Tuesday 20 August 1991

Regulated Health Professions Act, 1991, and companion legislation / Loi de 1991 sur les professions de la santé réglementées et les projets de loi qui l'accompagnent

Ontario Public Service Employees Union

Canadian Institute of Public Health Inspectors (Ontario Branch);

Association of Supervisors of Public Health Inspectors of Ontario

Ontario Ambulance Association

Toronto Art Therapy Institute, Ontario Art Therapy Association, Canadian Art Therapy Association

Ontario Society of Clinical Chemists

College of Doctoral Scientists in Laboratory Medicine of Ontario

Mission Services of Hamilton Inc

South Georgian Bay Ministerial Task Force on Bill 43

Ontario Secondary School Teachers' Federation

John Chin

National Council of Filipino Associations

Annette Dillon

Ontario Coalition of Visible Minority Women

Thomas Goodman, Goodman, Pomerantz, Robinson and Associates

Ross Johnson



Chair: Caplan, Elinor (Oriole L)

Vice-Chair: Cordiano, Joseph (Lawrence L)

Beer, Charles (York North L)

Haeck, Christel (St. Catharines-Brock NDP)

Hope, Randy R. (Chatham-Kent NDP)

Malkowski, Gary (York East NDP)

Martin, Tony (Sault Ste Marie NDP)

McLeod, Lyn (Fort William L)

Owens, Stephen (Scarborough Centre NDP)

Silipo, Tony (Dovercourt NDP)

Wilson, Jim (Simcoe West PC)

Witmer, Elizabeth (Waterloo North PC)


Coppen, Shirley (Niagara South NDP) for Mr Owens

Frankford, Robert (Scarborough East NDP) for Mr Silipo

Jackson, Cameron (Burlington South PC) for Ms Witmer

Miclash, Frank (Kenora L) for Mrs McLeod

Wessenger, Paul (Simcoe Centre NDP) for Mr Malkowski

Clerk: Mellor, Lynn

Staff: Drummond, Alison, Research Officer, Legislative Research Office

The committee met at 1003 in committee room 2.


Resuming consideration of Bill 43, the Regulated Health Professions Act, 1991, and its companion legislation, Bills 44-64.

Reprise de l'étude du projet de loi 43, Loi sur les professions de la santé réglementées et les projets de loi, 44 à 64, qui l'accompagnent.


The Chair: I would like to call the Ontario Public Service Employees Union. The committee welcomes you. You have 20 minutes for your presentation. We would ask you to leave a few minutes at the end for questions from committee members. Begin your presentation now, please.

Ms Casselman: Good morning. My name is Leah Casselman and I am a member of the board of directors of the Ontario Public Service Employees Union. With me are Fran Zaitz, a registered laboratory technologist and an elected representative on our medical division within our union; Beverly Dalys, a researcher with OPSEU; Amani Oakley, a registered medical technologist and local president of Wellesley Hospital, and Fred Wambera, also a member of our medical division and a registered X-ray technologist.

Thank you very much for hearing our presentation today. I will try to be as brief as I can. You have our document before you, and I will be running through it. Here we go.

Our union, the Ontario Public Service Employees Union, represents more than 10,000 health care professionals across Ontario. We are, of course, very interested in this legislation. We, as many of you will know, have been fighting for years and have recognized that health care workers are dedicated professionals and that their work is very valuable to our society. We also have been trying to let the employer and the public know that these workers have been denied the respect and dignity afforded to other professions.

It is for this reason that it is a pleasure to see the government leading the way in conferring upon these workers the esteem that they have long been withheld. But we are also distressed with the line that this legislation is taking forward. The Health Professions Regulations Act and its companion acts will shake up health care delivery in Canada. The effects will no doubt be felt by many interest groups and individuals across the province. OPSEU, like other groups, has many concerns about this legislation, and the one that we will be speaking about today in particular is triple jeopardy.

For those who are not familiar with triple jeopardy, it means that workers in the field can be actioned against by their employer, by their college and by their licensing board. When they are actioned by their employer, we have a grievance procedure, and the members, the workers, will be represented. If they are actioned by their college, they are on their own with a lawyer, and, again, they are on their own with the licensing board.

The other concerns that we will be discussing with this committee, and have discussed in the past, are the question of, again, absence of union representation on governing bodies, credentialism and the question of who gets admitted to the colleges and the financial cost our members have to bear to maintain the colleges.

We are very concerned about the discipline and that our members in health care will face this situation of triple jeopardy. As you know, the Health Professions Legislation Review was initiated in 1982 by Alan Schwartz. We have seen this as a very anti-worker bias to this committee. There was no presentation or acknowledgement or request for hearings from workers or their representative, the union.

We are not opposed to guaranteeing the public that it can rely on quality of service that the government provides. We have for some time been promoting quality public service in our campaigns, as I am sure you are aware. We become leery, however, when the burden of accountability, which properly belongs to the decision-makers such as ministry officials and hospital administrators, is passed on to the employees or the workers. Clearly, we see that this is what this bill does.

This legislation will pass on to employees responsibilities and liabilities that ultimately belong to their employers. Professional self-regulation is at odds with the work structure for many of the professions listed in schedule 1 of Bill 43.

Professional self-regulation is necessary as a check for self-employed professionals who possess a great deal of specialized knowledge and control over their work, and extensive decision-making powers. For self-employed practitioners who are in control of their work and who have no employer to determine how they will practice, it is imperative for a regulating body to set standards and step in when necessary. But for workers in traditional employment relationships who have some direct supervision in their jobs and who are responsible to their employers for carrying out the instructions they are assigned, professional self-regulating bodies may duplicate employer functions that are already carried out.

We are very aware, as I am sure the Chairperson of this committee is, of the financial constraints within the health care system in Ontario. We are struggling daily to provide and maintain our high quality of health care within this province, but health care providers are stretched to their limits. In laboratories and hospital wards, budget cuts have forced workers to struggle to maintain that high quality. With the cutbacks, we are convinced that those burdens will shift to the workers.

The combination of financial cutbacks and increased liability through professional regulation may be deadly to health care workers. If health care professionals are brought before the council of their colleges or the health review board on a complaint, they can end up paying for their employer's shortcomings.

Unions have fought hard both in the political process and in litigation to instil the principles of natural justice into our labour relations system. When organized workers are penalized by their employers, they have access to a grievance procedure with full union representation and are deemed to be innocent until proven guilty. With the complaints and discipline procedures and bodies laid out in Bill 43, these principles of natural justice are abandoned.


The triple jeopardy problem is related to union representation. The primary reason for the overhaul of the legislation covering health care workers is to make individual workers more open and accountable to the public. The bodies created under this legislation -- the Health Professions Regulatory Advisory Council, which determines the scope of practice for each profession and determines who is regulated under which terms, and the Health Professions Board, formerly the Health Disciplines Board, which is primarily responsible for conducting hearings and reviewing decisions made by the councils of colleges -- hold the balance of authority in the jurisdiction.

These bodies appointed by the Lieutenant Governor are charged with looking after the interests of the public. Clearly this lacks balance. In disciplinary matters, what possible incentive would the board have for finding in favour of the worker under investigation?

These bodies must be composed equally of lay public members and practising health care professionals. Without this balance, many variables which affect health care, such as technical specifications and working conditions, could be overlooked or misunderstood and lead to unfair or unrealistic decisions.

It is also important that the worker's perspective of how events may have transpired be considered in anything as important as a disciplinary hearing or in determinations on who should perform which controlled acts.

The one-sidedness that is blatant in the Health Professions Regulatory Advisory Council and the Health Professions Board is repeated, to a lesser extent, at the level of the college councils. There are a number of committees that members are appointed to, as outlined: the executive committee; the registration, complaints, discipline, fitness to practise and the continuing competence committees. These committees, which have immense control over who will be practising in each of these professions, are composed of members elected by the members of the college. On the one hand, they are public representatives of their professions. Naturally, many will wish to represent excellence. This means they will have an interest in being rigorous with their colleagues. On the other hand, they are practitioners who have firsthand knowledge of the difficulties in the workplace and the possibilities for errors and an understanding of how their peers may be reasonably or unreasonably charged with failing to maintain the standards of practice.

Presumably, some of the members elected to the council and subsequently appointed to one of the powerful committees will be able to balance their competing interests; others might have a more biased perspective. For the council to simply appoint members to committees that can make or break a number of careers and lives indicates a gigantic leap of faith to attain justice.

OPSEU would like to see assurances built into the legislation that would make the colleges more open to its members' participation. Specifically, OPSEU would like clauses in Bill 43 which would make it clear that members elected to the professional regulating bodies are provided with paid time off with no loss of seniority from their employers for college activities. If you do not do that, you limit it to those people who can afford to participate.

For the committees and health review board to work effectively and legitimately, they must adhere to the principles of due process under law. These procedures must more closely parallel justice procedures in criminal actions, where lawyers representing both sides make decisions in jury selection, and in labour arbitration, where arbitration boards are composed of nominees representing both sides in a dispute and a neutral chair, and where a single arbitrator is agreed upon by the two sides in a dispute. Under this bill, the committees at the college level, the advisory council and the Health Professions Board do not resemble mainstream justice bodies.

To correct the problems outlined in this presentation, OPSEU recommends the following changes in terms of composition.

At the colleges:

1. The appointees of the Lieutenant Governor be selected to represent two constituencies -- labour and public -- and that the two constituencies be equally represented;

2. The members of council be appointed to the committees on a basis of equal representation, though the existing proportions remain the same;

3. When any committee is convened to hear a case, the public representative can select one public Lieutenant-Governor appointee, the accused can select one labour Lieutenant-Governor appointee, and that the two appointees jointly select a neutral chair from the pool of elected members.

At the college level, this setup would have another advantage. In order to be selected as a neutral chair, the elected member would have to maintain a track record of fair decisions. This would force careful consideration of all the facts. The record may also influence re-election to the college.

OPSEU also urges this committee to change the composition of the advisory council and the Health Professions Board in a corresponding manner. It must be balanced to equally represent the two parties to any proceedings: the public and the health care workers.

We recommend that the appointees of the Lieutenant Governor on these bodies be selected from designees of the interested parties. We also ask that sections 8 and 18 be struck from the legislation. We apply the same reasoning to our position on the composition of these bodies as we do regarding the councils. Without firsthand representation of practising professionals, the advisory council and the Health Professions Board both run the risk of neither providing the public with the protection it requires nor providing the professions with the equity to which they are entitled.

The Chair: Thank you very much for your presentation. I have a question or comment from the parliamentary assistant, Mr Wessenger.

Mr Wessenger: You make a statement that I am somewhat concerned about. You indicate that the discipline procedures are contrary to the principles of natural justice. I would like you to elaborate on that statement, because I would like to know the specifics you have concern about.

Ms Dalys: I am Beverly Dalys, research education officer with OPSEU.

The principles of natural justice involve, among other things, equal representation for two sides. There is no representation for workers at any level. If you have the Health Professions Board having solely representation from the public and it is deemed to balance the interests of the public against the interests of the health care worker, there is obvious lopsidedness there. Where is the worker's representation or representative?

The legislation states that the Health Professions Board can hire consultants who know health care, but those people are not going to be practitioners. Those people are going to be former health care workers who might not be in touch with the realities in the health care settings today, which are undergoing a lot of change because of budgetary reasons. They are generally we think going to be management people who have gone on to the next stage in their career and are really quite removed from the reality, or workers, in the health care system. Certainly when we compare any of these boards we have talked about and the councils in the colleges to arbitration boards, they are quite different. I think the question of where natural justice is missing is quite evident when we look at that.

Mr Wessenger: You have no specific suggestion with respect to procedures under the act or no complaint about procedures. It is really just a question of representation on the college discipline board. Is that your only concern?

Ms Dalys: Representation is our primary concern. I can get back to you in writing with more details on procedure. It is not something we have consulted our membership on widely.

Mr Wessenger: I would just like to make a comment. I think you are looking at a traditional labour situation where you have a board composed of management and employee representation equally with an independent arbitrator, but I assume that is not the type of structure you are looking at with respect to this committee. You are not going to have management people on that committee. Therefore, you know, it is just like a judge. A judge gives justice, and an independent board -- I do not see the problem with respect to this whole question of natural justice in this regard.

Mr Martin: Just listening to your presentation, I wanted some clarity. You mentioned that you would like to have five labour and five public on the appointed side of the college. Presumably you mean labour from the particular group of people the college oversees. That, in my mind, would tip the balance of the committee in a direction that was different from the intent of the legislation, which was that there would be just a slight overrepresentation of the college, of the professional versus the public. Could you explain that a little further so I might understand it more clearly?


Ms Dalys: Okay. When you are saying this, are you talking about the amendments that were brought in about two weeks ago with respect to the colleges?

Mr Martin: No. Your recommendation this morning here that says, "The appointees of the Lieutenant Governor be selected to represent two constituencies: labour and public." The intent is that it would be the public. You are saying labour and I am asking, do you mean the folks the college is overlooking? If so, then that means the balance is tipped in favour of having certainly many more of the profession in the college than the public. The intent here was to keep that a little closer so that we would have more protection for the consumer.

Ms Dalys: We mentioned in the presentation that we think the elected members to the colleges have quite an opportunity to be neutral because they represent excellence in their professions, they know their professions, they obviously want the public to look upon them favourably. They also recognize where there may be difficulties in the workplace settings, where cost-cutting might mean they are forced to compromise their standards of practice. We seem to see some balance there, but when you bring appointees in from the public, they are going there to determine someone's fate, and if there is no pressure on them to say, "What's the balance?" they can say: "Better safe than sorry. Destroy this person's career because he may have made a mistake."

We do not see where the public representatives, if they represent only the public, which is trying to be protected from the health care worker, assuming it needs this protection -- we do not see a balance there. If your public members are looking at both sides of the problem, and one is, "Is the public being adequately protected from whatever may happen in the health care system?" and, "Is the worker really at fault?" I think that is where you get the balance.

Mr Martin: My reading of it is that if you put five, the profession then gets two shots at being on the board and the numbers then become greater. Anyway, I understand what you are saying.

Mr Beer: This really follows on with the question we just had, but I ask you to really think through what you are proposing here. It seems to me if I am a member of the public and am appointed, part of my responsibility in protecting the public interest is very much in looking at the concerns individual workers may have and in achieving that balance. The whole reason for public participation is to look at the whole broad spectrum of public interest.

It seems to me that what you create here is a further problem. I put it to you that part of the responsibility as a public member is ensuring that the interest of the worker, the professional, whoever it is who is coming before the body, the council or the college, is protected. You seem to juxtapose the interests of labour and the public as though they are two entirely different things.

Ms Casselman: Not at all. We just want to make sure that both sides are equally and fairly represented. That is why we would go to the model of an arbitration where you would have both sides representing, to ensure that the the cost-cutting factors that have affected the way this person can now do his job are presented; or these are the changes this local employer has implemented in this procedure, which may not be under the act, so he can get the job done faster.

We just want to make sure that someone from labour, representing the worker, is presenting the whole case fairly. We are not in any way negating the responsibility or the importance of having the public there at all. It is not a matter of trying to shift the balance. That is why we would see that neutral chair in there. It is a matter of ensuring that all the factors that affect the way a worker is told to do his job by an employer -- because we are talking about an employer situation. Those are the things we want to ensure are there. We do not think a public member would have access to that knowledge or that understanding.

The Chair: I would like to thank you very much for your presentation before the committee this morning. We appreciate your appearing. I say to you and to any members of the public or professions that if at any time over the course of these hearings there is additional information you would like to present, please feel free to do so in writing.


The Chair: I would like to call now the Canadian Institute of Public Health Inspectors (Ontario Branch) and the Association of Supervisors of Public Health Inspectors of Ontario. I ask that you please introduce yourselves. You have 20 minutes for your presentation. I ask that you begin now, and if you would leave a few minutes at the end for questions from committee members, we would appreciate that.

Mr Callanan: Thank you. My name is Paul Callanan and I represent the Canadian Institute of Public Health Inspectors (Ontario Branch). Pamela Cook represents the Association of Supervisors of Public Health Inspectors of Ontario. Klaus Seeger is the president of the of the Canadian Institute of Public Health Inspectors (Ontario Branch).

Thank you for this opportunity to address you on Bill 43. The purpose of our presentation is to affirm the interest of public health inspectors in being designated under the legislation. It is our understanding that from the outset the primary purpose of regulating health care professionals was to advance the public interest by protecting consumers from unqualified, incompetent or unethical health professionals. Public health inspectors are currently unregulated. It is our position that this is not in the best interests of the citizens of Ontario.

Our submission details briefly the role of the public health inspector, education requirements, the need for and benefits of public health inspector registration and registration in other provinces. We will try to be brief and, in the interest of time, we will perhaps skip over a few sections in our brief.

Contemporary preventive health care is a highly complex, multidisciplinary system. Public health inspectors act independently in fulfilling many diverse program responsibilities, and their supervisors must rely on their sound judgement, integrity and competence as they serve the public in a myriad of ways each day. Designation and establishment of a college would assist program directors and the medical officer of health in providing the highest quality of service to the public.

In 1989, a national study of the profession established that the national percentage of public health inspectors were monitoring or advising with respect to a wide variety of environment health program areas, some of which are listed in our presentation.

At appendix A, you will find a generic job profile for a public health inspector, as prepared by the Ontario branch of the Canadian Institute of Public Health Inspectors.

Citzens place their health, and often their financial security, in the hands of the public health inspector when dealing with problems such as contaminated water, unwholesome food, food poisoning investigations and various land development issues. The citizen cannot be expected to know if the advice is correct or if the public health inspector is competent and acting ethically. The difficulty the public has in screening practitioners -- and the same difficulty faces employers -- increasingly imposes an obligation on the part of the profession to ensure that minimum standards of conduct and competence are maintained, but in order to do so effectively, however, professions must be legally mandated.

Subsection 26(1) of Bill 43 provides that:

"No person shall perform a controlled act set out in subsection (2) in the course of providing health care services to an individual unless,

"(a) the person is a member authorized by a health profession act to perform the controlled act."

Subsection 26(2) goes on to list controlled acts, one of which is "communicating to the individual or his or her personal representative a conclusion identifying a disease, disorder or dysfunction as the cause of symptoms." It is part of the job of a public health inspector to "communicate a conclusion identifying a disease, disorder or dysfunction as a cause of symptoms," and it is certainly foreseeable that the conclusion will be relied upon by the client. A few examples include food-borne and water-borne disease investigations, communicable disease follow-ups such as bacterial meningitis, and infections resulting from drinking contaminated well water or swimming in contaminated water.

The public health inspector might indicate, "You had food poisoning caused by salmonella enteritidis," or, in another example: "The lab report indicates your well water is contaminated. Your symptoms result from drinking contaminated water." Yet another example is, "It is possible that you contracted conjunctivitis from swimming in a pool with unchlorinated water." In each of these examples, members of the public relying upon the information provided by the public health inspector are exposed to harm if the information is in error.

In addition, physicians often refer their patients to health units and public health inspectors when they suspect a patient's symptoms may result from environmental exposure. Examples include blood lead level studies, methaemglobinaemia investigations and carbon monoxide exposures. An incomplete investigation in any of these cases poses a significant risk of harm to the patient.


Sanctions for the offence of performing a controlled act contrary to section 26 include fines of up to $25,000, imprisonment or both. Public health inspectors are justifiably concerned about their potential liability. Moreover, since public health inspectors perform controlled acts and since there is a risk of harm resulting from the performance of these acts, public health inspectors should be designated in order to protect the public from harm.

Education requirements: The current requirement to practise as a public health inspector in Canada is certification by the Canadian Institute of Public Health Inspectors. Certification follows university education, an apprenticeship period and successful completion of oral and written examinations. Continuing education is an essential part of the life of a professional person. Once practising, there is no requirement that the public health inspectors in Ontario maintain minimum standards of competence, however. Public health inspectors who received training many years ago may not be adequately familiar with changing technologies and new health issues.

In addition, certified inspectors may re-enter the profession after an absence of many years without adequate retraining. We maintain that the public is not well served by a system that does not ensure that public health inspectors, in addition to other health professionals, are trained to current standards. The field of environmental health is complex and rapidly changing and a requirement for continuing education should be enshrined in the profession. The Canadian institute is not currently mandated to require continuing education for its members, but designation in Bill 43 would allow standards of continuing education to be established by the college.

Ms Cook: Turning to the need for registration, it is our belief that designation of public health inspectors is necessary to protect the public from harm resulting from this conduct. A number of examples of public harm were discovered during preparation of this position paper. In one case, a public health inspector issued a number of certificates of approval to construct private sewage systems which were contrary to requirements of the subdivision agreement and the Environmental Protection Act and regulations. Each applicant was directed to deal with one particular contractor, who allegedly extended financial rewards to the inspector for the business.

In another example, a public health inspector who also owned a private business allegedly used confidential information gained from public duties to arrange contracts for his business. He also allegedly issued approvals contrary to the regulation in return for personal benefits. In another case, a public health inspector routinely coerced a restaurateur to cash cheques, all of which were returned NSF. The restaurant operator permitted a number of NSF cheques, being concerned about reprisals by the public health inspector if he reported the inspector. Unfortunately, there are other examples.

In some of the cases of misconduct we uncovered, the inspectors were dismissed once the malfeasance was brought to the attention of his or her employer. This does not, however, prevent employment as a public health inspector with another agency and the possibility for further public harm.

Without disciplinary authority or procedures, the Canadian Institute of Public Health Inspectors is powerless to control its eligibility for rehire. The public deserves the right to independent investigation of public complaints regarding public health inspectors. The field of environmental health and the role of the public health inspector have changed significantly in recent years, and their certification by the Canadian institute, which is required to practise as a public health inspector in Canada, is insufficient to regulate the conduct and competency of a public health inspector once practising.

The self-regulation envisioned by Bill 43 would allow establishment of a system of continuing education which will ensure that only competent public health inspectors practise in Ontario. In addition to health care consumers, employers in the public health inspection profession would also benefit from designation. Employers would benefit from a system designed to strengthen the abilities and competence of existing staff and ensure the competence of new employees who may have been working in other fields for a number of years.

Formalized standards of practice and a code of ethics would also assist the employer in establishing expectations of employees. If designated, the public health inspection profession would also benefit from a new-found ability to deal effectively with complaints of misconduct or incompetent practitioners who may cause the reputation of the profession to fall into disrepute. The impartial review process contemplated by the legislation would provide for a thorough review of any complaints while at the same time protecting members from frivolous and vexatious allegations. Members would also benefit, through greater employee support for continuing education, to maintain minimum standards of competence.

Turning to registration in other provinces, Bill 43 provides Ontario the opportunity to show leadership by designating public health inspectors, thereby requiring self-regulation with appurtenant public benefits. Other provinces, however, have already granted self-regulation to public health inspectors. By a 1985 amendment to the Society Act of British Columbia, registration was granted to public health inspectors.

A board of registration which is affiliated with, but acts autonomously from, the CIPHI British Columbia branch, is empowered to administer all matters respecting the registration of members, including qualifications for membership, continuing education, conduct of members, ethics and standards of practice and sanctions of misconduct, including suspension or expulsion from the membership. The BC branch has developed standards of professional practice which are outlined in appendix B. Similarly, legislation has already been passed in Alberta, and public health inspectors in Saskatchewan and Quebec have requested registration, and it is presently under consideration in Manitoba, Newfoundland and Atlantic branches of the institute.

The Health Professions Legislation Review criteria were developed to address four basic issues. While the Ontario branch of the CIPHI addressed the four criteria in our 1984 submission to the Health Professions Legislation Review, we found it may be useful to review our position in this paper, and these have been outlined for you in appendix C.

In conclusion, public health inspectors are key players in the increasingly technical world of health care. They are part of a team but do not share the same protection as other members of the team. Consequently, the public cannot be assured that all practitioners they come into contact with have met with the same minimum standards. Designation of public health inspectors is necessary to ensure that the public has access to competent and professional public health inspection services.

Inclusion in the health professions legislation will bring benefits to the following: The public will be better protected through a system designed to ensure the ongoing maintenance of competence of public health inspectors it turns to for advice and guidance; and inclusion in the legislation will ensure the highest standard of service to the public. The employer will benefit from a system designed to strengthen the abilities and competence of public health inspectors. The employer benefits from a system which ensures it a constant supply of well-qualified, competent, professional staff. Further, when problems such as incompetence or unethical behaviour arise, the employer is assisted in dealing with these. Professionals benefit through the support and guidance they receive regarding maintaining their competence and adherence to established professional standards. The profession will benefit from a system which permits unqualified, unethical or unscrupulous practitioners to be suspended, penalized or even barred from practising. The ability to regulate the public health professional helps to protect the health and safety of the public by setting standards for education, training and practice.

Mr Wessenger: Thank you very much for your presentation. Are you aware that under this act there will be a health professions advisory council created to which you can apply for designation?

Ms Cook: We are aware of that.

Ms Haeck: I definitely appreciate the kind of work you do out in the field, which basically is the foundation of my question at the present time. As a public health inspector, in most instances, would a physician be referring a situation to you for investigation, or what is the process by which you would be doing your examinations and investigations?

Mr Callanan: In most cases, programs are specifically mandated under the Health Protection and Promotion Act. Mandatory programs dealing with areas such as food safety, water supply, communicable disease control, etc are very specific to public health inspectors. In other cases physicians, the medical officer of health, associate medical officer of health or, more often, private physicians refer patients to the health unit and public health inspectors for assessment of environmental exposures. I would say that, in comparing the two, the bulk of our work is mandated programs.


Ms Haeck: You are going in to look at restaurants, or you might have received a complaint from the public, but in other instances it is just part of your regular inspection program. When you made the comment about providing a diagnosis or an assessment whereby someone might have food poisoning caused by salmonella -- and I will leave the rest of the description to you -- or when you were saying, "Your symptoms are the result of drinking contaminated water," would that then be under the bulk of the points of those situations where you would be making those examinations? Would somebody be going to you directly, or would the person have been referred to you by his or her doctor?

Mr Callanan: Generally they would contact us directly. Those would be complaints situations such as: "I ate in X restaurant and was sick. Would you please check it out."

Mr J. Wilson: Under current circumstances, has your institute thought of any way of decertifying public health inspectors for misconduct, or some of the cases you brought forward as examples of misconduct, for instance?

Ms Cook: No, we do not.

Mr J. Wilson: None whatsoever?

Ms Cook: Once you are certified, you are certified for life. That is what we are saying; we are unregulated and we would like to be regulated to give us the authority to deal with those types of instances.

Mr J. Wilson: I see in the appendix of BC examples of codes of practice there are no teeth to enforce those.

Ms Cook: Not at this point in time.

Mr Seeger: In addition to that, if I wish, I can leave the field for 10 years, come back in 10 years and find another job within a health unit. There is no mechanism in place right now to find out if I am still up to date. There is nothing to control that and that is where we see being designated as a way of at least requiring that person to become up to date.

Ms Cook: There is presently a 7% national vacancy rate of public health inspectors across the country. We are concerned that more desperate health units will hire inspectors within other fields for longer than five years. There have been many instances, and it is incumbent upon that health department to retrain those people, but we are concerned about their competency starting out. We are not convinced that every health department has taken it upon itself to retrain people properly.

Mr J. Wilson: I notice in the brief that one of the reasons the review board did not feel it was the time to include you in the act was that there were not documented cases of serious harm. Have you made strides in documenting those cases? You mentioned some today.

Ms Cook: Yes, there are several country-wide now that we do have.

Mr J. Wilson: You should have a good crack at it in future.

Mr Hope: I was looking over the job descriptions and I guess there is the certification of public health officers. Do you not work on a broader aspect dealing with environmental acts, water acts or whatever they may be? Are you working on a broader scope? I am not sure where the health professions regulations all come into place. I am trying to get a better understanding of exactly what you are doing. Are you upholding laws, food standards and whatever else? I am really not sure where it comes into play with the health professions.

Mr Callanan: Most of our work is mandatory programs under the Health Protection and Promotion Act, in essence dealing with health hazards: What is a health hazard? What may be a health hazard? Taking action to mitigate or eliminate health hazards. Regulations such as the food premises regulations are enacted under those types of provisions. In our estimation, diagnosing what is a health hazard and what is not a health hazard is where we fit into Bill 43. If we make an error in judgement, for example, during a restaurant inspection, by not condemning food that has been left at room temperature for a period of time that contains pathogenic bacteria and someone gets sick as a result of it, the error in judgement of the public health inspector affects the public.

Mr Hope: So you are not diagnosing the individual; you are diagnosing the product or the area that you are concentrating on. You are not diagnosing the individual as having food poisoning, but you are diagnosing the area you are focusing on.

Mr Callanan: In that particular case, yes. In another example the person would call us and say: "I think I was ill as a result of eating in this restaurant. Would you please investigate?" That is where we would diagnose food poisoning.

Mr Hope: Would they not go to a doctor first to find out why they were ill and the doctor would say, "You have food poisoning," and then call you and say, "Check that restaurant out"?

Mr Callanan: The doctor does not normally call us in a situation like that. Normally the person would call us first. Sometimes they would call their doctor and the doctor would say: "Call the health unit. I have no jurisdiction over restaurants." In cases like that we would take specimens from both the person and food samples from the restaurant, and the diagnosis would be based on the results of those laboratory reports.

Mr Hope: Would that be on the order of a doctor?

The Chair: I am sorry. Is that a serious question to the parliamentary assistant?

Mr Hope: Yes, because I would like to know, if a doctor says it is out of his jurisdiction and refers you to a public health officer, would that be on the order of the doctor?

Mr Wessenger: I will ask staff to answer that.

Ms Bohnen: I think it is unlikely that the physician is actually delegating to the public health inspector the responsibility to diagnose what is wrong with the patient who is complaining of various symptoms, in terms of identifying a disease that is causing this patient's symptoms. That situation described, where somebody calls up and he has various symptoms and the patient suspects it is related to eating particular food in the restaurant, and then the inspector obtains samples from both the patient and the restaurant and then discovers the bacteria and draws a causal connection between the two, is not a diagnosis captured by this legislation.

The Chair: Thank you for your presentation.


The Chair: I now call the Ontario Ambulance Association. Please introduce yourselves. You have 20 minutes for your presentation. We would ask if you would leave a few minutes at the end for questions. Please begin now.

Mr Moir: My name is John Moir, and this is my colleague Rob Wright. We are here to represent the Ontario Ambulance Association.

I will just give you a little bit of background on myself so that you can understand my qualifications and why I am here. I have been a practising paramedic for the last six years. I have been an ambulance officer in Ontario for 14 years. During those years I have been an auxiliary training officer with the Ministry of Health. I have been an examiner for the Ministry of Health. I have also served on the air ambulance program, flying out of Timmins, servicing northern Ontario.

I have also been president of the Canadian Society of Ambulance Personnel, a national professional body for ambulance officers, and the vice-president for the former Association of Casualty Care Personnel, a provincial professional organization. For the last five years I have been publishing a national academic journal called Emergency Pre-Hospital Medicine for my colleagues across the country. I am presently chair of the steering committee for the formation of the Ontario Ambulance Association.

That said, you realize that this process is probably one of endorsing the groups that have already been admitted under the pending Health Disciplines Act. We are here to make an appeal to include the ambulance profession and, if that is not possible, then to present or promote the idea that the process be accelerated, once the legislation is passed, to quickly include this group. I do not feel that by excluding the ambulance profession the public has been served at all. I believe that it has not been in the best interests of the general public at all.

When I think of what my colleagues do in the field, I am dismayed by the fact that we are not included. An ambulance officer -- there would probably be two; generally there always are two -- would be responsible for responding to a scene. It may be a high-speed motor vehicle collision. It may be a medical emergency in the home. If it is a two-car accident, for example, and depending on the location of where this accident or illness may occur, there may be a level of service from a very basic level, such as a volunteer body that has basic first aid, CPR, or right up to what we refer to as advanced life support, which is basically a direct extension of the emergency department to the community.


These individuals are responsible for assessing the scene, assessing safety, providing initial patient care, making provisional diagnoses, treating those patients based on that judgement, co-ordinating with allied health care people and updating the emergency department. The level of care they would provide could be anything from intubation, which is introducing an airway tube into the trachea, to providing intravenous solutions. It may be cardiac medication or basic spinal immobilization.

There are a number of basic medical procedures that can be carried out. Personnel may be under direct supervision of a physician or they may just be providing this level of procedures through standing orders that, if they recognize and diagnose the patient as having such and such, they will go ahead and perform a number of procedures before they contact the base hospital physicians.

With the way the advanced life support programs have been developing in the province over the last five years, there is not one consistent program from one centre to another. The government has been developing a system based on a modular approach, based on community needs as it identifies them. I am quite concerned because I do not believe the communities' needs are being addressed appropriately.

We do not have a recertification process in the province to ensure that the standards are maintained. I am also concerned about the fact that the government provided in the Ambulance Act, a document that covers financial management, vehicles and equipment, very little in the way of training standards. I am concerned that, again, the public's safety and best interests are not being met.

On the idea of recertification, the logic escapes me that funeral directors have to be certified, for example, every five years, and they are dealing with the dead, whereas our profession is still dealing with those who are with us, and we do not have those requirements.

With the advanced life support programs, ambulance officers, in consultation with their base hospital physicians, are pronouncing death in the field, and at that point they are helping the families with the initial grieving process. Since we first made our initial submission to the committee back in 1983, a lot has changed. As you can see, in 1983 we did not have advanced life support. In fact, ambulance services in the province have accelerated greatly since that time.

There are a number of developments that may take place in the future, such as antithrombolitic therapy or interosseous infusion, which is basically sticking an intravenous needle into the bone marrow of a small child to administer solutions. There is another procedure we call transtracheal jet ventilation, which is sticking yet another needle into the windpipe of an individual to help him breathe that way. As well, there is further development of the air ambulance system. All these pending new procedures on the horizon not being included under the Health Disciplines Act, again, I think is a grave omission.

I find the union involvement at present a bit threatening because if the general public have a complaint with regard to the duties of an ambulance officer, they would go to one of, I understand, four investigating officers in the Ministry of Health or emergency health services. Four people to investigate a province of this size is greatly understaffed. It then becomes a disciplinary function, which then, I believe, goes between the union negotiations and management negotiations, and there is no real penalty for the individual.

As an example, if we had certification and were included under the act, similar to the medical profession, the professional body would investigate. If it were deemed that the malpractice had indeed occurred, then you could administer a penalty, and it would take it out of the hands of union involvement and take it out of the hands of direct management involvement. For all those reasons, I just cannot understand why the original submission was not entertained.

In closing, if there is no access to an appeal process to be included before third reading, then I hope the process will greatly accelerate to include this group in the future review.

Mr Hope: Looking at your presentation and looking at Bill 43, under the legislation ambulance attendants are not held back from performing their jobs.

Mr Moir: I am sorry? Say again.

Mr Hope: They are not held back from performing emergency jobs.

Mr Moir: No. Right now what happens is you have two individuals who are basically individual practitioners. There are two people, a crew, that respond to a call. There is no supervision. There is no supervision from any medical organization. In the hospital you have a nurse who is obviously under the health disciplines body. She or he may have great amounts of resources to draw upon. They have the medical community within the hospital; they have laboratory services; they have everything, as well as supervision.

The ambulance officers in the field -- it may take a half-hour from the station to respond to a call -- are the only ones who are responsible for initiating medical treatment and transportation.

Mr Hope: But they have communications with the hospitals and emergency rooms.

Mr Moir: No. In Toronto, for example, we have an advanced life support program. There is direct consultation with the emergency room physician, a physician who is trained in emergency medicine.

In smaller centres the hospital emergency room may not be staffed by an emergency physician. Most likely it would be a general practitioner who may or may not have additional training in emergency procedures. Emergency medicine is, in my mind, a mindset. It is training you to act quickly, giving you a number of resources, certainly the experience of working under that high-pressure environment.

It is, I find, a very unstable environment out there. If it is a motor vehicle accident, there are a number of other associated dangers. If it is in the home, it is just those two ambulance officers and the patient and the patient's family. As you can appreciate, when a patient is brought to the emergency room, he is brought out of that unstable environment. They are under bright lights, the family is usually separated, or loved ones.

You must appreciate when these ambulance officers work in that kind of environment they have the emotional distress of the family, in a sense, pounding on their shoulders. So you not only have to look after the patient or a number of patients, you also have to look after the family members.

Mr Hope: Just under the Ambulance Act and regulations -- and you talk about the physical strains, you talk about the issue of training and certification. Would that then not fall under that act? I am not well versed on the act so that is why I am asking the question. Would you not address those concerns you have raised in your brief under the act?

Mr Moir: First of all, certification was set by the emergency health services, in consultation with other groups, in all fairness. It was not set solely by the people who practise in the field. Those standards initially were set as entry-level certification. If you have been practising in the field for five years there is no mandatory recertification; there is no mandatory continuing medical education where there is an ongoing process.

You can appreciate, if you are responsible for responding to a multicar accident or a paediatric emergency or trauma, if you have not had one of them in several months, how good are you going to be in the sense of responding quickly, making the appropriate decisions, if you do not review that information on a consistent basis? That is why we have trauma centres, where we have physicians who are certified in emergency medicine. That is a specialty. That is all they do. That is why we do not have emergency physicians or trauma centres spread out in every hospital in the province; the volume is so low. So it is hard to maintain skills.


Mr J. Wilson: I have a question for the parliamentary assistant. Could we have explained to the committee why the Health Professions Legislation Review committee did not see fit to recommend this group for registration at this time?

Mr Wessenger: I will ask ministry staff to respond to that.

Ms Bohnen: I believe the reasons were twofold. First, the invasive and other high-risk procedures performed by ambulance personnel are sanctioned medical acts, and the qualifications to perform them and the requirements for direction and supervision are provided by physicians. Second, the Ambulance Act and regulations, imperfect though they may be, provide a structure for regulation, provide a structure to ensure adequate qualification and safety in the provision of ambulance services.

Ms Haeck: In light of the fact that you have the additional Ambulance Act -- and I realize that we are going more and more to the pre-paramedic mode -- is there an inclusion of the paramedics under the Ambulance Act or has that been handled through regulation?

Ms Bohnen: I am not expert in the Ambulance Act, so I cannot really speak to that. What I can say, though, is the high-risk procedures that are performed by ambulance staff, including paramedics, are dealt with in some detail in a document called Sanction to Medical Acts, which is prepared, if I understand it, in consultation with the College of Physicians and Surgeons of Ontario, ambulance authorities and so forth. It sets out what activities may be performed in what circumstances, what kind of linkages have to be maintained with physicians and so forth during their provision.

Mr Moir: The physician body is part of the certification process for advanced life support, no doubt about that. The pilot program that we had was taught by ambulance officers to ambulance officers, with a supervisory overview by physicians. Certainly the one that gave the final endorsement was the physician body. But these acts are taught by my colleagues using mannequins and other educational devices.

But out there, once you are certified as being at a certain level, these acts are carried out by ambulance officers. It is no different from nurses being sanctioned by the college of physicians and surgeons where there are invasive medical acts. When I think my daughter or my own family could be involved in an incident where they would need the same type of high-level care, it concerns me that we do not have the same type of legislation that is available to control the medical profession, the nursing profession. I see the midwives are included. We do emergency childbirth in the field.

So it just confounds me, the fact that we were overlooked initially, because our document really has not changed. The roles have changed. The purpose of this process, I believe, was to take a look at the needs of the public in the future, not in 1983. The process was to take a look at what the needs for the public were 10, 20, 30 years down the road. As you can see, this profession has accelerated. There is still potential to accelerate, not only in more procedures, but certainly to move across the province in greater numbers. Alberta has been very progressive. They moved, and their ambulance profession is legislated in their health disciplines act.

Mr Martin: Just a comment or question on the evolution of delivering health care in our province, certainly in areas like northern Ontario, where the ambulance becomes so much more a critical part of the delivery of health service. In Sault Ste Marie right now, we are looking at a base hospital that depends very much on the ambulance. You are aware that there is provision for you to apply to the advisory council once this piece of action is over so that you might become regulated. After having heard you today, I would very strongly suggest that maybe you do that. Maybe you might want to comment a little bit more on what I have just said re the base hospital phenomenon.

Mr Moir: I am not sure the base hospital process is the best solution. I see that only if there is a professional body in Ontario. I see that the reduction reduces the health care cost because it is being borne by the individual. Certification is borne by the individual. Recertification costs are incurred by the individuals as they recertify. I am really not sure why it was overlooked, other than it must have been something behind the scenes, because it is very important to what we do.

As I said earlier, our purpose in coming here today was a small possibility that a last-minute, last-ditch effort would somehow be squeaked under the wire; then fine, that would really make us happy. We really did not believe that, but we wanted to go on record with our position that we are just dumfounded that our group was not included and to appeal that the process be greatly accelerated for our group, so that once this part of the process is completed, then the ambulance profession in Ontario will be included in the Health Disciplines Act.

The Chair: Thank you very much for your presentation. We appreciate your appearing before the committee. As our hearings progress, if at any time you feel there is additional information that would be helpful to the committee, I encourage you to send us your comments in writing.

Mr Moir: I did bring some copies of our academic journal. I am not sure if it is appropriate, but I thought if members of the committee wanted to look through it, it really does encapsulate where the profession has gone in the last five years that we have been publishing.


The Chair: I now call the Toronto Art Therapy Institute. Introduce yourselves to the committee. I believe the Canadian Art Therapy Association and the Ontario Art Therapy Association are also part of the presentation. You have 20 minutes for your presentation. We would ask that you leave a few minutes at the end for the questions from members of the committee.

Ms Grossman: My name is Gilda Grossman. I am the senior art therapist with the Toronto Art Therapy Institute and president of the Ontario Art Therapy Association. I am connected to the Canadian Art Therapy Association. I am associate editor of their journal.

Ms Merkur: My name is Barbara Merkur. I am an art therapist in private practice. I am also the membership chair of the Ontario Art Therapy Association.

Ms Grossman: In your packets we have included information about the training program at the Toronto Art Therapy Institute. It is the blue brochure and the thick white one that begins, "Dear prospective applicant." The submission from the three organizations is the copy beginning "Submission." Letters of reference from psychiatrists, nurses and executive officers of community agencies: We have three from physicians at Sunnybrook Medical Centre and the head nursing manager at the Wellesley Hospital and three other letters from Bloorview Children's Hospital, from Baycrest Hospital and from the Barbara Schlifer Commemorative Clinic on the work of art therapy, just for your reference.

Art therapy is a well-established method of treatment in the United States. It is about 50 years old there. There are over 50 universities that grant the master's degree. Five now have granted PhD in art therapy. Their professional association numbers in the thousands.

It is achieving recognition in Canada and Ontario. Graduates of art therapy programs are being employed now in hospitals, social service agencies, schools, community centres, mental health facilities.


When the initial survey was done years ago to decide whether art therapists could be included in the act, the team could not predict the growth of the profession, the responsiveness of other mental health professionals to the use of art therapy. At that point, it was decided that we were not going to be included in the act, in that we could not regulate ourselves. I can understand that then, but since that time, many things have changed. I think we are at a point where we can regulate ourselves, and in fact, members of the national organization are able to have liability insurance, and do so not only as members of a team but as private practitioners.

This legislation would seriously impede the use of art therapy as a highly beneficial and cost-saving intervention. Our experience is that the length of treatment time can be significantly reduced through the use of art therapy as part of a team approach and part of treatment. Populations with special needs, such as delinquent youth, children who have been sexually abused, children and adults with chronic physical and emotional needs, respond well to art therapy in a way that they cannot respond to verbal therapy.

The non-verbal aspect of art therapy permits freer expression of issues which are both past as well as recent ones which are difficult to impossible to access verbally. We have letters at our institute from women who were sexually abused or victims of incest who have commented that without this intervention, they could not hope for the healing that has taken place.

Art therapists have worked at many hospitals in Toronto through the province -- Bloorview Children's Hospital, the Hospital for Sick Children, Doctors Hospital, Toronto General Hospital, Sunnybrook Medical Centre, St Michael's Hospital, Mount Sinai, Thistletown Regional Centre, Humber Memorial Hospital, Whitby Psychiatric Centre, Wellesley Hospital, the Clarke Institute of Psychiatry, Penetanguishene General Hospital and other settings -- where information elicited through an art therapist on the team contributes to a refinement of the diagnosis and helps with treatment planning.

The contemplated legislation would limit our effect in this and freedom to work with clients. This would be counterproductive to the purpose and meaning of therapy. In spite of having received specialized training in education, in the theory and practice of art therapy, there would be considerable apprehension about the possibility of being held criminally responsible by encouraging the patient to share his or her suffering with a professional art therapist, and that is the chief healing.

In terms of professional standards, the institute was established in 1968. We are the oldest training program in Canada. We were established in 1968 by Dr Martin Fischer, who has used art therapy -- he is a psychiatrist -- in this province since 1944 at the old Lakeshore hospital. He has been an outstanding pioneer in the field of mental health. In 1989, the Ontario Medical Association awarded him the Glen Sawyer award for his contribution to the community. He is also the founder and first president of the Ontario Group Therapy Association and the Canadian Art Therapy Association. He is a life fellow of the American Psychiatric Association and the Canadian Psychiatric Association, a fellow of the American Group Psychotherapy Association. He is internationally known for his work and he has been invited to speak in Canada, the United States, Holland, Israel, Norway and South Africa.

Both Barbara and myself are graduates of the Toronto Art Therapy Institute. Our institute follows guidelines established for training by the Canadian Art Therapy Association and currently, as members of the executive of the Ontario Art Therapy Association, we have been working actively to promote and maintain standards on a provincial level.

Our training is extensive as art therapists. Just to summarize it for you, we have to undergo at the Toronto Art Therapy Institute 530 hours of class time -- this is after a BA -- 700 hours of internship time and, in addition, all of us must go through 80 hours of personal psychotherapy with a qualified psychotherapist in the community. These again are guidelines set by the Canadian Art Therapy Association.

Our recommendations is, we would like you to include us in the legislation and to promote and facilitate the use and contribution of art therapy to the spectrum of available therapies in the province. The integrity of the profession of art therapy is safeguarded by guidelines utilized for the establishment of training and practice in Ontario which conform to standards established by the Canadian Art Therapy Association. We are the oldest art therapy association in Canada. The Canadian association publishes a scholarly journal biannually and has held an annual conference for 12 years, as well as regional conferences.

Mr Beer: Thank you very much for your presentation. I think what is particularly interesting here is seeing, while in your terms a reasonably old profession, I think for a lot of laypeople one we are not as familiar with.

In art therapy, and music therapy, which increasingly is being used as well, your sense is that in terms of your own organization, you would be ready today to become self-regulated in the same vein as the other organizations.

One of the difficulties, you will appreciate, with the legislation is that it has taken a long to time to get to this point. There is a provision where there will be an advisory council, which is going to look at, for example, the naturopath question. Is that something that would be acceptable as well, if this was put to the new council? They are going to be looking new bodies before we do.

Ms Grossman: Yes, it would. I think that sometimes committees are not aware of all the trends that can exist, and if you learn from the United States, if it takes off in the same way, which I am sure it will, some of that will be part of typical treatment. So yes, very much so.

Mr Beer: At the present time, in your work, would it be fair to say that you always perform your work as part of the team or directly with a psychiatrist or psychologist?

Ms Grossman: The majority, but there is always the percentage of professionals. Just as in social work or in psychology, once they attain a certain level of expertise, they do begin private practice.

Mr Beer: And you may practise privately without other restrictions?

Ms Grossman: You have to be part of a registry. Part of it is -- and this is something that I think is important -- if the standards correspond to the national body, you can call yourself a registered Canadian art therapist or a registered provincial art therapist. Then you would be part of that registry, and you would have had to complete X years of training and X years out in the field. That is why we included that paragraph in terms of our standards that we wanted to see go on record as ones that should be established.

Mr Hope: Just as you are looking for self-regulation, and in the meantime, as Mr Beer has indicated, the advisory council -- taking that away, if the legislation gets passed, would there be jeopardy of you performing your job? I have been listening to some of the conversation. You work in co-operation with the psychiatrist, which is usually by reference. Usually, a psychiatrist cannot communicate with the individual or get the feeling out of the individual, so then it is referred to you, where there is a way of expression. That will still happen, will it not, though, under the regulations, because you will have the ability to communicate with the psychiatrist who has been examining the individual?

Ms Grossman: I think it will curtail your interaction with the client or the patient and he or she will pick up on it. If the legislation goes through -- I think it is in the paragraph -- anything you say is going to be heard and might be commented on in a certain way. It is going to curtail your freedom to interact.

Mr Hope: Yes, but the recommendations I guess then that the unregulated practitioners are making to the issue of communication -- if we took a look at that communication, would that then help?

Ms Grossman: I guess what we want to go for is really the optimum.

Mr Hope: Yes, I know.

Ms Grossman: That is what we would like to go for.

Mr Martin: I have come in contact with some of the work you do through some work I did with teenagers and drug abuse and coming from a dysfunctional family and was actually quite impressed. I am impressed this morning by your reiteration of the qualifications, the preparation that you go through, and particularly the 80 hours of personal psychotherapy. You are very together people.

The bottom line for this legislation to me seems to be the protection of the public. You might elaborate on maybe how this particular therapy would be in any way threatening to the public.

Ms Grossman: Art therapy?

Mr Martin: Yes.

Ms Grossman: In the hands of a trained professional, it would not be of harm to the public.

Mr Martin: But there is potential?

Ms Grossman: Just as in anybody's hands, it is important that it is a trained art therapist who is administering art therapy. If it is in the hands of a trained art therapist, then the public cannot be harmed, as far as I am concerned, because safeguards have been built in. We have checks and balances in terms of our own work.

The Chair: Thank you very much for your presentation. We appreciate your appearing before the committee today.



The Chair: Next is the Ontario Society of Clinical Chemists. You have 20 minutes for your presentation and we ask if you would leave a few minutes at the end for questions. Please begin your presentation now.

Dr Lustig: Yes, we will. We represent the Ontario Society of Clinical Chemists, four of us -- Dr Luxton, Dr Ambus, myself, Viliam Lustig, and Dr Graham Ellis -- and we will have two presenters. The first presenter will be Dr Ambus, who will illuminate the committee on what the clinical biochemist does in his daily work.

Dr Ambus: Thank you for the opportunity to give you a glimpse about clinical biochemistry.

First, I would like to tell you how one becomes a clinical biochemist. It takes about 12 years of education after high school to become a qualified clinical biochemist, in the following order. First you get a bachelor's degree, then a PhD in a basic science, such as biochemistry or physiology, or you might obtain an MD. Then you go for a diploma in clinical biochemistry at a university; this takes two years. This is followed by a year's working and passing the fellowship examinations of the Canadian Academy of Clinical Biochemistry so you have the FCACB.

What does a clinical biochemist do? A biochemist may be the appointed laboratory director and report to hospital administration, or the biochemist may report to a director, such as a pathologist or a medical biochemist, and these people are in the regulated health professions. In turn, registered technologists who actually perform the tests report to the clinical biochemist. This group also is in the regulated health professions. So there we are, and we are appealing also to be one of the regulated professions.

The clinical biochemist is responsible for establishing the laboratory standards of practice and directing the clinical laboratory in the areas of biochemistry, special tests, urinalysis, toxicology, and he or she serves as a clinical consultant to the medical staff on matters of clinical biochemistry.

In these times of economic constraints, I feel that the role of the clinical biochemist in choosing the most economically and technically appropriate instrumentation for testing of the specimen and a computerization system for reporting back the results to the physician and personally interfacing with the medical staff and the rest of the hospital just cannot be overemphasized.

I have given some examples of typical situations a clinical biochemist meets on a daily basis.

In the first example, a patient in emergency is suspected to have a heart attack. The physician orders some lab tests and telephones the clinical biochemist for an interpretation of the test results before confirming the diagnosis.

In another example, a physician has received a lab report from biochemistry and is not sure how to interpret the results. In this case, it is an elevated blood level of an enzyme called alkaline phosphatase, and the questions are: Is this abnormal for an adolescent patient; could it indicate cancer; could it indicate liver disease?

In another example, a physician suspects that his patient has taken an overdose of acetaminophen, or Tylenol. The blood drug level is taken and the physician then calls to ask how to interpret the results from the laboratory in relation to the suspected time of poisoning in the patient.

In another example, a physician is concerned about detecting diabetes in a pregnant patient and calls to ask at how many weeks into the pregnancy the special glucose challenge test should be done and how to interpret that.

In another case, a physician has ordered a lipoprotein electrophoresis test. This is an expensive test that is usually sent to another lab, on a patient suspected to have high blood cholesterol. In this case, the clinical biochemist communicates to the physician that several simpler lab tests can be done in-house in a more cost-effective way and suggests the change.

Finally, a serum protein electrophoresis test has revealed that a patient may have a form of cancer. The clinical biochemist orders a follow-up immunoelectrophoresis test to rule out or to confirm the presence of the disease.

These are a few glimpses, and Dr Lustig will continue the presentation.

Dr Lustig: I wish to thank the committee for the opportunity to express the views of the Ontario Society of Clinical Chemists on Bill 43; As a prelude to my remarks, I wish to assure you that the OSCC is supportive of the intent and spirit of this legislation, namely, to protect the public from harm.

By way of introduction for members of the committee, the OSCC, short for the Ontario Society of Clinical Chemists, represents the interests of clinical biochemists in Ontario, most of whom hold either a PhD or an MD degree or, in some cases, both. In the clinical setting, one of our major roles is to interpret a variety of laboratory results and convey this information and our recommendations to the physician, who relies on our input in deciding the course of treatment. We are one of the health professions that applied to be regulated under the Health Professions Legislation Review and were not accepted, although we believe we came very close to being included at the first round. We therefore have maintained an ongoing and positive dialogue with the Ministry of Health, which we intend to continue in the future.

It is our understanding that Bill 43 is still subject to amendment at this stage in the legislative process, and therefore today's presentation will focus on two aspect. First, we would like to ask the committee to amend bill 43 so as to include the OSCC in the family of the regulated professions to facilitate our working effectively in concert with the other health professions. Second, we wish to express our concern regarding section 30, dealing with the restriction of the use of the title "doctor."

With regard to the first point, the reasons that prompt us to seek self-regulation are based on the sincere desire of our membership to protect the public from unqualified practitioners. In our role of clinical biochemists, we believe that we present a potential risk to the public through five of our important functions summarized below:

1. Clinical biochemists establish normal values for tests, against which all patient results are interpreted.

2. Through the interpretation of test results, clinical biochemists advise physicians about treatment decisions which could well pose a risk to the patient.

3. Clinical biochemists serve on utilization committees which determine which of the tests should or should not be ordered for specific categories of patients.

4. Clinical biochemists are directly responsible for quality assurance in the clinical biochemistry laboratory.

5. Clinical biochemists take an active role in the laboratory proficiency testing program, LPTP, of the Ontario Medical Association. LPTP strongly influences the standards of practice of laboratory medicine throughout the province of Ontario.

The omission of the clinical biochemists from Bill 43 poses other potential serious risks to the public in that anyone could call herself or himself a clinical biochemist and practice without being qualified. This would lead to (a) clinical biochemistry tests being interpreted improperly; (b) physicians receiving unsuitable advice upon which to make patient care decisions, and (c) inappropriate utilization of scarce health care resources.

Furthermore, there is a clear inconsistency in Bill 43 in that the technologists who perform the clinical biochemistry tests and the physicians who rely on our interpretation of the results of these tests for patient care are included, while we, the clinical biochemists, who obviously are an integral part of the continuum of health care provided by laboratory medicine, are not included.


A severe shortage of clinical biochemists is anticipated in the next decade. Even with the Ministry of Health's financial support for post-doctoral students in clinical chemistry, the non-regulation of the profession may deter some promising candidates from becoming clinical biochemists. This would deprive the public of the high standard of clinical biochemistry services which it deserves.

Our second concern with Bill 43 is focused upon section 30 and its restriction on the use of the title "doctor." As clinical biochemists, we interpret a wide variety of laboratory results. Our interpretations are often relied on by physicians in making patient care decisions. These interpretations are an integral component of the health care continuum. Therefore, we as clinical biochemists fall within the scope of "providing or offering to provide, in Ontario, health care to individuals" as stated in section 30. It follows that we could then be subject to the restrictions in the use of the title "doctor" as currently drafted in section 30.

Under clause 39(1)(d) of Bill 43, the minister may make regulations allowing the use of the title "doctor." Therefore, the OSCC strongly urges the committee to exempt by statute or regulation OSCC members who hold a PhD degree from a recognized university from any restriction regarding the use of the title "doctor."

In summary, the OSCC asks that Bill 43 and any regulations thereunder be amended such that (1) the profession of clinical biochemistry should be included in the regulated professions; (2) clinical biochemists should be permitted to continue to use the title "doctor."

Should your committee, for whatever reasons, be unable to include us at this time, we will seek inclusion by making the necessary submissions to the Health Professions Regulatory Advisory Council as expeditiously as possible.

Mr J. Wilson: Thank you for your presentation. It was very informative. On the question of the use of the title "doctor," I have a great deal of sympathy for PhDs and would like them to continue using the term, although under the current Health Disciplines Act there really is a prohibition against using the term now. In the hospital setting, are you commonly referred to by your colleagues on the medical staff as Dr Such-and-such?

Dr Lustig: Yes, without fail.

Mr J. Wilson: Second, on the regulations, actually this committee will not see the regulations. They are established by the advisory council, the minister and will be adopted by cabinet, so we will have to clear up the area of title protection in this particular bill.

Ms Haeck: Following up on what Mr Wilson has presented, how much patient contact do you actually have?

Dr Lustig: Generally speaking, not very much patient contact. It is mainly physician contact. Physicians are our prime customers, if you wish.

Ms Haeck: Obviously, in the eight years this piece of legislation has been part of the long-standing agenda of the various governments, the case has been made that the patient or the consumer of health care services can be confused by the use of the word "doctor" by the wide variety of specialties he may come in contact with. In reality, as far as the academic designation is concerned, I believe it is also the feeling of the Ministry of Health that you are not prevented from calling yourselves PhDs or some sort of designation in that way.

Dr Lustig: That is fine. All we want is to be specifically included under clause 39(1)(d). That is what we in essence are saying.

Ms Haeck: But you are not really excluded here. As part of your academic qualifications you have PhD attached to --

Dr Lustig: It is certainly a grey zone. We would like to have a clearer image. Therefore, we continue to ask to be specifically included those with a PhD from a recognized university, so of course that does not apply to MD colleagues who are entitled to do so.

Ms Haeck: I would like to ask one more question, if I may, which relates to Dr Ambus's wonderful list of the academic qualifications you do have. Does that form the normal job description, the criteria under which you would each be selected for your job?

Dr Ambus: If you are a fellow in the Canadian Academy of Clinical Biochemistry, yes, these are your qualifications.

Dr Lustig: If I may comment, 98% at least have these qualifications and maybe some older people, two, three or four, who have been grandfathered have their MSc, but this no longer occurs now. You must have a PhD.

Mr Beer: If I could pose a question to the parliamentary assistant, in the organizations that are being self-regulated, we include the radiation technologists and the medical laboratory technologists. I am wondering in the reasoning of the review why it was found this organization should not be self-regulated. I do not claim to understand exactly how all of these groups work, but there does seem to be a certain commonality around doing tests and investigations in a clinical or laboratory setting. I wondered if we could ask to have that clarified.

Mr Wessenger: I will have counsel reply to that question.

Ms Bohnen: The primary reason the review had for not recommending this profession for self-regulation was its numbers. It is a very small group, certainly relative to the number of medical laboratory technologists. As they have pointed out, many of their members also have MDs, and if they are licensed by the College of Physicians and Surgeons, they are regulated in that way.

Dr Lustig: May I just comment on these remarks?

The Chair: Mr Beer has a question.

Mr Beer: My question will allow you to comment. In light of that, could you underline why you believe, as an organization, you need a specific regulatory body instead of falling essentially under the College of Physicians and Surgeons?

Dr Lustig: First, I would say that no more than 10% of our members are medically qualified practitioners. Second, I do not think the numbers are particularly relevant. One ought to be regulated to protect the public, not because one is a big group or a very big group. I think we present a significant risk to the public. We make major decisions and we are listened to by our clinical colleagues.

Mr Beer: Just for the record, roughly how many members do you have in your association?

Dr Lustig: Right now, 183 in Ontario, roughly 500 in Canada.

Mr Martin: From some tours I have had of various medical centres, it seems to be that a lot of computers are used now to do certain work in this area. You could respond to how that impacts on what you do and how that also perhaps produces a risk to the public.

Dr Lustig: We are the people who choose a computer system. We are intimately involved with the system. Of course, computers will make health care more efficient, but they are just machines that need to be guided. Again, it is a clinical biochemist who very often sets the standards as to what these computers should be doing.

The Chair: Thank you for your presentation. We appreciate your coming before the committee today.



The Chair: Next is the College of Doctoral Scientists in Laboratory Medicine of Ontario.

Dr Groves: I am Dr David Groves. I am a microbiologist at St Joseph's Hospital in Hamilton and I will make the presentation. Dr Max Chernesky, a virologist, and Dr Jim Mahony, also a virologist at the same institution, are here as resources for me. We are appearing before you on behalf of an organization which represents the Doctoral Scientists in Laboratory Medicine of Ontario. It is a little bit of a long name but it covers quite a broad area. We would like to increase your awareness of the vital and significant role these individuals play in health care in Ontario, that their regulation may be formalized under the Regulated Health Professions Act with which we are concerned today.

This is an extension of the previous excellent presentation by the clinical chemists, and I will explain that as I go along -- an extension in concept, not of their presentation.

Every hospital in Ontario of any significant size has a laboratory to assist in the diagnosis and management of disease, and in many cases doctoral scientists are heavily involved in the performance of these laboratories. They often set policies for the processing of specimens, interpretation of results, and maintenance of quality assurance, with emphasis on the word "policies." They are especially equipped to apply new and more basic scientific technology to the analysis of patients' specimens.

Doctoral scientists hold PhDs or DSc degrees, usually achieved by working in medically oriented problems, and have had additional training in clinical diagnosis. In my case, I have a PhD from the University of British Columbia in basic bacteriology and molecular biology. During my post-doctoral training in the University of Rochester in Rochester, New York, I took a training course that converted me into a clinical microbiologist capable of directing a laboratory in the United States. I have subsequently, by examination, received a diplomate of the American Board of Medical Microbiology and I am a specialist in clinical microbiology as certified by the Canadian College of Microbiologists, which is an equivalent certifying organization.

In Hamilton, as in other centres in Ontario, about one third, and in fact in several disciplines up to one half, of the laboratory professionals are laboratory scientists. The specialty areas include, but are not limited to, clinical chemistry, microbiology, haematology, genetics, pathology, and immunology. Several of these groups have established self-regulation mechanisms which endeavour to ensure, on a voluntary basis, that the public good is not compromised by a lowering of standards, either in training or in practice. The voluntary accreditation of training programs and voluntary certification programs are in place nationally due to the efforts of the Canadian Academy of Clinical Chemists and the Canadian College of Microbiologists, and other groups are partially self-regulated or in the process of developing such regulation mechanisms. Maintenance of certification through continuing education is a major requirement for the certifying agencies. In my case, I have to submit for recertification a record of my continuing education every three years to the American board and every five years to the Canadian College of Microbiologists.

In spite of these voluntary efforts, and because of the multiple disciplines involved, there still is significant potential for delivery of substandard care to the patients through either inappropriate training or certification or getting the wrong person in the right job. There are over 300 doctoral scientists in hospital public health and private laboratories in Ontario who are responsible for the processing of clinical specimens. In a survey of these individuals across all disciplines, over 150 responded, all favourably, to the concept of forming a multidisciplinary college of clinical and laboratory scientists in Ontario. Incorporation of such a college has been initiated and the structure of the college is as outlined in our brief. It is specifically designed to conform to the outline of structures of colleges in the initial draft legislation.

This organization is intended to initiate specific self-regulation for Ontario on a voluntary basis if necessary. Inclusion of this college in Bill 43 will formalize and strengthen this mechanism of self-regulation. Our objective in making this presentation to your committee is to have doctoral scientists in lab medicine included under the Regulated Health Professions Act through an amendment and to obtain a separate amendment relating to our profession. This will formalize the self-regulation of our profession in Ontario, thereby ensuring the safety of the public.

Mr Beer: Your presentation and the one just before it -- it seems that every day we find there is yet a new area that, as laypeople, we are not necessarily as aware of as perhaps we ought to be. We noted that there are people who are working in laboratories who are being registered doing different kinds of things. This may be an absurd question, but is there some sense that you yourselves, the clinical chemists, perhaps some others -- if it appears part of the problem is around, or was seen to be around, numbers but not necessarily around function, is there some point in looking at bringing together people who are engaged in a clinical setting with a number of different backgrounds and approaching the problem that way? I am thinking specifically of what you do and what the presenters before you did.

Dr Groves: In actual fact, this presentation is intended to include the clinical chemists, clinical haematologists and other disciplines. We happen to be microbiologists.

Mr Beer: So in fact what you are looking at here really is covering all of those who are working within some kind of laboratory clinical setting.

Dr Groves: Those people who hold a PhD or a DSc, who have clinically specific training and who are working in the clinical environment, a laboratory.

Dr Chernesky: If I could just follow up on that, our initial discussions began two years ago to formulate this college and our discussions included all six disciplines Dr Groves has talked about in Hamilton and subsequently Toronto. We have spoken with our colleagues from London through to Kingston. The idea of this is to form a college of all doctoral scientists covering all disciplines, including the clinical chemists, and we think that is a rational approach.

Mr J. Wilson: Had you appeared before the legislative review committee? It sounds like you are well on your way to meeting the requirements. About how far along in the process are you in meeting all the requirements of the legislative review committee?

Dr Groves: We have not appeared before them. I am afraid I do not know.

Mr J. Wilson: When I read the table of contents on your charter, it seems to conform very well with the legislation.

Dr Groves: We specifically designed it. We took the original document and we specifically adapted it for this purpose. We would like very much to make it as easy as possible to meet those requirements and get in this time around, as opposed to in a later process.

Mr J. Wilson: It is a decision the minister herself would have to take and bring before this committee, the government itself would have to take, but there is the advisory council which would give you another kick at the can once it gets going, I think, the way I understand the process.

Dr Mahony: Thank you very much. One of the reasons we have not been in at a previous time is because that is a relatively new concept. We really only started a couple of years ago, but I think all of the representatives of the disciplines in Hamilton, where it all started, feel quite strongly that the major objective is to form a college. Whether it gets included in the legislation or not is another matter, but we do feel quite strongly that the college will regulate. We can self-regulate ourselves to the point that we can be responsible enough to make sure the public is protected, because these people are doing major things within laboratories, have patient contact and make fairly important recommendations along the way. I think this group of people really needs to be regulated one way or another.

Mr Frankford: Have you given any thought to your relationship with medical lab technologists, and could you see any model or way you could include them as well?

Dr Groves: The roles of the technologist and of the doctoral scientist really are significantly different. The doctoral scientists are working at the level of interaction with colleagues. For instance, I am on the special professional staff of the hospital where I work, which is a subsection of the medical staff of the hospital. We are involved in direct discussions about management of patients. We are involved in deciding what proportion of the reports will actually get into the patients' charts. We make policy decisions concerning the management of information that comes from the laboratory. The technologists, to a large extent, carry out those policy decisions. That is a big difference in role.

In actual fact, the technologists are such a large organization and have such specific activities and specific interests that the regulation of doctoral scientists would probably be swamped in the larger body. I believe the technologists were not very interested in having us have anything to do with them when they were originally generating their proposal. There are a number of reasons, historical or whatever, that it probably would not fly.

Ms Haeck: I was going to ask how much patient contact you really do have. I would assume, and obviously you are in a position of correcting me, that you do not perform the actual pricking of my finger to do a blood test or some of these other things; it is someone else who would be doing that.

Dr Mahony: I would probably be the best person to respond to that because I am the director of a laboratory. As far as patient contact is concerned, I probably see three or four patients a week in my office. These are specifically recommended to me because of my specialty as a virologist and my experience in being able to assess a clinical situation, look at a rash and try to make a recommendation as to the type of tests and specimens that ought to be taken. There is that arm of the patient contact.

Most of my time, however, is used up in consulting with physicians as to what they ought to be doing with their patients as far as management of the patients is concerned and as far as specimen collection and diagnosis are concerned. Virology specifically is such a rapidly moving field that most physicians have a very difficult time keeping up with that particular cutting edge of microbiology, and so it takes a specialist like me, who can spend the time, to keep them abreast.

Ms Haeck: Are you doing some research as well?

Dr Mahony: Yes, we have an active research component. We are particularly interested in my laboratory in the rapid diagnosis of infectious diseases, so we are actively pursuing that type of activity. Because of my previous training, I am able to take those basic concepts in microbiology and apply them to the patient as far as diagnosis is concerned.

Ms Haeck: You all have the same basic educational standards as well.

Dr Mahony: Yes.

Ms Haeck: It runs consistently through, even with the previous presenters, that really, in order to fulfil your job function, you have to meet certain academic standards.

Dr Groves: Just one quick additional comment on that: Another area that we are discussing as far as its speciality is concerned is genetics. There are a number of PhD-level or DSc-level people who are working in genetics diagnostic labs who are also involved in direct patient contact and counselling of patients as a result of the laboratory results, and so they do have patient contact as a major component of their particular activity.

The Chair: Thank you very much for your presentation. The committee appreciates hearing from you today. As I said before, if there is any additional information that you think would be helpful to the committee members during the course of these hearings, please feel free to communicate in writing via the clerk.

The committee stands adjourned until 2 o'clock this afternoon.

The committee recessed at 1155.


The committee resumed at 1401.

The Chair: I have a request from the parliamentary assistant to add something on the record.

Mr Wessenger: Yes, I would like to have staff make a comment with respect to ambulance attendants.

Ms Bohnen: I would like to give you one more piece of information about the review's reasons for not recommending that ambulance attendants be a self-regulating profession, which is that the review was aware that the Ministry of Health was planning to conduct a review of ambulance services. In fact, there is currently a review going on of not just ambulance but emergency health services which is intended to be completed in 1991. The review felt that kind of review would address the issues being raised by the ambulance attendants.

Mr Hope: So there is always a possibility they may be self-regulated, depending on the outcome of the review.

Ms Bohnen: I think the review was mindful of the fact that there are different mechanisms whereby issues raised by the occupational group can be addressed. One of them is self-regulation under this framework. Another is often a different kind of regulation under a specific statute, such as the Ambulance Act, for these people. The review knew they had issues, but felt they were best addressed within the framework of the review of emergency services and ambulance services, rather than making the determination at that point that they should be a self-regulating profession. Certainly the ministry has no idea what is going to come out of the current review of emergency services, but in any event the advisory council will be there for the ambulance attendants' association to make its application in the future.


The Chair: I now call Mission Services of Hamilton. You have 20 minutes for your presentation, and if you would leave a few minutes at the end of your presentation for questions from committee members, we would appreciate that.

Mr Buckley: My name is Mike Buckley. I am the director of the Marty Karl Centre for Personal Development, which is one of the four service divisions of Mission Services of Hamilton Inc. With me is Kelvin Honsinger, our newly appointed executive director.

Mission Services of Hamilton Inc, and we as the mission's representatives, would like to thank the standing committee on social development for this opportunity to speak today regarding the effect that Bill 43, the Regulated Health Professions Act, would have on our various services if it were passed into law in its present form.

Mission Services of Hamilton is a non-denominational, evangelical Christian mission that has been active in Hamilton for over 35 years. We currently operate four front-line service divisions: Inasmuch Home for Women in Crisis, Ontario's largest and longest-running shelter for abused women; the Men's Residence and Rehabilitation Centre, a men's hostel providing crisis care and drug and alcohol rehabilitation; our Family Help Centre, which operates several stores providing used clothing, furniture and appliances at affordable prices or as a free gift to those with a demonstrated need, a crisis food bank and a Christmas hamper program; and the Marty Karl Centre for Personal Development, which provides vocational assessments, training, case management and a supported employment program for adults with various physical, intellectual and psychiatric disabilities.

Three of these four programs' services are mandated by existing agreements with the region of Hamilton-Wentworth and the Ontario Ministry of Community and Social Services to provide assessment and counselling services. In the course of providing these services, we routinely deal with the disease of alcoholism and the effects of physical, mental and sexual abuse which include, among others, eating disorders and sexual dysfunctions. When dealing with disabled adults, we provide our assessment conclusions regarding a given person's functioning -- or dysfunctional aspects -- in writing.

These examples name only a few instances out of many possible ways in which we communicate to the individuals in our care a conclusion identifying a disease, disorder or dysfunction as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual will rely on the conclusion. We therefore have been justifiably concerned that paragraph 26(2)1 of Bill 43, the so-called "diagnosis" clause, would create a situation where the activities of our staff, functioning within the limits of their professional training, would be considered unlawful. This, according to section 36, would cause them, their supervisors and our volunteer board members to be open to charges carrying a penalty of up to six months in jail and/or a fine of up to $25,000 in each instance.

We have not been convinced by statements made by the members of this and the previous government that we are unlikely to face these risks. Although the chairperson of this committee, Elinor Caplan, in her previous role as Minister of Health stated that it was not the intent of this legislation to attack social workers, pastors and counsellors, among others, who were functioning within the level of their professional training, we are well aware that once legislation is passed into law it is the courts who interpret the law and the officers of various police forces who are charged with the duty of enforcing the law.

It would be irresponsible of this Legislative Assembly to pass any bill that has ambiguous terminology or that relies on an unstated and unwritten "intent" to guide those who must work out the practical aspects of applying legislation to cases. Therefore, if the terminology of this bill is permissive and would allow for an unintended application whereby Mission Services of Hamilton, similar agencies and unregulated professionals might face prosecution, the wording should be changed to protect innocent parties from the unintended effects.

We are aware that the current Minister of Health, Frances Lankin, has said to the Legislature that she is not convinced the diagnosis clause would cause problems for the unregulated practitioner. Therefore, we have sought legal opinion to clear up any uncertainty she, this committee or the Legislative Assembly charged with the duty of passing this legislation may have.

In a legal opinion given to Mission Services of Hamilton by George Gresko of the firm Milligan, Gresko, Charuk and Rogers, we have had our worst fears confirmed. It reads in part, "The work presently carried on by the personnel at the mission fall directly within the scope of section 26(2)1 of the act and accordingly, the present `counselling' function carried on at the mission would, in all likelihood be rendered unlawful."

There are in Ontario uncounted numbers of crisis centres, hostels, shelters and other mental health services and programs that rely heavily on the services of professional counsellors and staff who are not eligible to become members of a college of a designated health profession within the meaning of this bill, nor able to be supervised by a member who could delegate such authority, and who are providing counselling and assessment services which this legislation would undoubtedly throw into a similar lot with Mission Services of Hamilton. We would therefore urge this committee to take a closer look at this bill.


If it could be shown that this legislation itself is in contravention of its own stated purpose, would this committee be prepared to make changes to this bill? According to section 3 of Bill 43, it is the duty of the Minister of Health and the purpose of this legislation "to ensure that the health professions are regulated and co-ordinated in the public interest...and that individuals have access to services provided by the health professions of their choice." We believe we can show that the diagnosis clause, paragraph 26(2)1, would not provide for regulating and co-ordinating the health professions in the public interest and that the end result of this legislation would be to decrease the access individuals have to the health professions of their choice.

We first raise the question of whether "diagnosis" as an activity, however described, is rightly the sole domain of the medical profession. It would appear not, in that social workers and licensed professional counsellors in many jurisdictions in the United States have been granted the right not only to diagnose, but to do third-party billing to insurance companies based on their diagnoses. For that purpose, they use the Diagnostic and Statistical Manual of mental disorders, referred to in its current edition as the DSM-III-R.

It is interesting to note that the DSM came into existence as a companion to the International Classification of Diseases, which is the medical doctor's standard for diagnosis, so that mental health professionals who did not have medical training would be able to provide diagnostic services. It therefore seems ludicrous, with such an extensive diagnostic tool as the DSM-III-R intended for non-medical use, and the clear precedent set elsewhere, to attempt to claim that diagnosis as a whole is only and solely the privilege of the health professions.

Second, if, as seems apparent from the legal opinion we have obtained, social workers, psychotherapists, counsellors and other mental health professionals are to be forced to run the risk of legal prosecution or cease to provide their services which necessarily entail "diagnosis" as described under the act, there are two likely results. Either these services would have to be provided by medical doctors, psychiatrists and psychologists or the individuals under their supervision, or eventually these and other professions would have to be licensed under this or other legislation to carry out these much-needed activities.

In the first case, Ontario is already having a difficult time with the ever-increasing costs incurred through the Ontario health insurance plan, OHIP. With the increased duties for these high-priced medical professionals, it is clear we can look forward to increased costs. Currently there are many more unregulated mental health practitioners than there are psychologists and psychiatrists. Therefore, there would also necessarily be reduced access to mental health services.

In the second case, there is some doubt whether this legislation even allows for an exemption for professionals licensed under separate legislation. Section 28 of Bill 43, which contains the exceptions under which persons could seek relief from the regulations in the act, does not mention the case of a different act providing for the licensure of professionals who are currently unregulated and who might wish to organize and seek licensure so as to carry on their professional duties, which in part, and certainly in the case of "diagnosis" as currently defined in section 26, would parallel proscribed acts under Bill 43.

Under clause 39(1)(b), the minister can create an exception at a later date, but if the intent is to allow other regulated professions to practise in the future, why not state so explicitly now? The current situation could be misunderstood by suspicious persons as putting up as many barriers as possible to currently unregulated professions becoming regulated at a later point in time, so as to preserve a lucrative monopoly in third-party billing for counselling and assessment services for the medical profession as long as possible -- possibly for ever?

As a case in point, the Ministry of Community of Social Services, in its consultation paper entitled Regulation of Social Workers and other Social Service Practitioners, has responded to the request of the Ontario Association of Professional Social Workers and the Ontario College of Certified Social Workers to consider legislation regarding the regulation of social workers and other social service practitioners in part because "the Health Professions Legislation Review found merit in the association's proposal [but] determined...that if professional social workers were to be regulated it would be more appropriate that such legislation made them accountable to the Minister of Community and Social Services."

Therefore, it is clear to see that steps have already been taken by at least one body to be recognized as a regulated profession outside of this act. Why not recognize this all too likely possibility now with the appropriate wording?

However, returning to our argument that the diagnosis clause does not fulfil the intent of the act in that it does not provide for the co-ordination of health services in the public interest and that it decreases access and public choice in professional services, in the case where this committee was able to make changes to this legislation so that either other acts would be expressly permitted exception to the Regulated Health Professions Act, or they were expressly permitted to organize under the act, we would submit that this would naturally entail an increased cost to employ such licensed individuals which is either passed on to the public directly or indirectly through the increased cost of insurance, whether it be private insurance or OHIP, or as in the case of transfer of payment agencies under the Ministry of Community and Social Services, increased taxes and/or reduced services to cope with the increased costs.

It is important to note that while this might increase the credentials of the individuals in a given field, there is no guarantee that it would in any way improve the services, but it most certainly would push up the costs and decrease the accessibility and the element of choice of such services to the public.

It is the responsibility of government to pass legislation that fulfils its intent and at the same time does no unintended harm. We feel we have shown that this legislation, in so far as the diagnosis clause, paragraph 26(2)1, is concerned, fulfils neither of these prerequisites. We have a legal opinion that states that our everyday activities in three quarters of our programs would be unlawful under this bill. We have demonstrated that many other social service programs, including drug and alcohol rehabilitation programs, shelters and hostels, would all tend to be at risk of the same fate. The end result of passing this legislation in its current form would be to bankrupt many social service programs, increase costs and decrease public choice and accessibility.

It would therefore be unconscionable for this committee to return this bill to the Legislative Assembly without changes to paragraph 26(2)1 that would clearly protect the medical profession's right to medical opinion without at the same time taking away many other legitimate mental health professionals' right to express an opinion within the limits of their training and experience. If suitable wording is not forthcoming, it would be better to strike the clause from the bill, and in so doing fulfil the intent of the legislation, which is to ensure choice and access by the public.

As a final point, we would like to say that we have come to this venue today in good faith that this committee is indeed unbiased and willing to make changes to this bill to make it both fair and reasonable. We urge this committee to make changes in this bill to preserve the rights of unregulated practitioners to work within the limits of their training and experience, including the communication of opinions and diagnoses, so that the public really does get freedom of choice, of access and a responsibly co-ordinated health system organized in the public interest. We will be watching these proceedings with great interest.


Mr J. Wilson: Thank you for the excellent presentation. I think you have made one of the most compelling arguments. Although we have heard from a number of other groups concerning the diagnosis clause, you have made one of the best and most succinct arguments that we have heard to date. I think it is the intent of this committee, and certainly the will of this committee, to try and make changes to the bill so that unregulated practitioners will be more comfortable.

I note in your legal opinion that there is not a suggestion of any new wording we might put into the act. I am just wondering if you gave any thought yourselves to that, other than I see you also make the suggestion we should simply strike the clause. We are grappling as a committee, trying to come up with wording. There is the exemption section, section 28, that I think tried to give some relief in the area of your concerns, but given the current act, perhaps you would comment on what you might exactly do with it, other than strike the clause, which might not be a good option.

Mr Buckley: I do think that striking the clause would be a very good option in that it leaves the whole area then open. I think the consumer still has quite a bit of protection in other areas of law about mismanagement and misrepresentation by individuals.

Mr J. Wilson: Some have suggested in the area of protection that perhaps all that is needed is title protection.

Mr Buckley: I would agree with that. If that is not acceptable, probably the next best option might be the inclusion of something in terms like "medical diagnoses" or something. Although not expressly, that would tend to limit that to, for instance, items that are included within the International Classification of Diseases, and probably, I would think, leave the DSM-III-R and similar types of volumes to their original intent, or at least it could be argued in court that somebody made a diagnosis under a different body of publicly recognized information, rather than necessarily going into the medical area. At least there is a defence there, whereas currently there is not.

Mr Beer: Thank you for your presentation. At the bottom of page 9 where you say "and in so doing fulfil the intent of the legislation, which is to ensure choice and access by the public," I think we also would have to add to that "and protection."

I recognize there is a balance here, but personally I do not think we can simply drop the clause. We see, through presentations that have been made, that there are real concerns around how that might affect people, but from outside, looking at how we achieve that balance, we have to look at the intent of the legislation as being twofold.

The Coalition of Unregulated Practitioners gave us a number of proposals to look at changing the wording and how we might approach that. Have you had an opportunity to look at any of their proposals? I think we have to find something that is going to help achieve that balance, and I suspect we would find that simply dropping it could open up the possibility of risk to the public, not from you but from others. I am just wondering if you have had a chance to look at that other wording, and if you have, chance to look at that other wording, and if you have, if you could elaborate on that.

Mr Buckley: I did get a chance to look at that document. Unfortunately I did not go into it at length. I did not find any of the options particularly exciting.

Speaking to your question about balance, yes, there definitely is a need for balance. At the same time, I think we need to recognize that the medical perspective is one perspective of many. As a rehabilitationist, my perspective is the rehabilitation philosophy, which is a non-medical philosophy. In dealing with individuals, we find ourselves at times at odds with medical professionals and we need to respect each other's positions. Right now the balance of power and the balance of protection seems to be wholly on the medical side, so I am not as concerned about protecting the medical profession's turf at this point, because at this point they do not seem to have that much need of protection.

Mr Beer: From the committee's perspective, I do not think that is our specific interest either. I think, though, that in trying to reflect some sense of public good, there is an interest to protect the public from those who, whether medical or non-medical, would seek to provide some sort of diagnosis for which they had absolutely no training and no responsibility. It is just that I think we have to be conscious that this is the dilemma we face as a committee in finding the balance that, frankly, will allow you to do what you have been doing, but do both of these things.

Mr Buckley: We are a certifying society. Long term, we are probably looking at a whole host of social service professions that are certified and have some legislation allowing them a certain rein. From my perspective, that is a bit unfortunate, but it is probably the direction we are going. If you look in the United States, you will find there has been an awful lot of work done. I was recently down in the United States over the summer and was able to talk to people about the state down there of the different bodies of legislation. It is quite confusing, but that seems to be the direction they are going as well. Again, I would say it is unfortunate.


The Chair: I would like to call now on the South Georgian Bay Ministerial Task Force on Bill 43.

Mr Gehrels: My name is Ken Gehrels and beside me is Ken Barker. If you just refer the questions to Ken, we will make sure they are properly taken care of. "Hey you" or a suitable grunt in either direction, and we will make sure we get across.

Thank you for giving us the opportunity of presenting to you. I do not envy your job. I do not have to sit in that kind of chair except but three days a year, and those are the three lousiest days of my life. So hats off to you folks for the work you are doing.

I will just run you quickly through the presentation you have before you. Who are we? Basically, a task force that represents the ministerial associations, and hence the churches, pastors and parishioners, who run all the way from the Wiarton area, around the south edge of Georgian Bay, right up again to Penetanguishene, Midland, Victoria Harbour and all the communities in between.

Our concern, which I understand has been a concern raised by many other folks already to you people -- I certainly hope we are not beating a dead horse, to use the old phrase -- is that part of our mandate is to provide pastoral care and support to our parishioners, so we, as many others, have an interest in Bill 43.

From our understanding of the bill, having read it, we are appreciative of your desire to revamp the health care regulatory process. We support the basic intent of it. However, as with others, our concern is paragraph 26(2)1, the concern that the diagnosis clause could lessen the quality of pastoral care provided to the parishioners whom we are representing to you here today and inhibit the positive contribution that presently is made by clergymen and clergywomen on a grass-roots level all across the province to the quality of life in this province.

It is with those words "disease," "dysfunction" and "disorder," and the concern is whether you intend in the legislation to retain a narrow medical definition of the words or whether it allows a broader understanding. I think it is safe to say from the intent of the legislation, if one looks at it overall, that we are probably looking at the narrow medical model or definition of the words. Of course, both are technically possible. The legislation does not really say which one is intended.

It is our hope, and we were glad to hear what you mentioned to the group prior, that you are seeking to work as a proactive rather than a reactive sort of committee so that work does get done in a positive sense to prevent, somewhere down the road, a possible hindering of the work that clergymen and clergywomen carry on all over this province in -- I give some examples -- things like alcoholism that families who are struggling with wife assault.

That is a particular interest of mine at the moment. I also sit on the board of the Collingwood women's emergency shelter which we just celebrated the opening of, My Friend's House. I bring here personally not only my own concerns as a clergyperson, but also the concerns of the staff whom we have hired on at My Friend's House. What is their status going to be if the legislation were to be passed as presently implemented here?


Struggles with victims of incest; brokenness surrounding divorce; grief counselling -- how many people do not avail themselves of clergy if at no other point than there? -- pre-marital counselling. We do all that sort of work on a regular basis and the question becomes then, are we going to be able to carry on that sort of work which often does involve, in a broad sense, diagnosis- and directive-oriented counselling?

I think of one individual I counselled who had been convicted of and openly admitted to an incestuous relationship with a child. I had to work arm in arm, together with a social worker in the community of similar persuasion to mine, to help this person understand the particular implications of his acts and the damage it caused to the child. We worked on that and some time later this person came down with a very strange disease whereby his hands were rendered numb and tingly and he could not use them. He came down with this complete conviction that he was suffering under a punishment and the guilt of God for his activity. The guilt he was feeling was so tremendously crippling to the man that he just simply could not carry on with life. He was unable to proceed with medically healing his disease, so we had to deal with the diagnosis then, in a guilt sense, of what he was struggling with and help him overcome that.

That is one example. There are others. One person I was on the telephone with this morning, before I came down here, had been betrayed by a member of her family, had been hurt deeply, was losing weight and could not sleep and the symptoms went on. Over time we were able to diagnose the cause of these symptoms she is experiencing as her resentment, her rage, properly so, against that particular individual and then help her directively to work that through, just to give you a couple of concrete examples of where we are coming from in our profession.

We understand you are seeking to regulate, not to box in. We appreciate that. It is with that in mind that we would like to present to you four different suggestions, on page 2, as to what possibly might be helpful, or at least provide an avenue in sorting through the present predicament.

I would like to begin with proposal 2, "Delete 26(2)1 entirely," and just ask the question, perhaps in a rhetorical sort of sense, recognizing what Mr Beer has already mentioned, is the rest of the list, paragraphs 26(2)2 to 26(2)13, not sufficient in terms of the protection it provides to the public? I think here of the way our society in general runs. We are a society that works very much with individual responsibility, individual freedom and freedom of choice, recognizing that it is government which then sets the boundaries of safety so that people do not get unnecessarily damaged or hurt when they make the particular choices they are seeking to make.

Paragraphs 26(2)2 to 26(2)13 speak of all the different poking and prodding and working with various corners and crevices of the body. The question I ask to members of the committee, and perhaps we can discuss this in a couple of minutes, is, does that not provide, in and of itself, sufficient protection for people who honestly are going to look for some kind of assistance for whatever conundrum they find themselves in? If you say no, then up to number one: Would it then perhaps be beneficial to stake down what I would put in quotes as "individual fence posts," perhaps an item-by-item designation of what kinds of diseases, disorders and dysfunctions may or may not be diagnosed by only those in regulated professions? I know it becomes a little more awkward, a little longer.

If we are concerned with working on the narrow meaning, the narrow definition of the words, especially "dysfunction" and "disorder," then perhaps something like number three, communicating a conclusion regarding a medical, dental or optometrical disease, dysfunction or disorder -- I do not know exactly how you would want to word that -- and then in some way, somehow refer to the body of common law that has already been built up which prevents people from practising medicine without a license. That body of law is there now. Can we not perhaps make use of that somehow by using the words "medical diagnoses," perhaps? Then when we have this whole body of legislation in place it can be utilized. It seems to be working fine so far. It has not impinged on social workers, parole officers or clergy to date. I cannot see that changing.

Then there is number four. I like that one the best because I wrote that one.

Mr Owens: Sounds good to me.

Mr Gehrels: There you go. No, the basic idea for that one came from Don Evans from the coalition. His concern, as he has probably mentioned to you, is with scope of practice rather than specific item-by-item definition of what may or may not be done. Where are we going to get our hands slapped? Where are we not going to get our hands slapped? That got us in the south Georgian Bay task force thinking, is it perhaps not misrepresentation that is in a large way the concern of you folks in the committee, playing doctor? If I look at clause 26(1)(a), subsection 30(1) or subsections 31(1) and (2), that seems to be the case. It seems to come up over and over again in the bill. That is a concern we share. I do not want to, and as clergy we ought not to want to, engage in detailed medical or psychiatric analysis of our clients. We are not called to that and are not trained for that; wrong bailiwick.

Could we say something like, "Communicating to the individual or his or her personal representative a conclusion regarding a disease, dysfunction or disorder in which it is reasonably foreseeable that the individual or his or her personal representative will understand this conclusion as having been made by an individual authorized by a health professions act to perform treatment regarding this conclusion"?

Then you go to the scope of practice of each of the individual professions as you define them with the various health provision acts that go along with this particular bill. I guess what we are looking for is complete legal assurance that our day-to-day provision of competent pastoral care is not hindered. I have no interest in protecting the quacks, like the guy who receives a vision after a bottle of wine, calls himself a reverend and starts counselling practice. That is not our intent. Competent counselling, pastoral care: We do not want that hindered. We do not want that put under a cloud of possible legal action in any respect. I think the parishioners we represent deserve nothing less and I am sure you would agree on that.

The final thought is that we do not understand how the government could on the one hand call for grass-roots health care -- I consider mental health, spiritual health to be part of the overall wellbeing of a person. I think our society is more and more coming to see that. We are not just bodies with little minds stuck in them. We are whole people and with all different aspects to our wellbeing. I agree with the call I hear coming from Queen's Park, time and again, for front-line care, for grass-roots care, for community-owned and cared-for work, preventive care especially. I think that is good. But then we cannot at the same time hinder that by trying to stuff everybody into a narrow medical model. As you know by now, we just simply do not all fit. I thank you for your time and attention as a committee and welcome any questions or dialogue.


Mr J. Wilson: Thank you for coming down from God's country and making this representation. I have a stake in that area of the province also. I was just wondering whether while you are here we could ask legal counsel, through the parliamentary assistant, if she has any cursory comments on the suggested wording as outlined in point 4.

Ms Bohnen: I will just make a couple of comments on items 3 and 4, although I think it is really dangerous to comment before these hearings are completed, so this is really very tentative.

Mr J. Wilson: We understand that. You are covered. We will not hold you to it.

Ms Bohnen: I will just raise one concern I would have with item 3, extending it to "regarding a medical, dental or optometrical disease, dysfunction or disorder." The intention of the governments has been to really focus on the kinds of diagnoses medical doctors make, and there is common law that helps us to define what the scope of practice of medicine is and therefore what medical diagnosis might be. As soon as you start referring to dental and optometrical, and I think you would have to extend that in this framework to psychological and so on, you are starting to expand rather than confine the scope of the controlled act, which I do not think would be your desire to an amendment such as this.

Also, I think you might ask: "What is a dental disease, disorder or dysfunction? What is optometrical?" I am not sure the adjectives are modifying the right nouns. Those are just some preliminary comments. The second suggestion, as was clearly said, is that it really focuses on harm resulting from people being misled as to the qualifications of the provider. The review thought there had to be protection both against confusion and diagnoses provided by people who were just not qualified to provide them regardless of how they identified themselves. It it is one thing for the quack to pretend to be a medical doctor, but there is still a risk of harm from a quack who does not pretend to be something he or she is not, who provides a diagnosis that is outside his or her competence.

Mr Gehrels: May I comment on that, Madam Chair?

The Chair: Did you want to ask a question, Mr Wilson?

Mr J. Wilson: Perhaps you could comment on that. If I raised my voice that would be a question.

Mr Gehrels: In response to Mr Wilson's timely question, if I could comment on that, regarding item 3, "dental or optometrical," we are not fussy. The words are hard enough to pronounce, let alone anything else.

Ms Bohnen: Or spell.

Mr Gehrels: Or spell; that is right. It was not even in the spell checker, at any rate. But whether or not that is in there, we agree we are looking for a narrow definition and if taking those out works, great. Regarding item 4, I really wonder whether there is a tremendous danger from someone who does not claim to speak with particular authority such a person is not qualified with, whether that person still poses so much a danger.

To put it bluntly: "Hi, I'm a quack. I think you've got such and such and I think you should do such and such," does not carry near the weight as: "Hi, I'm Dr So-and-so. I think you've got this. I think you should do this." Of course I am not going to go around and say I am a quack: "Hi, I'm Ken Gehrels. I think you've got such and such. I think you should do such and such." Fine, that is what grandma told me too, but I am not going to put my life in jeopardy or carry on some kind of specific assessment because of what grandma, Mr Jones who has the farm behind me or whoever says. In our day and age, especially where we are so specialist-oriented, people look for that before they carry on with any specific activity. I think we owe it to the members of our province, the citizenry, to recognize that they have enough brains to do that. I think that preventing misrepresentation would carry us far enough.

The Chair: Thank you very much for your presentation before the committee today. If over the course of these hearings you, your organization or any group or individual would like to present additional information to the committee or feel there might be some helpful information, I hope you and everyone else will feel free to communicate with the committee in writing to our clerk at any time.


The Chair: I would like to call now on the Ontario Secondary School Teachers' Federation.

Ms Suddick: I am Mary Suddick. I am president of the professional students' services personnel occupational sector of OSSTF, and Neil Walker is executive assistant of the external policy department at OSSTF. On behalf of OSSTF I would like to thank you for your time. The process of public involvement is an important one and we appreciate the opportunity to be able to outline our concerns about the legislation. I shall now proceed to take you through our brief, which I believe members have in front of them.

The Ontario Secondary School Teachers' Federation is proud to number among its 43,000 members a growing number of professional and non-professional educational support services staff. Among the latter are audiologists and speech-language pathologists. They will be directly affected by the new Regulated Health Professions Act and the Audiology and Speech-Language Pathology Act. In addition, other federation members such as guidance counsellors and behavioural therapists and counsellors -- in short, any member of the educational team who deals with questions of student disability, behaviour and mental health -- may find their professional effectiveness impaired by provisions of the new bills dealing with diagnosis as a controlled act.

The functions of diagnosis and assessment, which are a key part of every speech-language pathologist's and audiologist's intervention to help students in difficulty, under the terms of RHPA become a controlled act whose communication is licensed. A controlled act is defined in the prohibitions section of Bill 43, paragraph 26(2)1: "Communicating to the individual or his or her personal representative a conclusion identifying a disease, disorder or dysfunction as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the conclusion."

As can be imagined, within the school setting speech-language pathologists and audiologists in the normal course of their activities on behalf of students in difficulty communicate their assessments to students, parents, teachers, counsellors and other resource personnel, and if necessary to administrators. Depending on the complexity of the difficulty and the extent of the resources that must be marshalled to meet it, a speech-language pathologist or audiologist may have to involve all of the above to help a child whose problem is serious. Under the terms of Bill 43 as it now stands, speech-language pathologists and audiologists would be stripped of the right to do just that.

If the terms of the bill and the related bills stand, none of the professionals touched by the RHPA would be able to function as above in a school or school-related setting, with the exception of licensed doctors and psychologists. In other words, as the bill stands, a speech-language pathologist or audiologist would be able to diagnose a disability or dysfunction within his or her professional capacity, but must seek out the services of a doctor or psychologist to communicate the diagnosis to anyone else who might of necessity be involved in the treatment of the dysfunction. It would seem on the face of it that the speech-language pathologist or audiologist would be in the ludicrous position of not being able to communicate the nature of the disorder or its treatment to the student or to the parent where appropriate.


One can empathize with the concerns of those who have drafted the RHPA and related bills to protect the public from unlicensed charlatans and unqualified care givers who have the potential to do public harm. It is our belief, however, that it was not the intention of the government to disrupt or render more difficult the successful practices of therapy that are now benefiting some of our most vulnerable children within the school system. In fact, it has been a struggle within many boards to convince trustees that such support services are the lifeline essential to the survival and ongoing success of disabled children. Only persistent and effective lobbying by parent groups and associations in the field of special education have convinced trustees that these services are indeed essential.

In this respect, the battle is not over. The sad case of Oxford county, where trustees, squirming under tax revolt pressure, recently slashed support services for children in difficulty, including speech-language pathologists, audiologists and behaviour therapists, is a sharp reminder of the fragility of these services. They may not be necessary for the broad population of students, but they are absolutely vital for the minority of children who need them.

One can easily imagine the destructive frustration of a child, having lost access to the therapy that is allowing him or her to communicate for the first time with other children, being faced with a six-month or longer waiting period for help at the nearest clinic or hospital.

We call on the government to amend Bill 43 and/or the related bills to allow those professionals who are now functioning in a school setting to continue to do so without the impediment posed by the bills' approach to controlled acts.

Deputy Minister of Education Robert Mitton has brought to the attention of the Ministry of Health the difficulty posed by the definition of the "controlled act" within the school setting for teachers and guidance counsellors. We have attached a copy of the letter to our brief.

He contends that the prohibition of the communication of conclusions by the unregistered personnel would prevent them "from performing their assigned functions. For instance, in the Ministry of Education guideline for guidance curriculum one of the roles assigned to guidance counsellors in the intermediate and senior divisions is to `assess students' particular social and emotional needs and make recommendations for referrals to or consultation with other staff or community agencies.'" Such referrals, involving an assessment of a "pupil's emotional or psychological disorder or dysfunction," would constitute a prohibited act.

Boards of education employ other professional personnel such as occupational therapists and physiotherapists. In addition, within the context of section 27, schools in clinical settings, all professional personnel, because of the special nature of the needs of these students, may be involved with the communication of assessments of dysfunctions that are, by definition, controlled acts. The potential for disruption of present practices with educational settings affected by Bill 43 is thus relatively widespread.

The deputy minister, Mr Mitton, to remedy these problems suggested the removal of the definition of diagnosis from Bill 178. It appears that paragraph 26(2)1 of Bill 43 perpetuates the same problem. Mr Mitton's alternative suggestion may be more acceptable, and if broad enough in scope would solve the problem for educators. OSSTF endorses his request that "education professionals be exempted by regulation under subsection 26(3)." If the exemption is extended to all educational settings, professionals in education will be able to maintain present practice, to the betterment of those students with special needs.

Thus, our first recommendation would be that education professionals be exempted by regulation from the terms of paragraph 26(2)1 of the Regulated Health Professions Act, 1991.

We believe the public interest would be served through the above amendment and the public protected at the same time through the safeguards inherent in the choice and supervision of professional personnel by the boards of education and the Ministry of Education.

OSSTF has several concerns related to title protection within the scope of Bill 44. Subsection 15(1) of the bill reads, "No person other than a member shall use the titles `audiologist' or `speech-language pathologist,' a variation or abbreviation or an equivalent in another language in the course of providing or offering to provide, in Ontario, health care to individuals."

To obviate any ambiguity as to whether this subsection applies to those qualified individuals working in educational settings, we recommend that the final phrase of the section, "in the course of providing or offering to provide, in Ontario, health care to individuals," be deleted. Our second recommendation would be that the phrase "in the course of providing or offering to provide, in Ontario, health care to individuals" be deleted from subsection 15(1) of the Audiology and Speech-Language Pathology Act, 1991.

Furthermore, as the title "speech therapist" is used interchangeably and synonymously with that of "speech-language pathologist," it too should be protected to avoid a potential glaring loophole in the act. As "speech therapist" is the historical designation for "speech-language pathologist" in Canada and elsewhere, and many practitioners presently hold licences and display the title "speech therapist," such protection would help to avoid any confusion among school board officials and the general public as to whether the practitioners are indeed licensed professionals.

Therefore, our third recommendation would be that subsection 15(1) be amended by the addition of the designation "speech therapist" as one of the protected titles.

In addition, OSSTF recommends an amendment pertaining to subsection 15(2) of Bill 44. The subsection reads, "No person other than a member shall hold himself or herself out as a person who is qualified to practise in Ontario as an audiologist or speech-language pathologist or in a specialty of audiology or speech-language pathology."

To prevent non-qualified persons from skirting the law by attempting to offer such things as audiological services within a school setting, OSSTF recommends that subsection 15(2), "Representations of qualifications," of Bill 44 be amended to read as follows, "No person other than a member shall take or use any name, title or description implying or calculated to lead people to infer that the person is qualified or recognized by law as an audiologist, speech pathologist or speech therapist."

Although it may be argued that the difference in terminology is not momentous in import, OSSTF feels that the protection of the public would be better served by the amendment of the wording.

Thus, recommendation 4 is that subsection 15(2) be amended to read, "No person other than a member shall take or use any name, title or description implying or calculated to lead people to infer that the person is qualified or recognized by law as an audiologist, speech-language pathologist or speech therapist."

OSSTF believes that these amendments would improve the legislation and recommends that the government consider them for implementation.

The Ontario Secondary School Teachers' Federation is convinced that the above suggested amendments to the Regulated Health Professions Act and the Audiology and Speech-Language Pathology Act will allow those professionals in education who are providing vital services to students in difficulty to continue to do so without their effectiveness being impaired.

At the same time, the protection of the public, which is the principal aim of the Regulated Health Professions Act and related acts, would be better guaranteed. We strongly urge that the government respond favourably to our recommendations.

We would now be prepared to answer any questions you might have.


Mr Jackson: Mary, Neil, welcome, and thank you for an excellent brief. I have quite a few questions but I know time does not allow us. There is no reference to the Ontario student record here, but I would suspect, knowing protocol, that upon certain suspicions there might be an entry in the OSR and that also the act of entering in the OSR might be proof in a court of that breach as well.

Ms Suddick: Yes.

Mr Jackson: I briefly read the letter from the deputy minister, Mr Mitton. First of all, it does not have a date on it. Does anybody know the approximate date? Maybe that could be determined since it was to the ministry. Knowing that date, we could get a sense of whether or not the government considered any amendments post receipt of the letter or if, as the letter indicates, it clearly states for the record that, "Both this ministry and the Ontario Teachers' Federation do not seem to have provided input as to the serious and broad-ranging impacts which the legislation as proposed would have on the delivery of educational services in this province." I quote directly from the letter of Mr Mitton to the Deputy Minister of Health, Dr Barkin.

The Chair: Mr Jackson, it is time for questions.

Mr Jackson: I am making it abundantly clear, Madam Chair, that we would like an answer. According to this letter, Education was overlooked. We have a letter from the deputy minister, the second-highest-ranking individual in the province in education, as far as the government is concerned, expressing concern that they were not consulted.

The Chair: Mr Jackson, do you have a question?

Mr Jackson: I have stated the question and I was about to finish until the Chair was demanding clarification on my question.

The Chair: There are four minutes left entirely and I have four speakers.

Mr Jackson: Do you know the questions I have, because I think legislative counsel knows my questions?

The Chair: Would you like to respond, Mr Wessenger?

Mr Wessenger: I will have ministry staff respond to this matter of the letter.

Mr Burrows: To answer Mr Jackson's question, we would like to be able to table the response to that letter, but it by and of itself raises some questions. It is not signed and it is not dated, so we have no way of knowing that this in fact was a letter that was sent. We would like to look at the circumstances of the release of the letter and any possible response, but we would have to check with the ministry as to what we were actually responding to. If you could leave that with us, we will do that.

I would make a couple of general comments. Looking at the content of the letter, it apparently was received prior to the deletion of the harm clause, so my guess would be that it is somewhat dated. Second, prior to the introduction of the legislation, the entire package of course went to cabinet, at which time it was a cabinet decision to proceed. That is why the legislation was introduced. There is a consultation process that is part of the cabinet approval process and this legislation did go through that, so there was opportunity for comment. Last, at the bureaucratic level, I can assure everyone that we have discussed the legislation, some parts of it in great detail, with representatives of a large number of ministries including the ministry in question.

The Chair: Thank you very much. Question, Mr Beer. One minute.

Mr Beer: Perhaps more by way of something we could do in that week of the 16th. Given this letter and assuming that it is as it is, we could perhaps add officials from the Ministry of Education to talk about this letter and whether their concerns around the diagnosis clause remain the same or have been met.

The Chair: Your request is noted. Thank you, Mr Beer. One minute, Mr Martin.

Mr Martin: Mine is of the same nature, and that would certainly serve to --

The Chair: Thirty seconds, Mr Hope.

Mr Hope: Since I have been on this committee dealing with the audiologists and the speech-language pathologists, are there not current laws dealing with people under a certain age about hearing? Are not some of the comments currently under law that are expressed here today? The dispensers were saying about laws that are already in place dealing with a certain age for hearing and for speech.

Mr Wessenger: I will refer that to counsel.

Ms Bohnen: That particular question you are raising is not something I could honestly say I know much about, but I would be happy to look into it and report back. I will just have to get back. I do not know.

The Chair: Thank you for your presentation and for appearing before the committee today.

I remind all members that during the time that is available for questions, if you have long questions and wish a response from the ministry, you can also do that privately to the representatives from the ministry and they will then respond in writing, on the record, at the appropriate time.


The Chair: John Chin, please come forward. You have 10 minutes for your presentation.

Dr Chin: I am Dr Chin, a consulting surgeon at two hospitals, one in Toronto and one in the suburbs. I am a practising surgeon in this city.

I have read Bill 43 and I could not find anything that relates to my concerns. I have two areas of concern. One is that the board of directors of community hospitals is not accountable to anybody or even to the Ministry of Health. They are an autonomous group. They practise with immunity from any complaints whatsoever. This is my experience. The second concern is related to section 34 of the Public Hospitals Act. I will give more details as I go along.

As I said before, boards of community hospitals are not accountable even to the Ministry of Health. Perhaps it is best to give some examples. In recent years, three hospitals boards refused to give the applicant a hearing despite the fact that the Public Hospitals Act states quite clearly that the applicant is entitled to a hearing before the board, if requested. Three hospital boards decided not to give the applicant a hearing. Even the government failed to persuade the hospital to do so. The Hospital Appeal Board is ineffective in this regard. It does not have jurisdiction to order the board to give a hearing. Even the government failed in this regard. The hospital boards, as I said, are not accountable to anybody. They are a law to themselves.

One hospital board even ignored complaints of matters of serious concern regarding health care matters and irregularities, so much so that complaints were made to the government. No response was given by the government in this regard, so I have to conclude that the hospital board is autonomous, as I said before, and not accountable to anybody.

Also, if you suspect conflicts of interest at hospital boards, to whom do you turn? The chairman of the board ignores all your letters. What do you do? To whom do you complain? Do you complain to the government? They are very ineffective in this regard.

There is even collusion between hospital boards when they want to reject a candidate. Do you know how this comes about? There is a leakage of confidential, false information from one hospital board to another hospital. How is this possible? Because two hospitals appoint the same physician chief of the department in both hospitals at the same time for two years. How can that be? It is unprecedented. How can two hospitals employ the same physician to be chief of a department at the same time for two years? Because of such a situation, leakage of information went out from one board to another to defame the candidate. When you ask for an investigation about this matter, the hospital board refuses to investigate. It is none of their business. You have to take it to court.

The chairman of the hospital later found it necessary to correct the false information, but only after the damage had been done already to the candidate. What good is that now, when the damage had already been done? This gives you an example of what hospital boards can do without any accountability.


I know there is a debate about doctors not sitting on hospital boards. That does not solve the problem. Doctors should sit on hospital boards, but they should not be in private practice. What is needed is not so much doctors on the board; what is required is government representation on the board. The government should have someone represent the government on the board, or even the chief executive officer's appointment should be approved by the government. That is the only way the hospital board can function effectively. Taking doctors off the board is of no consequence whatsoever, because the board can still be influenced by the doctors. The doctors have their own interests; the board has its own interests.

What is shocking to me in this is that the government gives millions of dollars to the hospital, a global budget. I have information that one hospital spent 90% of the budget on salaries alone, and only 3% on equipment. How can a surgeon keep up with the latest technology? How can you get to do a laparoscopic cholecystectomy -- I am sure most of you have heard about laparoscopic cholecystectomy -- which only costs about $100,000. You cannot even get that because the bulk of the budget goes towards administration. The administration takes a big portion of the budget. Even a special secretary in the administration -- some are getting $120,000. I cannot even imagine what the executive director is getting. I am sure they are over $250,000, most likely.

That is so because the government has no input whatsoever. They give the money and tell the hospital to do what it wants to do with it. How they spend it is up to them. As long as they are accounted for, they do not care. The government has no input whatsoever. That could never work in a business at all. You cannot just give millions of dollars and tell them to help themselves to salary increases, to whatever they want, an exorbitant amount. Nobody is accountable to anybody. That is the situation right now. You read in the papers about, "It's not money." Of course it is not money; it is mismanagement in the middle level. They are giving themselves exorbitant salaries. They do not have to be accountable to anybody. Why do doctors not complain? Because they have an interest themselves to protect. They do not care. Why should they bother? Why should they worry about what the chief executive officer does? They are rather interdependent in some ways.

What I advocate is this: The government must have representation on the board. For that matter, appointments of chief executive officers should be approved by the government.

Let me run on to the next area of concern. I am running out of time. Section 34 states quite clearly that every physician has a right to, is entitled to apply for privileges. It is very misleading. It is unjust. It puts the candidate to unnecessary expenses and unnecessary harassment because it gives a false sense of success. We have no chance whatsoever. All a hospital has to do is say, "The complement is full." Who says the complement is full? The doctors themselves. "The house is full." One chairman said, "They don't want to share the pie." It is as simple as all that. They do not need to give another reason to tell you how they can reject you unfairly. All they have to say is, "The complement is full," and you cannot do anything to anybody.

To go further, if they are not satisfied with that, do you know what they say to you? They give you a hearing after giving away the job or they refuse to give you a hearing. One president of a hospital was asked this question, "Three plus one is what?" She refused to answer because it comes to four. She testified in court that the proper complement was three when in fact it was four. That gives you the extent of what the president of a hospital will do to protect the doctors. Of course, in turn the doctors protect them too, sort of vice-versa.

What about the appeal board? It is only a rubber stamp. They go further. In fact, they give more reasons than the hospital give if you go to them. Also, to give you an example, the Hospital Appeal Board gives you what reason? Personality. The hospital never brought it up, but people will say personality to give the hospital a lending hand.

Also they fail to provide a transcript to the court if you want to go to court and appeal it. You have to fork out thousands of dollars, $5,000 to get a transcript if you want to go to court and yet it is stated quite clearly in the Public Hospitals Act that the hospital people must provide a transcript if it is not part of their transcript.

If you go to the court, the court punishes you. If you ever say, or your lawyer ever says, that the Hospital Appeal Board is biased you will get hit for it. You will get charged for client as well as solicitor's fee to punish you. That is why this act should be taken out. It is useless. No special candidate to my knowledge has ever successfully applied and got in. If the hospital wanted to check you, there is a foolproof answer. There is nothing you can do about it.

This act needs changing. It is a futile exercise. It causes unnecessary expense to the candidate. It is time the government did something about it. To summarize it all, the hospital board should be made accountable to the government or government should put a representative there to see how its money is spent. Otherwise, things will never change. Taking doctors out of the board is not the answer.

The Chair: Thank you very much, Dr Chin, for your presentation before the committee. The committee is dealing with the Regulated Health Professions Act. Your representations were with regard to the Public Hospitals Act. We are aware that the Ministry of Health at the present time is reviewing the Public Hospitals Act and as chairman of this committee, I will undertake to ensure that the Hansard of your presentation as well as your documentation is forwarded to the Minister of Health for consideration as part of the deliberations around the new Public Hospitals Act.


The Chair: I would like to call next the National Council of Canadian Filipino Associations. Welcome. I know you have appeared before a number of committees. I do not think I need to tell you how to proceed. Please introduce yourself. You have 20 minutes for your presentation and we would ask if you would, Carmencita, leave a few minutes at the end for questions from committee members.

Ms Hernandez: My presentation is short but hopefully concise. I would like to thank the members of the standing committee for giving me the opportunity to present our views on Bill 43, the Regulated Health Professions Act. My name is Carmencita Hernandez. I am the regional vice-president of the National Council of Canadian Filipino Associations. The NCCFA is a federally incorporated organization representing its member associations across Canada. Formed in 1963, the NCCFA aims to contribute to a viable, visible Filipino Canadian community that can actively participate in the social, cultural, political and economic life of Canada.

We strive to serve as an effective voice of the Filipino Canadian community. We are committed to working towards the development of a strong community, proud of our heritage and active in the building of a just, humane and prosperous Canadian society. As individuals, we are also members of the Ontario Coalition of Visible Minority Women, the Toronto Organization for Domestic Workers Rights or Intercede, the Network of Filipino Canadian Women. NCCFA is a member organization of the Canadian Ethnocultural Council, a coalition of 37 national ethnic organizations across Canada.

As the regional vice-president in part of Ontario, my mandate includes campaigns, projects, programs and activities and development of policies on issues such as accreditation of foreign credentials; employment equity; education equity; wife assault, sexual assault and violence against women; AIDS; access to health and social services; and systemic discrimination. These campaigns, projects, programs and activities are a result of our collective work in the community as workers, as community leaders and representatives, as community activists, as Canadians. Our work is framed by the principles of equity, equality and justice. This is strengthened by our recognition of our contribution to the economic, social and cultural and political growth of this province and country. It is steeled by our commitment to a just society.


Striking a New Balance: A Blueprint for the Regulation of Ontario's Health Professions presents the recommendations of the Health Professions Legislation Review. In the overview of the recommendations, under the subhead "Mandate", it states that the review was created at a time when much pressure for change to the existing regulatory legislation was being exerted. It appears, however, to have missed the concerns of individuals, community groups and agencies for accessibility to health services and for health professionals and health service providers to reflect the diversity of this province.

The participants and others in contact with the review fail to include women's groups, including immigrant and visible minority women's groups, ethnoracial organizations and community health clinics. It seems to me that a balance could not be struck without representation from the abovementioned constituencies.

It is very important to recognize certain institutional barriers that face foreign-trained health professionals. I am certain that the members of this committee are familiar with the report entitled Access, a report of the Task Force on Access to Trades and Professions.

Bill 43, as presented, provides for the establishment of an advisory council, section 7, and the Health Disciplines Board, section 17. It is very important that the members of this council and board be representative and reflect the diversity of this province.

With reference to schedule 2, the Health Professions Procedural Code, we strongly recommend that section 9 also include committees on equity in health education and practice and accreditation. This would encourage different colleges to adopt policies and establish programs that will acknowledge the diversity of their community and make a commitment to fair treatment and opportunity for all Ontario residents.

There are also certain requirements that have to be met before an application for registration is even received. The experiences of foreign-trained nurses in their attempt to be registered in this province are well documented by the Coalition of Visible Minority Women and other organizations such as the Filipino Nurses Association.

We would like to ask that there be provisions in the code that would also allow third-party representation on behalf of applicants rejected, and not only when an applicant dies or becomes incapacitated. I hope this opportunity given to us would serve as a first step in reaching out to the various colleges.

Mr Beer: Thank you very much for your presentation. I think you have touched on a number of issues, but one, I believe for the first time, relates to the procedural code and your suggestion that perhaps there should be a committee dealing with equity. I know certainly in other forums many people have said that this issue of employment equity is perhaps one of the most critical. Do you have any sense whether, in the deliberations that are still going on with respect to the Task Force on Access to Trades and Professions, consideration is being given to this particular point you made?

Ms Hernandez: Yes, this is part of the demands for the new government, to act on the recommendation of the Access report, a recommendation to install a plan which is the pre-learning assessment network. It is being asked for by communities. I believe there are initiatives, but we do not know about the details.

Mr Beer: Would it be fair to say that regardless of what initiatives come out of the government response to that task force, you would still think it useful to have a committee on each of the councils that dealt with this process?

Ms Hernandez: Definitely, because we see that there is resistance among colleges to address the issue even of gender equality, and much more so in race equality. The establishment of accreditation or equity in the health profession, in terms of practice and education, would be very useful. It is opening up their minds to the different composition of this province. We are very aware there appears to be resistance to acknowledging the fact that as immigrants come to the country, we bring along our credentials, and maybe what is needed is a different kind of program that would help us adjust to the profession we would like to practise.

Mr Jackson: Mr Beer has asked some of the questions I wanted to ask, but going further on this issue of employment equity in the health professions, it is my understanding that the native community will at some time be presenting to this committee its concerns with respect to self-government and separate colleges for native people because of that model. That is not what you are requesting. You are requesting an equity access model within the existing framework of the regulated agencies. Do you support -- this is a question I will ask the minority women's group who are coming next -- native Canadians with respect to their request for separate, independent colleges for purposes of graduating, regulating and training their native health professions?

Ms Hernandez: We support the call of the native people, even asking for their own justice system, and we believe they are very right in asking for their own colleges to be able to train and give credit to their professionals.

The Chair: Thank you very much for your presentation. The committee appreciates hearing from you. If, over the course of these hearings, there is anything further that you feel would be of assistance to committee members, I know you will communicate with us in writing.


The Chair: Annette Dillon: Welcome to the standing committee on social development. You have 10 minutes for your presentation.

Ms Dillon: I am not from the minority women's group. I am speaking primarily as an individual. That was the understanding I had when I made the appointment. I am a little concerned by the last speech, in more of an organizational approach.

The Chair: Please relax and be comfortable. The committee is hearing from individuals as well as from groups and organizations. The only difference between you and the previous speaker is that they had 20 minutes because they are an organization. You have 10 minutes as an individual and we are here to listen to what you have to say. Just relax and tell us how you are feeling.

Ms Dillon: I am coming as an individual, even though I am working for an organization that would be affected by this legislation. I have seen the report. It is primarily the harm clause and the diagnosis clause I am concerned with.

Many years ago I had problems, which I realize now are generally termed as being part of a dysfunctional family. If one person has a problem, it is not just that person -- that they are schizophrenic or something -- it is the whole system that has an error in it.

I did not get help then. I was sexually assaulted by a psychiatrist. That was my first experience. I know there is some legislation to protect you against that, but that was the first problem. The next time I tried to seek help, I was referred by a family doctor to a psychiatrist, who insisted that I had to take drug therapy to see her. I went to her for one session and I chose not to see her again, partly because some of the original problems resulted from early experimentation with drugs, and I knew instinctively that this is not the answer.

About four years ago a friend suggested I try someone, whom I only saw because I heard that she was a feminist, socialist doctor, and I thought that was the combination I needed, somebody with medical knowledge who could find out what medical problem I had, and someone who was a feminist -- it is men's fault -- and socialist because it must be to do with the political system.

I learned in a few sessions that no, I did not have any medical problems; that no, it is not men's fault, that men are not stopping me from progressing in the world; that it is not the political system; that it was internal things, conflicts that we all have to a degree. I am discussing what is called an Adlerian approach which is an educational model, not medical, that these people do not have mental illness, but they lack education.

The main thing the institute does is parenting programs, the idea that it is just errors in training; in my case a lack of self-esteem, all kinds of things relating to dysfunctional family, including alcohol dysfunction.


In any case, it did not take long. A few sessions and I had my house in order and I have got on with life. Even coming here is probably a step in that. Years ago, I would have never spoken out. Coming from the sort of family I did, I just would not have done it. So that is a sample of improving.

In any case, the reason I am here is because it did change my life and it is changing the lives of people who are using this approach. I am also a supporter of other humanistic approaches -- Rogerian, Gestalt, all of these things -- but I am primarily knowledgeable and have had experience personally with the Adlerian model.

My concern with the legislation is that a lot of the people who are doing this kind of counselling have an MA degree, specialized in counselling and psychotherapy. It is an intensive degree that covers all areas: family and marriage counselling, individual counselling, substance abuse counselling. They are highly trained. Yet none of the doctors I went to recognized that I came from an alcoholic family. They did not clue into it. They were not able to assess that. The referrals that were made were not good. The medical doctors themselves do not have training. Really, that is the issue, and this legislation is handing it back to doctors. It is saying that medical doctors are the only ones who can make a diagnosis, again along the lines that it is a medical model, that there is some kind of medical problem that has to be diagnosed.

My concern really is that in a courtroom, people with an MA degree can be discredited easily by a psychiatrist. I have given an example here that could apply where someone is accused of rape. If it was an Adlerian counsellor who had, through the lifestyle analysis, analysed that they have a belief that women are dangerous, which could lead to feeling that they have to protect themselves against women, overcome women, that could be a sample. But that could be discredited in court by a psychiatrist who says, "No, the person was temporarily insane and he has an organic schizophrenic disorder," or something like that. I was diagnosed as latent schizophrenic, psychotic, all kinds of things, which I realize now was just absolute garbage and absolutely damaging to me. Fortunately it is not a problem any more.

Right now I know it is going on, coming from my family. A sister currently is in and out of addiction centres in the United States, all paid for by OHIP, but every time she comes out, in a month or so she is back. There is no follow-up treatment. She is not from Toronto and there is nothing in the area she is in, and these are all areas where recovering addicts themselves who have certificate programs, for example, can help, but that help is not getting to people. That is a main concern. This legislation seems to be perhaps not entirely responsible for that, but still, taking away the ability for someone -- let's say a nurse who also has a master's degree in substance abuse counselling. She could, I am sure, run a clinic with other counsellors and help these people.

Those are basically the areas I wanted to touch on.

The Chair: Thank you very much for your presentation. The committee appreciates your coming forward today and telling us how you feel about this piece of legislation. Your presentation will become part of the public record, and if over the course of the hearings you think of anything else that you think the committee should hear, please just write to us, and we would be interested in hearing from you.


The Chair: I call now on the Ontario Coalition of Visible Minority Women.

Ms Prescod: Good afternoon, everyone. Thank you for having me here. My name is Elaine Prescod. I work for the Coalition of Visible Minority Women as a project manager and co-ordinator.

The Coalition of Visible Minority Women lobbies and advocates for changes in legislation policies and issues that impact on the lives of immigrant and visible minority women in the areas of housing, immigration, education, racism and sexism. Those are just a few of the issues we deal with on a daily basis.

We are presently conducting a language skills training program to allow foreign educated and trained registered nurses and health care professionals, through English as a second language instruction, to prepare for the test of English as a foreign language and test of spoken English exams -- these exams are part of a series of requirements and criteria needed before they can be allowed to upgrade their skills to meet the required standards for re-entry to the profession -- and to become familiar with the health care system in Ontario.

An act is a binding and arbitrary law entrenched in the Charter of Rights and Freedoms. However, each bill of government deals with a particular area and becomes an act, which constitutes the laws pertaining to a particular issue. These bills are often very verbose and superficial, with a number of clauses and subsections, which make it sometimes impossible for the ordinary citizen to understand their content and implication.

Bill 43, the Regulated Health Professions Act, with a total of 91 sections and subsections, constitutes the laws and provides for the regulation of health professions and the delivery of health care service. Like all laws, it is legal, superficial and complicated. Being here this afternoon will allow me to deal with some areas of concern regarding the health care professions, with a focus on the nursing profession.

Statistics show that 61% of the professionals arriving in Canada are non-white and non-English-speaking. Approximately 45% of the immigrants to Ontario who were employable and would join the workforce were looking at professional or technical categories as their intended occupation.

Fifteen or so years ago, all professionals were coming from primarily European countries and familiar locales, such as England, Australia, Ireland, Wales. This is now expanded to include significant numbers from a large number of different countries, about which generally less is known and less information is available to Canadians regarding the educational system. Quite often, the candidate's qualifications are ignored.

With this large pool of human resources coming into the country, it becomes an imperative and necessary function of the occupational bodies to easily and equitably integrate these individuals into their different professional occupations. However, it has been found that the requirements have a disproportionate and negative impact on members of minority and ethnic groups.

Under section 7, the advisory council composition: My concern there raises many questions. Why the number of five to seven? Are these members representative of the diversity and varied cultural backgrounds of the people they serve?

Under section 8, the reappointment is an area of concern. These qualifications as set out in this section regarding the qualifications of the members of the advisory committee are very negative, beginning with, "A person may not." Why not turn this clause around to become a more positive statement? It should be redefined with positive qualifications for the members of the advisory council.

The next section goes on, "Members of the advisory council are eligible for reappointment." It should clearly and specifically state the numbers of times the members can be reappointed, and if there is a lapse of time between appointments, it should be clearly defined.

The same concerns are raised with the composition and qualifications of the Health Professions Board.

They go on to say, "The college is a body corporate without share capital with all the powers of a natural person." Questions arise as to what is the meaning of the "powers of a natural person" as it relates to the college? Would it not be better understood if the wording were changed to define these powers and to give recognition to the fact that the college can have all the power and authority to own assets and also to meet its obligation?

Schedule 2, section 9: "The college shall have the following committees." A total of six committees are listed in the bill. While there is a need for committees to be set up to deal with specific areas of the function of governing bodies, there is the concern that some of the smaller occupational and professional bodies may be overburdened through a lack of human resources to serve on these committees and a lack of financial resources. Although each committee as set out in the bill has a distinct function, they can also be integrated to limit the need for a large number of statutory committees.

Schedule 2, subsection 3(2), "In carrying out its objects, the college has a duty to serve and protect the public interest." While it is the main obligation and duty of occupational bodies, whether they are authorized to grant licences or certify professionals as competent, to protect the public interest in regard to health and safety, there must be a second obligation. That second obligation must be the policy of government to ensure that all individuals receive equal treatment and equal protection under the law, while respecting and valuing their diversity. These two factors should be contained in the bill and should be complementary with each other, not conflicting. The act as it now stands excludes the professional and seems to be in conflict and inequitable.


There are some issues not reflected in the bill which we would like to talk about, such as the assessment and evaluation of credentials. Studies have shown that many immigrants are coming to the country, and as stated before, several of them have already been educated and trained and have been employed in professional and technical careers before arriving in Canada. They must undergo rigorous competency tests. If English is not their first language, they must pass the required test of English as a foreign language, or TOEFL, and the TSE, where the passing scores can vary from profession to profession, successful completion of which is a prerequisite to have the opportunity of re-entering the profession.

Some professional groups, like nursing, may take foreign experience into consideration through formal test development and validation to measure that their licensure standards or certification examinations reflect recognized standards of fairness and adequate and comprehensive appeal rights.

The present assessment of professionals can lead to conflict, doubt and mistrust. There is no concern of issues to relate to individuals of ethnocultural and ethnoracial backgrounds who are professionals. Right now the entry requirements for professionals rest largely with the certifying body. Many of the requirements for entry seem to have a greater negative impact on members of minority and ethnic groups.

Accreditation of professionals is an issue, and for those who are already trained and immigrate to Canada, what is contained in the bill to deal with the concern of accreditation? As regards registration, set out in schedule 2, the bill should contain an assessment procedure to look at the education equivalent to Ontario, with specific time of practice for immediate licensure, before being required to take retraining courses.

Schedule 2, section 21, under registration hearings: Where an applicant is refused registration, it is recommended that an appeal mechanism should be enacted into law that will allow the individual to have the right to appeal the decision or decisions. The applicant should be provided with the right to review his or her admission file before an initial decision is made. There should also be a process to appeal to the Health Disciplines Board and from there on to the Divisional Court.

What is the difference between registration hearing and registration review? This is another issue of concern. When we speak to our clients regarding a registration review, we all see a review, especially in the nursing profession, as a review of nursing documents, written transcripts and references, which are for review by a registration committee. There should be a definite distinction for these two terms as they appear in the act.

What I have outlined in this report is from my understanding and interest in working with health care professionals who are foreign trained and educated, coming into this country and wanting to continue to work as professionals in careers for which they have trained. Re-entry to their profession on arrival in Canada is almost a nightmare for the majority of immigrants, especially if they face the greatest barrier to access and information, the language barrier.

Mr Beer: Thank you for the presentation, in particular the comments on the assessment and evaluation of credentials and the registration hearings. I believe you were present when the previous witness gave her suggestions, one of which was that there should be a committee on equity within each of the colleges. I wondered whether your organization had considered that or what your sense of that might be.

Ms Prescod: As you know, sir, Carmencita is my chairperson of the Coalition of Visible Minority Women and we work together very closely.

Mr Beer: I thought you might be in some agreement.

Ms Prescod: Yes, and I am in total agreement with that. We have been working very hard with the Alliance for Employment Equity. Both Carmencita and myself are on employment equity committees and we are therefore very familiar with the employment equity and I agree with her. That is why it was not in mine after she was going to talk about it.

Mr Beer: As follow-up, could I ask the parliamentary assistant, in the code, one of the six committees, number five, is the fitness to practise committee. I am just wondering, during the review was there any discussion that you or staff recall around this issue of equity, and was it intended that this would come under that particular committee, or was there any focus on this at all?

Mr Wessenger: I will ask staff to answer that question.

Ms Bohnen: The fitness to practise committee was very clearly intended just to deal with cases where there are allegations or evidence that a health professional may be physically or mentally incapacitated. The review felt that having a fair registration mechanism, including of course the right of review or appeal to the Health Professions Board, including regulations setting out admission criteria being reviewed by the Health Professions Regulatory Advisory Council, was the best way of ensuring all applicants are treated equitably.

If I could just add to that, Ministry of Health staff worked quite closely with staff at the Ministry of Citizenship charged with considering and implementing the Access report. I think it is fair to say and I do not think I am divulging anything to say that they viewed the procedural requirements and mechanisms set out in this legislation as quite some distance ahead of what is provided for in much other legislation that we have.

The Chair: Mr Owens, a question?

Mr Owens: Actually it is more of a statement.

I wanted to thank you for your presentation, along with Ms Hernandez. It certainly brings a different perspective and a much-needed perspective on the health professions. I think you may be aware that our government is currently working on access legislation that will help break down the barriers to professionals coming in from other countries. I think, again, that this is much needed.

I would like to request that the Chairperson send this Hansard, as well as the presentations of both Ms Hernandez and the current presenter, Ms Prescod, to Juanita Westmoreland-Traoré for her information, as our employment equity chairperson.

The Chair: That is noted, and we will have Hansard, as well as the presentations, forwarded to the commissioner for employment equity.

I would like to call now Goodman, Thomas Goodman, Pomerantz, Robinson and Associates. They are not present? All right, is Ross Johnson here? In that case, the standing committee on social development will recess and reconvene at 4 pm to hear Goodman, Thomas Goodman, Pomerantz, Robinson and Associates.

The committee recessed at 1548.



The Vice-Chair: I believe we have Warren Robinson next before us, of Goodman, Thomas Goodman, Pomerantz, Robinson and Associates. It sounds like a law office or an accounting office.

Mr Robinson: It is a psychotherapy office.

The Vice-Chair: Now that we have that straight, we can proceed.

Mr Robinson: To be precise, it is an office of two psychologists and two psychotherapists who are unregulated.

Basically I come today to just -- I guess I am getting old enough almost to say "share the experience of an old practitioner," as I had the weekend with two of my granddaughters. So I am feeling a little old. But I have worked for nearly 30 years in private practice, for the last 15 or 16 years as a psychologist, both with people who come under your definition of regulated and unregulated. I just want to share a body of experience that I have had working in this field with professionals of various types, because my fear around the legislation is that there is just too much limitation, too much constriction based on training, based on professional group, and not enough recognition of the wisdom and experience people have had from whatever areas they have obtained it, part of it being their own training and their own education.

For example, as I say, in my partnership we talk about causes of symptoms all the time and I do not have a sense that the two of us who are psychologists are any wiser than the two who are not. In fact, if you pushed me, I would probably say I have got most of my understanding and my wisdom, not from my graduate training at the University of Waterloo that led to my PhD, then to my being registered as a psychologist, but as much if not more from the various experiences I have had since then, the various informal training programs I have had since then. Basically I want to say please understand how much goes into making a competent practitioner. It is not solely based on one's professional training in a higher educational institute.

Two things strike me right off that I would like to speak to: One is, it seems to be ridiculous to make a difference between assessment and diagnosis. As I read it and reread it, it seems to me any trying to find some legal definition is hedging words. Diagnosis and assessment are a professional's competence that comes to bear on understanding what a person's problem is and understanding how to best go about alleviating that problem. To try to say one group can be assessed and the other group can use diagnosis, to me, will run into a lot more problems than it will solve. To me, they are basically the same.

It also seems to me that to limit diagnosis of any particular condition to a single professional group is a mistake. For example, over the last six or seven years I have been suffering from high blood pressure. I went to my physician and he said, "Here, I have some drugs for you to take." I said, "What causes high blood pressure?" He said: "We don't know that. For ninety-five percent of the people who have high blood pressure, we do not know what causes it." I said, "That's a rather strange thing." He said, "That's just the way things are." So I said, "I want to get a second opinion and a third opinion about what I can do about my condition."

I went to another physician who has a lot of training in homeopathy and naturopathic medicine and he said: "We're finding that an awful lot has to do with the kidneys, and from other assessments that I make of you, like the white spots in your fingernails, I think you have too much yeast in your system. When you have too much yeast in your system it constricts your kidneys and will increase your high blood pressure."

I said, "That sounds like a reasonable plan." I went to a dietician and she said basically the same thing. So I worked together with the dietician around my own diet and, lo and behold, my blood pressure went down to a normal level. These people diagnosed it and I would want to encourage you not to throw out the ability of people from other lines of work to really see truth, to really see how things work. I think people are very wise about how to use Bach flower remedies. In the field of psychotherapy a lot of understanding has come out in the last 10 years about abuse that I did not learn about in my professional education.

A lot has come out in terms of addiction and the impact of shame upon people's lives when they have had early childhood experiences that have induced shame. A lot of people who I refer to have done a lot of study and have done a lot of work in this area and have read people who have done outstanding work around shame and addiction. I find that I refer people for specific work quite often to people who are unregulated who have had really up-to-date knowledge and experience around new things that are developing in the field of psychotherapy.

You have, particularly in the city of Toronto -- I cannot speak for all of Ontario -- a very talented body of unregulated practitioners. I think it would be a mistake to say, "Psychologists, or physicians or whoever really have the bottom line and really know how to deal at the core of your problem," and to tie the hands of these people to really do what they can do well. There are an awful lot who do a lot of beautiful, wonderful work.

The Vice-Chair: Can I just interrupt, Mr Robinson. Please forgive me, I forgot to mention that you have 10 minutes for your presentation. If you would like to allow some time for members of the committee to ask questions, you have about three or four minutes left.

Mr Robinson: Fine. I do not have that much more to say. I am not here to present a well-documented brief. I am really here to present my experience and what I have brought to bear from my practice, so I will finish it up in another two minutes.

Basically I would recommend that there not be any difference made between assessment and diagnosis. If you need to deal with the issue of diagnosis, I can understand the need to have some teeth in the legislation that would deal with people who are either going way beyond their level of competence or who are incompetent to deal with whatever problem is coming up. That would make sense to me. I think the Coalition of Unregulated Practitioners has done a good job in terms of providing some alternative solutions. I certainly would recommend something around proposal 2 that they have presented to you, some wording that states that those who are really going far beyond their level of competence need to be controlled. I have no problem with that. In fact, I support that.

But I think we need to decide on an individual basis whether a given person, based on his own training and the experience he has brought to his work and reputation, is operating within his level of competence or not, and not based on whether he has a particular degree, MD, PhD or whatever, or a psychologist or a non-psychologist, not to rely on that as the sole criterion. I certainly agree that people should not call themselves psychologists if they are not psychologists. That needs to be there as it is in the present legislation. But not in terms of competence.

I think that is the essence of what I have to say. I just want to again encourage you not to tie the hands of the great number of wonderful professionals we have who are unregulated in Toronto.

The Vice-Chair: Thank you for your presentation. Unfortunately we have run out of time and will not be able to allow for questions at this point. I thank you for appearing before us.


The Vice-Chair: I call on Mr Ross Johnson. Welcome to the committee. I should point out that you also have 10 minutes to make your presentation. If you would like to leave some time for questions, that is entirely up to you.

Mr Johnson: I come from the other side of the fence from Warren in that I am not licensed. I am not a registered psychologist. I have a master's degree in psychology and I have been practising psychotherapy for about 20 years. My background includes working at the Dellcrest Children's Centre for about seven years as a front-line worker, supervisor and trainer. Since that time I have had a private practice and have been involved in teaching psychotherapists in training who have included people with MSWs, MA psychologists like myself, MDs and registered psychologists.

What I want to say is that although I support the major thrust of the RHPA, my big concern is around paragraph 26(2)(1), which is the diagnosis clause and the one Warren was referring to. My concern about that is that even though I think it is very important that unscrupulous practitioners not be allowed to practise and that it is important that incompetent practitioners not be allowed to practise, I think, as Warren said, there are a lot of very competent unlicensed and unregulated practitioners whom this legislation, I think, would put at undue risk.

I am certainly not asking for anything that would make it easier for me and my group, the unlicensed group, to get away with things that the licensed group could not get away with. I think it is important that not happen. But on the other hand, I think the legislation is going too far the other way. Maybe it is an overcorrection or whatever, but it feels like it is placing the competent unlicensed practitioners at undue risk.

I have not written in my letter, but I recently trained as a Shiatsu therapist. Shiatsu therapy is a pressure point therapy, mostly using thumb pressure, developed over a couple of hundred years in Japan. The heritage is Chinese medicine. It appeals to me and I have enjoyed the treatments I have had and I believe it is very helpful for people receiving the treatment.

My concern about the legislation is it will place what might be termed as the natural healers also in jeopardy for making diagnosis and for treating people. I think there is a whole group of people in our society who believe it is important to look after one's own health. I think the eastern tradition is that; one has a responsibility to eat properly or exercise properly to look after one's own health. I have some concerns the legislation will reduce the opportunity of people getting that kind of advice and learning. I think that is all I want to say right now.

Mr Hope: I guess we are trying to play with this issue of communication, of diagnosis. How do we stop those who are not capable of performing a job in the unregulated sector? They may take advantage of individuals, and the legislation is to protect people. Keeping in mind there are the professional groups and the non-professional groups, it is the general public in larger centres such as Toronto and other larger centres throughout Ontario where there is an ability for more cases to pop up, whereas in rural Ontario we kind of know where each other comes from. We hear what you are saying about trying to make sure there is still some type of protection for people.

Mr Johnson: Are you asking me what the wording might be?

Mr Hope: In your own terms, so that you are clear. Are you part of the ones that are unregulated?

Mr Johnson: Yes.

Mr Hope: We all have to have it clear in our minds what the wording ought to be. I only bounced it off you now in case you have a quick response. If you do not, I would like to hear back on that because it is important we all understand.

Mr Johnson: I think the legislation should have the same kind of expectations of unregulated as of regulated and I do not know how that might be included -- maybe the people who have drafted this legislation could come up with some wording -- but I think it would be possible to have wording that would allow a person who has gone for help to somebody who is basically grossly incompetent to have easy access to some kind of courts to deal with their misuse or abuse by the unlicensed practitioner.

Mr Owens: My question is to staff, through the parliamentary assistant. I think Mr Johnson raises an excellent point about line workers in group home situations and especially children's mental health settings where they are called on to make assessments and diagnose issues and also communicate those assessments to parents. I am wondering why the psychologists, the MAs, were left out of this particular piece of legislation.

Ms Bohnen: The review, of course, recommended that the profession of psychology continue to be a regulated profession. Currently in Ontario the issue of who gets to register as a psychologist has been determined by -- I believe it is set out in the Psychologists Registration Act and the governing body is the board of examiners and psychology and it is indeed restricted to psychologists who have PhDs.

The review knew there was a large occupational body, those with MA qualifications, who very much want to be eligible for registration -- I think they are on the agenda for tomorrow -- but the review felt that what we are doing has to do with what profession should be regulated under what structure.

The issue of who should be able to register as a member of the psychology profession is not to be dealt with at this stage, but at the next stage of the process which is the writing of the regulations under the new act which will set out what the criteria are for registration as a psychologist in Ontario. It is not that the review said, "No, you people should not be able to register." It is that the review said, "That is a second-stage issue, not one that we are looking at."

Mr Owens: In terms of how subsection 26(2) will impact on practitioners like Mr Johnson with respect to the communication of a diagnosis, which he is essentially doing, where is that going to leave that person?

Ms Bohnen: I would not necessarily conclude that is what he is doing. I think the central core of the issue the committee has been struggling with so far is trying to think of language that might differentiate between the kind of diagnosis physicians do and the kind of assessment -- I will use that word -- that many other care givers, social workers, psychometrists, psychotherapists provide. So I think the first issue is trying to carve out a distinction between the two. If you are still concerned that this distinction is not clear enough to give comfort, then another issue would be considering things like exceptions for definable occupational groups.

The Vice-Chair: I am afraid we have run out of time. I would like to thank you, Mr Johnson, for making your presentation today. We are adjourned until tomorrow.

The committee adjourned at 1621.