're the experts in AIDS; we're the experts in many of the new, emerging viruses; we look after sexually transmitted diseases; parasites; we test well water in our community to make sure that everyone that's on a well is drinking safe water. We go to outbreak situations; we help coordinate; we look after food poisonings.
That's what we're doing these days. We used to do more routine laboratory work: throat swabs, urinalysis, the sort of things that the private health labs have now taken over. But over the years that has been basically taken away from us by the private health labs and we have been left handling the more, as I see it, important things.
You might actually compare us to the Centers for Disease Control in Atlanta for the province of Ontario. We track diseases and we keep them under control, and infectious disease is a fact of life. It still is; it has been in the past; it's going to be in the future. TB is a fact of life in this province. It is not a dead disease; it is a living disease. I know. I worked with it for the last two weeks. I saw some of it. It's still there.
AIDS is an epidemic, and anyone who knows anything about Africa must have seen the reports on whole villages that have their young population totally wiped out by this disease. The grandmothers and the young children are left. Anyone who thinks that can't happen in Canada doesn't understand infectious diseases. They don't respect boundaries, they don't respect political parties and they don't respect income -- not entirely anyway.
We at the provincial health labs find this idea of the lean, mean 1990s kind of amusing. We've been lean for a lot more time than the 1990s. Ever since the 1970s, we have been getting leaner and leaner. I hope we haven't been getting meaner and meaner. As a matter of fact, I think the opposite is true. The idea that we have all sorts of extravagance going on is a very, very, very old idea and it simply is not true any more. We are about as lean as we can possibly get and probably even less than we should be.
The private labs make a profit, and they make a profit from the tax dollars of the citizens of Ontario. We do not. We work on a budget, and a budget that's been more and more restricted over the years. Because we've worked under leaner conditions, we have gotten smart and we have gotten efficient. We have gotten good at what we do. What I take from this bill and the rumours I have heard -- there's talk about privatizing us, and it just does not seem reasonable. We do a good job and we do it for a lot less money than the private health labs do. We don't take any money out of the taxpayers' pocket. We give you your money's worth.
We spend a lot of time these days watching our own team members, though. My son was a hockey player in his younger days. He was a goaltender, and I remember one game where one of his own players was scrimmaging for the puck in front of his net, got the puck and then immediately turned around and put it in his own team's net and lost the game. I talked to my son afterwards and I said, "That's really too bad," and he said, "Well, mom, that's one of the things they teach us as a goalie. You have to watch the other team just as much as you have to watch your own."
These days, where I'm working, we seem to be doing an extraordinary amount of watching our own team. It takes an extraordinary amount of energy to deal with all this downsizing. Are we going to lose our jobs? What's going to happen? Are we going to be out in the street? Are we going to be on welfare? We want to do our jobs. We're trained that way. We're all well educated.
I can tell you, when I went into this profession, I did not do it to become rich. I did it because it's the profession that I wanted to do and because I get deep satisfaction from doing it. I did not go into this profession because of the cushy pension at the end of it. That was not my motivation and it isn't my motivation now. Like the lady who was here before, I'm getting a little resentful of that finger being pointed at me. For some reason, by doing my job and doing it better and better and better, I have become the reason for the financial ills of Ontario. It just doesn't make sense to me.
Quite frankly, my household budget is in good form. I have a mortgage. I have a bit of money on my credit cards. After all, it is January. Other than that, my budget's fine. I've done okay. I certainly have to say I resent the fact that as a public servant, I am being told that because my government owes billions of dollars, it's somehow my fault. It isn't. It is not my fault.
I would just like to ask you for your support so I can go on doing my job and go on protecting you people and your children and your grandchildren from possible disaster from infectious disease. I thank you very much for listening to me tonight.
1840
Mr Veitch: I would like to speak on the impacts of Bill 26 on this community and on this province. Never before has a piece of legislation been proposed by any government that would give them the powers that this bill will. The ramifications will be devastating to this and many other communities. Peterborough has an aging population. Health care is important to them as it is to the rest of this community. This bill gives the Minister of Health the right to close hospitals. This is something we find abhorrent.
The decision as to whether or not our community can support two hospitals must be decided by this community and not some bureaucrat in Toronto. The loss of service would be detrimental to the wellbeing of this community. Both Civic and St Joseph's are already making attempts to develop ways to ensure their continued existence by sharing services and equipment. They have gone as far as to establish areas of operation that prevent duplication of service, thereby making them viable and symbiotic in their relationship. This works for us.
User fees: Seniors and social assistance recipients will have to pay $100 a year for medically necessary prescription drugs plus more than $8 for each prescription. Think about it. With the changes to social services and the amounts paid to recipients, this is outrageous. As for seniors, they're already living on fixed incomes that are generally below the poverty line. This prompts me to ask, where's the justification for such a move? These people, and the impacts on them, are at the least likely to afford such fees. This is a criminal act on the part of government, as they're effectively causing the people to make a choice: eat, pay the rent or buy the drugs required to make them better.
My own mother, who lives in Toronto, will be forced to pay out $100 for the high blood pressure medication she requires, an outrage, considering that she lives on less than $600 a month. She pays her taxes on time and has worked all her life. She too will be forced to make a choice or be subsidized by family members. We love this woman and we'll ensure that she sticks around, but how many others out there don't have anyone?
The province will remove the ceiling on drug prices under Bill 26, making us the only province that does not have a drug ceiling. Who will benefit? The government, the taxpayers? No. Drug companies will be the winners, not us. And this prompts me to ask, why? What possible benefit is there for Ontarians to remove the drug ceiling? Prices will soar, and we will all have to pay. Imagine the revenue that the government will lose when prescription drugs become part of the underground economy.
We've already seen the effects of government trying to privatize lab work and know the cost in comparison is much higher. All this is doing is providing yet another means to privatization. Eventually I see that our hospitals, clinics and labs will all be privatized, opening the door to a two-tier system of health care: those who can pay go to the top of the list, while those who can't wait until the service they require is in the budget.
Confidentiality: We've a real problem with this one. Despite assurances to the contrary, if this part of the bill is passed as written, we will face having our innermost secrets revealed by the government and the Ministry of Health to employers, prospective employers and the community at large. My health is my business, and its treatment is the concern of my doctor. He is a trained professional. We're the only ones that should have access to personal files, and not the ministry.
Hospital fees are to increase under Bill 26 in an attempt to recover lost revenues.
The solution is simple. Take my 30% of the tax cutback, put it back into the social and health services where it belongs. As well, start taxing the corporations in this province at a reasonable rate, not the current 2% to 4% that they pay now. Start with drug companies, Liberty Mutual and other health care insurers.
As to dictating where a doctor can practise, I always thought we lived in a democracy. Yet I hear the government will dictate to doctors where they can practise, or no licence. This must be the new reality of the Harris government: Don't listen, look to business for your support, and ignore the electorate. Obviously, the current government is not looking for another term in office.
So there you have it, the presentation of the Peterborough and District Labour Council. Thank you.
Mr O'Toole: I'd like to thank the members for the presentation. It's important to hear from all the constituent group, and more specifically, I'd like to recognize the impassioned remarks by Annemarie. I appreciate your comments and just draw to your attention that just recently the minister has announced the dialysis unit for Peterborough. You're aware of that. And further, the immunization program, some $5 million for measles vaccination which is going on now, and also at the same time there's $5 million in the immunization for hepatitis B.
I recognize what you're saying and I believe also the minister does as well. The question I have for you is not a question of throwing the ball back and forth or that I would disagree with you. I myself have five children and I consider myself to be a compassionate, responsible citizen. I'd sort of put it to you: Do you think that the money is the problem? We're already spending $17.4 billion in health care overall. Now, do you think really that spending more money is the solution or do you think that real rethinking and real change is part of the solution as well?
Ms Powell: The solution for what?
Mr O'Toole: For the overall management and delivery of health care in this province. The question again, just to be brief: Is spending more money the solution, or is it to re-examine the priorities that we're spending it on? When I think, "Does everyone have to go to Toronto to get things done?" what we're trying to do is redistribute the delivery of health care fairly across the province, and to do that there's some hard restructuring that has to be thought through. Do you think more money is going to solve the problem, or should we restructure?
Ms Powell: I don't know the answer to that.
Mr O'Toole: That's really what this is about. It's my sense that we're attempting to restructure the delivery of health care. The redeployment of doctors in underserviced areas has been talked about for 20 years. No one has had the courage to make the tough -- unpopular sometimes -- decisions, the fee for service --
Ms Powell: Yes, I understand what you're saying and I understand there are tough decisions to be made. I guess I speak from my own point and from my own experience. I am just talking for the provincial health labs and I am saying, in that instance, that it isn't even an economically feasible decision. It isn't an economically feasible decision to privatize us, to start with. We do a good job for less money.
I do not know how to fix this. If I did, I would probably be running for Parliament, but I'm not. I'm sorry, I'm not an economist. That's not what I studied and it's not particularly what I'm interested in.
Mrs Ecker: Come and run.
Mr O'Toole: That's why I ran. I would suggest perhaps that's why I ran, to make fundamental changes, and really that's what we're really trying to do. But there are great powers of strength, be it the doctors, the pharmacists, the anaesthesiologists, all the groups in the hospitals, that have difficulty breaking down the structures and redeveloping a plan that's affordable and effective, with quality health care.
Ms Powell: I understand. I think what perhaps your government doesn't realize is that these changes have been going on for years. This is not news to us. We have been doing this, and you're right, it takes a lot. There were a lot of little kingdoms out there and we have had to learn how to cooperate. But then that's a change in our society, and it has happened. It has happened in our institution and I'm sure it has happened in other places. This was my point: We have gotten leaner. But we really are at the breaking point. I can identify with the doctor who sat here and said, "I'm tired." I'm tired too, and I'm not 62. I'm 51, and I'm tired.
1850
Mr Miclash: I must say that I hope the statements from the member opposite in terms of caring will translate in his free vote on this legislation come January 29. It's going to be interesting at that time.
Folks, let me read to you about schedule L, the amendments to the Public Service Pension Act and the Ontario Public Service Employees' Union Pension Act. It reads: "The net effect of Bill 26 is to remove protections for public sector workers which all employees would normally have in relation to their pension plans and give cabinet the power to decide if the pension plan provisions and relevant benefits on windup will take effect. Bill 26 prevents any access to the courts remedy as a result of this legislation. Any employee who made additional payments to the plan since January 1, 1993, because of a plan windup would be entitled to reimbursement for those payments." That's the impact that we feel Bill 26 will have on that plan. Could you maybe comment on what I've just indicated?
Ms Baker: It's supposed to be health care.
Mr Miclash: Yes, but it also deals with the pension act as well, and what I'm looking for is feedback here.
Ms Baker: But today we're supposed to be talking about health care.
Mr Miclash: I thought as members of OPSEU you might want to give me a comment on that.
Ms Baker: No.
Mrs McLeod: In that case, let's return to the issue, appreciating the fact that you are concerned about health care. You've indicated in a general way your concern about the powers that this bill gives to the government and to the Minister of Health, and you're right: Somebody said earlier in the week that this bill gives the Minister of Health the power to practise medicine without a licence. He does that not only through the ability to make decisions to close down hospitals or to appoint somebody else to make the decisions to close down hospitals, but it gives the Minister of Health the ability to make decisions about hospital care without any regard to the legislation or regulations under the Public Hospitals Act, so he is truly acting unilaterally. It also provides absolute protection from liability for any decisions that may be made, funding decisions or decisions about hospital management. These are enormous powers, and I believe your concerns are extremely well founded.
We also have to keep coming back to what my colleague said earlier, as we hear repeated expressions of concern from the government members, that this is a bill about taking $1.5 billion out of the health care system and having the power to do it fast because the Minister of Finance needs those dollars for his deficit. If those dollars are not coming out of the health care budget, then the Minister of Finance has not in fact made the cuts that he said he had made.
I agree with your last statement; I think these kinds of cuts are going to push health care past the breaking point. So I share your concerns.
Let me ask you one specific one, and I'm not sure if you would feel comfortable addressing it, but you did mention that in the lab testing area you're working with HIV/AIDS patients in the testing. One of the concerns that's been expressed is that disclosure of information, access to information under this bill, will make individuals with HIV/AIDS very hesitant to come forward for a voluntary testing program in Ontario. Would you want to comment on whether that's a concern for you?
Ms Powell: Again, I'm not sure that I'm qualified to address that. I do know that the sexual health clinics go with anonymity and it does seem to work. This is a very touchy area for a lot of people and it's open to big discussion. I know if I had AIDS I certainly wouldn't want everybody to know it.
Mr Marchese: I want to make some comments and then if there's time for questions I'd like to direct them to some of you. Annemarie, I was very concerned about the comments you've made with respect to the privatization of the labs. I have to tell you I take very little comfort in anything the members opposite are saying with respect to how much they care. This government drools at the thought of privatization. They just can't wait. It's coming. The only way to avoid the privatization of some aspects of health or other aspects of things that we control as a government is through the kind of interventions that people are making in these kinds of consultations we're having at the moment. Without it, you can bet your life that they will privatize whatever is within their control.
We've seen in Mexico that when the government decided to privatize there, we had billionaires become the recipients of the privatization and the rest of the population left entirely poor. It's not entirely new. It happens everywhere. They know it, we know it, but they're still going to do it. Anyway, I didn't want to disappoint you or to make you despondent about this whole thing, but I think people need to be politically sharp because this is the reality as I see it.
Downsizing is going to hurt us, no doubt about it. They say no. They say: "We have a deficit. People gotta go." Where do people go? They go into a very weak economy. Unemployment is now hovering consistently at 9% or 10%, and it's likely to remain that way. So where do these people who work for the government delivering the services go? They go on unemployment at reduced levels that the Liberal government is engaged in, and then on welfare at the reduced levels that this government is engaged in. That's what you have. It means you don't contribute through the income tax system to the government. You're not paying anything. You're just receiving from the government, impoverishing it and impoverishing us all. That's what's happening. Can we convince them? I'm not sure. The only way we can do this is if the public, of course, remains vigilant and decides that they're going to fight back as they see the introduction of bills of this nature.
The question I had concerns public and civic participation, because I believe that if there's going to be any change in any field, you need the participation -- in this particular example, of health care providers and health care users. Were any of you ever consulted? Had you heard about this government doing this in the short period of time that they were in government? Had you heard that something was coming up, and did you think somehow you might be consulted? Did you know? How did you know? All these questions are things that are important to us because I think we're shutting the doors on public participation. I'm interested in knowing how you got involved in coming here to address issues contained in this bill.
Ms Powell: As far as I know, there was no consultation. I got involved through my union. They keep track and they are concerned.
Mr Marchese: Do you believe we need more time to be able to properly assess a document that one doctor said, having read it, he can't understand a third of?
Ms Powell: Yes, I do. Yes.
The Chair: Thank you, Mr Marchese.
Ms Powell: I beg your pardon?
The Chair: I was saying thank you to Mr Marchese.
Mr Marchese: He just shut me off.
The Chair: We appreciate your interest in our process in coming here tonight to present to us. Thank you.
CANADIAN UNION OF PUBLIC EMPLOYEES, DURHAM, NORTHUMBERLAND KAWARTHA AND HALIBURTON REGIONS
The Chair: Our next presenters are the Canadian Union of Public Employees, the Durham, Northumberland and Kawartha regions. I believe appearing on their behalf are Gwen Hewitt, Marie Boyd, Casey Thomson, Bill Nichol, Jim Woodward and Randolph Millage. Good evening and welcome to our committee.
Mrs Gwen Hewitt: Good evening, Mr Chair and members of the committee. My name is Gwen Hewitt. I am an employee at the Minden Hospital, which is in the Victoria-Haliburton riding. To my immediate right is Casey Thomson, an employee at the Oshawa General Hospital; to my far right is Bill Nichol, CUPE national staff representative from the Oshawa office; to my immediate left is Marie Boyd, an employee at the Fairhaven home for the aged in Peterborough; and to my far left we have Jim Woodward, legislative liaison, CUPE.
I'd like to draw your attention to the "List of Appearance." There is an inaccuracy on the inside page, listed Local 2225.6 and 2225.12. The employees are representative of Marnwood Lifecare Centre, if you would please make that change.
This evening we will be presenting chapter 1 and chapter 2 of our brief. Appendices A and B reflect the resource materials that we have used.
1900
On behalf of the 90 bargaining units and the 9,000 members represented by the Canadian Union of Public Employees, many of whom are present with us this evening -- these people live and work in the Durham, Northumberland, Kawarthas and Haliburton area -- we wish to thank the committee on general government for allowing us to make this submission. At the same time, we recognize that hundreds of citizens' groups in Ontario have been denied the opportunity to consider the Savings and Restructuring Act. This is because of the government's great haste to do quickly the enormous task that needs to be done wisely and with respect to the due process that underpins true democracy.
I live in the village of Minden. My husband owns a small business. We have two children, one of whom requires frequent medical care, and I have been a health care worker for all of my adult life. Casey Thomson lies in Lindsay and works in Oshawa. Marie Boyd lives in Peterborough and works at the Fairhaven Home for the Aged. Together, we have almost 50 years of experience in the health care field. We are involved in community activities ranging from sporting activities to fund-raising activities.
We work in three different provincial ridings. In the last election we voted for the candidate we believed would best serve our communities. Each of our chosen candidates had experience in municipal government and advocated excellence in public health care, education and social service. Ironically, each of our chosen candidates represented a different party.
Our experiences are pretty much representative of the CUPE members who live in small towns and rural communities. We are ordinary people who share in every aspect of community life. We work hard for modest income. Our average annual wage is just slightly under $30,000, and many of us work for a great deal less. In fact, nearly 40% of our health care workers are part-time employees. We live, work and spend in our communities. We don't send our money to fancy head offices on Bay Street whose governing boards are filled with ex-politicians or to tax shelters in foreign countries. We go to our local merchants to purchase the necessities of life, and some weeks we don't have enough to go around.
So today's submission is not about the ideology of a particular political party. We understand that true democracy doesn't guarantee that every viewpoint will prevail every day, but only that every citizen be entitled to participate in the process and be given a fair hearing in good faith.
The process of hurrying passage of the Savings and Restructuring Act is anti-democratic because it denies the basic right of citizen participation. It seeks to enact some of the most radical changes to our governance without being the least bit concerned that ordinary citizens are accurately informed, consulted, given the opportunity to voice an opinion and afforded the respect of a fair hearing. That issue alone unites the members of CUPE, regardless which political party they support, and brings together workers, small business people and others dedicated to promoting the wellbeing of their communities.
Moreover, the Savings and Restructuring Act goes far beyond the traditional ideology of the Conservative Party. It lacks responsibility and accountability. It seeks to destabilize communities, drive wedges between various social groups, tear apart our network of social services and victimize workers. If this is a new ideology, then we submit it is one that even traditional Tories will emphatically reject. It will be the first explosion in a chain reaction that will lead the provincial Conservatives to the same destruction that Brian Mulroney bestowed upon their federal counterparts. Only a few short years ago, Prime Minister Mulroney exulted at having a huge parliamentary majority. We all know what happened to the federal Tories when the electoral body spoke.
So it is that we recognize the government has gained a majority of seats in the Ontario Legislature and a mandate to reduce the provincial deficit. We acknowledge that actions may be taken which are contrary to our desires as public employees, rural residents and ordinary citizens. But we will not be forced into servitude without subsistence and will vehemently resist all attempts to undermine the basic democratic orientation of our communities.
We ask that the committee on general government insist that more time be taken to consult with all stakeholders on the ramifications of the Savings and Restructuring Act. We agree with the proposal of the Windsor and District Chamber of Commerce and the Windsor and District Labour Council that at least six months' time be allowed to give Bill 26 the second sober thought it deserves. We need to ensure positive outcomes for Ontario's precious communities. We agree with the expressed opinions of the majority of the academic, religious, socially committed and labour communities, as well as the commentators of all political stripes, that Bill 26 needs to be broken down into rational segments which are comprehensible to the cabinet ministers, elected representatives and affected population. We ask that you protect the collective interest of communities in Ontario.
Marie will continue the presentation.
Ms Marie Boyd: The Savings and Restructuring Act appears to be an unprecedented grab for power by ministers of the provincial government, yet even they profess not to understand its real scope and effect. Clearly, the act amends at least 47 statutory regimes and potentially affects a great many regulatory authorities. It is a massive document which defies comprehension, even by its authors, who are exceedingly reluctant to come forward and explain exactly what it means to elected officials at various levels of government and the Ontario people in general.
With the help of our legal counsel, Sack Goldblatt and Mitchell, we have developed the following understanding of Bill 26.
On November 29, 1995, the government introduced at first reading the Savings and Restructuring Act. This unprecedented and sweeping omnibus legislation contains 17 schedules which enact or amend over 40 separate pieces of legislation. If passed, this bill would vest in cabinet and ministers of the crown the unconstrained power to make decisions affecting the delivery of public services, together with the operation of public institutions. In many cases, these decisions could be made by regulation, ministerial direction or administrative order, without parliamentary debate or meaningful opportunity for public scrutiny and without community, local or stakeholder input.
This bill would also grant cabinet and appointed officials the authority to make decisions affecting important individual and group interests and societal values in many areas, including denial of public benefits, removal of access to public facilities and resources, loss of the right to earn a livelihood, interference with vested rights and disclosure of confidential information, without traditional procedural safeguards, in many cases without a hearing or any right of appeal to the courts. These powers are granted in the broadest of terms, without the statutory limitations or conditions traditionally provided in order to ensure political accountability and effective recourse to the courts.
The bill also contains provisions authorizing cabinet or ministers to extinguish contractual rights and obligations contained in existing binding agreements and to prevent enforcements in the courts. These provisions specifically apply to agreements between the government and the Ontario Medical Association and the Ontario Public Service Employees Union. The bill would also extinguish the statutory bargaining rights of the Ontario Pharmacists' Association and seriously undermines Ontario's long history of relatively harmonious relations.
The bill would empower cabinet or ministers to make regulations or to issue directions overriding the provisions of any contractual agreements and even overriding or providing exemptions from the provisions of other legislation. The bill also purports to reverse and render of no effect certain decisions already made by courts or tribunals under existing legislation and agreements and to insulate the government against liability arising from future court or tribunal decisions. These measures constitute a serious attack on our judicial or quasi-judicial bodies which endeavour to provide fair hearings and objective dispute resolution.
1910
In all of these respects, the bill goes far beyond merely enacting the provisions of the Treasurer's economic statement of November 29, 1995. It fundamentally alters democratic processes to autocratic ones. It diminishes the authority of arbitrators and others dedicated to dispute resolution and immunizes ministers from liability for their actions.
The complex provisions of Bill 26, running over 200 pages, affect many areas of public life, including:
Providing unilateral powers to the Minister of Health and cabinet to fundamentally restructure the operation of public and private hospitals and independent health facilities, while at the same time eliminating procedural or substantive protections against adverse ministerial or hospital decisions affecting the livelihood of hospital service providers.
Significantly revamping the operation of the Ontario health insurance plan, OHIP, including providing near total authority to the Minister of Health and cabinet to change and undermine the rules for payment and delivery of medical and other professional health services.
Granting government the power to unilaterally terminate agreements between the government and the Ontario Medical Association setting out representation, arbitration and other legal rights of physicians.
Introducing user fees under the Ontario drug benefit plan, which provides drug benefits for seniors and low-income individuals and families, as well as terminating the statutory bargaining rights of the Ontario Pharmacists' Association.
Legislatively imposing government-mandated criteria, such as the employer's ability to pay, on the interest arbitration process, thereby striking at the independence and integrity of the only method available to essential service workers for settling the terms and conditions of their collective agreements.
Eliminating the proxy method of comparison under pay equity legislation, which was intended to extend pay equity benefits to women working in certain female job ghettos.
Exempting many public sector employees from the protection of pension benefits legislation otherwise applicable in the case of significant downsizing.
Empowering the provincial government to restructure municipal governments, while at the same time extending to municipalities enhanced powers, including the right to charge user fees for municipal services.
Limiting access to records under freedom of information legislation.
Casey will speak from here.
Mr Casey Thomson: The full implications of the broad power granted to cabinet and individual ministers under the bill are difficult to assess.
Other schedules to the bill would enact various amendments to certain taxation, capital investment, toll highway, government borrowing, natural resources and mining legislation, as well as legislation requiring salary disclosure for employees earning over $100,000 in the broader public sector and in non-profit private sector organizations which receive significant government funding. Profit-making private sector organizations which receive government funding would be exempt from this provision.
Bill 26 is an ominous bill because it is portentous of an unprecedented arrogance among our elected lawmakers. It not only assumes that cabinet ministers have a unique grasp of the truth and therefore should be empowered to override all skilled and heretofore legitimate authorities of the state, but that they are sufficiently superior in intellect, understanding and expertise to nullify awards, agreements and understandings made between agents of the crown, public servants, public agencies and the citizenry as a whole.
These suppositions are ludicrous and proven absurd by a simple review of the qualifications and experience of the various cabinet ministers. They have been elected to fulfil a political mandate, that is true, but that does not in any way imply that they have the requisite skills, ability or experience to dictate levels of service in the public interest absent the advice of those who possess real expertise and accountability.
Not only does Bill 26 bestow dictatorial powers upon ministers, it absolves them of all responsibility for making wrong decisions. They are saved harmless from the effects of their folly, while those to whom they have whimsically allowed some residual authority are now to be held personally liable for their decisions. No wonder the government wants this legislation passed quickly without any meaningful legislative or public scrutiny.
Bill 26 is an act that legitimizes irresponsible, incompetent and corrupt government. It proposes no improvement to the quality or cost-efficiency of public services. It does not seek to serve the people of Ontario. Rather, it makes every activity of government subordinate to the desire to privatize services and cut the cost of people services. It replaces health care with wealth care. It seeks to make the corporate welfare bums of the Mulroney era the corporate wealth care barons of the Harris regime.
Consider: Stats Canada has shown that spending on social programs in Ontario is not out of control. Bank profits are at their highest in history, corporate profits are on a steep upward curve and yet none of these windfalls has been passed on to workers or to government to reduce the debt.
Why do we have a provincial debt? Experts argue that the state has the responsibility to develop social infrastructure. Roads, airports and public transit are just a few examples of projects whose cost is traditionally amortized over part of their long life expectancy. Taxpayers, both corporate and individual, therefore assume a long-term liability for a long-term sustained benefit. If we have roads, we can engage in industry and trade, and the wealth generated by these activities helps us to pay for our services. It simply cannot work the other way around. The horse must be in front of the cart and the cart must be on a navigable path before real progress can occur.
Debt by itself is not a bad thing and is sometimes absolutely necessary to move forward. Government decisions about the method of supporting or paying down the debt not only aspire to balanced budgets but ought to include fairly shared responsibilities among corporate and individual citizens.
Most CUPE members earning $30,000 or less have received wage increases in the last four years which are far below the rate of inflation. Those earning $30,000 have received no increases, and some employees, such as those in the city of Peterborough, are entering their sixth consecutive year without a wage increase. In the same period, the cost of living has climbed by over 14% and the real rate of taxation has virtually doubled.
Why should these poor, stalwart workers bear the incidence of the tax that attacks the deficit? Why should threats to this very subsistence be imposed upon the elderly, the infirm, the unemployed, the injured and the desperately poor? Social spending on their needs is a necessary contribution to continued civilization. To provide universally accessible health care, education, public utilities and social services are required to maintain safe, healthy and economically able communities.
Meanwhile, in the midst of these dark days for the workers and the needy of Ontario, banks and financial institutions are celebrating their biggest profits in history and major corporations are increasing profit-taking and are not sharing the benefits with employees.
We mourn the demise of government noblesse oblige, openness, integrity and democratic accountability. There remain things in life, in society, which are more important than money. If worse comes to worst, a debt can be paid tomorrow, but a life lost to a cost-saving decision can never be recovered.
No sector is more affected by Bill 26 than the health care sector. It will reduce the quality of care, demoralize physicians and all other health care workers, undermine the principle of universal access and regulate patient services on the basis of government whim rather than medical necessity.
Bill 26 does not attack overspending. It attacks the elderly, the poor and all who are in need of compassionate, high-quality care.
There are two big corporate winners if Bill 26 is enacted: foreign health care firms and multinational drug companies, but there will be 10,929,000 losers as Ontario's prosperous social welfare state devolves to a Third World marketplace.
For all of these reasons and those contained in the following appendices, we respectfully request the general government committee recommend that Bill 26 be withdrawn and that the reintroduction of any of its parts allow for full public hearings.
Perhaps those possessed with the greatest wealth could assist with the deficit and help Ontario break out of its downward recessionary spiral.
Cutting jobs, the effects on communities, means fewer services are available to the citizens of Ontario. But it also means less disposable income to support local businesses and therefore less revenue to small business to hire other workers and significantly less revenue returning to the Ontario government in the form of income and sales taxes. In fact, this generally explains the current phenomenon, that 10 years of persistent cutting of public services, public employment and social supports to needy people has had the effect not of generating savings but of actually increasing the deficit.
CUPE submits that a full employment policy is the only viable formula for eliminating the deficit and paying down the debt. We support a universally accessible health care, education and social service system which satisfies real human needs. We believe that those who profit most in society have a responsibility to contribute in a much more meaningful way to eliminating the debt and maintaining a high standard of living in the province that contributes so much of their wealth.
1920
Ms Boyd: At my workplace, privatization is a possibility because the funding to the municipalities has been reduced. Fairhaven has to try to exist with these cuts and provide an adequate level of care. I'm sorry, but I don't believe that an adequate level of care is appropriate. Quality service is what our residents require and deserve. These people are human beings, not machinery. When they require assistance, they expect assistance, not when we can get back to them.
Cuts in funding will result in cutbacks to staff, which will result in cuts to the services provided to our residents. Does the government believe that residents should sit in their wheelchairs or in their beds all day because the support staff are no longer there? Providing a minimal level of care is not the way I like to work, nor is it the way the elderly deserve to live the rest of their days.
Mr Thomson: As a hospital employee I have seen many drastic changes in the way care is given to the general public to date due to the enormous cuts to health care already. Ontario now has a two-tier system in place; patients with money get adequate care, and those who don't, suffer immensely, lying in urine-soaked beds all night, being awakened at 4:30 in the morning for their daily bath, not being fed because they can't feed themselves and there is no one available to feed them due to the cutbacks, and that is before Bill 26 is in effect.
If this bill is passed I see the poor and slightly poor not getting the care they need and deserve. Deaths have increased and will continue to. Call bells will be answered less than they are now. Unqualified people will be taking care of our families and friends,all in the interest of money. Disease and serious illness will go undetected until it is too late.
This bill, in reality, will cost the people of Ontario much more, if not in dollars, then in deaths.
Mrs Hewitt: The effects of cuts to health care services rendered by an omnipotent minister will be devastating to those of us who live and work in the targeted community.
Essential health care services cannot be determined at arm's length merely by budgetary considerations by people who feel no sense of ownership to the community. The needs of the community are best determined by those of us who live and work there.
We understand the geographic, demographic and logistical problems, such as the lack of a public transportation system and the seasonal population fluxes, that impact on the delivery of essential health care services that in turn ultimately determine the wellbeing of our communities.
It is imperative that consultation take place with all of the stakeholders involved. Input from the service staff is as crucial as input from those who provide hands-on care, such as nurses and doctors. Indeed, it is all of these people who provide the delivery of health care in the homes and the hospitals.
Health care providers and health care recipients are a vital link in the restructuring process. We must not be shut out.
In closing we ask you, the committee, to recommend that Mr Harris withdraw Bill 26. Common sense must prevail.
Mrs McLeod: I'll just touch back on the very first page of your presentation and your comment about the democratic process and the desire of people to be involved. I think the size of the audience here tonight, sitting through these hearings, is an indication of how much people want to be involved, and those audiences have been growing every day this week as more people become aware of what this bill is and become concerned about it.
Thank goodness the bill didn't become law in December, because if it had, we would not have been here, able to hear from people from Peterborough and the district. We would not have had a chance to have your very thorough brief. You've done a fabulous job of analysing virtually every aspect of the bill, and I agree with your final recommendation that the bill should be withdrawn and any parts that are subsequently put forward should have adequate public debate.
I have to warn you that we haven't had a lot of luck getting the government to support our resolutions, but we'll keep trying.
One quick question, because there's so much ground you've covered, but maybe I'll take advantage of the fact that one of you is working in a long-term care facility: Could you just comment on copayment, the effect of copayment for drugs on seniors who are in a long-term care facility and many of whom are living with a comfort allowance that may be $110 a month.
Ms Boyd: Quite frankly, it would probably mean the difference between eating and not eating. Does that answer your question?
Mrs McLeod: It does indeed. You know, we see $2 and it doesn't look like a lot of money, but when your comfort allowance is maybe $100 and that's all you've got for any of the extras, that means a great deal indeed.
Mr Marchese: Just a few quick comments and then a question, if I can. You made a comment around the banks and whether or not people like them are making their fair contribution to our economic deficits, and I can tell you they're not. It's interesting that 90% of what the banks invest is our dollars, not theirs; 10% is theirs. In Ontario alone, they control about $155 billion. Most of that goes outside; some of it comes back and is loaned to the government, safely, at high interest rates. So imagine this: They use our money, 90% of it, to then lend back to governments, that then goes back to them as profits, and we pay for all that. It's an incredible thing. It continues to happen all over, in every jurisdiction, and yet we condone it, and we don't attack it enough. You're absolutely right. They need to pay their fair share.
You made another interesting observation. This bill alters the democratic processes to autocratic ones. You made the comment that this act goes far beyond the traditional ideology of the Conservative Party, and you're absolutely right. My accusation of them is that they're not a Conservative Party; at best they're a Reform Party, and at worst something else I dare not name. But what do you think are the values that underlie the printing of this Bill 26? What values underlie this bill?
Interjection: Great greed.
Mr Bill Nichol: I guess I'll answer. It is totally greed, in my opinion, and I believe among most people in this room it's agreed. It's also that there is no consideration for the everyday citizen in this province. They don't care about us as individuals; they don't care about their constituents; they don't care about anyone. The ultimate goal is to pay off the debt, and they don't care how many of these people in this room will not be working tomorrow morning to pay off that debt; it doesn't matter.
Mr Rollins: Thanks for your presentation. Just a few facts that I think you people may already have heard; I know some of the opposition have. They don't always remember what we say, but we don't always remember what they say either. There are 750 groups like yourselves which will have come to these hearings going on. There would have been 360 hours of hearings allotted for, had it gone on through the way it was. It's cut back down to 300 hours. Granted, the 360 hours were in Toronto.
If spending is the right answer and, according to you people, that if you kept on spending you could solve all the problems of the province of Ontario, in the last five years we went from a $45-billion debt to well over $100 billion; $1 million an hour of interest. We may be interested in these people, but we're darned well interested in our grandchildren and our great-grandchildren not having to pay off the debt some of these other governments have had.
Interruption.
Mr Rollins: It's fact. There it is right there in fact. If those bills are not paid, it's a debt that we owe. We have a mortgage, and our obligation is to make sure that our grandchildren don't have that mortgage.
The Chair: Thank you very much. We appreciate your coming to us this evening and making a presentation.
1930
Mr Marchese: Mr Chair, I'd like to read a motion for the record, to be discussed now or later, according to your intent or interest.
Whereas there has been overwhelming public interest in Bill 26 and many groups and individuals have requested to appear before the standing committee on general government in Kingston and here in Peterborough, which far exceed the number of 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, that the order with respect to Bill 26 be amended and that the bill be returned to the standing committee on general government so that further public hearings can be arranged for the different communities;
Further, that this committee recommends that the three House leaders meet as soon as possible to discuss this issue.
The Chair: Thank you. I need a little direction. Do we take time away from one of the remaining presenters to debate this or do we defer it till next week?
Mrs McLeod: Do we have any indication that the government may vote differently than in the past?
The Chair: I don't think so. Anyway, we have to stop at 9 o'clock. We've got three presenters left, each with a half-hour; we're right on time.
Mr Marchese: Can we debate now, Mr Chair, as briefly as you would like?
The Chair: Would you like to take time away from one of the presenters to debate this?
Mr Marchese: Yes, I would, for one minute each.
The Chair: Okay, one minute.
Mr Marchese: Mr Chair, it's become apparent at every hearing that we've had that most groups wanted more time to understand this bill. Many people who have read it simply don't quite understand what is contained in it. The ones who have appeared before us understand the full implications of this bill and disagree strongly with its content because it will have adverse effect on the entire population of Ontario.
Keeping this in mind, it is my view that we need more time, that the public needs more time to assess what's here and that they need more time to be able to participate, not just the ones who appeared before us but those who have been unable to get on the list to participate.
Mr Clement: As we've said on numerous occasions, this committee process will have heard from over 750 presenters in over 12 cities in the province of Ontario. On both sides of the committee we are hearing a wide range of views, a diversity of opinions, some critical, quite critical of the government, others supportive of what the government has to do. I can only say this to the mover of the motion: Our job is to be legislators as well as listeners. We have an obligation, when the debt is going up $1 million an hour, when this takes money away from health care, away from palliative care, away from cancer sufferers and AIDS sufferers, we have a duty to act. The House leaders agreed to act on January 29. NDPs, Liberals and PCs agreed to that. I intend to stick to that agreement.
Mr Miclash: Mr Chair, I'll certainly be supporting the motion as well. What the motion has actually done is it's brought forth an indication of the concern and the interest in this piece of legislation. As we move from city to city, my leader indicated earlier, we see the crowds growing and the concern growing over this legislation.
We had a professional in this room this evening who said he read it and only understood one third of what was in the particular legislation. I must say that as I listen to the groups, as I listen to those who are not able to present their views and their concerns, I truly think we have to put this back into the House leaders' laps and have them take another, closer look at the decisions made after noting the overwhelming concern about this legislation.
The Chair: Those in favour of the motion? Those opposed? The motion is defeated.
PETERBOROUGH CITY RADIOLOGISTS
The Chair: The next group to present is the Peterborough City Radiologists, represented by Dr David Swales, who is a radiologist at the Peterborough Civic/St Joseph's Hospital. Good evening, Doctor. Welcome to our committee. You have 29 minutes to use of our time.
Dr David Swales: Thank you for allowing me to make a presentation to your committee. I'm a medical specialist in diagnostic imaging. I'm speaking on behalf of the radiologists who service 10 hospitals in six different counties in this region, as well as a number of independent health facilities in four counties. The hospitals are Peterborough Civic Hospital and St Joseph's Hospital in Peterborough, Port Hope and District Hospital, the Cobourg District Hospital, the Ross Memorial Hospital in Lindsay, the Minden Hospital, the Haliburton Hospital, the North Hastings District Hospital in Bancroft and the St Francis Memorial Hospital in Barry's Bay, so I truly represent rural radiology in east central Ontario.
This is a difficult environment for a high-technology service, as the escalating costs of the technology create a significant burden for small, rural hospitals. By working together cooperatively as radiologists in these institutions, we have tried to maintain a high quality of care.
Bill 26 has some significant recommendations that will make it increasingly difficult for us to maintain our standard of care. Some components of this bill are helpful, but I shall dwell upon the parts that potentially will harm the quality of care we deliver.
The first deals with the Public Hospitals Act amendments. Bill 26 gives extraordinary powers to the local hospital administrators and boards to unilaterally eliminate services and to revoke physicians' hospital privileges without right of appeal. This destroys the healthy balance currently in place between physicians and administrators. In my experience in this community, the physicians have been very strong advocates for the patients. The administrators and boards have a mandate to look after the welfare of the institutions. Their authority does not extend beyond the walls of the institutions.
The roles of the physicians and the administrators oftentimes come into conflict. However, currently this tension can be useful, with the physicians bringing the patients' concerns forward and the administrators bringing a sense of fiscal reality to the discussions. If this balance of power is destroyed, as proposed in this bill, then the voice of the patients will be silenced. Physicians won't wish to risk revocation of their privileges by speaking out. A better solution would be to give the community input into major changes of health care delivery.
Currently, the addition of a new clinical service in the community requires support from the district health council. Conversely, I would propose that the elimination of any clinical service similarly would require approval by the district health council.
Hospitals have the mandate to terminate a physician's privileges for quality of care issues currently, and that should remain so. However, the termination of specialist privileges for other reasons should require approval by the district health council as well, as this would affect the range of services available in the community.
This is not just a theoretical consideration, as we've had such an event here in this community, and this happened during my term as chairman of the local district health council. The Civic Hospital here in Peterborough ended the diabetic day care program unilaterally without any public or community consultation. We tried unsuccessfully at the district health council, after the fact, to have someone else pick up the service, but to no avail. Thus these vulnerable patients were set adrift without access to proper nutritional counselling etc.
There must be community safeguards in place to prevent a repetition of such actions. From my experience at the district health council, we have a body already in place with conscientious and knowledgeable community volunteers. In fact, I have talked to them about this off the record, and they would be willing to take on this role as they see it very similar to their current role for approval of new services.
This bill, as currently written, does not have these community safeguards in place. Please don't give this authority to the hospitals. They are not the right body to exercise this mandate.
The second point is the Independent Health Facilities Act amendments. The Ontario Association of Radiologists has a very good track record in working with the ministry in developing the ground rules for independent health facilities and, in particular, in developing standards for assurance of quality. This control of quality is achieved through monitoring other radiologists by the College of Physicians and Surgeons of Ontario. Failure to maintain standards of care is accepted and supported by the radiologists as a legitimate reason for a revocation of an independent health facility licence.
Bill 26 allows the ministry to revoke a licence without right of appeal. The capital costs of equipment for an independent health facility are very high. For example, if I take the major independent health facility here in Peterborough, it has a replacement cost of approximately $1 million for its equipment. One really needs a stable environment to invest these sorts of dollars. The potential for revocation of a licence by the ministry, even with verified high quality of care, will lead to the use of old and older equipment with no reinvestment in updating equipment.
In Peterborough, this particular independent health facility is not a duplication of services. It is the only local facility to perform nuclear medicine spec scans on the heart and skeleton. In fact, the presence of this service is taken into account in the planning of the local hospitals. The planning of the hospitals and this independent health facility have, in effect, become integrated.
1940
We must have a stable environment to allow us to upgrade our technology and properly serve the community. Thus, I would propose that the revocation of an independent health facility licence should continue to be based only on the quality-of-care considerations and with due process.
Currently, a request for a proposal for a new independent health facility is an open bidding process. Bill 26 would allow the ministry to preselect applicants without public consultation or disclosure and one could see that this would have the potential for all sorts of abuse, and thus, I would suggest that this amendment be reconsidered.
Thirdly, for the Independent Health Facilities Act, Bill 26 proposes to remove the preference for Canadian applicants seeking a new independent health facility licence. This opens the way for large American corporations to replace the local radiologists. It is difficult to see how the ministry could enforce the current level of quality assurance on an out-of-country, non-physician owner. This should be reconsidered as well.
Physician distribution: Physician recruitment to this area has been a real problem in recent years. Psychiatry and family practice are prominent examples that have received a lot of publicity and will be dealt with by others. Radiology has not made the headlines, but we too have had significant difficulties. We have been attempting over the last three years to recruit radiologists to replace retiring partners. We have not been able to attract a single body from the five training programs in Ontario. I'll elaborate upon our experience.
We had a number of final-year residents who would visit us and three seriously considered Peterborough. One was offered a position in Colorado with access to all the latest technology and he subsequently moved to Colorado. Another was keen to come to Peterborough, but her husband was a teacher and try as I might, I could not find a job for him in the Peterborough area and so she also left and went to the States. The third possibility had a lawyer husband whose area of practice required a large urban setting, so she ended up practising in Toronto.
Our experience verifies some excellent investigative reporting that was done a couple of years back by the Peterborough Examiner when the problem of obtaining family practitioners really became a big public issue here. They interviewed family practice residents in Toronto and found an overwhelming majority were going to stay in Toronto. The dominant reason was spousal employment.
We finally got our new radiologist by getting one into Cobourg and Port Hope via the underserviced area exemption, as he had trained out of Ontario and was from the University of Manitoba and otherwise would not be allowed to practise in Ontario. Our other two recruits were established radiologists we were able to lure away from other communities, so we would cause a void in those communities.
This is a very difficult problem. There is a maldistribution of physicians in Ontario, as has been well-documented, and although it is not as great for radiology, it also exists for that, our specialty. Thus, this has to be addressed. In the short term, ideally we would need incentives for rural practice, but if they don't work then I think we have to have deterrents to new practices in large urban areas. In the longer term, I believe we should set aside spots in Ontario medical schools for rural students, in exchange for a guarantee of setting up practice in rural areas. This is something that was recommended in the Barer-Stoddart report, which some of you may be familiar with.
I also have concerns about the risk of patient confidentiality contained in this bill, but this has been dealt with by previous speakers and also will be dealt with by subsequent speakers, so I won't duplicate that.
Finally, I would like to say that the physicians, for the most part, want to deliver good quality care and to be advocates for their patients. This bill, by eliminating formal consultation with the physicians, is squandering a very valuable resource in this province. Surely, a partnership between the government and the various health care providers is the way to go in this time of fiscal restraint. Thank you.
Mr Marchese: Dr Swales, I think you might have mentioned one thing that I understood that you liked of the proposals they've introduced; I'm not quite sure. Is there anything in here that you've read that you agree with or like, for whatever reason?
Dr Swales: There has to be some assimilation for the continued restructuring process. I'm disturbed by the centralizing trend of this bill. The district health council would be a very valuable asset in this area. The idea is good; I'm not sure the means is the correct one. Certainly we in this area feel we would like to have more local input into how health care is delivered in this region. There's always a suspicion that Queen's Park doesn't understand our needs.
I can illustrate that by the original document I got for this particular committee: It was to wind up at 12 o'clock at Kingston; you were to have your lunch, get on the bus and be sitting here at 1 o'clock in Peterborough. It implies that the people in Queen's Park don't even know where we are, let alone what our potential needs are in health care.
Mr Marchese: You were saying that if you couldn't get doctors to voluntarily come to some areas you might need some deterrents. I'm not sure you agree with what they're proposing. I find them autocratic, intrusive and draconian. I don't believe government should behave in that way. We've got to find another way to deal with our problems. If this is the way we're doing it, it's wrong. I'm assuming you agree.
Dr Swales: I'm saying that's the second choice, but we have to deal with that problem. The first choice is to try to make it more enticing to go to the rural areas. We do have a real problem, and it has to be addressed.
Mr Marchese: I understand that. I don't think this is the way to do it. My view is that the health care providers and health care users have not been consulted at all in the preparation of this bill, and that's a fundamental flaw. That's why we're seeing a lot of people today and from other parts of the province coming to these committees saying they disagree with much of what they have seen, heard or read. I believe that when you don't consult people, ultimately you're going to have something they will disagree with, that won't work.
Dr Swales: I would agree with that, yes.
Mr Clement: I want to thank you for your very thoughtful presentation. You can be assured that all the members on the government side will take it seriously. I note that none of us on this side represents Metropolitan Toronto ridings, so we're inoculated from that particular problem you mentioned.
You mentioned in your response to Mr Marchese that there is a centralizing trend in the legislation when it comes to hospital restructuring, I guess in terms of the hospital restructuring commission, but that the district health council should be the way to start in terms of getting the local input and analysis and planning.
We've had a lot of submissions from local DHCs and hospitals over the past few weeks, saying: "We know we're going to be there analysing the situation, planning the situation, but ultimately someone has to decide. We don't have the power in the local community to come to an agreement when there is perhaps paralysis in the community or a very bipolar situation where you've got two very different points of view, or even more than two points of view. Somebody's got to decide. It's got to be the Minister of Health or his delegate." Is that a fair tradeoff? If, as the minister has already stated, we sunset those powers after a period of time, do you think that's a fair tradeoff?
Dr Swales: I think a mixture of the two, I certainly agree. I've had experience: I chaired the restructuring committee between Port Hope and Cobourg, and Dr Galt will know that was a very difficult issue and has just been resolved, I think to everybody's satisfaction, but it was a real struggle. The government does have to do some nudging, but a lot of the groundwork should be done locally, as was done in that case. It's not easy and it certainly wasn't easy there on the lakeshore, but ultimately we did receive the results.
Mr Clement: I think that's a very good way to put it, sir. I might also parenthetically mention that DHCs are still enshrined in the act. They are not mentioned in Bill 26, which means they're not changed; their powers of analysis and planning are still found in the original act and will not be changed. If there's a way to tie that in and perhaps make that more explicit, that the restructuring commission does take in the information, the planning and analysis from the DHC, would that satisfy you?
Dr Swales: That would certainly be helpful.
Mr Clement: Let me talk a bit about the independent health facilities, because that's another area of concern you raised. You mentioned that you're familiar with and support the request-for-proposal idea rather than the minister having the authority to designate new independent health facilities. I have a constituent in my riding who has been waiting for four years now for a reply to his RFP, which indicates to me that the system may not be working as efficiently as it could. He wants to offer more medical services in my community but he has not found a way to break the logjam in the system. Given that kind of context, do you think there's a way we can improve that?
Dr Swales: I would think the fault lies with the ministry. The ministry should be able to deal with those in a swifter fashion.
1950
Mr Clement: They get logjammed at the local level, though, because they go to the DHC, from what I understand.
Dr Swales: With a good DHC, there shouldn't be a logjam at that level.
Mr Clement: We'll keep working on that one.
Let's talk about underserviced and overserviced areas, because that's something we've heard a lot about in northeastern and northwestern Ontario as well. I just want to understand completely what you're saying. You're saying, if I can paraphrase -- and you can agree or disagree -- that you would prefer there be a negotiating process involving the doctors, the community and the ministry, but ultimately, given that we've been negotiating for two decades now -- the Liberal government's negotiated, the NDP government's negotiated -- there has to be some authority of the minister to break the logjam. Is that a fair analysis of what you said?
Dr Swales: Yes. The problem is that we keep changing the negotiating teams. The government is changing, so we start over again. There hasn't been a continuum in negotiations, because they've stopped and started again with a new organization. This is one of the big problems, that there hasn't been continuity on the government side.
Mr Clement: Our government has accepted incentives and acknowledged that there has to be a process for the education of general practitioners and persons who are in medical school. But ultimately, if all that breaks down and we have a two-tiered medical system developing whereby some communities have doctors and other communities don't have doctors, the government, as the custodians of the public, has to act. Is that a fair thing?
Dr Swales: Ultimately, if we fail on the incentive and encouragement end of it, and possibly restructuring the admission pattern to medical schools, the government has no choice but to step in in that circumstance. But we want to give it a shot first before we bring in that sort of thing.
Mr Miclash: I appreciate your comments about Peterborough and Queen's Park. Try to get Queen's Park to realize where Ear Falls is and you've got a real challenge.
I'm interested in what you're saying in terms of the attraction and retention of health care professionals into underserviced areas. You talk about the long term and the short term to alleviate the problem. I agree with you that it's going to take negotiations between the government and new people coming into the field; the OMA should be heavily involved. Do you have any particular solutions you would like to put on the table today? You mentioned a number of problems, but I'm wondering whether you have any solutions.
Dr Swales: The selection process into medical school is a critical one. If you're selecting students from an urban background, the chances of them wanting to go to a rural setting are much slimmer than if you choose students from a rural background. From my own family, one of our children is in medicine and he is practising in a small community because he came from a more or less rural background and enjoyed that way of life and has gone back to that setting. I think that truly does work. The biggest problem, as I see it, is that you want to be sure they don't marry someone with an urban occupation. I don't know how you beat that.
Mrs McLeod: Before we leave the issue of more positive alternatives to billing numbers, as northerners, Frank and I always like to recognize the fact that there are success stories. The Family Medicine North program has a retention rate of 67% of people training in that program, and I think some of the proposals for rural training residencies would have the same kinds of retention rates.
I want to come back to the Independent Health Facilities Act and our frustration with the act. It touches so many areas of concern; each of them needs individual debate, and you've raised a number of them. The Independent Health Facilities Act is one we've not had a lot of time to talk about. I thought that's where Mr Clement's question was going, because he raised it initially under independent health facilities and then got talking about a local problem. I hope he doesn't see independent health facilities and new facilities as being a way of getting around district health council planning, but I'll let him speak to that.
Do you find it strange and can you think of any reason why, even with a government prepared to shift some services to independent health facilities and to open new facilities, to take away the Canadian preference, there would not be a request for a proposal? Wouldn't any government want to get the best proposal for offering a service in an independent facility?
Dr Swales: This is certainly what I was proposing, that it be an open process. Presumably, the selection would be on the basis of the quality of the proposal.
Mrs McLeod: Yet in this legislation, the ability to determine who would operate an independent health facility is left entirely to the minister, without a request for a proposal.
Dr Swales: That's my understanding, and I think that's a dangerous plan. I hope none of you are from the Maritimes, but it happens with the post office in Nova Scotia that when the government changes, the postmaster changes. You could see the same sort of thing happening in independent health facilities, but you have a big investment in these facilities, and that's frightening.
Mrs McLeod: One of the other things the act does in relationship to independent facilities is give the minister the power to say what new services can be offered out of independent health facilities, which are currently often hospitals. Is that an issue you think we need to be concerned about and need to be on guard with?
Dr Swales: I don't have the same concern with that, particularly. My big concern from the community's point of view would be that the service, if it's dropped from a hospital, is available in that community. Particularly in this area, in the four counties we serve, we have a disproportionate number of seniors, and travel can be a very difficult thing for seniors. Ideally, we should be able to deliver the services as close to home as we can. In Peterborough, we're more or less integrating the planning of the independent health facilities and the hospitals, and I think that's the ideal.
Mrs McLeod: So the withdrawal of Canadian preference might be a somewhat greater concern in terms of the long-term implications.
Dr Swales: Yes.
Mrs McLeod: One of the things we heard in Ottawa yesterday was that physicians in Ottawa are already hesitating to make decisions about testing because of the climate that's now being created about physicians being second-guessed by the general manager of OHIP. There are probably 10 seconds left, if you'd care to comment on whether you see that as a danger or even some of it happening now.
Dr Swales: It is a danger. I can't speak to it, because I don't self-refer; we have strictly a referral practice. I can speak to it secondhand, that it is a big concern among physicians in Peterborough. A brief will be appended to one of the presentations by one of the local neurologists dealing with this particular issue. I think it is significant.
The Chair: Thank you very much, Doctor. We appreciate your presentation.
RENFREW AND DISTRICT LABOUR COUNCIL
The Chair: The next presenter is the Renfrew and District Labour Council, represented by Robert Patrick, who is a member and an ambulance officer. Good evening, and welcome to our committee.
Mr Robert Patrick: I'm very happy and surprised to be here, and I want to thank the opposition for this opportunity -- surprised because page 7 of the Common Sense Revolution says health care spending won't be touched. On page 17 Mr Harris says that he appreciates the expertise that's in the Ontario Public Service Employees Union and he would look forward to soliciting our ideas and working with us. I never dreamt this was going to be the forum in which I would be expressing my ideas. So much for my prologue.
2000
I'm an ambulance officer and I'm with the Renfrew and District Labour Council. The Renfrew labour council is very concerned about health care in Renfrew county and in the adjacent counties. The catchment area for our medical facilities and related services -- health labs, nursing homes, hospitals and ambulance services -- is very expansive and undefined.
Our medical facilities serve a geographical area stretching from Ottawa to Mattawa, from the Ottawa River to Highway 7. This includes communities such as Arnprior, Renfrew, Pembroke, Petawawa, Deep River and Chalk River on the north to Smith Falls, Perth, Callander, Madoc and Peterborough on the south. Within these boundaries are found communities such as Eganville, Barry's Bay and Bancroft, just to name a few. We're looking at a geographical area of approximately 850,000 hectares, with a sparse population of 150,000 people. These people deserve health care.
We feel that Bill 26 threatens the very existence of our already meagre health care infrastructure and the services that are already having difficulty attracting health care professionals: doctors, therapists and the likes of those people. Bill 26, I believe, will exacerbate this situation, mainly because we're not considered north and we're not considered south. We're in that no man's land somewhere in between. The bureaucrats in Toronto think Barrie is north, so I don't know what they think about Renfrew and Bancroft and those places.
The obstetrical delivery systems are being curtailed and centralized. Hospital labs are operating at a fraction of their capabilities and are not allowed to compete with the private for-profit, more expensive health care labs. The profits of one private health care lab, MBS, increased from $1 million in 1994 to $33 million in 1995. That money came out of OHIP, I suspect.
As an ambulance officer, my personal interest is in the future of the ambulance delivery system not only in rural Ontario but across this province. For the past 20 years my colleagues and I have fought to improve the ambulance delivery system and the level of care and treatment that we can extend to the sick and injured citizens of Ontario. I fought three successive governments, and I mean fought -- it has been a struggle; I have become apolitical as a result of it -- I don't know, about seven Health ministers. It has been very, very frustrating, and now we're threatened with privatization.
I remember when ambulance services were run out of funeral parlours, service stations, furniture stores, taxi companies. I remember when competing ambulance services fought over their patients on the streets of Ottawa. They'd fight over their patients. They'd sabotage each other's vehicles because they were paid by the patient carrying call.
Probably one of the main strengths of our existing present ambulance system is the fact that there are no boundaries. Back in the days of the private ambulance operators, pre-government involvement, private operators established what can best be described as elastic boundaries, influenced by the nature of the call, their current call volume, the availability of staff and greed.
In spite of the advantages that have been made over the past 20 years, the present cost of ambulance delivery system is still less than 2% of the total health care budget. I'm heartened by the minister's announcement that this government is willing to inject $15.5 million into the system and make paramedic ambulances a reality.
But if this money is spent and then the ambulance delivery system is turned over to the private sector with all its inherent problems, we will have achieved nothing, as I believe it will self-destruct. Bill 26 gives the minister the autonomy and the authority to make that decision, and I mean the decision as to whether to privatize or not. We know Laidlaw is sitting on the sidelines, just waiting to swoop in, and we've had a very good illustration in Ottawa of what Laidlaw will do.
I believe that a vibrant, viable ambulance delivery system is one of the cornerstones of a credible, effective health care system. The present trend to hospital downsizing, closing of emergency facilities, centralizing of obstetrical delivery units, cardiac and cancer units, the total closure of some hospitals and the ever-increasing volume of patients being treated at home make it imperative that the ambulance delivery system be there and be dependable.
I have seen expectant fathers burn out their motor rushing to the hospital in Renfrew because the ambulance was in Ottawa. I've seen parents of children driving to Ottawa at 100 mph on the highways because there was no ambulance. On a night call, when I'm working night shift and I go to Ottawa, there isn't an ambulance from the city of Ottawa to the city of Pembroke. That's 100 miles of Highway 17 and all the communities in between. There is no ambulance coverage for them. We're playing the law of averages, hoping that we don't get a call.
I've struggled and fought -- not only me; there has been a group of us on both sides, the labour side and the management side, and even within the ministry -- against the bureaucrats and the politicians to get improvements. Here we are on the threshold of a paramedic ambulance service and the whole thing could be for naught, if it gets privatized to somebody like Laidlaw.
Over the past several years, the present Ontario system, with all its warts and wrinkles, has been studied by other jurisdictions -- provinces and states -- as a model they would like to adopt all of or some of.
My presentation is very brief because I have not read Bill 26. I've read synopses of it. I've followed it in the newspapers. I've opinions and thoughts on several aspects of it. But the thing that's near and dear to my heart is ambulance. I'm 55 years of age, I'm two years away from my retirement and I could be gone this week, next week. The minute the minister decides he wants to privatize my ambulance service, under Bill 7 I'm history. I tell you what: It's a very discouraging outlook, after dedicating 22 years to this and seeing the advances that we've made, to see the whole thing go down the toilet.
Mr Doug Galt (Northumberland): Thank you very much for an excellent presentation. It's kind of refreshing to have a nice brief one.
Mr Patrick: It's right off the top of my head because it's a gut feeling presentation.
Mr Galt: We have a budget of $17.4 billion. That was what we promised in the campaign, a closed envelope, and that we would try and do our very best within that to make it as efficient as we possibly can. It's over a third of the spending budget of the Ontario government. The fastest-growing portion of the budget is interest, that is, the interest piece of the pie is what's growing the fastest in our budget, and we're frightened about that.
It's now 18 cents on the tax dollar. If we don't do something, if we remain the status quo, the way we've been running the last few years, it'll be closer to 40 cents on the tax dollar, and we're very, very concerned as to what our grandchildren are going to inherit. That's the premise we're coming from and struggling with, and regardless of where we turn, we find that those are not the right possible areas to be cutting. People are concerned about various reductions.
Having made those introductory comments, one of the examples of growth that you should be aware of, and it hasn't come out earlier this evening, is in the Ontario drug benefit plan. It started out 10 years ago at about $400 million; it's now $1.2 billion. It has increased three times in 10 years. That is the kind of thing that happens when you start giving something totally free, and it's of concern when you see it going at that rate. Something has to be done.
2010
We're committed to try and reinvest, reallocate, and that's where the paramedic training has come in that you made reference to. I, for one, think it's a great service, a great idea. I'm like yourself, a similar age, and I do remember when ambulances came out of service stations and came from the funeral parlours. I kind of wondered if there was a conflict of interest when they came out of funeral parlours.
Mr Patrick: Some of them definitely had, I'll tell you.
Mr Galt: No pun intended there, but you really did have to kind of wonder about it.
You've mentioned the concern about privatization of ambulances. Do you have other suggestions of what we may do in the ambulatory area of service, keeping in mind the concerns that we have with these dollars?
Mr Patrick: I would like to see the ambulance service, as I say, with all its warts and wrinkles, remain pretty much as it is. There are areas that can be improved. There are governance areas that can be touched up. Educating ambulance officers and training them after employment is a terrible waste of money. Like in the paramedic field, you get hired as an ambulance officer and then you go off and learn to be a paramedic. It costs the employer $50,000 to train a paramedic.
There's no reason why paramedics can't be in the college system the same as a nurse. It could be a two-year program or even a full one-year program of ambulance officer and then the second phase would be a paramedic. They'd be coming to the employer with their credentials. "I am a paramedic." Then it would be up to the hospitals, the base hospitals and the doctors in those base hospitals, to make the quality assurance things that they're doing anyway.
But right now, and Ms Grier can certainly attest to this, the cost right now, we have a desperate need for paramedic ambulance officers on the aircraft and we can't get them. We can get them, but the employer is not willing to invest $50,000 into somebody who after they get the job may go and work in Metro or Hamilton. They're not going to stay up in Timmins and Sioux Lookout and those places when they get to be paramedics.
It has to be a pre-employment, and there's an evolution that's going to have to take place. It could take, say, five years to get that program into the schools. It should have been in the schools last September, because we certainly have been consulted and expressed those opinions. But that's just one area right off the top of my head I can tell you where we could save some money in ambulance.
Mr Galt: I think it's important that we talk to people in the field like yourself, talking with a separate school board recently trying to find out from them, "Where are your extra dollars?" Through the planning of secondary school teachers in that board $5.5 million is spent. Every two years we could build a school from those dollars.
Mr Patrick: We have ambulances sitting in the same communities today that they were in 30 years ago. In some places we've got ambulance services 10 miles apart, some even closer. They should be redistributed and moved into the different communities.
Mr Galt: Should they go out from the hospitals?
Mr Patrick: No, because you're bringing the patient to the hospital, and this is a fallacy too. Hospital-based ambulance services are somewhat contradictory in this sense. Now, there are a lot of interhospital transfers. But we just moved into a new ambulance facility built by our hospital in their front yard. We used to be at the other end of town, which made more sense. It got me to that call faster because I was closer to the call when I started out.
Mr Galt: Can we just change a little bit from your bringing patients into hospitals into the area of restructuring? Over this last term of government we've reduced the number of acute care patient beds by 6,700, which is equal to some 30 medium-sized hospitals. We're trying to get more non-political by this new commission that's being placed in Bill 26 to try and come about having some of these hospitals close. Just having 6,700 empty beds and empty rooms is not saving very many dollars. You're still heating the hospital and making it operate. Do you have any thoughts on getting these hospitals restructured?
I'm coming from an area where there are two hospitals about six miles apart and, as mentioned by Dr Swales, the two boards are now working together. They're amalgamating their boards, their services. That's going very, very smoothly and I'm just thrilled about it. Do you have some thoughts on this commission and giving some teeth and getting it out of the politicians' hands so that it would be a more neutral body?
Mr Patrick: It would be a neutral body, but my concern about them is who are they accountable to? If they don't make the sorts of things the local communities support, who do they go after? Who would be accountable in the final for the decisions that are made by these people? Do you say, "Oh, they made a bad decision; we're going to take them off the commission and put somebody else on," and that will solve the problem? No, that doesn't solve the problem because the decision was still made.
Mr Miclash: Mr Patrick, thank you very much for your presentation. I think this is the first we've had from somebody in the field of the ambulances and representing the ambulance workers across the province. I notice that you're from Renfrew District Labour Council and you quoted a couple of comments from the Common Sense Revolution going back to consultation. The question I've been putting to groups such as yourself and to groups across Ontario as we've travelled is the fact that I don't believe there was any consultation in the drafting of Bill 26. I would just like to know if you know of any consultation in the actual draft of Bill 26. Were you or your council consulted in the actual draft?
Mr Patrick: No, to my knowledge. I suspect there was consultation, but it certainly wasn't with the communities at large. I believe it was with people like the vice-president of the Bay, Liberty, London Life, IBM.
Mr Miclash: I have to agree with you because we haven't met with any of those folks yet to ask them.
Mr Patrick: You won't see them coming before the panel. I'll guarantee you won't. They've had their say.
Mr Miclash: We're certainly hearing the same thing from folks such as yourself.
In terms of the delivery service, you were indicating that it's 2% of the total health care budget, and you indicated that the ambulance delivery service and the system is the cornerstone of delivery of good health care. You've alluded to a good number of points that privatization would have an effect on this particular service. I would just like to again thank you for getting those on the record and hopefully we'll have some results from what you've indicated here to us today.
Mr Patrick: If I may volunteer something just for a moment that the doctor before me sort of addressed, there's another area where I think we could make the service a little better, if we get nurse practitioners and paramedic ambulance officers working in emergency units, such as Barry's Bay or Bancroft or even in some of the larger communities, because you don't have to have a doctor for everything that comes into that emergency department. You could supplement the doctors with the people who certainly have the skills and the knowledge to treat the fractures and the scratches and the lacerations. Hey, a nurse can stitch you up as good as a doctor can and in many cases the nurse is the one who ends up doing it.
Mrs McLeod: I'm just wondering whether or not you as an individual citizen concerned obviously about health care is starting to feel as frustrated as I am. Maybe it's just because it's Friday night and I've been in hearings all week long, but I hear the government lecturing us about how all of this bill and all of its powers and all of its changes to health care are necessary because, after all, the debt is growing at $1 million an hour. I don't yet understand, having heard that lecture I can't tell you how many times, every day this week, why it makes sense then if you're worried about the debt growing, to put $5 billion more into the problem by giving that income tax break to people. I see that income tax cut driving the level of cuts that this bill is all about, and make no doubt about it, this is about cutting health care.
I notice Mr Galt saying that people are very concerned about reductions, that times are tough and everybody's going to worry about reductions in every area. I think people are worried about reductions particularly when it comes to health care, and I think they're worried about reductions in health care, cuts in health care from a government that said it wasn't going to cut a penny in health care and is cutting $1.5 billion. I want to ask you, as a private citizen concerned about health care, how you feel about cuts in the health care system.
2020
Mr Patrick: I support cuts in some areas of it. The drugs, Mr Mulroney's drug patent act that allowed drugs to skyrocket: When I go and pick up a little old lady, 77 years of age, with an overnight travel case this big -- I'm not exaggerating -- full of drugs -- the doctors will prescribe a drug for you and you go home and you have a reaction to it. Guess what? They say, "Don't take that drug any more, here's another one."
All of a sudden, you've got a cupboard full of drugs. You can't take them back, you can't refund them. They just keep issuing more and more. I see this in the nursing homes, I see it in the private homes I go to. Drugs to me are one of the greatest drains on OHIP going because of the proliferation of them out there, and as I say, if you have a reaction to it, you can't throw it in the garbage, so they give you another prescription.
Mrs McLeod: Exactly. It's interesting you raise that because we've had a number of presentations from people who are concerned about utilization of drugs but don't think that copayments and the government getting information about individuals' health records is the way to control it. One of the things that's interesting, because you talk about the wastage, is that about 15% of the increased use of drugs is because of large volumes of prescriptions, that drugs should be prescribed in smaller volumes so that seniors won't be taking more or wasting more.
Mr Patrick: Drug overdoses among seniors is one of our more common calls, especially in the wintertime when it's dark earlier in the day and their eyesight is not as good.
Mrs McLeod: The point I was going to make was it's ironic, because one of the effects that this copayment will have is that because people will be concerned about charging the copayment too often to seniors, they're going to prescribe drugs in larger volumes at once so they don't have as many copayments. I think what you're just describing is going to get worse rather than better.
Mr Patrick: Or the senior will say, "I can't afford to buy my drugs this week," or this month, and they won't buy them. They won't go and get them because they can't afford the copayments.
Mr Marchese: I agree with you with your fear about privatizing ambulance services and what that would mean to the workers and to our citizens. My hope is that this would never happen. On the other hand, I would be very vigilant; you never know.
It's important for governments to consult. We certainly did a lot of that when we were in government. Some claim we did too much. We did plenty of it because we felt it was important to hear all the sides. When you do that, you get attacked on all sides, both from your friends and from your foes. We have an obligation, however, to do so. They were almost successful in having no consultation whatsoever, which I think is the worst thing any government could do in a democratic society, so it's good to have people like you here. I hope you will keep an eye on what this government is going to do. They will continue to introduce bills with very little consultation and the only way you will hear about it is by staying tuned or keeping in touch with some member who is likely to give you information as to what is happening. I appreciate your presentation and hope you will continue doing that in the future.
The Chair: Thank you, sir. We appreciate your presence here tonight and your interest in our process.
Mrs McLeod: Mr Chairman, I note that the Northumberland Community Coalition is one of the groups that was not able to make a presentation this evening. They have tabled a written brief and I'm just wondering whether or not that has been noted for the official record.
The Chair: Everyone has a copy? Okay. Thank you.
PETERBOROUGH COUNTY MEDICAL SOCIETY
The Chair: Our final presenter for the evening and for the week is the Peterborough County Medical Society. Thank you very much for being here. We appreciate your attendance. You have a half-hour to use.
Dr Marshall Trossman: Thank you for the opportunity of appearing before you. My name is Marshall Trossman. I come here as the president of the Peterborough County Medical Society, which represents some 200 physicians in this area. I'm joined by two of my colleagues, who will introduce themselves.
Dr Carlo Bos: My name is Carlo Bos. I'm a fellowship obstetrician and gynaecologist practising here in Peterborough and I represent my four colleagues in the submission to the committee.
Dr John Gray: My name is John Gray. I'm a family physician of 21 years in Peterborough. I was president of the Peterborough County Medical Society in 1980 and I'm currently chair of the board of directors of the Ontario Medical Association, representing the Ontario physicians on the board of directors of the OMA for this area.
Dr Trossman: I am a semi-retired family physician. I have been involved in medicine for over 50 years, 24 in this community. As I said, I speak on behalf of the county medical society.
It must be clear to the committee that the local doctors, as other members in the province, are concerned about Bill 26. An initial reaction of anger has been followed by anxiety, discouragement and disappointment. About whom? Not ourselves alone, as comments from government have implied, and indeed we deplore the argumentative and pejorative comments that have been made about physicians and have been attributed to the Minister of Health. We are concerned for our patients, the public, our community and for the health care system.
Irrespective of the system of health care delivery -- I have seen a number of these -- the primary concern of a doctor is for the wellbeing of his or her patient. The relationship between a patient and a doctor may range from being episodic and transitory to one that is lifelong and involves intimate details. It is one wherein a patient confides details of his or her life that are not released to anyone else. Would any person want this information conveyed to an unknown official for fiscal reasons?
But this is one aspect of this bill which could occur. Patient records could be examined without the patient's permission to determine if a "medically necessary" treatment or test was ordered. Do you want a faceless bureaucrat looking at your doctor's records of your case, knowing everything about you, and deciding if you had appropriate treatment? I think not.
I referred to the patient-doctor relationship, one which takes time to develop and longer to last. What if the doctor cannot remain in that relationship? This does occur, of course, due to death or retirement or a move to another community. But the provisions of this bill, or the implications related to it, may lead to government intervention. A doctor may be deemed to be superfluous to his or her community because it is overserviced, this by government decision, or else a specialist may be refused a hospital appointment, often for financial reasons, and so would be denied the right to bill and therefore be denied the right to continue to practise. What if the government decided that a doctor is "too old" to practise and terminates his billing number? What would that do to the patient-doctor relationship, to the continuity of care to the public?
I assure you that one comes close to my heart. I find it passing strange that the princes of the church and the justices of the Supreme Court may continue their function until 75, but a doctor may not be allowed that option.
Maldistribution of medical services has been referred to: not enough doctors in rural areas. This is a problem faced by many communities, this one no less. The bill proposes to remedy this situation by forcing doctors to go to these rural areas, essentially by not allowing them to practise in larger communities because they are dubbed overserviced.
I submit that this method is heavy-handed and doomed to failure. Forcing a physician to go where he or she is unknown, where he or she has no family ties, where a spouse may not find employment, raises many hurdles. The prospect of professional isolation is another hurdle. When our neighbours to the south are ardently seeking young, Canadian-trained doctors, how many will agree to go north or elsewhere? And if they do and are unhappy, what kind of rapport will they have with their patients? We come back to the patient-doctor relationship, which is the key.
How should we remedy this bleak scenario? By using a carrot, not a club. The OMA has proposed an incentive program. Financial and professional advantages can work. If a doctor can improve his income and have access to consultation and further medical training, I submit that many doctors would overcome their concerns about isolated postings. After all, this happens in the armed services. Why can't we do it in the health care system?
2030
You have heard from my colleagues about the concerns regarding malpractice insurance, the CMPA, and I'm sure Dr Bos will refer to this further. This protection is important for a practising physician in case of accident or misadventure, but it is most important for patients, for if there is an unfortunate occurrence, a patient has some recourse to pecuniary recompense.
I would remind you that the reason government returns a part of the premium is in lieu of an increase in fees. The intransigent attitude of government towards payment of these funds may well have far-reaching effects on methods of practice and on adequate health care of patients. If expert care is not available, total care will suffer and people will suffer.
I'd like to return to my theme of our concern for our patients. It has often been said that doctors don't own patients but that patients own doctors. If we get beyond billing numbers and prescriptions and medical records and offices and house calls, we, as doctors, must recognize that we are servants to our patients. We represent them. I refer to the psalmist who wrote, "He shall defend the needy among the people; he shall rescue the poor and crush the oppressor."
We live in a democratic society. I suggest our legislators remember they are the servants of the people.
In view of the fact that we've had a long day and you've had a longer one, I purposely kept my presentation short. I will now defer to my friend Dr Bos.
Dr Bos: I, like Dr Trossman, am sure that it's been a very long evening for you and perhaps even a very long week, and I very much appreciate the opportunity to address these proceedings.
I would like to speak for a moment from a personal perspective about what I think would be some of the effects on reproductive care of the implementation of Bill 26 and the termination of the CMPA rebate.
By way of background, I'm a specialist in obstetrics and gynaecology, having received a bachelor of arts in 1970, an MD degree in 1974, and was admitted as a Fellow of the Royal College of Surgeons in 1978.
I have been practising obstetrics in Peterborough for the past 17 years, and for most of these years, along with three other obstetricians similarly trained and equally experienced, each of us has cared for and delivered between 200 and 225 mothers/babies per year. We, as a group, have taken responsibility for providing consulting obstetrical services at the Peterborough Civic Hospital, where between 1,650 and 1,800 deliveries per year are performed.
We provide emergency consultation and high-risk obstetrical services for the family practitioners and citizens of this community, as well as those of Port Hope and Cobourg in the south, Lindsay in the west, Minden, Haliburton and Bancroft in the north and as far east as Havelock and Campbellford.
We work one night in four to provide these services. Each one of us works 91 24-hour time periods per year on call. To put this another way, each of us puts in 1,700 hours per year of on-call time over and above the 40- to 50-hour weeks that we work in the office or doing elective surgery in the operating rooms. This represents a huge investment in time and energy, because for us, "on call" means being available to get into the hospital and be at the bedside within 15 minutes of an urgent summons, at any time of the day or night, on any day of the year -- 15 minutes, whether I'm watching my kid play soccer, whether I'm eating Christmas dinner or I'm asleep at 3 o'clock in the morning -- in the hospital, at the bedside.
Maybe I'm getting on, maybe I'm getting tired like Dr Redhill, but I find it more and more difficult to deal with this commitment. I really don't have a clue what kind of a problem I may be facing: a woman bleeding from a placental separation, a woman having seizures from toxaemia of pregnancy, a woman with twins with her babies in trouble because of fetal distress. Who knows? The pressures of having to deal with sudden obstetrical emergencies and the short- and long-term consequences to mother and baby of such events can be enormous, particularly since in this increasingly litigious society the risk of being sued is almost entirely dependent on events over which we have no control. Hence the huge increase in malpractice insurance premiums.
Who gets sued? It's the obstetrician who's trying to do his level best at 3 in the morning, having been up for the preceding 36 hours looking after a myriad of other problems. With the end of the CMPA rebate program, the financial cost of practising obstetrics in this province is prohibitively high. I will have to deliver 77 babies -- Dr Redhill has to deliver 90 babies; I don't know why -- to cover the CMPA premiums, and of the remaining 123 deliveries that I do per year, I have to pay office overhead, taxes, RRSP contributions. A further cost, and perhaps the biggest cost to me, is the rather dubious privilege of being on call 91 days and nights per year.
Furthermore, the provisions of Bill 26 I believe are unnecessarily intrusive and restrictive to the other aspects of the practice of medicine in this province. Among other things, Bill 26 allows for a bureaucrat at OHIP, in the first instance, at least, to decide that a diagnostic test or a surgical procedure is "unnecessary" and therefore remove the costs for such service from the doctor's OHIP remittance. How can a bean counter in OHIP tell a surgeon that an appendectomy is unnecessary or an obstetrician that a Caesarean section is unnecessary? That's like a frequent flier telling an airline pilot to do a barrel roll and then billing the pilot for the cost of the crash.
Ladies and gentlemen, I despair at the consequences of Bill 26 and the CMPA rebate program to the health and welfare of my patients, because I can foresee it becoming more and more difficult, if not impossible, for me and my obstetrical colleagues, both here and throughout Ontario, to continue to provide obstetrical services -- services which our communities have enjoyed for many years and indeed to which they are entitled. I'm concerned for the mother who needs an emergency Caesarean section, for the mother whose baby is in distress, for the mother who's bleeding in a life-threatening fashion. Who will care for her if there is no obstetrician?
I am profoundly disillusioned and disappointed in the Harris government's apparent inability to understand the ramifications of Bill 26 and the cancellation of the CMPA rebate program on the provision particularly of obstetrical services but also other health care services as well. These programs I believe are ill-conceived and poorly thought out. It is time for the Common Sense Revolution to inject some common sense into the relationship between doctors and the Ministry of Health. Let us stop being adversaries. Let us start working together for the benefit of all.
I'd like to give Dr Gray an opportunity now to say why he is here, because nobody knows.
Dr Gray: Actually, I'm sure to the delight of the committee, you'll be pleased to know, and I'm sure to the astonishment of many of my colleagues in the audience, I have no formal remarks to make to the committee. However, because primarily, as all of you know, I had the good fortune to address the committee formally when you were in Toronto, I have offered to my colleagues on my left to be a resource to them, because there are some technical parts of the bill to which I'm sure some of you may wish to refer. I have had the good fortune to read the bill in detail and have been part of the process at the OMA trying to sponsor or recommend some reasonable changes. That's why I'm here.
2040
Mrs McLeod: Since early this evening I've expressed my shared concern about the effect of the withdrawal of the CMPA rebate on reproductive care obstetrics in the province, an area where I think there is a real pending crisis unless the minister acts quickly to deal with this.
I'm going to go on to another part of your brief and the concerns that you've jointly raised about the government determining what is medically necessary and the ability to deny payments to physicians if in fact care is provided that is later deemed to not have been medically or therapeutically necessary. You're quite right. As we read the bill, it would be the OHIP general manager who has the power to deny that payment and I'm sure the government members will hasten to say, "Well, he has that ability to make that decision now," although that would have to be on reference to a committee of professionals.
There is another change to this bill, one of those changes that makes us very nervous because we have no idea what it's going to mean in the future, that you can be denied a payment for a service given because it was not medically or therapeutically necessary, was not provided according to professional standards or other such circumstances as may be prescribed. And we relate that back to another section of the bill in which it says very clearly for the first time ever that the definition of "medically necessary" will not be those services that are rendered by a physician, but now will be prescribed medically necessary services rendered under such conditions and limitations as may be prescribed and those conditions would be prescribed by cabinet, by politicians. I think, even as a sitting politician, that would be equally as scary as a bean counter deciding what was medically necessary.
Obviously, this raises concerns. We have limited time. As we raised this concern earlier in the week, one of the things that one of the members of the government Ms Johns, said was that we shouldn't be worried because somehow the OMA medical tariff committee will be deciding what's medically necessary. Now, I can't find any reference to that anywhere in the act. We've raised the question with the Ministry of Health and have not yet had a response. Are you aware of any committee on the Ontario Medical Association that could be involved in this or that has been approached to be the arbitrators of what is medically necessary?
Dr Gray: I'll take a crack at that, having been a member of the central tariff committee at the OMA for four years, and the simple answer is no. That is not a body within the OMA that would attempt to undertake that kind of an exercise. The member who made reference to that may be referring to the Medical Review Committee of the College of Physicians and Surgeons. It's not uncommon at times in the past when the OMA has been confused with the College of Physicians and Surgeons, but we are separate organizations. CPSO's mandate is to protect or represent the public and the OMA's mandate is to represent the physicians of the province. So, no, it would not be the mandate of any group within the OMA and we certainly have not been approached to try to define "medical necessity."
But I think an equally important point to remember in all of this is that under schedule I of the bill, the formal agreements between the Ontario Medical Association and the government will be terminated and there will be no forum to discuss this or any other issue between the government and the OMA if those agreements are abrogated.
Mrs McLeod: The Medical Review Committee does continue to exist and, according to this legislation, would be called upon in some circumstances, but in the case of the general manager of OHIP deciding to withhold payment for a service that a physician has given to a patient, the only way you could appeal to the Medical Review Committee is for the physician to make an appeal. Whereas, as I understand it, currently if there was any question about a medically unnecessary service having been provided, that would have been a determination by the Medical Review Committee. It would be medical professionals deciding whether or not there had been, in some way, a mispractice. Is that correct?
Dr Gray: Yes.
Dr Trossman: I think that's correct, Mr Chairman. I'd like to point out, though, that we're getting off into the abstruse in discussing this. I think I would like to reassure this committee that physicians as a group, whether it is a group of two or three physicians together or a group practising in a community in a hospital or in a larger area, the College of Physicians and Surgeons, through their organization and through their peer review committee, all of which I have been involved with as chief of staff in this city and elsewhere and as a member of the peer review committee, these are all methods for, as it is called, peer review, for supervision of medical care, and indeed if a patient has a complaint, they have the ability to call the college and their complaint will be investigated.
As has been pointed out, there has been a complaint that there is a delay, but there's always a delay if there is an excessive number of complaints. However, as has been pointed out, if there is some indication that there is poor practice, shall we say, then the Medical Review Committee, which is a subcommittee of the College of Physicians and Surgeons, is empowered to look into this problem, and that is the committee that currently may refer the case to OHIP if it is found that there has been some irregular procedure.
Mr Marchese: I know that the Scott report, which had been commissioned by us, was dealing with the whole issue of distribution of doctors, and I understand the Provincial Coordinating Committee on Community and Academic Health Science Centre Relations was also studying that particular matter and many other things. I'm not quite sure why it is that this government would not decide to consult those particular groups that are dealing with this before deciding to introduce a piece of legislation that says something totally different on their own without the benefit of this advice. Do you have a sense of what these committees are saying or proposing, or do you have a comment as to why this government might deem itself to go in a different direction without the benefit of these kinds of reports? Anyone?
Dr Trossman: Well, I can't respond for the government, but I think the general tenor of your remarks indicates a disregard for the concerns of the medical profession by the government, the abrogation of the agreements between the OMA and the government, which have existed. The minister has said the agreements of 1991 and 1993 will be terminated. If there is no forum to discuss matters of common concern, there can be no progress, and I suggest, as many previous speakers have indicated, there should be cooperation and an agreement between government and practitioners.
Mr Marchese: I've asked a few other doctors some of the same questions earlier about whether or not they think there is anything in this bill that they agree with or that they find practical, useful, effective for the purposes of enhancing our health care system. Is there anything in here that you think will benefit our health care system generally?
Dr Trossman: I know you've asked that question before, sir, and I think among doctors the immediate reaction is no. But I think on reflection one has to say that from the philosophical point of view, anything that would attempt to solve the problems that the health care system is dealing with has to be approached with an open mind. Unfortunately, I feel that the current government and Ministry of Health is not approaching it with an open mind but with an idée fixe, with a previously determined process.
Dr Gray: I've given some thought. I've heard you ask that question of many people, and as you asked it I've been thinking many times, is there anything in this bill that I in fact could find acceptable or even advantageous, and in fact I think there is one. At the moment, physicians in Ontario are very discouraged because we all, for the last three years under the social contract, have had earnings clawed back. But now the government is calling them contributions and I think that makes me feel good about myself -- just as long as these contributions are tax deductible.
Mr Marchese: Anyway I just wanted, Dr Bos, to agree with you that I think governments need to stop being adversaries and to start working together for the benefit of all, and I think it isn't just for the medical profession but everybody who is affected by this bill. So thank you for coming.
2050
Mrs Ecker: Dr Trossman, Dr Gray and Dr Bos, thank you very much for coming and taking the time to bring forward your suggestions. While it's been a very long, tiring week, it's been also a very, very useful week, because the members of this committee do have an open mind and have been quite interested in many of the suggestions brought forward by members of the medical profession, workers and hospital providers etc.
One of the points that you made is that we should all stop being adversaries. I guess one of the things I've had a lot of experience in various capacities with the medical profession over the years and one of the things that has distressed me greatly is that every government seems to have had some problem. The Liberals had extra-billing, the NDP had social contract, block fees and consent legislation, and it would appear that we have some difficulties over Bill 26.
One of the things I would like to assure you of, and some of this information I'm sure you already know, on the CMPA difficulty the minister has clearly made a commitment that in areas where obstetricians and GPs -- we don't wish to drive them out because we need those services and they are important, and I think that's something the minister has said he wishes to address.
The points you make about the underserviced area program: Again, the NDP did have the Scott report, which was an excellent report, and one of the things Mr Wilson has tried to do is to start moving on some of those suggestions -- financial incentives, the beginning being the $70 emergency fee, but also the training of young doctors, CME support, locum support, those kinds of issues -- because we recognize that it has to be a multifaceted approach in order to get physicians within the area.
One of the areas that you've talked about is the difficulty with deciding medically necessary, whether the general manager -- as you know, the general manager now, with the powers under the Health Insurance Act and OHIP, makes the decisions of what is medically necessary for payments based on physician advice, and I think that is certainly something we want to ensure and continue in the process.
The Medical Review Committee -- which again, as you know, is not patient-driven, not patient complaints that make that, it's the information from OHIP, the general manager, that drives the Medical Review Committee -- the college has said there are problems with it; it's not working as effectively as it can be. If we were to have proposals to streamline the Medical Review Committee to make it more effective, to make it do what I think most physicians agree is something that has to be done, would we be able to solve the difficulties of medically necessary, who determines that? Would we be able to solve the concerns about confidentiality, because if it is under the auspices of the CPSO with physicians and the public members on that committee, who are under confidentiality restrictions etc? Would it address those two issues which you have pointed out, any of you?
Dr Trossman: I would think the answer to that is yes. Although it may be peripheral, I have referred to the peer review committee, which is not quite the same thing.
Mrs Ecker: That's true, yes.
Dr Trossman: I refer to it because I've had experience with it. For example, when it started some 15 years ago, the pattern was to have two assessors review a physician and it has been found that it is adequate to have one trained assessor do it. The same thing could be done with the MRC, and I'm sure that if the appropriate approach was made to the college, which supervises, that could be effected.
Mrs Ecker: Okay. Just to change topics a little bit, one of the things that we've heard mentioned here at the hearings is difficulties with the prescribing of drugs, to seniors particularly, but other people, and obviously the inappropriate prescribings, a minority of physicians. But we've also heard many physicians talk about the need for clinical guidelines for prescribing, for practice etc. Some physicians have said to me that they're looking for more guidelines on that.
Do you have any guidelines on how the ministry can encourage not only the development of appropriate clinical guidelines for practice and for prescribing, but also ensure and help to make sure they are followed? Because that's always the debate. You can get guidelines, but how do you ensure that practitioners are educated about them and then are prepared to follow them? Have you got any comments on how, as a government, we can assist that process?
Dr Bos: I'd certainly agree that there is the need for some kind of ongoing, some kind of continuing medical education in the very rapidly changing fields in which we practise. I think there's a danger in having clinical practice guidelines in terms of getting involved in cookbook medicine. Medicine is not a Betty Crocker recipe. It is a combination of training, of science and, probably most importantly, of art, of having the nose to smell a rat, of having that je ne sais quoi that you can't teach anybody but which you gain by dint of experience of being up at 3 o'clock in the morning and seeing it all.
I would agree that on the one hand there needs to be a mechanism in place to help physicians to keep themselves up to date. How the ministry can help in particular I really don't know. That's certainly a question that is worth addressing seriously.
The Chair: Thank you. We appreciate your presentation and thank you for your interest in our process.
Before we leave, I want to thank the people of Peterborough for allowing us to have a good dialogue with the presenters and we appreciate your cooperation. We are adjourned till Monday in Windsor.
The committee adjourned at 2057.