Monday 8 March 1993

Long Term Care Statute Law Amendment Act, 1993, Bill 101

Canadian Union of Public Employees, Ontario Division

Sid Ryan, president

Canadian Auto Workers, Local 40

Laurell Ritchie, representative

Leo Robinson, representative

Gloria Edwards, representative

Sue O'Brien, representative

Victorian Order of Nurses, Metropolitan Toronto Branch

Vicki Wootton, board member

Barbara MacKenzie, executive director

Canadian Federation of Independent Business

Pat Thompson, associate director, research

Ontario Coalition of Senior Citizens' Organizations

Dan McNeil, co-chair

Mae Harman, member, steering committee

Mark Frank, member, steering committee

Bea Levis, co-chair

Bendale Acres Home for the Aged, home advisory committee

Valerie Clarke, co-chair

Gord Blades, co-chair

Families' Association of Oaklands Regional Centre

Catherine Rhodes, member

Kit Nero, past president

Charitable Homes for the Aged in the Niagara Area

John Buma, administrator, Albright Manor, Beamsville

Jake Friesen, administrator, United Mennonite Home for the Aged, Vineland

John Janzen, board chairman, Tabor Manor, St Catharines

Gord Midgley, representative, Heidehof Home for the Aged, St Catharines

Melis Koomans, administrator, Shalom Manor, Grimsby

Idlewyld Manor

Mary Lou Dingle, board member

Daniel Oettinger, administrator

CHO Network of Ontario

David Murray, secretary-treasurer

Susan Goble, president


*Chair / Président: Beer, Charles (York North/-Nord L)

*Acting Chair / Présidente suppléante: O'Neill, Yvonne (Ottawa-Rideau L)

Vice-Chair / Vice-Président: Daigeler, Hans (Nepean L)

Drainville, Dennis (Victoria-Haliburton ND)

*Fawcett, Joan M. (Northumberland L)

Martin, Tony (Sault Ste Marie ND)

Mathyssen, Irene (Middlesex ND)

*Owens, Stephen (Scarborough Centre ND)

White, Drummond (Durham Centre ND)

Wilson, Gary (Kingston and The Islands/Kingston et Les Îles ND)

*Wilson, Jim (Simcoe West/-Ouest PC)

Witmer, Elizabeth (Waterloo North/-Nord PC)

*In attendance / présents

Substitutions present / Membres remplaçants présents:

Carter, Jenny (Peterborough ND) for Mr White

Hope, Randy R. (Chatham-Kent ND) for Mr Drainville

Jackson, Cameron (Burlington South/-Sud PC) for Mrs Witmer

Jamison, Norm (Norfolk ND) for Mr Martin

O'Connor, Larry (Durham-York ND) for Mr Gary Wilson

Sullivan, Barbara (Halton Centre L) for Mr Daigeler

Wessenger, Paul (Simcoe Centre ND) for Mrs Mathyssen

Also taking part / Autres participants et participantes:

Czukar, Gail, legal counsel, Ministry of Health

Quirt, Geoffrey, acting executive director, joint long term care division, Ministry of Health and Ministry of Community and Social Services

Wessenger, Paul, parliamentary assistant to the Minister of Health

Clerk / Greffier: Arnott, Douglas

Staff / Personnel: Drummond, Alison, research officer, Legislative Research Service

The committee met at 1005 in committee room 1.


Consideration of Bill 101, An Act to amend certain Acts concerning Long Term Care / Loi modifiant certaines lois en ce qui concerne les soins de longue durée.

The Chair (Mr Charles Beer): Good morning, ladies and gentlemen. We begin our final week of hearings. This is the standing committee on social development and we're here to discuss Bill 101, An Act to amend certain Acts concerning Long Term Care.


The Chair: The first representation will be made this morning by the Ontario division, Canadian Union of Public Employees. We'd like to welcome their representatives to the committee. Please take a seat. If we need another chair, feel free to move the camera out of the way. Once you're settled, would you be good enough to introduce yourselves for Hansard, then please go ahead. A copy of your submission has been circulated.

Mr Sid Ryan: Good morning. My name is Sid Ryan. I'm the president of the Ontario division of the Canadian Union of Public Employees. With me is Ruth Scher; Ruth is a senior research officer in CUPE. Flo Taffe is also with us; Flo is the chair of CUPE Ontario's health care committee, and also a nursing home worker. Also with us is Jim Woodward, CUPE Ontario's legislative assistant.

On behalf of the 170,000 public sector workers CUPE represents in Ontario, 40,000 of whom work in the health care field, we do appreciate this opportunity to outline our views on Bill 101 and the future of long-term care in our province.

Let us be frank: Our main difficulty with Bill 101 is that we've been asked to comment on legislation restructuring the delivery of long-term care in this province without having seen the government's detailed framework for restructuring. Although we are operating in the dark, we believe the standing committee must see the complete picture, that is, the ramifications of long-term care beyond the limits and parameters of Bill 101. Consequently, our presentation and brief will explain CUPE's concerns about the overall direction of long-term care reform, as well as deal with specific aspects of Bill 101.

As we reviewed Bill 101 and the overall plan to restructure long-term care, we were struck by the significant shift in policy approach they signal. In fact, this actually marks the end of a 20-year period in long-term care delivery and ushers in a new and very disturbing era.

We are seeing the culmination of a clash between two opposing views of society. On the one side of the battle line is the view that people have basic rights to a share of the country's resources. This view supports collective financing of human services through progressive taxation. It holds that people are entitled to health care services that are universally accessible, publicly funded and run on a non-profit basis. On the other side is the view that resources are available to be controlled and owned by a few people at the expense of the majority. This side advocates commercialization. It says universal programs which benefit everyone should be replaced by selective ones. It wants the burden of paying for services to be shifted from the tax-supported public system back to individuals.

The battle between these competing divisions has been waged on many fronts. Health care is just one of them, but it is crucial, because it has a huge impact on the quality of people's lives. We believe that commercialization must be fought, and more than that, it must be turned back. If it is allowed to expand, it will inevitably lead to lower-quality services, unequal access, lack of accountability and the danger that public policy would be even more strongly determined by corporate interests. We believe we cannot afford to let that happen.

In the area of long-term care reform, much of the long-term and acute care reform is supposed to be based on a comprehensive and expanded system of community agencies providing home care services. The government says this approach will meet the needs of the elderly by allowing them to live at home, in their communities, instead of going into a hospital or another long-term care facility. The idea sounds sensible: It appears to give people more options, more choices. But let's take a look at what's really happening.

First of all, despite the promise to maintain chronic care hospitals at their existing levels of service until the chronic care roll study is completed. A number of these hospitals have been forced to close beds and restrict services to seniors and people with disabilities. But where are the community-based services that are supposed to provide the cushion for what's taken place in the chronic care system? Secondly, the huge cutbacks that are taking place in our acute care hospitals will result in thousands of jobs being lost and beds closed. Front-line services are simply disappearing into thin air almost overnight.

Seniors occupy 50% of acute care beds. The Senior Citizens' Consumer Alliance for Long-Term Care Reform has pointed out to the government that the closures and cutbacks in acute care will force tens of thousands of seniors to seek more appropriate care from the community-based home care agencies. Again we ask, where are these agencies? Where are the expanded services that take the place of the substantial ones that have already gone missing? What's the plan?

We don't believe there is a plan, at least not one that aims at delivering equivalent services. The plan constructed by the government is really all about cutting back service and care and placing the burden of responsibility back on the shoulders of individuals and families. For a variety of reasons, the elderly, people with disabilities and their families may not request home care services but may prefer some other setting, such as along-term care facility. With a freeze on nursing homes and homes-for-the-aged beds and the reduction in chronic care hospital beds, there will simply be no real care alternatives for families. Waiting lists will be so long that matching the appropriate facilities to the care needs of the individuals, including ethnic, linguistic and geographic preferences, will be virtually impossible.

We'd like to focus on where we believe the burden will be placed as a result of this change in direction of long-term care: We believe women will be hit the hardest. Under this new plan, there will be a lot more pressure applied by the proposed placement coordinators to push people into providing home care. Think about it this way: If you cut beds, services and people from the acute and chronic care part of the system, and if you take into account that waiting lists will grow even longer for long-term care facilities, the only place left to put people is either back in the home or out on the street, kind of like what happened not too long ago when the mental health care was supposedly shifted from hospitals to community-based services. While hospital beds were closed, the necessary services never materialized, and ex-psychiatric patients were left to fend for themselves.

Now, as last Saturday's Globe and Mail reports, thousands of vulnerable adults live in squalor, in unregulated rest homes and boarding houses. Most of these bootleg nursing homes are horribly understaffed and living conditions are deplorable. Owners hire mostly unskilled and untrained workers because they are too cheap to hire higher-paid health care aides and RNAs. You can't close down all the options and then call it choice; it's anything but. It's actually a forced march back into the earlier century. And it's women who will bear the brunt of this new order, because despite important political advances that women have made over the past decade, to a large extent they are still the primary care givers in the home; that means there's going to be more pressure on women, not less, to take on either a triple burden of responsibility or withdraw from the workforce entirely.

This plan is an attack on all the hard-fought gains that women have made through their unions and political organizations. That fight for equality has been waged on many fronts. To get into the paid workforce in the first place and get out of the low-paid job ghettos, it has been a struggle for pay equity, for employment equity and much more. Now we are seeing an orchestrated plan that once again relies on women to fill in the cracks, and they are expected to do this in the absence of any meaningful child care programs, which are absolutely crucial. In fact, 15,000 families are on the waiting lists for subsidized child care. Over the last year, more than 1,000 child care spaces have actually been lost from the system. How on earth do we expect anyone to cope in this kind of climate?

Women workers who are actually in the workforce will also be hit hard. The long-term plan will also adversely affect women in the area of paid work. The health care system has long been recognized as a ghetto of lower-paid, predominantly female employment. Since 1974, there has been steady progress made in advancing the employment status of all unionized institutional care workers.

Just when collective bargaining and pay equity had begun to address these inequities, the government's strategic plan is to transfer work to the community sector -- traditionally lower-paid work.

Thousands of decently paid, secure, unionized positions in institutions will be eliminated and replaced by low-paying, less secure, unorganized jobs in the community. This, of course, will all end up being a boost for the commercial operators.

There are some other problems with the government's approach to home care. We fear we may see an accelerated expansion of the private sector into this area. Since the 1970s, Ontario's drift to for-profit service provision has proceeded by both design and default. But with this plan to restructure, we now proceed by design to throw open the doors to the private sector, and that's bad news for workers, for consumers and for the idea of a publicly funded, not-for-profit system.

As an example, in 1978-79, the number of home care hours provided to Ontario residents was 82% non-profit and 18% commercial. By 1988, the ratios had shifted to 62% non-profit and 38% commercial. At a CUPE conference last fall, the former Health minister, Frances Lankin, stated that the ratio was now closer to 50-50.

Obviously, the increase in the commercial sector has been at the expense of the not-for-profit sector. This will result in a greater inability to develop, monitor and enforce standards of care. And it means money, our money, is simply skimmed off the top in the form of profit. If you think health care dollars are scarce now, just wait and see what happens when the for-profit sector expands.


Between 1976 and 1989, seven out of 10 provinces reduced the number of private nursing home beds. But in Ontario, the percentage of private beds actually increased from 47% to 54%, making this province the biggest supporter of the private sector in the delivery of extended health care services.

In addition, the Ministry of Health has assured the for-profit nursing home industry that funding for homes for the aged and nursing homes will be equalized this year. We are absolutely and vehemently opposed to this funding plan. It will further entrench and enrich commercial nursing homes at the expense of homes for the aged. We need an immediate conversion strategy to turn for-profit nursing homes into publicly owned, not-for-profit homes, not a policy that makes the commercial sector even more viable.

The serious problems with the underfunding of the entire health care system are mirrored in Bill 101. In recent years, the financial contribution by the provincial government for long-term care facilities has not kept pace with the increasing demand. We will need to see more money, not less, infused into long-term care. But the bill does not include any adequate funding commitment from the province and, worse still, as we've mentioned, it shifts dollars from the non-profit sector to the for-profit commercial sector.

We do not believe that health care should be structured for the benefit of private entrepreneurs. We also believe that the service provided by the for-profit care centre is actually inferior. Through long and bitter experience, we have found that the quality of care in for-profit nursing homes is generally inferior, as are workers' wages, benefits and working conditions. There are so many examples of residents and staff in for-profit nursing homes being mistreated that we would have to devote an entire brief to this issue alone. We do not want to paint all the for-profits with the same brush. Some commercial homes do a good job. Some of the smaller mom-and-pop operations went into health care because of a genuine interest in the care part of their operation. But things changed when the corporate chains started gobbling up these smaller homes. In our view, inadequate health care is not the exception in these homes; it has now become the rule.

A few years ago, one nursing home decided to lay off a large number of health care aides and turned the home into a GM-style operation, a health care assembly line. Night shift workers were told to wake up patients at 5 am to get them dressed and ready for breakfast. The staff, who had always given full sponge baths each morning to residents who couldn't walk, were given new instructions. They were ordered to wash only the hands and faces of the residents. Other areas were to be washed "only if required," whatever that meant. And to save even more time, the brilliant administrator ordered the staff to reduce the distribution of medication from four times per day to twice a day. Consequently, some residents began receiving double doses of their medication.

The commercial system also lends itself to the maltreatment of paid staff. CUPE has taken legal action against nursing home owners for retroactive pay that was freely negotiated or arbitrated and for the misuse of pension funds. For example, one nursing home chain owes the nursing homes' and related industries' pension plan between $400,000 and $500,000 in employer and employee contributions. The owners have deducted these moneys from the employees' paycheques, but have refused to send them to the plan.

There's also a problem with private nursing homes in that they are not monitored correctly. We believe the private nursing home industry in Ontario has not been adequately monitored or properly held accountable for the considerable revenues it obtains from residents and the provincial government.

In 1988, the Ministry of Health residential services branch changed its system of inspection from one based on enforcement to one based on consultation. The net effect has been to allow private nursing homes to remain largely unaccountable for the services they provide, except during the pre-announced annual inspections conducted by the ministry.

We've pointed out some flaws in that system and would like to reiterate them here today.

The 1990 Provincial Auditor's report pointed out the flaws in the current inspection and compliance system. Here are some of the findings:

-- Over 40% of homes did not receive any visits in addition to the annual licence renewal. Additional visits are important to ensure standards are met throughout the year.

-- Homes were not being referred to the enforcement section for further monitoring and investigation.

-- Long advance notice of licence renewal reviews could allow a substandard home to temporarily comply with requirements.

Our experience with the new compliance system is that it fails as an approach. For example, in 1984, 20 homes were charged, 497 charges were laid and 117 convictions resulted. In 1989, a year after the ministry changed its system of inspection, zero homes were charged, zero charges were laid, and obviously there were no convictions.

What we need are tougher rules. This situation cannot be allowed to continue. If the regulations are not tough enough, they then must be toughened up and they must be enforced. Ministry contacts told CUPE that the Nursing Homes Act and regulations are not fully enforceable as a result of previous court decisions.

These technicalities do not let the ministry off the hook. If the act requires amendments, this should be rectified as soon as possible. We have already wasted too many years dealing with a toothless piece of legislation.

Some briefs submitted to the standing committee have expressed concern about the expensive bureaucracy they think will result from the enhanced inspection and enforcement mechanisms. We strongly disagree. The provincial government has a responsibility to ensure that its funds are being spent wisely and that resident care conforms to provincial standards.

We can see why some homes would resist this change. They like the status quo, because under the current system of compliance, they are not being held accountable. Without a strong enforcement mechanism, inspections were nothing to fear. Now that they will be forced to conform to prescribed standards, they are worried. In our opinion, this is a good sign. It means the government is on the right track.

CUPE strongly supports the posting of service contracts in each home. At long last, both residents and staff will be able to know what services the home is expected to provide and thus will be able to ensure that these expectations are fulfilled.

An important element, of course, in the enforcement is the ability of the employees to bring forward concerns, and we believe we need whistle-blowing protection. If the government is really serious about ensuring that standards and facilities are adequate and that residents are receiving the proper levels of care, then it also must incorporate whistle-blowing protection into the bill.

It is the residents and staff who can monitor a service agreement better than anyone else. It is therefore essential that they be legally protected from any owner reprisals and, further, that they accompany the all too infrequent inspection tours.

It is clear that the ministry is not up to policing infractions. We have seen ample evidence of this time and again. Ministry officials are not the ones forced to live their lives daily with substandard and often dangerous conditions. Residents and employees are the very people who are not only knowledgeable but have the greatest stake in well-run nursing homes and homes for the aged.

In terms of the placement coordinators, in theory, at least, there is something positive to be said about the role of placement coordinators in bringing some order to the system. However, in the reality of declining institutional care and the completely inadequate supply of non-profit beds in the system, there is a real risk that the placement coordinators will become nothing more than the foot soldiers of government policy, marshalling the elderly back into their homes and apartments because there is nothing available in long-term care facilities.

We don't want the placement coordinator function to exist simply to do the government's dirty work. The government must address the fundamental inefficiencies in the system and must ensure that more non-profit beds are opened up for people who need and want them.

The appeal process outlined in the bill is completely inadequate as a dispute resolution mechanism. It's not one that is going to be either effective or fair to an elderly person who isn't happy with his or her placement or, probably more to the point, lack of it.

People are often not happy in the facilities in which they find themselves. They want to get out of a bad situation and they want to get out fast. They don't want to wait several months or more, and they certainly don't want to have to go to court and take on a government bureaucracy.

We think the process outlined is an inappropriate use of government power wielded against a single citizen. It represents the worst approach to resolving conflict. That heavy-handedness is also apparent in that it allows one single member of the appeal board to constitute a quorum.

We believe this entire section of the bill must be thoroughly redrafted. It must be redrafted in the context of more non-profit beds being opened up and, more specifically, must spell out to the consumers their choices of where they may want to live, and what kind of facility must at all times be taken into account.

As it stands now, this section of the bill appears to have more in common with an axe that can be held over the head of an elderly person than a tool to assist them.

We would like to highlight some areas where we believe waste is apparent in the system. We have outlined some of the problems with Bill 101 and with the overall plan to restructure long-term care. All these shifts and redirections are taking place because of money, or rather, lack of it.

While the government pleads poverty as an excuse for cutting services and boosting fees, the Health ministry is virtually tossing cash out the window. Sadly, it shows no interest in cutting the extraordinary waste that robs money from vital services.

There are plenty of opportunities for substantial savings. The most obvious, of course, is to eliminate the for-profit service so that health care dollars go into health care rather than corporate bank accounts.

I'd like to highlight here what happens to taxpayers' money when profit is involved. CUPE believes there's an inherent conflict between profit-making and quality of care. We have argued this point time and again with commercial nursing home operators and with key bureaucrats in the Ministry of Health. Each time we opposed the equalized funding scheme for nursing homes and homes for the aged, the commercial owners said a discrepancy in care between the two types of homes was because of the difference in funding. That's simply not true. A nursing home's desire for profit ultimately affects how it spends more money, no matter how much it receives from the government.


In fact, the Ministry of Health has proven this by its own study of the form 7s. Form 7s are the audited financial statements that nursing homes are required to send into the ministry each year. Attached to the end of the brief is a Ministry of Health document entitled Summary of Form 7s. As you know, about 11% of the nursing homes are non-profit; the remainder are for-profit. If you look at page 10 of appendix 1, you will see that the total revenue column indicates that in 1990 and 1991, total revenues were slightly higher in the for-profit homes than in the non-profit homes; 3.8% higher in 1990 and 3.5% higher in 1991.

But when it comes to the expenditures side, these are the startling conclusions that CUPE found:

Salaries and wages: Non-profit homes spent, on average, 8% more on salaries and wages in 1990 and 11.2% more than for-profit nursing homes in 1991. This is a positive development, since the average nursing home worker earns considerably less than a chronic care hospital worker, although their work is almost identical.

Resident care expenditures: We added up the following line items: continence care products, medical and nursing supplies, raw food costs, dietary supplies and services, housekeeping supplies and services, and laundry and linen supplies and services. On an average per diem basis, the non-profit nursing homes spent 37.3% more than the for-profits on these resident care items in 1990. In 1991, the non-profit homes spent 42.2% more on these products and services. So this should tell the standing committee where the priorities of the non-profit home lies.

Indirect expenses: This is where the commercial nursing homes are spending excessive amounts of money. On items such as management fees, consulting and professional fees, rent, mortgage interest, other interest, depreciation and other expenses, the for-profit homes spent 60.3% more than non-profit homes in 1990 and a whopping 65.8% more in 1991.

It is quite clear that for-profit and non-profit homes have different funding priorities. Non-profits put more money into resident care and salaries, while for-profits funnel a significantly higher proportion of their revenues into so-called indirect expenses. Let us be clear: This is how they're making their profits.

There are some other interesting points you might like to know. If nursing homes are claiming depreciation costs at 2.6%, as stated in 1991, and have been receiving tax relief for these costs, why are there between 10,000 and 14,000 beds in non-compliance in the province? Have the for-profit nursing homes used depreciation as a tax haven without spending these resources on upgrading their facilities?

These homes have claimed depreciation as a loss. We wonder if it is only a paper loss, which the rest of the taxpaying public has subsidized for many years, over and above the considerable revenues the homes receive from the provincial government.

We'd also like to address the question of corporate concentration of the nursing home sector. In 1991, 62.8% of the nursing home beds were owned by corporate chains. The breakdown of revenue and expenditures by ownership type, group-owned versus single-owned, is listed on page 11. We would like to point out that nursing home chains are even less cost-effective than their single-owned counterparts.

One would have thought that owning several homes would reduce the indirect expenses on a per capita basis, since a nursing home chain could presumably operate with the benefits of economy of scale. Unfortunately, the facts point to a completely different financial dynamic. Nursing home chains spent 24% more than single homes on indirect expenses in 1991. We wonder if parent companies are engaged in some form of transfer pricing by charging excessive amounts of rent, mortgage interest and management fees as a way to hide profits.

We are not clear where the money is going, but we would like the standing committee to recommend that the provincial government request the full disclosure of this financial information in the interest of the residents and the taxpayers of Ontario who are funding these operations.

Finally, if the commercial nursing homes are paying so much mortgage interest, we suspect their capital investments in these homes are minimal at best. Highly leveraged mortgages funded out of these per diems could easily be transferred to municipalities or non-profit societies. After all, it is clear that the banks and mortgage companies are in fact the real owners of these facilities. Surely, it would be in the public's interest for these moneys to be spent on resident care rather than on so-called indirect expenses.

Based on this evidence, we urge the standing committee to recommend that the government transfer commercial nursing homes to the municipal or not-for-profit sector.

Until the transfer is complete, we further urge the committee to recommend that the proposed equalization of funding between nursing homes and homes for the aged be postponed until expenditure directives are put in place requiring all for-profit homes to spend a minimum amount on all residents' supplies and services and on salaries and wages.

Strict limits should also be placed on the amount nursing homes may spend on indirect expenses.

If you step back and take a look at what's happening to health care workers, the picture is pretty grim: 1,500 to 2,000 jobs are going to be lost in homes for the aged due to the changes in the government's funding plan for long-term care facilities. Add to this the more than 3,000 hospital jobs that are disappearing due to this so-called reform and you get some idea of the enormous changes taking place in our health care system.

The people we are losing are irreplaceable. They are the very people with the training, experience and expertise needed in any reformed system. All the health care restructuring currently taking place is doomed to failure if one of the most important parts of the system -- the workers who are the skilled, front-line people -- are simply thrown out.

That's why we want job guarantees. We think laid-off hospital and homes workers in one part of the system must be given first crack if jobs open up in another part, and we want those workers to be paid at their equivalent salary levels. You can't have it both ways. If you want stable service delivered by experienced workers, you have to pay for them and you have to pay them what they're worth. Otherwise, we'll continue to see high turnover rates and unskilled people delivering crucial care.

In conclusion, a major assault is being launched against working people in this province and in this country. It's orchestrated by the federal Tories who have cut billions of dollars in cash transfers to Ontario for health and education.

Sadly enough, it's being enforced and assisted by a government that should know better. With good reason, we are beginning to lose confidence in the ability of the provincial government to take on the huge task of restructuring our health care system on its own. To do this effectively requires health care unions and consumers to be involved at the highest level of decision-making.

Former Health minister Frances Lankin agreed unions needed to be more formally involved in the decision-making process and this is how we would propose doing that: a guarantee of health care union representation on district health councils, equal representation on the Joint Provincial Planning Committee, currently made up of government and Ontario Hospital Association reps, and regular monthly consultation meetings of health care unions with the Minister of Health.

I would like to bring my remarks to a close now and thank you for your attention. I would just like to point out that a full summary of our recommendations is included at the back of our brief and we ask that you consider them carefully. If there are any questions, I would be happy to answer them. Thank you.

The Chair: Thank you very much for your presentation and for the document and attachments you've provided us all with.

I'm afraid our half-hour is complete. We began at 10 after, on my watch here. I'm in the hands of the committee, but the problem is that we started late and I think we're going to have to bring this presentation to a close, unless members -- I regret it's a very --

Mr Larry O'Connor (Durham-York): Perhaps one round, one question each -- maybe short.

The Chair: I'm just concerned about our time. We are late and we're going to be late and we have a very full day. I think there's plenty of material in here as well as in the presentation, and I want to thank you for coming before the committee today.

Mr Ryan: Thank you.



The Chair: If I could then call on the representatives from the Canadian Auto Workers, Local 40. Welcome to the committee this morning; we're glad to have you. Would you be good enough to introduce yourselves, and if I could just note that if you would like some questions we could allow a little time. We have half an hour from when you begin but, in fairness to others, I'm afraid we have to keep to that schedule. So, please introduce yourselves and then go ahead.

Ms Laurell Ritchie: We will be placing our comments in writing and getting them to the committee within the next few days.

I would like to just take the opportunity to introduce myself, Laurell Ritchie from Local 40, Leo Robinson and Gloria Edwards, who work at Nucleus Housing, and Sue O'Brien, who works at Participation Apartments. As well, we have Irene Millar, Marjorie Stuart and Tony Sewell, who also work in these projects.

First of all, happy International Women's Day, and we hope you will keep this in mind as we make some of our comments. Frances Lankin, as Minister of Health, has already been quoted some while ago. We want to quote another statement that was made: "We've got one last chance to reform the long-term care system, so we better do it right. That's why we're here: because we don't think it's being done right. We are here to address the specific concerns of our members in five of the province's support service living unit programs, better known as SSLUs. We favour some reforms in this system, where it makes sense and does not reinvent the wheel, but with the current initiatives, we see some potential for disaster.

The government's 1991 consultation paper called SSLUs "a very successful example of supportive housing for adults with disabilities. The projects are cost-efficient, providing support care staff in each building who are available around the clock. The underlying philosophy is one of independent living with a high degree of self-directed care for these disabled adults. There is a total now only of 1,000 designated SSLU apartment units spread throughout a number of apartment buildings in Ontario.

In Metro Toronto, where our members work, there is a total of 270 such units. The official waiting list in Toronto includes some 976 disabled adults. This is actually a remarkably large number, given that the existence of these projects is not widely advertised or known. Notably, more disabled women have been accessing SSLUs in recent years. These projects are already popular and working well as a community-based middle option between what is called institutional care and, at the other end, isolated living situations on one's own or with one's family.

As workers at the ground level, the delivery end of the system, our members are witness to the real-life consequences of the government's long-term care agenda as it appears to be unfolding. We are not here to talk about theories but to talk about what is actually happening or beginning to happen to human beings and to an SSLU system that was operating effectively.

Support care workers, the majority of whom are women and workers of colour, are most certainly concerned about their jobs and working conditions, and they have every right to voice those concerns. What some may not appreciate is the complexity of their concern and the insights that can be gained from their recent experiences. Some entered this field of work because of a special interest or predisposition in services for the disabled in our communities; others grew to appreciate the concerns of disabled adults as they went about their day-to-day work with them, providing a physical and emotional support system. Finally, most of our members are also concerned because, perhaps more than most, they realize how quickly one's life can change if oneself or a family member becomes disabled, and of course they know that most of us will confront the issue of care in our own old age. So long-term care is a subject matter close at hand.

Bill 101 can be fairly characterized as a technical piece of legislation, one that reflects the intended overall redirection of long-term care but which also denies us an opportunity to debate the guts of that redirection. What is clear, however, is that Bill 101 does reflect a move to commercialization and privatization. It gives a green light to a shift of public dollars from non-profit services to the profit-making commercial nursing homes. Such a shift will inevitably infect the provision of other services, including SSLUs. SSLUs cannot ultimately be quarantined from this rationale. As time goes by, the rationale used in one service area will be cited by those looking to turn a private profit in another sector.

We also want to ask whether legislators have forgotten to take into account what this could mean in the context of a North American free trade agreement, with its extension of investment codes and the right of national treatment for foreign firms in its expanded term for services. This is all the more so given the new disciplines under the proposed NAFTA on provinces. We need only think of the problems with what I think we would call the rapacious greed of some of the giant US enterprises in the private health care sector to begin to appreciate some potential problems there.

We also challenge the shift of dollars to the private profit-making sector because it represents an unnecessary burden on the public purse. Why should any part of our health and social service dollars go into private pockets?

We also want to talk about the failure to ensure decent funding. We see no commitment in Bill 101 to provide reliable and decent levels of funding for the very successful support service living unit programs or any other service area covered by the bill. In fact, the very future of what the government called a very successful model is in jeopardy with the funding cutbacks.

With the funding cutbacks, it is difficult to imagine anyone calling SSLU a success story for much longer. The joint ministries of Comsoc, Health and Housing have gotten away, to a considerable extent, with describing SSLU funding, for the next two fiscal years, as a freeze. The reality is very different. Many projects built up their services and numbers of disabled-tenant units on a budget that incorporated both a base budget and, for many years now, a so-called special one-time funding budget.

The base budget is indeed frozen, but on the other hand, the special funding is being deleted in its entirety. Accordingly, cutbacks in services which already have many constraints on them must occur. Even now services are strained, as we witness a disproportionate number of high-care tenants moving into SSLUs, presumably on the government's assumption that those with lower care needs should simply stay where they are.

We want to look here at two of these projects, both Trimbee Court and Humberview Co-op, which are administered through Nucleus Housing. Because these are non-profit projects, about 85% to 90% of labour costs are associated with support-care staffing, so the only real place to cut back, of course, is in those labour costs. Specifically, at Nucleus Housing, as of April 1, just a few weeks from now, we are told that some 7,500 service hours must be trimmed from the services that are available there. That means cutbacks in staffing complement, which in turn means that the disabled tenants -- they have expressed this themselves in letters to the government, and some already are undergoing reduction in their meal-time service booking times -- face the prospect of getting up at 4 am or 5 am instead of 6 am or 7 am in order to arrive at work, because many of these people do have jobs. In independent living situations that is a possibility, but as disabled people they already have long days of 12 hours, because what takes you or me perhaps five minutes takes a disabled adult much longer. With those extensions, the 12-hour day becomes a 16-hour day or more. It has impacts on health and it certainly has impacts on the social and family lives of these persons.

It also means reductions in personal care. Treatment times -- for example, bowel and bladder treatments and procedures -- must be fitted into available staff hours, as opposed to being self-directed. It will reduce the times when they can call for non-booked time assistance from staff, either for emergencies or for other forms of assistance that are given. It will reduce the washing and hygiene times. This not only compromises the health and safety of disabled tenants; it potentially jeopardizes their jobs if they are late for work, and in general, forces them to fit their lives into an extremely regimented existence.


In short, SSLUs would appear to be on their way to becoming mini-institutions, the exact opposite of what was intended by the deinstitutionalized option for disabled adults. This would be a sad day. If anything, the supportive housing model is one that should be expanded upon, not only for the disabled in our community but for seniors looking for options other than living in isolated apartments or moving into nursing homes. We note that the CAW retired workers' executive submission of March 1992 in speaking about seniors said, "It is the physical structure of particular institutions that needs to be examined. Our question would be: Could a chronic care bed not be delivered under the roof of a group home seniors' apartment or a retirement community? We think this is one such model that would address that. However, having said that, there is no point in extending an already underfunded system; and that's where it is.

For support care workers in these projects, the redirection agenda sets the stage for -- and we're already beginning to witness this because April 1 is rolling around and the agenda is being laid out for us in meetings with management and boards, often made up of tenants as well as outside administration. We're confronting, as I said, already or down-the-line layoffs, reduced shift hours for part-timers. In the case of Nucleus, anybody working less than 40 hours a week is considered part-time. If you want to work 38 hours a week, you're part-time, and those people are being hit with reduced shift hours; fewer shifts on a schedule -- again for those who are classified as part-time; swing shifts, working an evening shift and moving on to a day shift the next day -- these are not things that were happening before; speedups, as they move between shorter booking times between apartments, increasing stress and the chance of injury, particularly back injury, where they do lifts of disabled tenants who in turn will risk falls and injury.

Cuts in benefits: This we believe was never dealt with properly or addressed properly in looking at funding. The reason the cuts in benefits are on the horizon is because private insurance companies are significantly increasing their premiums, and I mean significantly, in part to match the phenomenal growth in prescription costs occasioned by the recent federal drug patent legislation, to be made worse with the more recent legislation passed there, and dental charges under the Ontario Dental Association's fee guide.

We see as well the erosion of pay, not only because people will be and are working reduced hours and other forms of remuneration, because if you're not full-time, you're a part-timer and part-timers do not have benefit coverage and more are falling into the category of part-time. We see housekeepers being told that their rates of pay, which are far from healthy, must now begin to compete with the homemakers: may face the prospect of competition with the homemakers' associations where people are earning $7 to $8 an hour. These are the same women as housekeepers in these projects, who just recently tackled the problem of these traditional female job ghettos to get equal pay for work of equal value; and we'll use the legislation there to achieve that.

On a more ironic note, these are the same workers whom the government has recognized in recent years as being underpaid in comparison to similar work being done in institutions and went through phase 1 and 2 upward adjustments to those rates. Phase 3 never developed. I say "ironic" because this was the money they used to call the beer money. We never saw phase 3.

A stressful work environment is the other prospect here. As we have read the government's redirection plans, the prospect of having an Alzheimer's patient in one apartment in the building and a spinal cord injury victim in another is not a prospect for anything other than more and more stress. Here we also face the problem of displacement, quite frankly, by those RNAs who are being squeezed out of hospitals and into institutional settings and who now have to register with the health training and adjustment board presumably to move into the kinds of projects where our members work, and with that goes an increase in standards but based on a health model. A lot more discussion has to happen on this particular model being enforced within SSLUs because we don't think it's appropriate in all circumstances. It's extremely time-consuming and costly for a lot of our members to look at the prospect of retraining to meet these so-called standards that are being talked about. It's going to be especially hard on the women, who typically have less formal schooling although most have done this job for many years and quite successfully. We have tried to get in on the reference group that is looking at this issue, but we are told that now there are 29, 30 members of this committee and the doors are closed; there will be no others brought in to participate in the committee's deliberations on standards. So we have that fear.

Finally, we have concerns about the placement coordinators and service coordination agencies and the powers that would be vested in these coordinators, subject, of course, to a costly and time-consuming appeal procedure. We believe that this is going to present considerable problems for those in SSLUs or trying to access SSLUs. The community boards are certainly highly politicized and have a traditional bias to those parts of the sector that are based on the health model.

To close, we want to suggest, and we will attach it to our final document, that an examination be given of some of the data on waiting lists now for SSLUs. The one we have is for the Metropolitan Toronto area, and some of the things are quite fascinating. For example, as a total, the largest group seeking entry into SSLUs is those disabled adults currently living with their parents or their spouse or other adult. In other words, the idea that everybody wants to or should be living in a home environment is not one that is shared by all those in the disabled community. We also find in these numbers that there are those who are disabled and senior, and we also find a large grouping of those who are at the young adult level who are obviously seeking some privacy and dignity to operate on their own in a supportive community.

In summary, we think the direction things seem to be headed in flies in the face of the much-touted phrases about care and service and choices. As workers and as citizens, we don't think the choices we see are real choices at all: institutions with fewer spaces, community-based projects like SSLUs with inadequate funding, home care with stressed-out older parents, primarily mothers, to provide 24-hour care, or highly privatized outreach services to isolated dwellings with all the problems that entails. We believe that in some cases the wheel is being reinvented and that in other cases, where reforms are needed, the cart is being put before the horse. Certainly municipalities agree with us on that one. In a time of economic crisis, the last thing we need to do is repeat the experience of the deinstitutionalization of psychiatric patients. That is where we see things headed and we're very upset and very angry, because we're facing this day in, day out, even as of the last few weeks.

The Chair: Thank you very much for your presentation, and as you indicated, we'll circulate a copy of your remarks when you send it in, but of course we have it on Hansard in terms of what was said this morning. We do have some time for questions.


Ms Jenny Carter (Peterborough): I certainly appreciated your presentation. It was a rather different emphasis to most that we've had. I particularly appreciated your mention of NAFTA, which I think could be a factor we would have to look at in the field of privatization and the general situation.

We had a presentation from a gentleman who I believe was living in an SSLU. He referred to something you didn't mention, and that is that the act provides for direct funding for people to hire their own care providers. He was suggesting that if there were suitable accommodation for disabled people to move to and funds to hire their own care providers, then there are people in SSLUs who would be ready to leave them and move to a more independent lifestyle. I just wondered what your comments might be on that.

Ms Ritchie: Others of our delegation may want to comment on that, but that's a subject that has been discussed with management. Some of the tenants are also on the board that constitutes management. I would say that we come at this one from a different approach than the tenants who are part of the management situation. As we listen to them, quite frankly, I suppose we might characterize it as somewhat naïve. I think that from what we've heard in those discussions, a lot of the disabled tenants we're talking about have the idea that somebody is going to give them a pile of money and that they will be able to hire what amounts to a full-time companion. We have had discussions before.

We've already seen problems in the discussion of these so-called outreach projects. First of all, right off, we had problems because management, in talking about experimenting with these outreach projects, which is more or less what you're talking about, said that the problem with having the labour contract collective agreement apply was that the collective agreement provides for a minimum of four hours' call-in pay, either work or pay for four hours. They said that under an outreach program they couldn't possibly guarantee that anybody would get four hours' work or four hours' pay.

In general, I think the problem is that somebody somewhere has encouraged them to think they're going to have 24-hour companion care. I don't know whether somebody wants to reveal the name -- I won't suggest it myself -- but we know that there are already people who operate outreach projects on these private models who are saying -- well, you used the phrase.

Mr Leo Robinson: Yes. Actually, what he says is that if someone's got a bowel accident or something like that, he might have to wait for quite a few hours before he could get somebody to come and take care of him.

Ms Carter: I think people --

The Chair: I'm sorry, Ms Carter; I'm afraid we're tight for time. I'm going to have to move on. Ms O'Neill, last question.

Mrs Yvonne O'Neill (Ottawa-Rideau): I really thank you for coming this morning. I've felt from the beginning of these hearings -- and I've been here since day one -- that the disabled have not had the profile they needed in this. The whole basis was just on this direct funding, which we don't know very much about. I would like you to say a little bit more about your recent problems regarding the deletion of the special funding and the service hours, because we've had one witness in Windsor who talked to us a little bit about her own personal experience, a disabled individual, but we haven't certainly had what you seem to be suggesting is a real trend, so could you say a little bit about what kind of messages you're getting and, if you want to, who you're getting them from?

Ms Gloria Edwards: I work in SSLU Nucleus Housing and, as my colleague was saying, if they have an outreach and they have an accident, they will have to wait a couple of hours. In the SSLU with 24-hour care, if you have an accident, you can call someone on the pager, on the phone and they'll be there in a matter of minutes to take care of you. That's where you're dignity is concerned. No one wants to lie around in a mess or be dirty or anything like that.

The thing is that the care is one on one. They may be disabled but their mind is not disabled. They can tell you what they want. You do not have to go by a paper that you do this or you do that. You learn about this person. You grow to care about these persons, their likes and dislikes, how they like their hair, how they like to dress, what scent they like, what foods they like, and you go along with that.

Taking this away from them is like throwing them right back where they wanted to get away from, to come into community living.

When you cut their service hours, it's like going back and saying, "You have to do this," and they have no choice in saying that. "I want to get up at 6 o'clock." You say, "Due to service cuts, you have to get up at 4 o'clock." There's no choice.

Mrs O'Neill: What about the special funding? What does it cover?

Ms Edwards: Basically, what's been happening for the last number of years is that it's one of those things where there was a category called special one-time funding, but it got carried year after year after year and got worked into the budgeting for the projects. They took on new units. They took on staff to go with those increased units and so on. Now the word out there is there's a freeze, but as much of a problem as that would be, that is not the whole story because a significant segment of that budget is being withdrawn. There will be no more of the special one-time funding.

Part of what has been treated by these projects -- and not just the ones we're representing -- has been treated as part of the regular budget. I'm not going to comment on the advisability of having gone that long in that way, but at this point, the only real resolution of that is to incorporate into what is the base budget.

Otherwise, those units are at risk, and certainly if the service hours of those units aren't cut out of the system, then the only option is to reduce the service hours. We've just gotten faxed copies of new schedules even as of Friday. It's one of the reasons this is not all typed up, because we're battling now on these fronts with people being moved on to swing shifts, having their hours cut, and that includes many women who are single parents or whose income is very crucial to the family. Their hours are getting cut. There's more than one side to this.

Ms Sue O'Brien: It also meant 1% increase in our wages last year. We're talking zero this year and zero next year. It's affecting quality of service, quality of living on both fronts, for clients and for people in the workforce. Choices are very limited and I appreciate your comment in terms of there's not enough said about this sector. It really needs to be talked more about before pushing through all this legislation. We need to be heard to be able to express our concerns on both sides.

Mrs O'Neill: I thank you for your perspective.

The Chair: Thank you very much. I apologize that we're out of time. Just on a personal note, having paid a visit to Nucleus Housing, I think at the Humberview Lodge, I was very impressed with all the work that was being done there. I wish you all the best in the future. Thanks, again, for coming.

Ms Ritchie: We could do with some more beer money.

The Chair: I had a feeling that wasn't just for entertainment.

The Chair: I'd like to call our next witness, the Victorian Order of Nurses, Metropolitan Toronto branch. As we get organized here, we have to get a few wires set up, so we'll just get that done or perhaps it's already been done.

Mrs Barbara Sullivan (Halton Centre): Mr Chair, while that's being done, I wonder if I could ask if ministry officials would provide us with a clarification of changes in funding for the SSLUs. I think that would be useful.

The Chair: We'll note that request and get that information.

Mrs O'Neill: If I might just add to that, particularly the special funding component of it, if that could be broken out over the last three to five years, that will be very helpful.

The Chair: All right, fine. In order to get all our technology straight, we're going to need a one-minute recess, I've just been informed. So if everybody wants to take a one-minute recess, so stretch, get a cup of coffee and we stand recessed for one minute.

The committee recessed at 1112 and resumed at 1113.


The Chair: We'll now reconvene. Perhaps I might first of all say welcome to the VON, Metropolitan Toronto. As we have said on many occasions to other VON representatives, we appreciate what I guess I would call a full-force frontal involvement in this committee. We have found it extremely useful and we welcome you here today. Perhaps you would be good enough, first of all, just to introduce yourselves before beginning the presentation.

Ms Vicki Wootton: First of all -- can you hear me? -- we'd like to thank you for inviting us to make the presentation. Deborah Simon is director of client services for VON Metro. Barbara MacKenzie is the executive director of VON Metro Toronto. I'm Vicki Wootton. I'm a member of the board.

As you say, many VON branches in VON Ontario have made submissions to this committee, and so as not to wear out our welcome, because there are more coming -- I looked at your agenda -- we would like to focus on those concerns that we would like highlighted.

First of all, though, I'd like to tell you a little bit about VON Metro, just a quick summary of who we are. We were one of the original branches established in 1897. We're the largest non-profit nursing agency in Canada and certainly the largest one necessarily in Metropolitan Toronto. We also serve the largest, most diverse area in Canada -- six cities -- and last year we made something like 500,000 visits to clients.

The kinds of services we have are the visiting nursing program, where we provide both acute services and long-term care or chronic services, shift nursing, that is, for people who would normally be in the hospital for some circumstances, but we're able to look after them in the home because of shift with our volunteer visiting program, and a big component of that is palliative care visiting. We have dieticians on staff as well to provide service.

We have specialized expertise in a number of areas including maternal and child health, palliative care, enterostomal therapy and so on.

VON has a number of partners. Our biggest partner is Home Care Program of Metropolitan Toronto. We are a major provider for that agency. We're also in partnership with the United Way and many of its agencies. There are universities, colleges and high schools, and by that we provide placements for students, medical students, nursing students, RNAs, so they get a good taste of what it's like to work in the community and look at the other side of that. We've been doing that for a long time.

We work in partnership with hospitals. Much of the move to deinstitutionalize some of the procedures and the length of stay in hospitals is because agencies like VON are able to pick up a lot of that work and provide it in the community, provide the care. We work with long-term care facilities as more and more of their clients are at the other end of the spectrum where they require heavier care. VON works in partnership with these agencies to work with the nurses and the aides to perhaps show them how to start IVs, if that's going to be done, or to provide heavier care requirements. As well, we work with other community agencies and providers.

Our most important partners, however, are our patients and their families. The goal of VON Metro nurses is to get those patients back on their feet and get them taking some kind of responsibility for their own health and wellbeing, so the partnership is very, very important with the patient and family.

Being a community-based agency with nurses right in the community is quite a challenge. We're working in extremes. Our nurses might look after a newborn baby and mother; on the other hand, they look after a sizeable number of senior citizens to help them manage in the home. We cover the whole gamut of health status. Health promotion is a very important component, but we also do palliative care for terminally ill patients. The site of service can be in a very affluent neighbourhood with single residential homes, or it can be in a high-density, publicly subsidized housing unit.

Also, we have an extreme volatility in the service demand. We can be asked to provide service within one or two hours or will provide service on a planned schedule basis, and that requires a lot of responsiveness.

One story that we're very proud of: A few weeks ago, we had a gentleman call on a Friday morning. He wanted a nurse to go to Poland and pick up his father and bring him home. The father required someone to accompany him on the plane. This gentleman had tried quite a few agencies. He got to VON. Within two hours we were able to find, first of all, a nurse who was willing to go to Poland on the weekend, which was extra time for her; second of all, one who could speak Polish; and third, one whose passport was up to date. In three or four hours we were able to provide that service. Now, I call that very, very responsive.


Our staff and our volunteers, as I said, have worked in the most ethnically, culturally and racially diverse area in Canada and our staff speak something like 36 languages, so we're able to provide quite a bit of service that is culturally and linguistically sensitive.

We are also a very responsible, accountable provider. While the legislation before us does address quality assurance, VON has had that in place for a long time -- many, many years. We're not into a quality management framework that guides all of our service delivery and our management activities. We have a very well defined strategic plan that's updated regularly, and different strategies and objectives are tied into our annual budget. We know exactly where we are in any kind of endeavour.

Our board members and staff have all participated in multicultural, anti-racist training and, as well, we've been fully part of long-term care redirections since its inception.

We feel that there are a lot of strong points in Bill 101. First of all, we applaud the fact that it initiates standardization of long-term care facility legislation. That's long overdue and we support that. It also promotes a more coordinated access to services. It enhances accountability and quality assurance and introduces a uniform method of funding. Again, we do support that direction. It empowers people with disabilities and it also attempts to control unreasonable or excessive costs.

We do have some concerns, however. Our concerns all come around the issue of choice and consumer control. We support the right of the consumer or the consumer's surrogate to choose the site of service. An institutional site is not always the site of preference for the consumer. Some people require that services in the home would be more in keeping with what's right for them and we would like to see that addressed, that people have a choice of where they want to be cared for.

Another major issue is the facility of choice. This is of paramount importance, particularly in an area such as ours where we do have a large number of people from different races and backgrounds. Picture, if you will, yourself, supposing you were to go into a long-term care facility. You don't speak the language that's the language of use in that facility. You're not used to the food; you don't understand the people, the other residents there; you're isolated from your family. You can see how lonely, isolated and frightened you would be if you were put in one of these facilities. Instead, what we're advocating is some choice in facility that will meet your needs.

Our other main comment and concern is that we believe the appeal mechanism must be much more timely and flexible. Supposing a person is already in a facility. We want to see the appeal mechanism kick in very, very quickly. You shouldn't have to wait a long time in a situation that you are uncomfortable in. We also believe that the facility's inspection process is rather prescribed, as opposed to consultative. We don't see chronic care facilities or rehab facilities included in this legislation and, overall, a lot of the changes are incremental rather than comprehensive.

In summary, we advocate for legislation that empowers the consumer, that promotes sensitivity to cultural, racial and ethnic diversity, particularly as it affects Metropolitan Toronto, and most of all, legislation that supports choice. We invite any questions you may have and we'd be happy to answer them. Thank you.

The Chair: Thank you very much for your presentation, and we'll move right to questions. Mrs Sullivan.

Mrs Sullivan: Thank you very much. I think all members of the committee have expressed their appreciation to the VON in various communities who have appeared before us, and I think one of the things that's been useful is that we've been able to see the diversity of operations of the VON across the province through presentations to us.

I'm interested in your written presentation. Under "Issues and Recommendations", just to follow on from what you've presented, where you indicate under section III a suggestion that would mean that financial boundaries or caps could be provided through a funding envelope for clients, how do you see that funding envelope working, directly with clients or directly through agencies? I'd like to hear more on that particular point.

Mrs Barbara MacKenzie: The reason we didn't give a lot of information on that was we understood that you had heard an awful lot of them from VON Ontario and that their presentation encompassed that.

We wanted you to understand that we don't think that services could be provided without some kind of financial constraints, because there are limitations. So we basically support the concept that VON Ontario presented, and that could be done by the consumer having the choice of determining whether, with the funds that are available, that service be provided in the community, and were there enough funds to support the services that they would require. Does that answer your question?

Mrs Sullivan: I think so, yes. I thought that we had another question here.

The other question I wanted to ask but which once again isn't in your presentation but moves one step past Bill 101, where we have the placement coordinator, looks towards the multiservice agency. One of the issues that is of some concern, certainly in my community, is that organizations which have had a viable and strong community identification may lose that identification. Can you speak to that?

Mrs MacKenzie: That's a concern to VON in general and to VON Metro. The largest component of what we do is currently done through the Home Care Program; about 96% of what we do is through the Home Care Program. Currently, we have registered nurses, registered nursing assistants and dietitians as well as our volunteer component, but we don't have the homemakers or health care aides or generic workers, so we are still waiting with great anticipation and interest for the more definitive implementation plan that we're all expecting before the end of the month. We have been trying to --

Mr Jackson: The month?

Mrs MacKenzie: I guess we've been saying that for a few months.

However, we would like to be able to ensure that there is a place for VON. We feel very strongly that the part that VON has played in the community for a number of years is something that's valuable and shouldn't be lost. We feel that the enhanced value that our volunteers, both those who are involved in friendly visiting and palliative care visiting, as well as the involvement of the volunteer board of directors that we have, adds a great additional value to the community that could be lost if VON were not around as an organization as it is today.

Mr Jim Wilson (Simcoe West): Thank you very much for your presentation. I think any members who have ever had any dealings with the VON realize very quickly how important your services are to our own families and our constituents.

Because this is our last week of public hearings and during the break next week, which is March break, each of the caucuses will be putting together, and we've already begun to put together, amendments to this legislation, in your presentation you make a point that your branch has already adopted and has in place quality management practices. I'm wondering, on the page entitled "Issues and Recommendations" at point IV, you talk about Bill 101, that it's built on an adversarial-confrontational model rather than being consultative, if you can you expand on that, because we've heard that and I've asked many witnesses as we've been on the road during these hearings to give us some examples or ways we can improve the legislation to get some of this adversarialness out of it.


Mrs MacKenzie: We also referenced the Woods Gordon study that was conducted in 1986, and I think many of the recommendations that were made in the Woods Gordon study could be helpful in looking at the consultative model rather than an adversarial-confrontational model. This was raised as an issue based on the segments of the legislation about the powers of inspectors, and it really is introducing a new inspection process to some types of facilities that haven't had that in the past and yet from a perception viewpoint have provided a good quality of care over the years.

I think that the quality management, if we look at identifying agreeable outcomes and have a consultant approach looking at the outcomes and planning with facilities or providers, how they can improve the results, would lead to a better quality of care than an inspection or enforcement type of operation.

Mr Jim Wilson: I appreciate you reinforcing what many other groups have told us.

You mentioned in your oral presentation the need for a more timely and flexible appeal process. I was wondering if you had an opportunity to look at the eligibility criteria for admission that are contained in the draft manual and whether you had any comments on that, because while I think we can put some amendments forward that might improve the appeal process, I'm worried that we're looking at a very medical model and a model that says you have to exhaust all community-based services before you can be admitted to a facility. In my area of the province we don't even have the luxury of arguing about many of these community-based services; we simply don't have them that you may have in Metro, and if we didn't have the VON we'd have basically no in-home services at home. Do you want to just comment on that?

Mrs MacKenzie: I'm not familiar in great detail with the eligibility criteria, but I think that the recommendations we have made are around consumer choice. We'd like to see this be consumer-driven and feel that the consumer should be the one who is directing where his services are provided.

Mr Jim Wilson: Okay. We'll do our best there.

The Chair: Thank you. Mr Owens.

Mr Stephen Owens (Scarborough Centre): On page 10, when you talk about the facilities inspection process being prescriptive, not negotiated: Could you explain that for me, or clarify it a little bit further?

Mrs MacKenzie: I think what we're talking about there is the same as the adversarial-confrontational model, where the inspector comes in, sees, gives reports, people will reply, is the same type of confrontational model rather than something that's negotiated looking at consumer outcomes and outcomes of care.

Mr Owens: I agree, having had some experience with the organization in Toronto in a former life, that your group has already done all the right things. In other presentations "total quality management" is the new managerial buzzphrase that is around -- I guess it's the newest megatrends or in search of excellence book that's come out.

My concern, however, is that we've had some fairly spectacular examples of nursing homes that have been left to their own devices or have been involved in this internal responsibility process where things have broken down. When I look at the inspection process that's listed, I don't see it having an adverse effect -- if VON, for instance, were running a facility and doing the good things that you're doing now, I don't see how that would have a negative effect. I would see that in some facilities where things aren't happening as they should.

I'm currently looking at a situation in my own riding where things have broken down -- I would suggest fairly seriously -- and we can't seem to get things done because we don't have the muscle or the teeth, whatever words you would like to use to describe that. So how do you balance that, the good work that's going on in some homes versus the not-so-good work that's going on in other places?

Mrs MacKenzie: You're right, quality management is the latest buzzword, and I guess one of the things that we've tried to look at is, what is it that the consumers want and need, how well are we doing that and how can we do it better? As the consumers' needs change, we need to be responsive to those needs and we need to look continually at how we can better do that.

When we talk about prescriptive rather than negotiated, if all the effort that is put into a prescriptive or adversarial process could be directed towards making the improvements that the consumers -- whether they're consumers in a nursing home, or homes for the aged, or other type of facility or in the community, if all of that could go towards trying to make things better, then perhaps the results would be better and meet the consumers' needs more appropriately, what they want.

The Chair: Thank you very much for coming before the committee today and making your presentation. We appreciate it.

Mrs MacKenzie: Thank you very much. We appreciate the opportunity.

The Chair: I would then call upon our final witness for this morning, the Canadian Federation of Independent Business. Just as we're waiting for that representative to come forward, could I indicate to committee members that the 2 o'clock group will be unable to come. What I would suggest would be that we start at 2:15. I suspect the 2:30 group would be here, and that would mean we could get through our afternoon with some dispatch. If I could also ask the members of the subcommittee if we could just meet very briefly at the end of this morning's session, I would appreciate it.


The Chair: I want to welcome the Canadian Federation of Independent Business. If you would be good enough just to introduce yourself, then please go ahead with your presentation.

Mrs Pat Thompson: Good morning. My name is Pat Thompson. I'm associate director of research with the Canadian Federation of Independent Business. The Canadian Federation of Independent Business is a non-partisan, non-profit organization representing independently owned Canadian-operated enterprises across Canada.

On behalf of our 40,000 members who do business in the province of Ontario, including those who operate private nursing homes, we welcome the opportunity of presenting this statement on Bill 101, An Act to amend certain Acts concerning Long Term Care.

Mr Chairman and members of the committee, against the backdrop of the outright attack by the Ontario government on private-sector service providers in the province, the Premier of the province has now called for action on ballooning government debt. Just a week ago, after a meeting with the premiers of Saskatchewan and British Columbia, Ontario Premier Bob Rae stated that, "Change must be the order of the day."

Now, the small business sector in Ontario applauds this sentiment. It is time for the Ontario government to drop its attack on private-sector service providers.

Mr Cameron Jackson (Burlington South): It's time for the government to change. I thought that's what you were going to say.

The Chair: Order, please.

Mr Jackson: Did Hansard get that, Mr Chairman, I hope?

Mrs Thompson: I shall continue.

It is a well-established fact that an aging population increases the demand for health care and related services and, furthermore, that the cost of this increased demand strains the resources of even the most successful economies. If the demand is to be met, it is essential to mobilize a full spectrum of care resources, drawing from both the private and the public sector and welding them into an efficient, flexible service catering to the changing needs of the elderly, within the means of the taxpayers.


Let's look at the government's attack on private sector service providers. To date, the Ontario government's strategy with regard to the delivery of health and related services has been formulated without proper recognition of the vital role played by independent operators. Indeed, any participation in social care giving by the private sector appears to be anathema to this government. It is time for a change in direction.

In the case of child care, the government's strategy has been to eliminate the private sector centres and switch to a public sector child care system. In its child care reform public consultation paper of January 1992, the government stated its preference for developing the public sector. I quote: "Central to this effort will be non-profit services. We believe that the best way to use public funds to improve the quality of child care is to direct them to publicly accountable non-profit services."

The government subsequently backtracked on its contention that public sector child care equated with better quality care, an unjust claim which, central to their original strategy but not substantiated, was both challenged and overturned.

The document then made the ridiculous and wrong-headed statement that, "Child care, like health care and education, is simply too important to be left to the influence of market forces."

Meanwhile, the government announced that its first step in switching to a public sector child care system would cost taxpayers $75 million without adding a single extra child care space.

Next, let's look at the long-term care issue. The Ontario government's public consultation paper on long-term care, which came out in October 1991, also laid heavy emphasis on the public sector, stressing that one of the government's goals was a "continued preference for a not-for-profit service delivery system of long-term care." This preference, confirmed by a speech by the minister in July 1992, would be given the power of law by Bill 101, which if enacted without amendment would set the scene for increased difficulties for private nursing homes.

The current maze of legislation concerning long-term care is confused by the existence of many discrepancies and anomalies and we therefore welcome the government's attempt in Bill 101 to develop the same set of regulations to treat all types of residential homes alike. However, as it stands, the provisions of the bill lead to considerable uncertainty on the part of private nursing homes on the role they can expect to be playing in the long-term care system of the future.

The proposed new service agreement system is central to the new approach. However, since service agreements must be renewed every year, funding could vary from one year to the next, causing major difficulties and uncertainties for independent nursing home operators in terms of their business planning.

Furthermore, the legislation also states categorically that the minister may provide capital funding for a non-profit nursing home, entrenching in the new law the consultation paper's continued preference for a not-for-profit delivery system. Taxpaying private nursing home operators find it ironic that taxpayers' money should be used to develop public sector nursing homes while the private operators themselves face the prospect of increasing uncertainty.

Furthermore, this provision could enable the current Ontario government to effectively move in and take over private nursing homes along the lines of the current strategy of socializing child care operations. Uncertainty will lead to inaction and, if the government does not fill the breach, will result in fewer facilities when the need is for more. This is clearly a serious equity matter.

As a matter of policy, earlier Ontario governments decided that residential care for the elderly should be provided by both public sector and independent operations. Private sector business people have taken the risk. They've invested their capital and they've played a major role in fulfilling the crucial need of caring for the elderly. It is unconscionable that a business person should invest his savings in a business operation, fulfil a major need in the local community, provide an essential community service and then face the prospect of expropriation of a lifetime's work by the current government based on ideological grounds. This has already happened in the area of child care and appears to be the strategy with regard to independent nursing homes.

Now, who's next? The government's strategy of attacking the private sector service providers has already permeated many other areas within the health and related services sector, three of which I'm going to look at today.

In particular, the private home health care operators have real cause for concern at the present time.

These independent operators currently provide about 45% of the home health care services across the province and play a crucial role in enabling many of the elderly and the disabled to remain in their own homes. This is a vital service which can only grow in importance. Furthermore, these operators provide an efficient, innovative and flexible round-the-clock service for their clients, while their public sector counterparts are more likely to confine themselves to a rigid 9-to-5 regime. If delivered by the public sector, the spectre in future may be that these facilities will close down on weekends, as many hospitals effectively are doing now. These independent operators, too, face growing uncertainty. Against the backdrop of the government's declared preference for a not-for-profit delivery system of long-term care, they are aware that they are currently the subject of government scrutiny and that a new system is on the drawing board which will virtually eliminate referrals to the private sector operators.

Another example is afforded by the case of the independent ambulance operators. All operators, independent and public sector alike, are rigidly governed by the Ambulance Act of Ontario and are subject to inspections, both pre-arranged and impromptu. All of this is as it should be. But the Swimmer report would change all of this. This report and the subsequent consultations held on its proposals led to widespread uncertainty and worry concerning their future among the independent ambulance operators who, like other private sector service providers, have invested heavily in their operation. To date, the provincial government has not acted on the radical proposals contained in this report, which was effectively a blueprint for converting the existing system of private and public operations to a public sector service. We strongly recommend that the government totally reject such proposals and focus instead on making the public/private sector mix of operations work better to get maximum value, efficiency and service for taxpayers' money. Similarly, the government should ignore the self-serving pressure by public sector unionists for these operations to be now reclassified as crown agents.

Meanwhile, independent operators are also experiencing unfair subsidized government competition in service areas which until recently have been exclusively met by the private sector. A particularly blatant example is to be found in the area of home respiratory services. This is an area which previous governments, as a matter of policy, decided not to get into and which has been fully served by private sector business people who have invested heavily to provide a vital service in the community. At the beginning of this year, a hospital in southern Ontario started to provide the subsidized service, with obvious advantages over existing private sector operators as far as referrals by medical staff are concerned. A senior official of the hospital concerned made no bones about the reason for embarking on this particular commercial venture, noting that the program was designed to capture a portion of existing markets in the community.

Finally, I come to our conclusions and our recommendations. The demand for health and related services, including nursing home facilities and home health care, can only escalate with the aging of the population. At the same time, however, the provincial deficit is ballooning and the province's taxpayers, both individual and corporate, are suffering from tax exhaustion. Under these very serious circumstances, it behooves government to ensure that the taxpayers' money is being used wisely. The government has a clear responsibility to provide the best possible care for the recipients of social care services within tight spending constraints.

Just a week ago the Premier of the province expressed his deep concern over the debt problem facing the country and stated that change must be the order of the day.


In the interest of containing public expenditure and obtaining the maximum value for taxpayers' money, we recommend that the Ontario government now change track and adhere to the following guiding principles:

(1)Government must retain the private sector/public sector mix. In an era of growing pressures on taxpayers' money, sharply rising provincial deficits and a skyrocketing public debt, a skilled blending of private and public resources is required if we are to adequately address growing demands on the system.

(2)Government must focus on making the existing system work better, creating an efficient, effective and economic service.

(3)Government must ensure that the cost of the overhauled system is kept within the means of the taxpayers of the province, now and in the future.

(4)Government must recognize that businesses need to be able to plan, and should act accordingly. For example, the uncertainty generated by the proposed service agreement for private nursing homes, as put forward in Bill 101, could well constitute a major obstacle to sound business planning.

(5)Government must recognize that business owners have invested heavily in their operations. Therefore, if the government makes major changes to the rules which adversely affect private sector operators, it is paramount that these operators should have the choice of either staying in business or receiving fair and proper value for their business.

(6)Government must separate the impulse to feed the interests of public sector unions from the need to provide a service to the public. To claim, as some unionists have attempted to do, that an independent operator providing such a service should be regarded as a crown agent is totally inappropriate and should be rejected outright.

The Chair: Thank you very much for your presentation. We'll move right to questions. Mr Wilson.

Mr Jim Wilson: Thank you for your presentation. Although you mention you're a non-partisan organization, I appreciate you coming forward and pointing out some of the obvious flaws in the government's strategy, with this legislation in particular and in the direction of long-term care the government wants to take us in with the particular socialist twist it's got on it. I'll tell you, my caucus colleagues and I very often feel that we're the only ones out there screaming for the private sector, so it's encouraging, and has been encouraging, during this round of public hearings that many, many operators have come forward, and business associations.

I want to deal head-on with the word "profit". It seems to me that this government while in opposition was very effective at sort of changing the language of Ontarians, no longer talking about capitalism or free markets; in fact, labelling those as bad things, telling the public out there that "profit" is a dirty word, that if Mr and Mrs Smith own a nursing home, somehow they're evil, they've been ripping people off all their lives, that they made a profit. There's a fundamental lack of understanding by this government, its members and the unionists in that they don't understand business, that profit is redeveloped, that profit is generated back into capital.

I want you to take a couple of minutes and give us a little lesson about profit and where it goes, and maybe make the public out there -- because we are on TV -- a little more comfortable with the term.

Mrs Thompson: In this particular context, I think what we have to remember is that the private sector operators who provide the type of service we've been talking about today -- child care, long-term care -- are basically committed professionals who are doing a job which they have been trained for and which they have dedicated their lives to doing. The so-called profits they make, the so-called wages they receive, are, generally speaking, lower than what is received by their employees. They do not make much out of this.

Let's just backtrack a little bit. We have here a situation where people have put their life's savings into their business. They've invested, they're providing a service to the community, they are providing employment to local people. They themselves are not making much money at all. Very often their wages are lower than those of their employees.

What we're seeing at this present time is an increasing attack by the government on these people. We've seen it in the area of child care. I understand that today we're not looking specifically at child care, but this is the area that is right out front and centre. We have it in the area of the nursing homes.

If you take a look at this particular piece of legislation, you'll see that the service agreement is central. The service agreement, as it stands in this bill -- which presumably is going to be amended -- is an area which is going to cause a tremendous amount of uncertainty for these people. They have invested their money and they are now finding themselves in a situation where they're not able to plan; they're not able to plan their next little while.

Let's just take a look at the small business sector in general, the confidence level at the moment as far as small business is concerned. Small business confidence is very low at this moment in time. The government's attack on these businesses, these private services providers, is a large contributory factor. Just take a look at what's happened over this last couple of years since this particular government has been in office. We've seen a situation where company registrations have fallen by a quarter. We've seen a situation where, over the past two years, business bankruptcies are up by 70%. Why should anyone invest under these circumstances? Yet the government still expects the small firms to continue their record of job creation, for which the small business sector received recognition during the 1980s and is still effectively carrying out at this present time.

Mr Jim Wilson: Just to look overall at this government, it seems to me that it's playing a bit of a game here with the public in an attempt to salvage its ideology and to salvage many of the speeches it's given in the past.

I think of just two quick examples where the government seems to want to rely heavily on the private sector. One is the leaseback of the GO transit rolling stock: Essentially, US companies are going to buy rolling stock and will be able to depreciate that rolling stock on the backs of the US government in terms of tax breaks and depreciation, and the Ontario government will lease back the rolling stock over a period of years. It's one area where the Treasurer has already moved to have a reliance on the private sector, and you could argue that those US firms are, rather than what they used to call corporate welfare bums, now becoming government welfare bums. None the less, Floyd Laughren and company will benefit from them. The second one is the Treasurer floating around the idea of leasing back our computer systems. Again, the private sector will be asked to buy them, and we'll lease them back and get a benefit from that.

So on one hand there seems to be some recognition -- in two areas anyway, and there are many other examples -- that this government has learned a few lessons in the last two and a half years. But then we look at this legislation and at the direction the government has been going in terms of health care and social services, with its continued preference for the not-for-profit sector. I wonder whether they really are just playing a game here, whether the idea of these committee hearings has been -- because it really is boiling down to private sector bashing and the private sector having to defend itself, with the public sector and the unions coming here and bashing away at independent operators. That has become much of the focus of these hearings, rather than the content of the legislation that needs to be addressed. I wonder if that isn't part of the plan: Let's have CFIB pitted against the unions, and let's continue to do this ideology, the divide-and-conquer society, so they can go ahead and keep closing the hospital beds and they can go ahead and keep driving private operators out of day care and out of the nursing home sector. Because all the public sees is this fight between profit and not-for-profit, and it's a bit of a red herring. Do you have any comments on that overall picture?


Mrs Thompson: I understand what you're saying. However, you have to also bear in mind that last week the Premier of the province indicated that change must be the order of the day. Now, as I indicated in my presentation, we applaud this.

Mr Jim Wilson: You didn't say what type of change.

Mr Jackson: Change the government.

Mrs Thompson: Drop the attack on the private sector.

Mr Jim Wilson: But at the same time he makes that speech, he goes to other countries and totally hammers the private sector and any trade agreements.

The Chair: Can you can answer the question? I'm afraid we're going to have to move on.

Mr Jim Wilson: It's part of the dual personality, I think.

The Chair: Mr Owens.

Mr Owens: Thank you, Chair. I want to thank you for your presentation. Needless to say, I have some difficulties with some of the assertions you've made in your presentation. Starting with page 3, when you talk about turning the facilities into rigid 9- to-5 regimes, you talk about hospitals that are effectively closing down on weekends. Can you let me know what hospitals are effectively closing down on weekends?

Mrs Thompson: Oh, I think this is an area that you yourself must do your own research in.

Mr Owens: Well, you've made an allegation here. I'd like to know which hospitals your group found were effectively closing down on weekends.

Mr Jackson: Joseph Brant Memorial Hospital --


The Chair: Order, please.

Mrs Thompson: You don't need to do your research; your colleagues have indicated.

Mr Owens: In terms of the preparation for your brief, are you familiar with the group called Concerned Friends?

Mrs Thompson: Why do you ask this, sir?

Mr Owens: I'm asking whether you're familiar with the group called Concerned Friends.

Mrs Thompson: There are a number of different organizations.

Mr Owens: Let me tell you about Concerned Friends. Concerned Friends is a group of seniors who act as advocates for seniors in the province. If you look at the back of the room, you'll find a person by the name of Freda Hannah, who is involved with this particular group. It might be instructive for you to go back and have a chat with Freda about some of the situations that are going on in nursing homes today. Further, if you had read the Globe and Mail's Focus section on the weekend, an article by Jock Ferguson and a sidebar article by Paul McKay talk about some of the things that are happening in for-profit nursing homes here today. I don't think it's a situation of pitting non-profit versus for-profit. This is real life. These are people who are not being treated appropriately. These are stories of these owners you talk about. Absolutely, there are people out there who are doing their jobs, working hard and doing the right things, but there are a lot of folks out there -- again, you can sit down and talk with Freda Hannah about some of the things that are happening out there.

One of the private sector unions you take an indirect shot at made a presentation earlier this morning: the Canadian Union of Public Employees. These are figures that come from the Ministry of Health itself on form 7s that come into the ministry. Part 2 of their analysis from the ministry talks about resident care expenditures. I'd like you to tell me, when I'm finished this list and give you the differences in percentages, which you feel your organization feels could afford to take the hit in terms of the differential expenditures: continence care products, medical and nursing supplies, raw food costs, dietary supplies and services, housekeeping supplies and services and laundry and linen services. It goes on to say: "On an average per diem basis, the non-profit homes spent 37.3% more than the for-profits on these resident care items in 1990. In 1991, the non-profit homes spent a full 42.2% more on these products and services."

In the view of your organization, which of these services -- again, continence care products; medical and nursing supplies; raw food costs; dietary supplies and services; housekeeping supplies and services and laundry and linen supplies and services -- in the view of your group, which of those should have taken the hit?

Mrs Thompson: I would point out to you, sir, that I am here representing the small business sector. I think that is the sort of question you should put to specialists in the field.

Mr Owens: With respect, you've come in here and taken a shot at the government. Your group has come in and started a new specialty in health care. I'm quite aware of what sector your group represents.

Mr Jim Wilson: Mr Chair, point of order.

The Chair: I think we'll just allow the witness to answer the question. That has to be her answer.

Mr Jim Wilson: On a point of order: Mr Owens, those statistics are out of order. Many of those non-profits don't pay property taxes or have the overhead the private sector has, yet the private sector has a smaller per diem. I suggest CUPE go back and incorporate all of the costs --

Mr Owens: On that point of order, Chair.

The Chair: Order, please.

Mr Jim Wilson: I can come up with a different list than Mr Owens.

The Chair: Order, please, Mr Wilson.

Mr Jim Wilson: I didn't get a chance this morning to pick on CUPE.

The Chair: Order, please. We are here to hear from the witness. A question has been asked. We have to allow her to answer that as she wishes. Do you have any further comment you wish to make on that last question?

Mrs Thompson: Thank you, Mr Chairman. I appreciate your intervention. I would like to return with some statistics of my own which in fact are not my own; they're the government's statistics. Let's get back to the central problem here. The central problem we're looking at is the increasing demand on the health care system. There is increasing demand on the system because the population is aging. Now I come to the statistics, and these are statistics I'd like you to think about.

The number of old people aged 65 years and over is going to increase over the coming 25 years from 1.1 million to 2.2 million. It's going to double, okay? That means that the proportion they make up of the total population is also going to increase. It is going to increase- -- and these are the government's own figures- -- from 11.5% of the total population up to 16.5% of the total population. The really old people, those who are aged 75 years and older, are also going to double in numbers, and their proportion is going to increase from 4.5% to 7.5%. There is a major problem looming before us with regard to the provision of care for the elderly.

Mr Owens: Absolutely.

Mrs Thompson: The recommendations I have made today, the guiding principles I have put forward today, are put forward in order to find some solution to the existing problem we all find ourselves in. It comes back to taking the services provided by the private sector -- the independent operators -- and the public sector and welding them together into an efficient system.

The Chair: Final question, Mrs Fawcett.

Mrs Joan M. Fawcett (Northumberland): Thank you for coming before us. Of course, this has been quite a battle as we have had these hearings: the private versus the public systems. Certainly I appreciate your comments on the independent ambulance owners too, because I've certainly had that problem brought up to me by the independent ambulance owners in my riding, who are really concerned that the government is systematically trying to devalue their businesses and then buy them out at a lower rate. That's another whole question as well.

If I could just carry on from what CUPE said this morning, there was one interesting statement where it said: "Permitting nursing homes to be run for profit under a lenient system of legislation and an impotent system of inspection is a measure of societal negligence we can no longer allow to continue. When an institution becomes the only answer for the care of an elderly person, it must be one that is run on a principle of loving care, not one of tender loving greed."

I wonder about that statement. First of all, the government talks about allowing everyone choices in life and yet it wants to certainly eliminate that whole system of choice. I wonder if you could just expand on your thoughts on that statement. Also, does one government-run deliverer of service, in your mind, ensure quality care? If we go to one system only, the government-run system, how can we be sure? I have been in both kinds in my riding, and we have good private care and good public care. I'd just like your comments.

Mrs Thompson: I would like to return to the guiding principles that I put forward. I think that we should retain the private sector/public sector mix and make it work better. We've got to have a more efficient system. Private firms are not averse to regulations. They welcome regulations. They want to provide a good service. This is the reason that they went into business in the first place.

They've invested their life's savings, very often, in order to set up their business and they are dedicated professionals. They're not making a lot of money out of this. In fact, many of them are taking less out of the business than their workers are receiving.

You should take the existing public sector/private sector mix and make it work better, but you've got a problem down the road inasmuch as the population is aging and the demands on this system are going to become very heavy. So you've got to ensure that the cost is kept within the means of the taxpayer.

I think that in reviewing the existing system of long-term care, the government must also realize that businesses need to plan and the government must act accordingly. It mustn't create this environment of uncertainty which many private operators are labouring under. We've got this situation in child care at the present time, and clearly there are difficulties in this legislation as far as the nursing homes are concerned.

I think also that the government must realize these private sector firms want to remain in business. They've set up their operations. This is what they have basically studied for. This is what all their expertise is moving towards. The business, for many of them, is basically their whole lives. I think the government has to recognize that too.

As far as the reference to greed is concerned, I would reject that completely.

The Chair: Thank you very much for coming before the committee.

We'll now stand adjourned until 2:15 sharp this afternoon when we'll reconvene. The committee stands adjourned.

The committee recessed at 1213.


The committee resumed at 1417.


The Chair: Good afternoon, ladies and gentlemen, and welcome to this afternoon's session of the standing committee on social development. As I noted this morning, the organization that was to come at 2 o'clock was unable to do so, but the 2:30 group is here and, it being 2:15, we thought we might as well get started. So I would invite the representatives from the Ontario Coalition of Seniors Citizens' Organizations, if you would be good enough to come forward and take a chair, a glass of water, a couple of coffees, whatever, and make yourselves comfortable. If you would be good enough just to introduce yourselves for the committee members but even more importantly for the purposes of Hansard, then please proceed with your brief. We have received a copy of it. Welcome to the committee.

Mr Dan McNeil: Thank you very much. I'm Dan McNeil and I'm co-chair of the Ontario Coalition of Senior Citizens' Organizations.

Miss Mae Harman: I'm Mae Harman. I'm a member of the steering committee.

Mr Mark Frank: I'm Mark Frank, a member of the steering committee.

Ms Bea Levis: Bea Levis, co-chair of the Ontario Coalition of Senior Citizens' Organizations.

Miss Harman: Thank you for the opportunity to make a presentation on long-term care. The Ontario Coalition of Senior Citizens' Organizations, which I will refer to as OCSCO from here on, is an umbrella organization of seniors' organizations in Ontario. It came into being at the time when the federal government was attempting to de-index old age security. Its interests have broadened since that time to include a variety of seniors' concerns, including long-term care, auto insurance, taxation, universality and many others. Membership in OCSCO presently includes 46 different groups which have a total membership of approximately 300,000.

OCSCO was one of three organizations comprising the Senior Citizens' Consumer Alliance for Long-Term Care Reform, which held 16 days of hearings and two forums involving the principal stakeholders in long-term care. Mark Frank is going to present our major paper.

Mr Frank: Before I deal with the actual text that you have in front of you, I want to explain that I may be departing from the text in the interests of time, and since you said we were early, I assume we have 15 more extra minutes on our time. However, you'll bear with us.

The Chair: The Chair is always open-minded on these matters.

Mr Frank: Before I get into the substance of this brief brief, we and I cannot let this moment go by without commenting on this important and auspicious day, March 8, which is the day of our appearance. It marks the Canadian and worldwide celebration of the achievements of women throughout the decades, their struggles for equity and against their senseless victimization. It also marks their renewed dedication, along with their allies', to better respond to the challenges and issues that still confront them.

I want to draw your attention to the button I'm wearing. You cannot see the wording from where you are, but it is the symbol of International Women's Day, 1993. The words on it are "No Time to Stop." Not a bad idea for any committee that is engaged in this important task of reforming the long-term care situation in our province.

Among the issues that bother women in our province is certainly the delivery of health and long-term care, because from the home through the community to the facility and into the institution, women make up the overwhelming proportion of the workforce, often at inadequate or unequal pay rates or without remuneration of any kind. We know that 90% of all the long-term care delivered across Ontario takes place in the home, and mostly by women who receive little or no funding and face difficult conditions as primary care givers. We will deal with that problem to some extent in our presentation, but we thought it important to remind ourselves that this was this day, specially marked internationally and in Canada, and this area we're dealing with does for the most part preoccupy working women.

The Ontario Coalition of Senior Citizens' Organizations, OCSCO, greets the tabling of the legislation dealing with the long-awaited need for an integrated and quality delivery of long-term care. We do not delude ourselves into thinking that Bill 101 copes with the extended meaning of a long-term care system, which must include, for example, youngsters requiring such care and others, or that it meets all of our concerns, nor do we believe the current Bill 101 and its declared aims can be meaningfully addressed separated from and out of context with the need for an ongoing overall reform of health services in general.

There are two vital questions, I think, in front of us: Will the Bill 101 changes accord with the as-yet-unannounced policy framework on long-term care and the expected chronic care role study report, and will the above as-yet-unreported announcements reflect the concerns of seniors and others seeking a genuine long-term care reform?

Some general observations: Seniors, as users of long-term care facilities, deeply appreciate the special support from ministries directly involved in long-term care reform. The resulting set of public hearings organized by the Senior Citizens' Consumer Alliance was an innovative form of user empowerment which needs strengthening in the period ahead in all directions.

We believe it is necessary and vital to a meaningful reform and its implementation that users be directly involved in governing and driving the proposed new system. Any effort to enlist seniors or users as advisers in the now obsolete, stereotyped sense is unacceptable. Basic commitments of the government itself to deliver overall health services will have to be adhered to and the autonomy and independence of users whose partnership is sought in implementation must be thoroughly respected when they offer critical input.

A major concern is that a long-term care reform not be undermined by the present economic restraint programs and priorities outlined by Minister of Finance Laughren. This wide swath of cuts in health service dollars for the critical years ahead seems to be a policy which the present superministry, corporate-model cabinet threatens to continue.

Our parallel concern, of course, is that Queen's Park will not strongly enough challenge similar belt-tightening moves by Ottawa to weaken our health services. We seriously doubt we can proceed with massive dollar cuts and layoffs in health services while advancing a reform in long-term care.

Does Bill 101 actually lead us to the promised land of meaningful long-term care reform? Or is this again a case of government lawyers and providers fighting it out while the consumers are outside looking in? We need to know more precisely how this legislation begins to address the concerns and recommendations set out in our widely supported Advance Report (1992) of the seniors' consumer alliance. It is reported that the final policy paper outlining a framework will not be released until late March, obviously too late for our response to be made here. In the absence of a framework, we question how the details of Bill 101 relate to the broader picture.

It's unfortunate that the policy on chronic care facilities and chronic care in general did not appear as an integral part of the long-term care reform consultation. This was inevitable once the chronic care study was separated out. We need some reassurances that whatever positive policies come forward be appropriate and not destructive. They must be reintegrated as part of the continuum of long-term care.

The idea being aired that nursing homes and homes for the aged be funded and reformed into kind of hospitals able to provide medical care -- oxygen, suction, IV and heavy nursing care -- is dangerous to the future of older residents in Ontario. Our question is, are heavy patients going to be switched from chronic care and acute care hospitals into nursing homes and homes for the aged under Bill 101?

The lack of a policy framework puts us in the position of being asked to take Bill 101 on faith and trust. We do not think this is the best way to go about things. New funding options, for example, should not mean increased user fees -- copayment -- in nursing homes and old age homes in the name of a consistent resident payment policy. Fairer funding should not mean even-handedness between the not-for-profit and the for-profit sector.

What does this bill do in fact to promote non-profit care? Since this matter of profit and non-profit care has been with us for a while and has agitated these hearings, I believe, I would like to recommend two recent books to the members of the committee: a United States book, Marketplace Medicine: The Rise of the For-Profit Hospital Chains by David Lindorff, Bantam, 1992; and in Canada, The New Bureaucracy: Waste and Folly in the Private Sector, by Herschel Hardin, McClelland and Stewart, 1991. I think both these books are very instructive on the subject and are worth reading.

The decision to impose increased user fees for nursing homes is a bad one. It will not help those it claims to help. It will hurt those least able to pay. While the rationalization of payment appears seductive, it punishes the most vulnerable. How the increased revenues will be disposed of is a matter of concern if it advantages for-profit nursing homes.


In the matter of moving funds to the community, the power to redirect funds from expensive, over-endowed pools of institutional money does not in and of itself guarantee success. It could in fact create turmoil and costs of another kind; for example, the consequences of unplanned layoffs of hospital staffs.

The power to flow funding could find funds going into the wrong administrative structure empowered to dispense such funds; for example, to the service coordination centre model widely rejected in the public consultation. I believe there are some recommendations that there be changes along the lines we have suggested here in our brief and elsewhere.

New roles being suggested for the district health council system and the proposed comprehensive multiple service organization are dramatic proposals, but they are not instant fixes. They require a dedicated overhaul of the current system in order to realize their roles, mastering a new mandate and enhancement, on the one hand; on the other, an awakened and new kind of input by users and their empowerment.

The need to strengthen the right to appeal, particularly affecting placement facilities or assessment, is a paramount concern. Such rights to appeal should be kept simple, direct, without delays, bureaucratic levels or complex litigation.

During our public hearings, we heard how a shift to the community would have a major impact on already overburdened family care givers, most of whom are women who receive virtually no compensation for their labour. The legislation lacks a response to this growing calamity. In addition, the presumption that family support is available is often made when there are no family care givers. We should not be cutting back on institutional care until appropriate community services are available.

During the consultation, there was widely expressed fear that the shift to community-based care would not be accompanied by a well-planned expansion of community and in-home services. The new influx of users as well as the new demands and complexities of in-home care require skilled, trained and decently paid workers.

The economic and administrative cutback in institutions and hospitals has resulted in mass layoffs of workers. This occurred without proper consultation with union representatives of the workforces affected. Appropriate relocation and retraining is essential. Anything less makes a mockery of community planning programs.

Success of long-term care reform rests on the issues of governance, accountability and empowerment of users. Will there be meaningful involvement of users? Much has been said about the empowerment of users and seniors, but there is little of substance to support all the talk. At most, the lowest common denominator approach has been used in its implementation.

I had an opportunity to catch some sessions with Deputy Minister of Health Decter before the standing committee on public accounts on February 24. I urge you to look at that Hansard. It gave me, personally, bad vibrations. Why? First, the emphasis on the high expectations of seniors and users of long-term care putting, in effect, almost a guilt trip on seniors, disabled and others affected.

The answer to meeting the high expectations was to issue a lot of fact sheets. Well, there's either feast or famine. It's either information overload or information zero. May I suggest that sometimes information overload is the equivalent of information zero because it doesn't get through anywhere. But the really loony suggestion that aired in those public accounts hearings had to do with the question of issuing an annual statement of services. Even Mr Decter had to report that this was kind of intimidating. If every user is going to receive an annual statement of services, not a bill, a guilt trip is being put on all the users of health services in general, and particularly on the vulnerable and the long-term care recipients. The professionals in the field were very worried about this particular idea of informing people. It's a bad idea.

Second, a rationing of medical procedures: Is that in the wind? Is there an Oregon plan coming for Ontario? We're told that the government is now spending $4 million a year to have nine doctors study all the procedures. Mr Decter tells us that according to the Rand Corp, which I think is a US-based corporation, 30% of all procedures are useless, so therefore there's reason to examine this. We're told that nine specialists are looking at this problem at Sunnybrook. The question arises, since I've raised the question of empowerment, are the paramedics, the thousands of workers organized in CUPE or in OPSEU, part of this consultation? How effectively are they part of it as to what fat should be cut in the procedures area? I think not. Last of all, of course, the users are not being consulted, or if they are consulted, it's at a distance.

The other preoccupation of the public accounts hearings was the health care fraud. There is misuse of the health card but the big fraud is elsewhere, in our opinion. That needs primary attention. The big fraud, for example, is the pharmaceutical companies. If Mr Clinton and Hillary could find that out, why can't we find that out here and deal with it, rather than focusing on that as the major issue to spend most of the report on?

Finally, Mr Decter is calling for exporting of our expertise. Is that to dovetail with the new NAFTA agreement? We wonder. Are we going to sell our medical expertise to the highest bidder somewhere? That's not so wild an idea. It's happening. There was a story the other day that Mead Johnson Canada, but really the United States, has made a deal with a women's hospital for taking over the infant formula.

You as a committee should have a look at that, because if that's what we mean by exporting our expertise, we're ignoring northern Ontario, the suicides at Big Trout Lake -- incidentally, Big Trout Lake elders are part of our coalition. We're ignoring the suicides at Osnaburgh and so on. Let's do a little bit of export of our surplus doctors and our surplus expertise into the rural areas of Ontario and the aboriginal areas and hunting areas of Ontario.


I am being told that I should generally cut down, and so I will swiftly move to the windup paragraph in my part of the submission, which is to say that any appeal by government -- I want to stress this -- or other players for a partnership with users must ensure that the latter not suffer a loss of autonomy and independence in the process, either as individuals or as those trusted and tested organized sectors devoted to user advocacy. I'd like to consider our organization one of those. There should be no mistake about who is a consumer; they are the final users of the facility and service.

Now I surrender to Mae.

Miss Harman: I'm sorry that you have before you a handwritten summary.

In summary, the prime concern of OSCSO is that to date we have little information on a comprehensive, integrated plan for long-term care in Ontario. In spite of all the consultations, written presentations, hearings and forums, we have few answers as to how long-term care will proceed. We worry that this may be a repeat of the mental health fiasco of several years ago, when institutions were downsized and people returned to their communities without community care in place. Ernie Lightman's recent report on boarding homes is one more piece of evidence as to how society has failed those people.

To date we have, through Bill 101 and other announcements, a piecemeal approach of new funding arrangements for institutional

care, a homemaking program, a placement coordination system and some assistance to palliative care. All of these are being set up, presumably, without input from planning bodies or consumers at the local level. To whom are these programs responsible? Will they be funded out of the community envelope? How will they dovetail with a comprehensive program of continuity of care ranging from health promotion to chronic care?

OCSCO looks for assurance that the following needs are met in a comprehensive long-term care program:

(1)Social needs as well as medical needs must be met; counselling, housing, transportation, socialization, shopping, assistance with those chores that homemakers cannot manage. Social workers must be a part of both assessment and care provider teams.

(2)District health councils as well as local long-term care committees must be transformed to include representation from social services, social planning bodies and consumers.

(3)Local planning bodies must have some overall authority for funding and programming as well as for planning.

(4)The area coordinators, who were so criticized as another and unnecessary layer of bureaucracy, must be removed from the picture.

(5)In areas where some comparable body does not already exist, comprehensive multiservice organizations must coordinate and carry out long-term care.

(6)Ethnocultural programs which provide long-term services to special groups whose language and culture differ from the larger community must be recognized as special units of comprehensive care.

(7)The needs of native groups must be addressed.

(8)The special burdens of family care givers must be recognized, and such care givers must be supported with financial assistance, counselling and respite care.

(9)Consumers must be truly involved as partners at all levels of policymaking and programming. Being informed is not sufficient involvement.

(10)There must be simple and clearly stated mechanisms for complaints and appeals regarding admission to services and inappropriate and inadequate services.

(11)The relationship of the Advocacy Act to any legislation re long-term care must be clarified.

(12)The special contribution of freestanding chronic care hospitals must be recognized, especially in regard to persons with need for intensive care and for the role these hospitals play in research and training in gerontology.

(13)Rehabilitation programs must be restored and used to help consumers regain health and independence.

(14)The role of volunteers must be recognized and supported.

(15)The not-for-profit principle in long-term care must be protected.

(16)User fees are counterproductive. They discriminate against those who can't afford to pay. Means tests are demeaning.

As seniors, we want to maintain our independence and dignity. We want the right care at the right time and in the right place. We have worked hard all of our lives and contributed to our communities and we still do, and we paid taxes and we still do. We feel we deserve a fair deal.

The Chair: Thank you very much for your presentation and also for a bit of a summary of public accounts from last week. There have been a number of issues in the health care system that have been discussed, not only in this committee but elsewhere as well. We'll move right to questions. Ms Carter.

Ms Carter: Thank you for your well-informed and caring brief. I think we're all aware that we have a disadvantage in discussing this bill in that it is just part of a pattern, so that there's a lot more to come and there are a lot of questions that are just not answered yet. But I believe the policy framework document is out there now. I haven't seen it yet, but hopefully we'll all have access to that very soon, and I hope that will fill in some of the gaps.

Certainly the principle of consumer choice is very much in the minds of everybody who is involved with this legislation, I do know that, that we respect the need for maybe an ethnic institution or whatever the special need might be.

What I really wanted to ask you about was the question of user fees. You seem to be very unhappy about what is being suggested in Bill 101, but I would have thought that what we have there was quite fair. There is a lot of discrepancy now: Some people are paying far more and others are paying far less just because of where they happen to be and for no particular reason.

Of course, under the bill the fees will be for accommodation only, so that as people get to need more care this will not affect them financially or the services that are provided for spiritual care, occupation, entertainment, all those things, will also be funded by the government so that they won't accrue to the person, except maybe a cable TV charge or something like that.

The remaining fee will be much more consistent right across the board. I believe it's going to be something in the order of $38. Of course, only income will be taken into account, not assets, so that it will just be a very quick process. My impression so far has been that a lot of people feel that is good. It will bring a little more money into the system. On the other hand, a lot of people will pay less than they have been paying up to now and, of course, if anybody can't afford those fees they will nevertheless not be penalized, they will still receive the accommodation and the services.

I just wondered if you could say a little more about how you would like that changed so that you would find it more satisfactory.

Mr Frank: I did too much talking, so I want to yield the floor to somebody else to deal with that.

Mr McNeil: As a coalition, we're not happy with the user fee in any form, and we certainly realize that when you use words such as "copayment", it's only simply to dress up two of the words we dislike the most. We are not in agreement. We realize that you made an adjustment there, and I'm trying to remember what the old system was -- $50 against $30 or something.

Ms Carter: Some people were paying in the $20s and others as much as $90.


Mr McNeil: All this system is doing is putting us somewhere in the middle. Our coalition believes it is putting a harsher payment, or whatever you want, on those people who can least afford it. We are not happy with the words "user fees" or "copayment." We don't think they should be used at all.

Ms Carter: Although by definition everybody is going to have enough money because of the income supplements that seniors automatically receive.

Mr McNeil: I don't agree with that. I gather that you people have a different opinion of that, but I don't see that anything that's happening now, in any form of payment to people,

in whatever way that is, is going to help us with a user fee, copayment fee or anything else. That's just my opinion. Anybody else here?

Miss Harman: Not around Bill 101 but in terms of care in the community, in the home, there was some talk in the beginning that certain medical care would be provided without fees but that for any kind of social care there would be some kind of copayment or user fee. I don't know what the picture is on that now.

Mrs Sullivan: I want to tell you how impressed I have been in the past with the work of OCSCO and the work you did in association with the alliance for long-term care. It was very valuable, I think, to all of us.

I'm interested in a number of things you've raised today. I'm going to concentrate only on the one, the financial aspect of your presentation, although I must say that I think your words of wisdom with respect to chronic care, by example, and several other areas are very valuable.

Your second recommendation relates to increased user fees as being counterproductive. One of the things that has occurred to me as I've been looking at Bill 101 is that in the three areas where it calls for payments from the government to the nursing home, the charitable home or the municipal home for the aged, the legislation says that the funding will be provided to assist in defraying the maintenance and operating costs incurred or to be incurred by the home, municipality or charity.

There is no ceiling and the difficulty is that the act isn't any more specific than that funding will assist. It doesn't say that it will cover all the costs of nursing care or other care, by example, food. It doesn't say that all those costs will be covered. We have to take it on good faith that only the accommodation portion will be charged to the resident, that no other costs, perhaps next year or the year after, in relation to nursing or other needs may well be added on to the copayment. I wonder if you've discussed that issue with the ministry officials in association with this particular piece of legislation and how you see that washing out.

Miss Harman: One of the things I wondered is, is this a place, an area, where the institution will cut corners and save, since the money may not be forthcoming for it -- perhaps not nursing care but, for example, recreational programs and that sort of thing -- whether they'll get short shrift.

Mrs Sullivan: I think that's a fair concern. One of the things we know is that the homes have agreed and ministry requirements will be that nursing and food costs are passed on. Even if it's the commercial sector, there will be no profit made in those sections.

The difficulty is that the care plan, by example, should be a multidisciplinary care plan. It should include more than simply nursing care and food; it should include recreational services and so on. What if the money that the government flows to assist in defraying those costs simply doesn't meet the requirement even of the care plan?

Miss Harman: I think that's something that has been a matter of concern to us.

Mrs Sullivan: If you are in further discussions with the ministry and want to consider that particular section of the bill, I think that members of the committee would be very interested in further discussion that you might want to bring back to us by letter or whatever. I think it's a real problem.

Miss Harman: Thank you. That's a good idea.

Mr Jackson: I'd like to commend you for your presentation. I appreciate hearing from your organization and the insights you bring. You have covered a lot of area, so I'll try to focus in two areas. You are aware, of course, that in spite of the government saying this process has been widely consulted prior to getting here, what we really didn't consult or talk about over the last two and a half years was that we are moving from an insured service to a contractual service with the state, that in fact the Ontario government is delisting extended care as an insured benefit, that the Ontario NDP government is bypassing the constitutional guarantee under the Canada Health Act and that we're moving into a contract agreement between the state and those persons it deems approved and appropriate for health care. Are you fully aware that the implications of this legislation are as clear and concise and meaningful as what I've just said? Are you aware of that?

Mr Frank: We keep learning things all the time about this legislation, and your revelation is no surprise in that sense generally. But my sense is that a lot of the things that are going to be imposed on us are going to take the form of regulations. We have not seen those regulations, and regulations change. They have a habit of changing with governments, and I include all governments.

Incidentally, the leader of the former Liberal government called user fees, when they were advanced for the hospital service, a "sick tax." Right on. But we're still hearing that idea, that user fees are the panacea to our financial problems; we think otherwise. We think there are other places to get that money and that we shouldn't undermine universality in trying to settle budgetary and fiscal matters.

Mr Jackson: But you'll forgive me, the two issues are separate. User fees are separate from the issue that this is currently an insured service in Ontario, protected and covered by constitutional guarantees --

Miss Harman: And a right.

Mr Jackson: -- and a right, and they're guaranteed and protected under the Canada Health Act. But this legislation opts us out of that framework and puts us into a contractual service agreement.

Are you aware and have you communicated this revelation to your members, that this is a fundamental leap in the approach here? The uncertainty of where it takes us is just that, the uncertainty, but what is clear in the legislation and the statements by the parliamentary assistant and the minister in the House are that this is no longer a guaranteed insured service under OHIP, as protected; it is now moving out of that.

Though they say they would never do that unless there was proper public consultation, we believe, and we've heard from groups, that this point was not publicly discussed and debated during the consultation period. I was more or less looking to you, as people who have been closely associated with some of the discussions with the government, to know if this point was ever glossed over or ever dealt with up front in its full impact, or was always sort of implicit in the wings but is now happening in the legislation.

I think this is the fundamental issue here of the change that is occurring. All the rest is fine-tuning, bells and whistles, who pays what, who gets access, who is the gatekeeper, who will lose, who will win. But the fundamental change here is that it's no longer a guaranteed service, an insured service, and we're moving to a contract service. I wanted to focus on that, because I want to make sure that your awareness is at the same level as ours as legislators, who have asked these questions of legal counsel and others.


Mr Frank: Can you cite that legislation?

The Chair: I'm afraid we are going to have to finish up, but please complete your response.

Mr Frank: I just wanted you to cite that section of the legislation.

Mr Jackson: It's the section dealing with the Health Insurance Act amendments.

Mrs Sullivan: I wonder, Mr Chairman, if we could have a clarification from the ministry at some point on that point.

Mr Jackson: We can get the pieces of Hansard, because it's been raised several times.

The Chair: Okay. We will do that.

I regret that the Chair always has to play the heavy. We've reached 3 o'clock and I must call this part of our afternoon to a close, but I want to thank you all for coming down and joining us today.

Miss Harman: You've given us some homework, which we will deal with.

The Chair: Mr Wilson?

Mr Jim Wilson: Just a question to research. When will the next summary of recommendations be made available?

Ms Alison Drummond: It's being worked on in the office. I don't know if other people are experiencing this, but we have a lot of illness among the support staff. We're hoping to get it to you tomorrow.

Mr Jim Wilson: Thank you.


The Chair: I call on our next presenters, the representatives from the home advisory committee of Bendale Acres Home for the Aged. Would you be good enough to come forward? Welcome to the committee this afternoon. Please be good enough to introduce yourselves, then go ahead with your presentation.

Ms Valerie Clarke: Valerie Clarke, chairperson of the home advisory committee of Bendale Acres Home for the Aged.

Mr Gord Blades: Gord Blades, committee chairman of the Bendale Acres home advisory committee.

Ms Clarke: Thank you for giving us time. Bendale Acres Home for the Aged was established in 1963 by the municipal corporation of Metropolitan Toronto to provide care for 300 residents aged 60 or older. At present, Bendale is under major renovations to provide private and semi-private rooms with ensuite washrooms.

Bendale Acres also provides community services which include adult day care, a geriatric day program with Scarborough General Hospital and Meals on Wheels. It also supports a satellite home program for residential care for 130 persons at Cedarbrook Lodge and Livingston Lodge.

The 13-member home advisory committee of Bendale Acres is made up of residents, family members of residents, representatives of local service clubs, professionals and concerned citizens. Our mandate is to act in an advisory capacity regarding issues related to the care of residents and the needs of seniors in the community and to act as systemic advocates making recommendations related to the rights and common good of residents.

We endorse the principles the government has espoused in its long-term care redirection, but have some concerns regarding Bill 101 and the following issues: consumer choice and funding.

Consumer choice: Part of the reform initiatives was to recognize the right of the people of Ontario to choice and improved quality of life. With Bill 101, there is a lack of choice. The following reduces the control individuals will have over making decisions that affect their own lives: the decision of where to live; residence in a home that meets their ethnic, religious and language needs; the spouse to remain with an eligible partner even when not meeting the criteria. We are concerned that only the placement coordinator will make the decision, without any input from the consumer or the facility as to meeting their ethnic, religious, language or other requirements.

As we all age, we still wish to retain the ability to determine our future and to have our needs looked after by a province that we have supported with our tax dollars. To have no choice in where we are placed and little or no chance of transfer to our choice after admittance does not bode well for the quality of life for us as we grow old and need care.

Funding: Residents and families of residents have not been advised that there will be additional charges for their accommodation due to Bill 101. When does the government intend to advise consumers that they will have to pay more and that extended care benefits will no longer apply?

Also, Bill 101 is revising residents' copayment scheme to be based on an income test only, rather than the current formula of income and assets. Individuals who are income poor but asset rich will be supported by the taxpayers. This places a greater financial burden on an already diminishing taxpayer base. The assets will no doubt be passed on to the families instead of paying for the consumer's care.

Many of our seniors do not have pension plans other than the old age pension, especially women. Widows may get a portion of their spouses' pension, but the vast majority would be income poor. However, their nest-eggs, if any, would be in assets. If you look to having some kind of tax levied at death to offset the expenditure undertaken by the province during their stay in a facility, then this could be years in coming, as people are living longer, but the province's outlay is immediate. We would urge that the formula of income and assets test be kept.

What happens when there is no longer a Canada pension plan available?

When we talk of funding for accommodation being paid for by the resident, and health care needs by the province, where is there funding for the stimulation programs that are a necessity for the continuation of quality of life for the elderly? If these types of programs are not maintained, we will see our elderly shunted off to the side and left to vegetate. Also, where is respite care when a care giver is unable to provide it due to illness or extenuating circumstances?

In conclusion, a major concern is that in some areas there are very broad statements. What guarantees do we have that we will have any input into the specifics which, when decided, could run contrary to the overall principles the government has espoused?

We thank you for the time to present and we hope that you and your committee will consider the points we have brought forward when making your recommended amendments to the Legislature.

The Chair: Thank you for coming and making your presentation. We'll start the questioning with Ms Fawcett.

Mrs Fawcett: Thank you for coming before us. We've had many similar types of presentations and many of the same kinds of concerns brought before us because, as we are finding out, people don't find in the bill exactly what gives them assurance.

Consumer choice is one area where we've heard a lot of concern. People are afraid they're not going to have a choice of where they want to spend the rest of their lives, especially in the ethnic area. That's a definite area that should be spelled out. We will be making amendments and putting forward amendments to the bill. Had you thought of anything you might like to see included in the bill around the placement coordinator? Another question is, do you have a placement coordination system now that you operate under? If not, how would you like to see the bill changed?

Ms Clarke: We don't do the placements. Bendale is under Metro homes, and the placements are done by Metro homes.

Mrs Fawcett: And it works well?

Ms Clarke: Yes, it does. I think it's more from the point of view that with ethnic people, they need to feel there are people around they can communicate with, especially at times when physically they're not as fit or they need a little extra care; someone with the same language, the same background. It's very necessary for the quality of life.


Mrs Fawcett: Do you have access to respite care at all?

Ms Clarke: There is some; it still is there at the moment. But my concern is, when Bill 101 comes in, what's going to happen? If a mother has children, and she's looking after her parents or in-laws, what is she going to do if there are circumstances beyond her control or when she needs a vacation? What's going to happen? Are you going to have people coming in and out of a home to give them the care, or are you going to have a facility where someone can go for two weeks to get some help?

Mrs Fawcett: We have been given some assurances from the ministry that if there is a placement coordination system in place, it will either be built upon or used. Certainly we're hoping to see that that is definitely what happens.

Mr Jim Wilson: Thank you very much for your presentation. I am particularly interested in your comments with regard to the income test. I gather that it's your experience that seniors don't object to the fact that currently, in municipal and charitable homes for the aged, there is an income and asset test. You've not had any problem with that?

Mr Blades: Not that we are aware of.

Mr Jim Wilson: Do you have any personal thoughts on why the government is going to strictly an income test? I find it completely ironic that a social democratic government is going strictly to an income test tied to the guaranteed income supplement, given that in my area of the province it's not uncommon in terms of farming to have large assets, for instance, but zero income.

Mr Blades: It's easy to hide some of the assets of the people, by way of their children, and not show the true assets of the individual.

Mr Jim Wilson: Just to give you credit, in terms of funding you also say that extended care benefits will no longer apply. From my reading of the bill and from what groups tell me, it seems to be the first delisting of an insured service. As Health critic, I asked the minister in the House a couple of times last year, and she assured me that she wouldn't delist any OHIP services until there was a full and frank public debate about such a delisting. The previous presenters from the seniors' coalition touched on the fact that maybe we're going towards an Oregon system of care or something. Has there been much discussion in your community about the loss of extended care benefits and the new service agreement model we're going towards?

Ms Clarke: I don't think many people know about it,

outside of people who are very involved with the issue. I think that's part of it. Even talking to people in my daily conversations, they don't know what's going on. Some of them, when you talk to them about extended care, don't even know they have that right.

Mr Jim Wilson: It's been a constant approach of this government that it uses these committee hearings as the public vetting of a piece of legislation, rather than taking the draft legislation out to the communities and getting it straightened out before it comes to committee, so I certainly appreciate your taking time. We will do what we can to introduce amendments along the lines you've suggested.

Mr Owens: I want to thank you for coming today and representing the riding that starts on the other side of Lawrence Avenue from where your particular home is located. I have some familiarity with Bendale. In terms of some of the issues you raise with respect to the spouse remaining with an eligible partner, what kinds of things does Bendale currently do now to ensure that happens, and how would it be impacted with the advent of Bill 101?

Ms Clarke: Just looking at Bill 101 and its very strict criteria, I feel that at present the criteria for coming into a home are not as strict as they're going to be with Bill 101, because there is some ability of people who need care. When you've got spouses who go into homes, I've watched where the other spouse has almost automatically needed to go into the home within a very short period of time. It seems they often need that ability to be with the spouse on a lot longer term than just coming in on a daily basis. Their health and their quality of life deteriorates.

Mr Owens: In terms of the ability for residents to transfer, say, within Scarborough, if somebody was devolved from Scarborough General, for instance, into Bendale but decided he wanted to move out to Seven Oaks because it's closer to home, how easy is it for you to arrange that kind of transfer at this point?

Ms Clarke: The home advisory committee doesn't do transfers;, that's done by the social and the home. It's not as easy but it is done. We've seen people come, not so much Seven Oaks because Seven Oaks is --

Mr Owens: Another Metro home.

Ms Clarke: -- is under Metro homes but it's also in the facility; it has a longer waiting list. Bendale has a short waiting list at the moment because it's under renovation. Some of the homes do have short and long waiting lists, but they have the ability to transfer at the present time. My concern is that in the criteria you give there are three categories and then there's a fourth: transfer to other homes. That concerns me because just even reading that, there's a concern that the choice is taken away because you're saying that at the very end there's a transfer to other homes.

Mr Owens: I appreciate your concerns around respite as well, and I know committee members on this side of the committee share that. For that reason, there are provisions within the legislation for respite care that currently, I would suggest, probably happen on an ad hoc basis. You're quite right that care givers, because this isn't just a piece of legislation addressed particularly to seniors but also persons with disabilities, and others tell us there's a critical need for that kind of respite care across the province.

Ms Clarke: My concern on that one is the fact that the care giver at home is going to be away and they're going to have people coming in and out of that home because of the way the bill talks about the social services doing more care giving in the home, and that there will not be an ability, because of criteria, for them to get into a home at least for two weeks to get good care.

Mr Owens: My understanding, and perhaps the parliamentary assistant could clarify for me, is that there will be institutional beds provided for that purpose.

The Chair: If we could move, there were a couple of clarifications the parliamentary assistant wanted to make, so we'll deal with that and the other points.

Mr Paul Wessenger (Simcoe Centre): Thank you very much for your presentation. One of the points I will have clarified is the whole question of respite care, but first of all, I'd like to assure you that it's certainly the intention of this legislation that there be consumer choice in the matter. Perhaps it's the way the legislation is drafted. It's very difficult sometimes to encompass intention in legislation, but I can assure you we're looking to see if there's a way to ensure that intention is set out in the legislation because it's clearly a basis that there should be consumer choice.

Secondly, with respect to your comments concerning quality of life, as part of the funding program there will be specific money set aside for quality-of-life programming, and that will be in the funding formula and they'll be reimbursed dollar for dollar. That certainly is being addressed.

With respect to the respite care situation, certainly again it's policy that respite care be available both at the community level and also at the institutional level, and we certainly believe there's been an enhancement at the institutional level. If I might have permission, I'll ask staff to indicate how that is going to work.

Mr Geoff Quirt: I am Geoff Quirt, acting executive director of the long-term care division. Currently, with our health insurance approach to funding extended care, we can only pay for services that are delivered to one of our insured clients. The new contractual arrangement with facilities will, in effect, fund the facility to keep beds open for respite care purposes. If a particular facility has a high demand for respite care, then our expectation of its occupancy level will be reduced to allow it to keep more beds open to meet the respite care needs in its community while still providing 100% of the funding committed to in the service agreement.

The Chair: Any thoughts or comments on those comments?

Ms Clarke: No.

The Chair: Fine. Thank you very much for coming here this afternoon and for making your presentation. Good luck with the renovations.


The Chair: I call on our next presenter, the Families' Association of Oaklands Regional Centre. If you would be good enough to come forward, please make yourselves comfortable. Welcome to the committee. We've received a copy of your presentation. If you would just be good enough to introduce yourselves, then please go ahead.

Mrs Catherine Rhodes: I'm Catherine Rhodes and this is Kit Nero.

The Chair: Welcome. The microphone will pick you up just fine if you sit normally. You don't need to lean right up to it.

Mrs Rhodes: Is yours on, Kit?

Mrs Kit Nero: Is this on?

The Chair: It will come on when you're speaking. We have these magic people up on the side here who do all sorts of wondrous things to make sure we're heard.

Mrs Rhodes: That's good.

The Chair: Please go ahead.

Mrs Rhodes: I'll begin by telling you that we are grateful for this opportunity to bring our presentation to the standing committee on social development. This has to do with long-term care and services. Our group is concerned with equity of access for developmentally disabled people in Ontario, equity of access to the range of services provided for the physically disabled people and elderly people.

Who are we anyway? The Families' Association of Oaklands Regional Centre is a group of 127 persons organized to act in support of Oaklands Regional Centre and its residents. Each member is a relative or a legal guardian of an Oaklands' resident.

Within the broad population of persons with developmental handicaps in Ontario there is a minority group of individuals. For this minority group, it is either the severity of their level of retardation or the complexity and chronicity of their additional physical or psychiatric handicaps which, when combined with their intellectual impairment, add up to a severe lifelong disability.

This group of adults with special developmental disabilities who require long-term care and special advocacy need the protection of the full range of the provisions of Bill 101. Most of the current 104 residents of Oaklands Regional Centre are representative of this minority of persons with complex, high-care-needs developmental disabilities.

The issues we want to go over with you: First, most of the individuals with developmental disabilities we represent, because of the very nature of their disability, lack the insight, judgement and communication skills to speak effectively for themselves, now or in the future. The advocacy of the Ministry of Citizenship is crucial to ensure that the rights of this especially vulnerable minority group to equity of access, needed services and other basic rights are protected.

Second, the citizens of this province who are developmentally handicapped are being denied equity of access by the public consultation paper Redirection of Long-Term Care and Support Services in Ontario to the provisions of Bill 101 because of the nature of their disability.

Citizens of this province who are developmentally disabled and whose severe or multiple needs necessitate facility-based care are being denied equity of access to this option which is made available to the elderly and adults who are physically disabled citizens of the province in the language and intent of the official consultation document for the proposed legislation.

Policy statements of the Ministry of Community and Social Services, published in Challenges and Opportunities: Community Living for People with Developmental Handicaps, expresses on page 22 its "commitment to the planned phase-out of institutional care for developmentally handicapped people." In the October 1991 consultation paper, Redirection of Long-Term Care and Support Services in Ontario, the Ministry of Community and Social Services provides this option of care to elderly and physically disabled citizens but not to developmentally disabled citizens.

Adults who are developmentally disabled and who require long-term care and special ongoing advocacy for the protection of their rights, because of the nature and complexity of their disability, need the integrated resources of the ministries of Citizenship, Community and Social Services and Health.

The proposed legislation: First, the public consultation paper, Redirection of Long-Term Care and Support Services published by the ministries of Community and Social Services, Health and Citizenship, excludes citizens of the province who are developmentally disabled from the consultation. Nowhere are the needs of the developmentally disabled persons specifically mentioned.

Physically disabled persons, however, are first specified in the preface, before page 1. There are many references to persons who are physically disabled in this document. On page 1, the long-term care and support system is described as "a system that serves elderly people and adults with physical disabilities".

Persons with developmental disabilities with similar service needs are overlooked or deliberately excluded. In either case, they are denied equity of access in the official consultation paper to the provisions of the proposed legislation. These individuals with developmental disabilities surely have a right to equity of access to the same range of service options as persons with physical disabilities.

Bill 101, part IV on page 35, amends the Ministry of Community and Social Services Act to allow the minister to "make a grant to or on behalf of a person who has a disability and who is at least 16 years old, to assist the person in obtaining the goods and services that the person requires as a result of the disability." It also allows the minister to make grants to various entities that have "entered into an agreement with the crown...to transfer the grant to or on behalf of" such persons to assist them in obtaining goods or services they require as a result of their disability.

This amendment would have more clarity and ensure fairness and equality for all those who have a disability if wherever the word "disability" is used in the proposed legislation, the words "physical or developmental disability" are inserted.

The new provisions governing standards, efficiency and accountability in the amendments proposed for the Nursing Homes Act, the Charitable Institutions Act and the Homes for the Aged and Rest Homes Act are commended by the families' association. The association believes that these standards should be extended to include all residential settings, community-based or institutional, for elderly and for persons with physical, mental or developmental disabilities.

The need: We feel that this is very important because of our minority group with very high needs. Persons with developmental disabilities and complex high-care needs who cannot effectively speak for themselves require the ongoing, coordinated services of knowledgeable professionals who understand these special needs. These individuals are very vulnerable to sudden critical changes in their physical or mental states, which must be addressed quickly, effectively and consistently. They also need trained, 24-hour, on-site supervision and individualized daily programs.

The integrated resources of the three ministries: Each of the three ministries -- Community and Social Services, Health and Citizenship -- has a key role to play in providing ongoing, cost-effective, coordinated, accountable services for all persons in Ontario who are disabled. This is especially true for persons with developmental disabilities with high-care needs. This group includes residents of Oaklands Regional Centre.

The services and continuity of an integrated team made up of the combined resources of Health and Community and Social Services are needed to provide the level of proactive individual care and programming needed by these individuals. This team must invariably include the direct-care staff, the Ministry of Community and Social Services, who interact with the disabled person on a daily basis and then whatever health care professionals are needed by this particular individual. Such professionals will include the family practitioner, the nurse, the dentist, and also the other health professionals as needed, such as neurologist, psychiatrist, psychologist, physiotherapist, occupational therapist, speech therapist and others, such as social workers, all working in concert.

The health care professional consults not only with the disabled person but consistently consults and interacts with the direct-care staff and other team members. The firsthand observations, monitoring and consistent implementation by the direct-care staff of the directions of the team provide the foundation for the individual's overall service. It is the most cost-effective use of the health care professional's time and the taxpayer's dollars. It is also to the great advantage of the developmentally disabled person.

Finally, the special need for the advocacy of the Ministry of Citizenship is nowhere more evident than in the ongoing need to ensure equitable treatment for persons with developmental disabilities and fair access, based on need, to the full range of services made available under the proposed legislation. Accordingly, we believe that the most appropriate and cost-effective approach to meeting the needs of adults with developmental disabilities who require long-term care is through the shared resources of the three ministries, Citizenship, Community and Social Services and Health.

The option of a congregate setting -- which we consider Oaklands Regional Centre to be. It is a small, modern schedule 2 facility located in downtown Oakville. The residents live in adjacent houses grouped around a central complex with meeting rooms, swimming pool and gymnasium which are shared with the people of Oakville on a daily basis. It is a community within a community situated on a main street with shops and restaurants nearby where residents frequently visit and are welcomed and accepted. The quality and the extent of the supports at Oaklands for these residents -- for example, the coordinating of the multidisciplinary team I just described -- would be difficult and perhaps impossible to replicate in the community. It certainly would be very costly.

Immediately north of Oaklands is another congregate setting where 250 senior citizens live in four adjoining subsidized apartment buildings, sharing a park-like setting with the Oakville Senior Citizens Recreation Centre. They also share the Oaklands swimming pool every Wednesday. These senior citizens choose to live there for various reasons, such as convenience, special amenities and services, security and social interaction with groups that share similar interests, abilities and limitations.

There are those who feel that senior citizens should not be ghettoized in congregate settings but should be fully integrated with the younger population. Some older people agree. However, the right of older people to have equal access to either option does not appear to be disputed.

We believe persons with developmental disabilities should have the same option.

The option of community-based settings: Community-based programs in Ontario have been, in varying degrees, successful for the majority of persons who are developmentally handicapped. However, it is only in the last three or four years that community-based services for that small minority of adults with developmental disabilities and complex high-care needs have begun. There is no independent documentation of the ability of these programs to provide appropriate or cost-effective care, or indeed of the degree of integration into the community of these persons with developmental disabilities. The association is aware of many residents with psychiatric behavioural disorders who are now at Oaklands after community placements were unable to meet their needs.

Our Families' Association has visited a variety of community-based agency settings in Downsview, the Peel-Halton-Dufferin and Durham regions. We have observed a varying quality of care and programs in these community-based services. We are concerned about the present accountability for MCSS-funded community-based settings. There is a lack of existing standards governing plan of care, professional support services, evaluations and inspections to guide the service providers in the delivery of cost-effective care. Such standards would protect these vulnerable recipients of service as well as the taxpayer's dollars.

For persons with developmental disabilities, living in a community-based setting does not mean that they are capable of participating in its social, employment or recreational activities, nor does it mean acceptance by the members of the community. Social and communication skills are often very limited. Neighbours do not welcome intrusive and often bizarre behaviour from adults.

The families of many of these individuals with developmental disabilities recognize that the more tolerant environment of a congregate setting is a realistic approach to meeting their needs for a sense of belonging, acceptance and the need for social interaction.

The expectation that with more supports families can or should go on providing care for the adult with developmental disabilities is frequently not realistic. It may not be in the best interests of the disabled person or of the family. More long-term care residential settings are needed now and in the future.

Failures in the past to provide appropriate ongoing supports and programs for adults with developmental disabilities and high-care needs have resulted in preventable suffering, disruption and further deterioration. They have also wasted the taxpayer's dollars.

The Families' Association of Oaklands Regional Centre believes that well-designed and well-managed facilities are the most cost-effective and best way to provide the quality of life and standards of care needed by most developmentally disabled individuals with complex and high-care needs. Such facilities should continue to be a part of the continuum of service options available for these persons.

Current legislation, policies and future options statements of the Ministry of Community and Social Services: The Ministry of Community and Social Services' Facilities Planning Project, central region, May 1992, sometimes referred to as the Muldoon-Henson report, rejects the option of facility-based care for persons with developmental disabilities, as did the earlier Ministry of Community and Social Services policy statement Challenges and Opportunities.

The Facilities Planning document does acknowledge the need for some institutional care in the future for some adults with developmental disabilities. For these individuals it suggests mainstream facilities, eg, mental health and corrections and something called "etc." The Families' Association rejects these options as acceptable redirection of long-term care.

The programs in the Ontario psychiatric hospitals or the institutional ones that we know of in Health are geared to a completely different set of needs and intellectual levels. Social interactions among these individuals are frequently and very stressfully incompatible. Moreover, the psychiatric hospital does not provide the daily care, training programs and other services needed by individuals with developmental disabilities and high-care needs.

The Ministry of Correctional Services also lacks appropriate programs and services for this group, with the added limitation of restricted freedom. There is limited possibility of anything but harmful social interaction between the incarcerated offenders and individuals with developmental disabilities.

Moreover, the per diem rates of both of these types of institutions are considerably higher than those of a facility such as Oaklands Regional Centre.

The Families' Association maintains that persons with developmental disabilities must not be denied equity of access to the full range of long-term care and support services options available through the proposed legislation. The option of appropriate facility-based care for persons with developmental disabilities must be included.

The summary, with a quotation from the redirection consultation paper, "the vision of an equitable and caring community": Citizens with developmental disabilities and high-care needs comprise a highly vulnerable minority group in our province. Because of their varying intellectual impairments and because of deficits in communication skills, insight and judgement, they are, with few exceptions, unable to speak effectively for themselves.

They already have or will have most of the same needs as elderly persons and adults with physical disabilities. They also have additional needs of varying complexity which must be addressed by the language and intent of the proposed legislation.

The public consultation paper Redirection of Long-Term Care and Support Services in Ontario specifically includes adults with physical disabilities in its provisions. Nowhere does it address the needs of adults with developmental disabilities. We affirm their right, as citizens of Ontario, to equal access to the provisions for consistent quality and range of needed services, including facility-based care, as those provided for elderly people and adults with physical disabilities.


Our recommendations:

(1)That the ministries of Citizenship, Community and Social Services and Health acknowledge the right of equity of access of people with developmental disabilities to needed long-term care and support services provided for elderly people and people with physical disabilities in Ontario.

(2)That the ministries of Citizenship, Community and Social Services and Health recognize the need of people with developmental disabilities for long-term care and support services in Ontario.

(3)That the language and intent of the proposed Bill 101 legislation be amended to include specifically people who are developmentally disabled as well as elderly people and people with physical disabilities.

(4)Very specifically, that the wording of the amendment to the Community and Social Services Act in part IV, section 19 of Bill 101 be changed so that wherever the word "disability" is used it is preceded by the words "developmental or physical."

(5)That the Ministry of Community and Social Services review its policies stated in Challenges and Opportunities, August 1988, and amend them to acknowledge the right of equity of access of persons who are developmentally disabled to appropriate facility-based care.

(6)Finally, that the responsibilities for ongoing advocacy and provision of cost-effective accountable care for persons with developmental disabilities who require long-term care and support services be shared by the ministries of Citizenship, Community and Social Services and Health.

The Families' Association of Oaklands Regional Centre asks you to consider our recommendations carefully and to give your support to their implementation.

The Chair: Thank you very much for a very full and thoughtful presentation, and we'll move right to questions with Mr Jackson.

Mr Jackson: First of all, let me commend you for your forthright brief. I'm familiar with the caring and supporting environment at Oaklands Regional Centre. I've been a guest in that home on many occasions.

Perhaps I can get right to the point. Have you received any indication from the Minister of Citizenship regarding your plea for inclusion into this bill, or have you written to the Minister of Community and Social Services either, specifically with an appeal for an inclusion?

Mrs Rhodes: On this day we have forwarded a letter to the ministers of the three ministries, and a covering letter including this brief.

Mr Jackson: We've raised these questions in committee and not really received satisfactory answers, but given that the parliamentary assistant to the Minister of Health is here today, perhaps he might use a moment to clarify why the exclusion is there, and yet we know that the differently abled community whom you represent specifically made presentation in the consultation period on the two occasions prior to us receiving this legislation. So it's not as though the government didn't hear -- not your association in particular, but generally advocacy groups for persons with Down syndrome, the developmentally disabled. The point was made during the consultation period that there should be some recognition and inclusion in the legislation. So it's not as though the government never heard from anyone.

So perhaps, if I might, Mr Chairman -- in the rotation if the parliamentary assistant might clarify for these family members' parents, I'll yield the balance of my time and perhaps at the end of the questioning he can indicate just why that exclusion exists and to the extent to which the government may be amenable to re-examining it.

The Chair: Okay, thank you. Ms Sullivan.

Mrs Sullivan: The Oaklands Regional Centre is just a few blocks from my own home and my children have taken swimming lessons there, and I can assure people on the committee that it is very much a part of our town and our community, and that the work that's done there is quite extraordinary and the involvement of the families is quite extraordinary.

One of the things that I have found significant, because cases have come to me in my constituency office, is that thinking over a period of time has changed with respect to community living options. What the board and the Families' Association at Oaklands is saying, as other groups before us have said, is that for those people who can cope with a community living situation and who will thrive in that situation, that's an appropriate venue, but for those who cannot, a long-term care approach with coordinated service plans, with coordinated and centralized specialties, is more appropriate and is indeed the more viable situation.

My understanding was that the ministry was going to consider or had promised to consider the inclusion of the developmentally disabled in terms of proposed amendments to the bill, and I think that certainly was where we left the last presenter. We haven't heard further from the ministry, and I will underline again Mr Jackson's question with respect to where the Ministry of Health, which is carrying the bill, is in terms of that proposal.

I also want to say that this is, once again, an absolutely excellent presentation and typical of the work that comes into my constituency office from Oaklands.

The Chair: Perhaps, then, I'll call on the parliamentary assistant.

Mr Wessenger: Thank you very much for your presentation, and I certainly appreciate your position and your concerns about the whole aspect of generic treatment.

What I would like to say is that this is a policy decision at this stage to only include in the long-term care legislation the elderly and the persons with physical disabilities. I don't think this necessarily precludes the matter of looking at an integrated system in the future. I think it's just a policy decision at this time that perhaps government can only take on so much in the reform at one stage. I don't know whether the parliamentary assistant for the Ministry of Community and Social Services would like to add something because, really, your area is within his jurisdiction. He might more appropriately be able to comment on the other aspects than myself.

The Chair: The parliamentary assistant for Community and Social Services?

Mr Randy R. Hope (Chatham-Kent): I was a little bit intrigued by the opposition's tone of voice about this proposal when I hear them saying now that they want institutions left open. Is that what I hear coming from the opposition?

Mr Jackson: You heard what was --


The Chair: Order.

Mr Hope: I just listened to a lot of waffling.

Mr Jackson: -- answer the question.

Mrs Sullivan: Good grief.

Mr Hope: I just listened to a lot of waffling, so I had to get a little clarification that that's what you're asking for.


The Chair: Order, order. Mr Hope, if you could --

Mr Hope: Well, I just wanted to make sure it was clear over there if that was truly --

Mrs Sullivan: That's shocking. That is absolutely shocking.

The Chair: Order, please. Order, order.

Mr Hope: But one of the things that had been brought up from a lot of the family auxiliary programs -- from the Southwestern Regional Centre, from the Rideau Regional Centre, from all of the centres -- is where do the parents and the client group play in this whole scheme of long-term care? I know the Ministry of Community and Social Services continues to push that they be a part of the overall deal, but I know there is still phase 2 of the multi-year plan, which was initiated for the downsizing of institutions by the previous government. That phase 2 of that multi-year plan -- as we discovered, it wasn't a total plan -- has to be re-examined in making sure that the services that we're talking about in the community and the services being provided for individuals are there. So the multi-year plan, phase 2, is a conversation that's continuing to this day. I know that with the previous minister and, I ought to reassure, with the new minister, we act as advocates on behalf of those to make sure that the direct funding model is one that's accessible, that whether it be mental, physical or all disabled groups, they access this funding one way or another. I know we continue to push that area to make sure we don't have a number of plans out there that are always allowing gaps. As you're well aware, there's a multi-year plan that's out there; there's long-term care. Where does everybody fit? The direction I've been hearing from a lot of the family organizations is, "Make sure there are no gaps for us as individuals."

The Chair: If you have a question back or comments, please.


Mrs Nero: It's more a comment. I would prefer not to refer to them as gaps. I would prefer to say that either ministry, Health or Community and Social Services, should be assuring the families, whether they be in institutions or whether they be at home, that there will be a continuum of service available from those who are able to be supported more independently in the community to those who need perhaps 24-hour supervision in group homes in the community to those who need the more secure setting of small, well-managed facilities. We don't see, as we said in our brief, any studies that have been done on the existing care that have happened even on the transfers from the nursing homes to the community or from Christopher Robin to the community -- the quality of care, that kind of thing.

When we're talking about quality of care, we're talking about a continuum of services. For example, when you hear, "If the nurse doesn't show up, we just call a service and get any nurse," this to us is not quality of care. So we're saying, "Where are the studies that are showing that this is a better trend," at the same time as MCSS is definitely still saying, "We want the hard-to-serve out in the community."

We're concerned, in the Oakville area, that we have a rather unique program for the more psychiatric-impaired developmentally disabled. If you were to close a centre like Oaklands and put these people in the community, the very nature of their illnesses says they're going to be up and down. That is the one given with these people. Where will they go to be stabilized? This is something that you and Health have to get together on to reassure us. There are those who perhaps would be willing to look at some small group homes if they knew the continuum of service was there. So if that sort of explains where we're standing, we need an awful lot of reassurance.

I'm very concerned about those who have kept their children at home and have found, at age 20 or 21, that there is nothing available. Having been somewhat in those positions nine years ago, thank God for the Oaklands Regional Centre. They'd have no place to go. I know how I burned out. It would take a lot more than respite care to help me through those situations. I'm really concerned that you do take a look. So to hear you say that you weren't sure whether you'd find any dollars for them, I would say maybe you have to prioritize whom these dollars are going for, but they certainly should receive some of the dollars that are going to be made available to the physically disabled and the elderly. The need is there.

The Chair: Would you care to comment as well?

Mrs Rhodes: I guess, just returning again to Mr Hope's comment on the first phase of the multi-year plan, or the overall deal in which everyone is to be included, you can't imagine how shocking this was to parents with older children to see some of the statements in this Challenges and Opportunities which just bore no resemblance, in reality, to the needs of our children. Mr Jackson, for instance, mentioned something which we hear a great deal. He talked about the developmentally handicapped and he mentioned persons with Down syndrome and so forth.

There is a widely held stereotype of what a developmentally handicapped person might be. Some of the people who are at Oaklands Regional Centre and in some of the other facilities belong to that special minority. They are people who can not only not live happily but they cannot survive in the community. Presumably, everyone would be part of the overall deal in the first phase. I guess we are so fearful because of what has been said and what has been repeated in 1992 again, just last year, that there is not going to be a viable option. Not only are there not going to be any more facilities, but then sheltered workshops, group homes too institutional in setting -- it's hard to understand what these people are thinking of in these statements.

The Chair: Thank you for coming here today. I think part of what we do also, as you know, becomes a record through Hansard. I think it's fair to say that in the hearing process we've had several parental groups come before the committee and have talked, as you have today, about the needs as you see them and the sense that we're all perhaps on a journey where we're trying to determine just what is the best care we should be providing to all of our people. What you have said today and in your response to our questions, not just in helping the committee -- but quite frankly, the ministries as they think through the policy decisions they have to make over the next number of months and years. We really appreciate the time and effort you put into your brief in coming before us today.

Mrs Rhodes: Can I make one more small comment? Mr Wessenger spoke of it being a deliberate policy to exclude the developmentally disabled from this consultation because it's such a big task to do this and there is such a -- perhaps some time in the future we'll have to address this and get around to it. But right now the families of Oaklands Regional Centre feel, because of documents such as the Muldoon-Henson report and some of the other things we are hearing from other organizations, do feel quite threatened and quite anxious and the thought of deferment is not very palatable to us at all.

The Chair: Thank you again for coming and making your concerns known to us.


The Chair: I call on the next presenter, the representatives from the Charitable Homes for the Aged of Niagara and Hamilton-Wentworth. Thank you very much for coming to the committee today. Please be good enough to introduce yourselves and then proceed with your presentation.

Mr John Buma: Thank you. We really appreciate this opportunity to come before you and present our concerns regarding the proposed legislative amendments known as Bill 101.

My name is John Buma. I'm administrator of Albright centre in Beamsville. I represent one of eight charitable homes represented in this presentation and those eight charitable homes are listed on the paper you have in front of you. Perhaps the other people here might wish to introduce themselves.

Mr Jake Friesen: I am Jake Friesen, administrator at the United Mennonite Home in Vineland, Ontario.

Mr John Janzen: John Janzen, representing Tabor Manor.

Mr Gord Midgley: I am Gord Midgley, representing Heidehof Home for the Aged, St Catharines.

The Acting Chair (Mrs Yvonne O'Neill): Yes, gentlemen, if you'd like -- you'd have to come forward to the mike, however, or you won't be recorded in Hansard. Would you like to sit in the chair at the other end of the table for the presentation?

Mr Melis Koomans: My name is Melis Koomans, administrator of Shalom Manor in Grimsby.

The Acting Chair: John, will you be making the presentation?

Mr Buma: Yes.

The Acting Chair: Thank you. Would you begin, please.

Mr Buma: The eight charitable homes we represent include the homes mentioned. Albright Manor in Beamsville is affiliated with the United Church of Canada; Foyer Richelieu home in Welland is a home for francophone Canadians; the Heidehof Home for the Aged in St Catharines is a home for German Canadians; Idlewyld Manor in Hamilton is a women-only home for the aged; Pleasant Manor in Virgil, German Mennonite Canadians; Shalom Manor in Grimsby is for Dutch Canadians of Christian Reformed origins; Tabor Manor in St Catharines, Mennonite Canadians; and the United Mennonite Home in Vineland is Mennonite Canadians. We're about 8 of approximately 80 to 85 charitable homes for the aged across the province of Ontario.


We've prepared a brief for you which I understand has been given out. This brief outlines the collective opinions of our homes and was endorsed by the board of directors of each of our homes for release and presentation. In addition to that brief, we have a document called Presentation to the Legislative Committee re Bill 101. It's from that document that I'll be making a presentation too, but the other one is more fleshed out in terms of what we're saying.

The amendment act and access to services are one of our primary concerns. In particular, section 9.5 of Bill 101 speaks to access and the whole area of placement coordination. In subsection 9.5(3) it indicates that "the minister shall designate the placement coordinator who may authorize the admission of persons to that home." In subsections 9.5(5) and (6), a person may be admitted (a) if the placement coordinator has determined that the person is eligible, (b) if the placement coordinator has authorized the admission of the person to the home, and (c) an approved charitable home for the aged shall admit a person who meets the requirements of subsection 9.5(5). Subsections 9.5(7) and 9.5(8) reinforce what is said. In subsection 9.5(9) there's a penalty. Where there's continuous or recurring contravention "the director may direct the placement coordinator...to cease authorizing admissions to the home."

In essence, our specific concern related to this is that all these decisions are being made on behalf of our homes in total and complete isolation from our homes. Our homes, in accordance with what it states in Bill 101, are not asked to participate whatsoever in the admission process to the homes we operate. The decision to admit, as I mentioned, is removed from the home. The consumer eligibility is based solely upon government prescription and subjects the consumers, in our opinion, to another level of bureaucracy at a most vulnerable time in their lives. Most who come to our home come from the hospital or by ambulance, in that kind of way. To think that at that time they would make application to a placement coordination service is a little bit ironic.

In any event, this section of the act -- placement coordination -- does not provide for any input of the home. As mentioned, there is no recognition of the consumer's needs in the context of the services and culture of our home, to which the placement coordinator is making the referral. We suggest that each individual who is referred is unique and that each home he's being referred to is a unique home in the services it can provide and what it has to offer. None of that is taken into consideration in the amended act as it's currently written, and of course we haven't seen any regulations to this act.

The director can cease authorizing admissions to charitable homes, which in essence means the home would go bankrupt because funding is based on keeping the beds full. In other words, the government has control of the home from the front door to the back door and every step in between. Our general concern in this area is that our facilities are owned by us and our board of directors is legally responsible for the day-to-day operations of our homes. Complete government control over admissions and/or no admissions to our homes, as per the act, through a government-operated broker -- a placement coordinator -- ignores the legal responsibilities of the community volunteer directors on our boards.

Complete government control over admissions ignores the objects defined in our letters patent, under which we are incorporated by the very same government. We suggest that in the process of becoming incorporated, we had to submit to the government of Ontario objects as to what we wanted to do as an organization, and those objects define whether we're providing service to francophone Canadians or service to religious groups etc. In our opinion, with government assuming complete control over admission, with no recognition of any of that, we believe that there are some problems in that area in relation to how Bill 101 currently reads.

Placement coordination for purposes of admission to a charitable home for the aged, in our opinion, is a third-party eligibility process that is extremely bureaucratic, unnecessary and a waste of the taxpayers' dollars. In the other paper, we have some recommendations and ways of getting around this and still achieving reform in the system etc, and we'd be more than happy to speak on those.

With regard to section 9.6, there's something there called "Immunity" where the placement coordination service or agency will be immune to action from any damages for any decision it makes or doesn't make in good faith. Our specific concern regarding this is that granting the placement coordinator immunity from all decisions made or not made in good faith creates almost, in a sense, a dictatorial relationship between government and consumer. This is done in the context of a time when a consumer is most vulnerable.

We respectfully submit that there is no accountability in a system where those who control it grant themselves immunity from their own decisions. It just doesn't make sense. At the time he requires access, the vulnerable consumer would be unable to hold the government responsible for decisions the government made concerning the vulnerable consumer's needs, only because the vulnerable consumer isn't in a health position to be able to even begin to advocate for himself what he may require.

There is also no accountability in a system where those who make the admission decision to our homes grant themselves immunity from any of the potential consequences of having made the very decision. The legal responsibility, as I say, is left to the home although the home had no say in making the decision whether or not to admit somebody.

Our general concern in this regard: A fully government-funded and completely immune placement coordination service, which makes decisions for a home in isolation from the home and which makes decisions impacting upon the tax paying and contributing competent consumer in a parochial manner, is potentially in conflict with the amount of funds the government has available. If the government controls admissions and at the same time hands out the money to the home to operate, depending upon the availability of the money, I suppose, it could shut the gates at the front end. We respectfully submit that this is a conflict of interest to those who may be needing the services that a home offers.

With respect to the amendment act and access to services, sections 9.7, 9.8, 9.9 and 9.10 of Bill 101, we'd like to make the following comments. Section 9.7 deals with notice of determination, 9.8 with hearing, 9.9 with immunity and 9.10 with appeal to a divisional court.

In section 9.7, "If a placement coordinator determines that an applicant...is not eligible, the placement coordinator shall serve on the applicant a notice of the determination of ineligibility." The applicant then may serve notice and be entitled to a hearing by an appeal board. The decision of the appeal board members would hold, but that decision can be made by the full board or, in its absence, the vice-chair, the chair or whomever.


Section 9.10: If the applicant does not like the decision of the appeal board, then we can proceed to the Divisional Court on a question of law or fact or both.

First of all, in this regard, we submit that a decision based upon prescriptive criteria issued by government, which has a direct conflict of interest as a financial contributor to the home, in making the decision as to whether or not a consumer will get in relates back to the initial comments regarding placement. What we're basically saying here is that you may appeal something, but again, the appeal board is a 100% government-driven board and that appeal board is in a conflict of interest with the placement coordinator, as it is with the government, in that the government is the funder of the whole thing, so again, it is the assuming of government control.

The applicant who is served notice of ineligibility: It seems unlikely that an applicant seeking to get into a home for the aged in this day and age would be of such physical and mental health that he would be in a position to proceed to the appeal board.

Under subsection 9.8(5), again there is a potential conflict of interest which is not addressed, which we talked about.

The last concern on that page: It seems unnecessary that one would have to protect a decision to admit or not to admit with full immunity status for the person or agent making the decision. Protection behind immunity does not provide for much accountability in any system. The board of directors of our charitable homes for the aged have the full legal responsibility for the day-to-day management of our facilities and have no immunity whatsoever for a much broader range of decisions that they must make. It seems ironic that a placement coordinator needs immunity for a decision as to whether or not a person is eligible and to what home he should go when a board of directors, with much more responsibility, isn't receiving any immunity from anybody for anything.

In regard to inspectors, subsection 10.1(5) of Bill 101 outlines the powers of the inspector, including the power to inspect the premises and records, question persons on matters relevant to the inspection, conduct tests or examinations as reasonably necessary, copy or remove records and call upon experts for assistance. Again, for some strange reason, under this bill they too need immunity; another government-controlled organization again requiring immunity for decisions and actions that those people take.

Our concerns: The role of enforcer through prescriptive management and governance by way of inspection seems to take precedence to the traditional role of partner in service. We've been partners up to this point in time. Everything we've done has been collaborative and cooperative and everything has worked well for our charitable homes up to this point in time. For some reason, at this point there seems to be a need to create an inspection and enforcement system, which we're not really sure we understand to begin with, nor why it's necessary, secondly, for our charitable homes.

The role of enforcer by way of inspection, coupled with their immunity status under the legislation, or complete protection to hide behind one's decisions, puts our homes in a no-win position regardless of how well we are governed and managed. It totally strips the right of directors on boards to even manage or direct the homes.

It seems the government prescribes what we must do in this bill, decides how we must do it and then hides behind its immunity for all its prescriptions and decisions. That's the way we're reading the words in Bill 101, without having seen regulations.

Our homes are already currently governed under a significant number of provincial and federal pieces of legislation as well as local bylaws. To be exact, we've come up with at least 25 different acts of the government of Ontario that affect our operation, there are at least eight different acts of the government of Canada that affect our operation, and then there are the local bylaws -- board of health bylaws, fire hazard bylaws, housing bylaws, municipalities' bylaws etc -- that all affect the operation of our homes. So inspection and accountability certainly are there when one looks at homes on a more global basis than solely the act under which they operate from a service point of view.

All of this already places a great deal of accountability in the system. In addition, our board of directors is personally liable for a significant number of areas of operation within our homes. That's defined in the other paper, on page 4; I think I've listed about 36 areas in which our board of directors is personally held liable under the various acts by which it is governed. They do not have any immunity status, as mentioned before. In addition, our constituents, which include our church and/or ethnic affiliations as well as our consumers, hold us accountable.

The introduction to our charitable homes of inspectors, including inspection and enforcement officers, together with a backup compliance unit and a backup enforcement unit at head office here in Toronto, is totally unnecessary and, as such, very wasteful of taxpayers' money, and is intrusive to the extreme. These measures create accountability overkill in our homes.

In summary, we, as eight homes, agree with the need for reform in acute and long-term care throughout the hospital and long-term care facility systems and the community-based systems. We agree that there are major ongoing operating expenditure reductions that can be realized without affecting quality of service in the system. We agree with the introduction of a patient classification system and related financing system and the introduction of service contracts with government. We don't have any problem with those things, and we think they're long overdue.

However, we also feel strongly, from our collective perspective, that in order to achieve this reform:

(1)Placement coordination agencies are unnecessary for charitable homes for the aged, a waste of taxpayers' dollars and another layer of bureaucracy. They disempower the consumers at a very vulnerable time in their lives. They in fact are the beginning, in our opinion, of the destruction of the raison d'être for, and the ethnic/religious flavour of, our charitable homes.

(2)The introduction of inspectors, enforcement officers, a backup compliance unit and an enforcement unit to our homes is unnecessary, a waste of the taxpayers' dollars, intrusive to the extreme and potentially in legal conflict with the legal powers of the directors of our homes to operate. The compliance system with full immunity, as proposed, is completely dictatorial, as accountability becomes a one-way street. Presently, we enjoy a two-way street accountability: us to government, government to us and both of us to the taxpayers. We feel this is completely lost under this section of Bill 101.

We have never been in the business of making a profit from our operations. As such, there has been and is no incentive for us to provide anything less in service than our resources allow. We believe that the introduction of placement coordinators and inspectors in this regard completely erases the "partners in care" philosophy so widely touted by the government. While there's merit in standards, it's not necessary to paint our charitable, non-profit, community-directed homes for the aged with the same brush as the for-profit, shareholder-directed nursing homes. In our opinion, we feel that's what's happening in Bill 101.

We hope that our comments in this paper will be considered to be constructive, useful and of assistance in the finalizing of the draft Long Term Care Statute Law Amendment Act, and we hope that regardless of the final product we will continue to enjoy the partnership with our ministry and our government we currently experience.


The Acting Chair: Thank you very much, gentlemen. Your brief certainly does bring a different perspective. I think you're the first persons who have actually taken sections of the bill and stated your direct concerns, and then put the bill in its legal context from federal, provincial and municipal structures. It's very helpful for us. I think Mr Wessenger has a question.

Mr Wessenger: Perhaps a couple of points of clarification. First of all, your comments with respect to subsection 9.5(6): I noted when you quoted that section that you didn't quote the words, "unless a ground for refusal of admission prescribed by the regulations exists," which would certainly give the right of refusal to a home, and certainly the intention is that the home would have the right of refusal in those situations where there was an inappropriate placement. Secondly --

The Acting Chair: John would like to respond to that.

Mr Buma: We don't have the regulations in front of us and have no idea what those are going to say. We could only comment on what Bill 101 says, and it's silent on that.

Mr Wessenger: Except that it did indicate that there were grounds for refusal.

Mr Buma: We don't know what it means. It doesn't say that. It doesn't say what that is or means; it just says that.

Mr Wessenger: The second point of clarification is your comment with respect to inspectors being immune from liability. That is true. As crown employees they are immune, but the employer, the crown, is still liable. In other words, there's still the liability of the crown, the employer, for any wrongful act or negligent act of the inspector. So the liability still does continue to exist in that.

I'd particularly like to ask you about your position with respect to placement coordinators. The role of placement coordinator exists already in about half the province. Certainly, when we've questioned people in the areas where they've had placement coordinators, they've been very supportive of the way they operate generally, in that first of all they tend to assist consumer choice, enabling the consumer to make a choice as to the most appropriate facility, and also to enable the consumer to have the choice of non-facility care too, if that is appropriate. So having a placement coordinator seems to be an enhancement of consumer choice rather than detracting from it. Also, it's a mechanism for ensuring that those persons with need get priority.

I'm wondering, in view of the intention and the way the placement coordination agencies work as they are intended to work, why you have particular concerns, particularly since, as I said, we have not had concerns expressed to any large extent in any of the areas where they do have placement coordination.

The Acting Chair: It may help, John, if you state whether there's a placement coordination service in Hamilton Wentworth.

Mr Buma: Yes, there is, and also in Niagara.

Mr Wessenger: Does it work well in your area now?

Mr Buma: To my knowledge it does, but we don't use it. Whether the other seven homes use it -- I can't speak for them. I should clarify that: We don't use it in its formal sense; there's a loose relationship between us and them.

I'd like to speak to that for a minute, but you mentioned another issue prior to this one, Paul: the liability concern in the crown. There are not too many people who are in a position to take on the crown. That's a very difficult process, as you know. If one could do that, they'd be worth a million dollars. In any event, to bring it up to the crown level as opposed to leaving it right at the placement coordination level and making them accountable, I'm not sure why that's --

Mr Wessenger: I was just referring to the inspection aspect. I think your point is correct. With respect to the placement coordination, there is not, at the moment, other than the employer, which would be the placement --

Mr Buma: With regard to the placement coordination agencies that exist, consumer choice etc, I think you have to understand that in the context of our charitable homes. I mentioned at the outset that, for example, the Foyer Richelieu is built and established for francophone Canadians of the Niagara region. It was initiated by them, and built and established for them. They have a large constituency, and there's not one of them who doesn't know that the francophone home exists and, "That's where I'm going to go when I'm ready to go." Chances are that that constituency gave a lot of money in order to build a home, because chances are that the home was built 100% by dollars of the constituency itself. The government operates a program in the home from a cash flow point of view, but often the bricks and mortar of charitable homes are raised 100% by the constituency of the charitable home.

That's perhaps why we don't have too much difficulty filling our charitable homes. The Mennonite people across southwestern Ontario know where the Mennonite homes are and know how to access them, and often there's communication between those homes and their churches and constituents in that way. We're very much different from a municipal home or a nursing home. I won't even speak to the nursing home situation, but we're different from a municipal home in that we have a very strong, very much involved constituency base.

The Acting Chair: Mrs Sullivan, would you like to begin your questions?

Mrs Sullivan: Yes, I would. I appreciate this presentation. I found it a very interesting one. I wanted to explore with you further the question of accountability. Who will sign the service agreement on behalf of your homes? Will that be the board or will it be the administrator? What will be the accountability in terms of your legal obligations and your corporate obligations, in terms of the responsibility for signing the service agreement and complying with it? How will the board itself, which is made up of people from the community associated with the institution, reflect its accountability with respect to the service agreement?

The Acting Chair: Can you get those all into three minutes?

Mrs Sullivan: One and a half, because I've got a second question.

Mr Buma: You ask very difficult questions. Who signs will probably vary between organizations. Whether boards want to establish a finance committee that signs or delegate that to an administrator would be, I think, up to them, depending on what the ministry's going to do with respect to how it lays these service agreements out. We haven't seen those yet.

With respect to accountability and their legal and corporate obligations, I assume that the service agreements are going to be based upon a patient classification system which derives a case mix index, which is going to relate to the funding we are going to provide. If we have a case mix index of 1.6 and the average in the province is 1.0, and then the dollars are attached accordingly, I suspect -- and the ministry people here will be able to answer this much better than I -- that we will sit down with the ministry people and develop the service agreement from that.

Now, from our point of view, that service agreement is going to have to be able to be an accomplishable thing before we sign it. If we can't accomplish it because we don't have the money, I think we wouldn't sign it. I certainly wouldn't recommend to the board of directors to sign something when it's not sure whether the funds are going to come in. That's going to create somewhat of a problem.

Mrs Sullivan: I'll give you a scenario where the inspector comes into your facility, makes a report and does not provide you with a copy of the report. Therefore, that report isn't necessarily available to your board. As a result of that report, your funding is reduced. Who's accountable, then, for delivery of services?

Mr Buma: I would make an argument under Bill 101 that, because the government has assumed complete, full control, it's accountable. I would argue that the way Bill 101 reads, without seeing regulations, without seeing service contracts, they are putting themselves in a position of potential problems, and they don't need to accomplish the same reform they wish to accomplish.


The Acting Chair: Mr Wilson, you have some questions?

Mr Jim Wilson: Thank you, Chair. I think this is an absolutely excellent presentation. You've put a lot of work into spelling out for us your specific concerns with various sections of the bill and I thank you for that.

I'm going to ask you a general question because I think I understand most of the points contained in your brief. Having served on a board of directors myself in an educational institution, but not in a homes for the aged, I know of the responsibility that individual directors take, and it seems to me that with increasing piles of legislation going on the books every year there's more responsibility on these people. Do you think that if the government -- I say "the government" because it is responsible for this legislation -- doesn't do something to correct the problems with consumer choice and facility refusal and facility choice and some of the other concerns you've raised, it may be very, very difficult to get people to even serve in a volunteer capacity? Would anyone like to talk about that?

Mr Janzen: I'd like to address that, if I may. This is one of our major concerns. Here we have privately owned charitable institutions that have, due to need, put up a facility, have operated for many years and have long waiting lists representing the people who actually own the place, now in a position where those boards of directors can no longer accept the people who actually own the place.

As a matter of fact, the decisions will be made by the agency as opposed to the board of directors. That will have a tremendous impact on the future of that home. For example, it will destroy the right of the owners to determine who will be admitted or whether they can serve the people who have actually put in their money. It's going to put a tremendous burden on that board of directors to raise funds, whether it's for ongoing purposes or future expansion.

Some of the homes have just recently spent a great amount of money on upgrading, realizing that when their turn comes they will have access to the home. This holds true for most of the eight homes we're talking about.

There's a tremendous amount of volunteer work that goes into the operation of such a home. If these volunteers and the constituency they represent now realize that they will not have access to the home, that will dry up. Not only will the funds dry up, but also the volunteer work.

As a matter of fact, it pulls the rug on the elected board of directors to operate the home as its constituency would want to see it. The long-term impact of this legislation spells the end of charitable institutions as we know them today.

Mr Buma: I might add that if I were asked to be a director on a board, under this piece of legislation as it now reads, knowing my personal liability as a director on that board, I would have great difficulty saying I would agree to sit on this board, because I would find myself in a conflicting position of being legally responsible with no corresponding authority to do anything. That just doesn't fit the bill.

Mr Jim Wilson: I appreciate it. I don't think I'll ask any more questions because I think you've done just a super job of stressing the importance of amendments that must come forward from the government and from ourselves to clean up this piece of legislation. I parallel your concerns with some of the private sector who feel they are being usurped in terms of maybe actually losing their businesses, while you're going to lose control over the good work you're doing on behalf of your communities.

The Acting Chair: Thank you very much, gentlemen, for bringing us your firsthand, day-to-day experiences about Bill 101. We hope we will be able to attend to those as we continue our discussions.


The Acting Chair: May I have the presenters from Idlewyld Manor, please. If each of you would like to introduce yourselves, that would be helpful for Hansard, and introduce your spokesperson.

Mrs Mary Lou Dingle: May I introduce everybody?

The Acting Chair: Yes.

Mrs Dingle: My name is Mary Lou Dingle. I'm a Hamilton lawyer who restricts her practice of law to wills and estates. I deal very much with the elderly in my practice. I'm also a director of the local Victorian Order of Nurses in Hamilton. One of VON's programs is placement coordination.

The reason I'm here is because I'm one of 15 volunteers who serve on the management board of Idlewyld Manor, which is a charitable home for the aged established, even before I was born, in 1846.

You're not funny. I can tell we're not going to have any fun.

Mr Jackson: Mary Lou, it's the end of the day.

Mrs Dingle: It's the end of the day for me too.

Idlewyld began its mission to elderly ladies in 1877, more than 100 years ago. Actually, Pat and I figured a minute ago it was about 116. Right now, Idlewyld is home to 101 elderly lady residents.

With me are Patricia Howell -- Pat is my neighbour but she's also the president of Idlewyld's management board -- and Daniel Oettinger, our administrator at Idlewyld. They're both ready to answer questions for you. While I present, they have to answer the questions.

Mr Daniel Oettinger: It's fair.

Mrs Dingle: It is fair. I believe Dan has written material to hand out. Has it gone? You already have it. Good. My job then is to highlight and summarize our concerns. I'm not going to follow Dan's paper altogether. I hope I'll make it a little more personal for you.

Our concerns fall into three major categories: first, choice -- I know you already discussed that minutes earlier; second, funding the care levels; and third, governance.

Beginning with choice, I'd like to tell you a little bit about my mother. She's 88, and five and a half years ago she applied to be admitted to Belmont House, which is a seniors' residence in Toronto. Perhaps you know of Belmont. It houses 190 people.

I think the reason mother did that was because she wanted to stay in Toronto. She didn't want to move to Milton where my sister lives, although I guess my sister can vote for some of the people here. She didn't want to go to Hamilton either, where I live. In other words, she wanted to stay in her community, which is not unusual.

She also preferred the company of her peers to the increased isolation and loneliness she was sure to experience if she stayed on in her own apartment. Finally, she wanted to maintain her independence. In fact, she sent us a change of address. We were very grateful.

It isn't a funny group. Oh, dear. One of the things I'm known for is having some fun when I'm speaking, but obviously we're on a different wavelength, my darlings.

My mother chose Belmont, and at that time I became acutely aware of the fact that not everyone is best served at home. I mention mom because she's my best friend, but also because I think we have to recognize the value in the alternative lifestyle. In other words, there are people who benefit from a seniors' residence like Belmont in Toronto, or Idlewyld, which is the board on which I serve.

Interestingly, having chosen Belmont, it then was up to mother to fit into Belmont. I'm happy to report that she has finished organizing the residents' council and she still is the chair of the reception committee for new people coming to Belmont. Of course, she's only 88 and she can hardly see now, but once a volunteer always a volunteer. What can I say?

That brings me to Idlewyld. I think probably the single most important element of Idlewyld's success over the last 116 years is the fact that our residents choose us. Our admissions policy selects reasonably fit elderly ladies who want to make their home at Idlewyld. That, I think, is really the gem of the whole thing.

What worries us about Bill 101 is that it proposes to replace our Idlewyld admissions committee with placement coordination. Placement coordination has a wonderful name in Hamilton. I told you already that I serve as a director of the VON, and placement coordination is one of the VON programs. In fact, placement coordination, for those of you who don't know, was created by Dr Ron Bayne who is a neighbour of Pat's and mine. We can all see his garage from ours.


As a lawyer, I use the service repeatedly because I can refer clients, and their job is to assess the client from a physical and financial point of view and narrow the facilities in the Hamilton area that are good for the particular person. So it's a magic program. But you can imagine how the 15 ladies on the board of management at Idlewyld react when we're told that placement coordination may well have the choice rather than our admissions committee at Idlewyld. We feel this is very inconsistent with the principle of self-determination, to say nothing of our partnership. That's our first point: choice.

The second point is funding care levels. We must have some fun on this or else I'm going home. Bill 101 requires us to assess the needs of our residents on an ongoing basis and to implement any changes required to meet those needs. Of course, that's what we do. That's our job. We do that all the time right now. We don't have any trouble doing that. But just like at my home, and I assume at yours, there are more needs than there are dollars, so we survive financially by establishing priorities. In other words, we manage. If the needs are being determined by government, then I think government has to fund the needs and the changes required to meet the needs.

It might be that government should be rethinking some of the requirements, and I'll come to that in two examples. One is residents' washrooms. We understand that the mandate will be that the residents' washrooms be cleaned daily. Now at Idlewyld, two ladies share a washroom. They each have their own room but they share a washroom. If we must clean these washrooms on a daily basis, we estimate that we'll have to add 1.4 staff people. As I said to Pat, I think we should hire a man. But in any event, be that as it may, the fact is that it will add to our payroll and if it adds to our payroll, somebody has to help us pay, because it's either the residents or it's going to be government; it's one or the other.

I just would like to address how often all our washrooms are cleaned. I live in a home with two teenage sons and a husband, and our washrooms are cleaned twice a week. I think some of these requirements may be excessive, and in a time of restraint they should be looked at. Certainly, at Idlewyld some of the washrooms are cleaned on a daily basis. We select what has to be done. That's what management and priorities are about.

The second matter that comes to mind is the requirement for a dietitian. Again, this is in standards and I realize they're proposed. But at the present time we have wonderful meals at Idlewyld, which is why I'm so round. We have a dietitian who serves us between eight and 16 hours each month. This seems to be a very sensible and adequate arrangement for Idlewyld. We understand that if the new standards are imposed, we will require 50.5 hours of a dietitian's time on a monthly basis because it relates to the number of residents. Again, we're concerned very much about funding to government standards.

Bill 101 also provides for inspections. Inspections are a little bit like motherhood. Of course we support inspections: They're part of life as we see it; they have a purpose. However, we have trouble supporting inspectors who can inspect, find us wanting, impose sanctions, and all of this without even submitting a report outlining the findings and without any appeal mechanism. We just feel that's very heavy-handed. Again, we're concerned about the partnership principle.

Let me then go on to our third point, which is governance. Idlewyld was created by members of the local Hamilton community in 1846, and it has been governed by members of the local Hamilton community ever since. We are getting tired, however.

No? I gave a couple of speeches for Hydro, and it was exactly the same. When I talked about the number of trucks we had, nobody laughed.

Mr Jackson: This isn't theatre, Mary Lou.

Mrs Dingle: I'm the Ontario Hydro rep on our local hydro.

The fact is, there's a mutual need for Idlewyld. The community needs us and we need the community; we need governors from the community. Idlewyld requires the community as the community needs the residents.

In the fall, residents and board members hold a tea. It's a little bit like an elderly lady calling her daughter and saying, "Gee, I'd like to entertain the rest of the family and maybe some of my friends, and will you come and help me?" It's a wonderfully successful tea party. I'm not very good at it because I can't cook, but in any event, it works wonderfully.

On Christmas Day, the tradition is that the president of the management board and her husband, should she have one, go to Idlewyld and serve sherry to the ladies who are staying at Idlewyld for Christmas dinner. All of the residents are visited by members of the board at Idlewyld. In fact, and this is something that my mom mentioned to me, apparently they do the same thing at Belmont here in Toronto. She said that's something that's very important to the residents, because they're all recognized by name by the board members.

In case you don't know, volunteers are fragile. I once resigned prematurely from a board -- now, you must laugh at this -- because the incoming president's voice was so high, I didn't think I could stand it for two years, so I resigned, and it was a very sensible thing to do. But as a volunteer, you get those choices. I mean, you can even leave here if you want.

But I think it's important for you to know that volunteers evaporate when their authority is eroded, when their leadership is usurped, when their judgement is continuously challenged and when their progress is thwarted. I don't think government should intrude unnecessarily. It's inconsistent with the principle of partnership.

So let me conclude and summarize by saying that, one, government should keep what works: Let the consumer choose. Idlewyld's success strongly relates to choice. Two, government must be willing to finance the changes required to meet the standards it intends to impose. Three, government should nurture and respect the partnership principle, volunteerism and local governance.

I thank you, and my friends are willing to answer questions.

The Acting Chair: Mrs Sullivan, would you like to try?

Mrs Sullivan: Yes, thank you very much. That was a fun presentation, I must say.

Mrs Dingle: Thanks.

Mrs Sullivan: I was very interested in the discussion you had. I think your presentation follows very well on the previous one, because you're dealing with many similar issues. But I was very interested in your discussion of the washrooms and of the dietitians, and I'd like to know how involved you have been in terms of commenting on the kinds of standards and regulations and requirements that are going to be made of homes.

My understanding is that many of the rules are taken from a completely different jurisdiction in a completely different context, that they make no sense in terms of operating here; that indeed the cleaning aspect, by example, is one where a square footage component, which bears no relationship to the patient care requirements or the cleaning requirements, is what's on the table. Can you talk to that? I just thought it was very interesting to hear you raise those two issues.

Mrs Dingle: I'd ask Mr Oettinger to respond to that.

Mr Oettinger: In my role as a member of the executive of the Ontario Association of Non-Profit Homes and Services for Seniors, I personally was involved during the summer for hours and days and days on end, it seemed -- I think Geoff will attest to that -- in developing a standards manual which is to be used by all long-term care facilities. So certainly we did have a lot of input into draft 1 of that manual. Draft 2, unfortunately, bears limited resemblance to draft 1, where there was, we felt, very much a collaborative and consultative approach.

There have been a number of unilateral changes on the part of government to that manual. Some of the kinds of things that Mary Lou just alluded to we felt were in non-enforceable guidelines and criteria, and they have now been moved into standards. Regarding the dietitians, assuming that draft 2 were to be implemented in its present form, it would require the 50.5 hours of dietitian time. My dietitian told me today that there is simply nothing for her to do for 50 hours a month. It's an absolute waste of time.


So we have had extensive input into the process up to this point, and certainly we would hope that some of these things will be flattened out by the time it actually comes into force.

Mrs Sullivan: The issue is one that's of interest, of course, because the funding question is one that will affect all of you. If funding is not adequate to cover the additional costs, then where are the nursing homes or homes for the aged in terms of delivery of fundamentally required services? We haven't seen draft 2 of the standards manual, am I correct?

Mr Quirt: That's correct.

Mrs Sullivan: Will we see draft 2 of the standards manual before this committee has completed its hearings?

Mr Quirt: Part of the second draft of the manual has been shared with members of the committee as well as with OANHSS and ONHA and our manual advisory committee. The second draft of those particular program standards has been shared. On March 15, there's another meeting scheduled with that manuals committee, including Dan. It's actually a two-day meeting to review all the contentious areas with respect to program standards and other aspects of the manual.

Mrs Sullivan: So there's a possibility that what is on paper now with respect to cleaning requirements or dietitians or other standards will still be adjusted, that the accommodation of the industry and the sector will be taken into account?

Mr Quirt: The whole purpose of the consultation and the two-day meeting is to make improvements in the manual, yes.

The Acting Chair: Mr Quirt, did you suggest that some members of this committee have that second draft and others don't, or did I misunderstand you?

Mr Quirt: All members of the committee received a first draft of the manual on the second day of the hearings, and all members of the committee received, I believe in London, Ontario, the second draft of the standards section of the long-term care manual. All the new material that is being produced and shared with provincial associations is being shared with the standing committee at the same time, including the materials that were used recently in the two-day presentation to OANHSS on funding arrangements and accountability relationships.

The Acting Chair: Thank you. Mr Jackson.

Mr Jackson: Mary Lou, welcome. I enjoyed your brief and your humour, as I always have. Never having met your mother, I feel that I get a really clear sense of the kind of person she is, having known you for 15 years.

Mrs Dingle: McMaster '26.

Mr Jackson: A delightful presentation. We have heard, in generic terms, this whole issue of cultural sensitivity to the residents. You bring a very unique focus, gender-specific. This has not really been raised, even when services for retiring sisters of various orders and so on are being discussed. The government has given a careful statement that it would consider these kinds of requests and concerns about cultural sensitivity, which could be ethnicity or could be a faith basis. I've only missed two half-days of all these hearings, and to my knowledge, I don't think the gender concept has come up.

So with your permission, and through the Chair, I would like to ask if the parliamentary assistant or legal -- I see legal counsel has abstained for a moment; maybe Mr Quirt will respond -- if there is anything that legal counsel of any ministry has advised you that would prohibit the inclusion of a gender-specific protection for a facility. I'm asking you if you've been given legal advice that you can't do this. I know what kind of answer you're going to give me, about your warm and fuzzy "We'll look at it"; I want to know specifically, for the record, if you've been given any legal advice that you cannot protect -- we may as well call it what it is -- gender exclusivity.

Mr Wessenger: I'll ask legal counsel to respond to that question. I don't know whether legal counsel heard the question: Is there anything that would prohibit ensuring that a gender-specific home like this Idlewyld remains gender-specific?

Ms Gail Czukar: My name is Gail Czukar; I'm a lawyer with the Ministry of Health. Of course the obvious piece of legislation that would apply would be the Human Rights Code, and it has primacy over all other legislation, not to mention the Charter of Rights, of course.

My view would be that there's very likely a way to structure a preference if it could be construed as an affirmative action program essentially, but it would have to be that in order to attract protection under the Human Rights Code. Otherwise, the rule would be that people who are going to be served in a facility should be served equally.

Mr Jackson: I'm sorry I have to rise to the bait, but as you probably know, we have a disproportionate number of women to men who are surviving to this age. Therefore, to use the argument you're suggesting, which in my view is a back-door way at best, presents several problems, as we're dealing with a facility that's already 100% female.

These are legitimate concerns, given that the cohort of potential clients can include ex-psychiatric patients and people experiencing psychiatric difficulties, and when you inject the gender uncertainties into that mix, this is cause for great concern, not just to the board of directors but to the residents themselves, as this is a completely foreign experience, or would be deemed a foreign experience, in the retiring years.

Could I hear from the parliamentary assistant, then, having heard a legal opinion, what he, if anything, is prepared to do or offer in terms of responding to what is, in my view, a rather genuine request which is placed before this committee on International Women's Day?

Mr Wessenger: The only thing I could say is that certainly I would think you could have a policy direction to placement coordinators to not make inappropriate placements. It would certainly be considered, in my opinion, an inappropriate placement to place a male in a seniors' residence that is designed exclusively for women. Of course, as far as someone going to court on the matter is concerned, that I'll leave to legal counsel, but I'd certainly give my assurances that I can't imagine any placement coordinator making such a decision: to place someone of a male background in a women-only home for the aged.

Mr Jackson: In the absence of the legislated guidelines, it could occur.

Mr Wessenger: As I said, a lot of things happen on a policy basis in the way institutions operate, and I don't think this legislation in any way changes the existing situation with respect to the matter of a male trying to get into the home. It in no way changes the legal situation.

Mr Jackson: On the contrary. I don't wish to be argumentative, but clearly you are taking the responsibilities of admission away from the current arrangement, which is the consultation of a placement coordinator with the board of directors, who approve and admit the intake, to a system where the government is the gatekeeper and determines, with the only appeal currently being that you have the right to appeal that you were turned down; and the choice is limited to the fact that you can choose not to go into a facility. I can't accept your statement that nothing's changing.


Mr Wessenger: As I understand it, there's no appeal process with respect to the question of where a placement coordinator -- for instance, to take the theoretical situation of a male who makes a choice, say he wants to go into Idlewyld Manor and the placement coordinator refuses to place him in there. I don't see that he has any right to appeal against that, because the only question that is appealable by the placement coordinator is the question of eligibility for institutional care and not the question of where he's placed in accordance with his choice.

The Acting Chair: Mr Quirt wanted to make a statement and then we will have to move on to the next caucus.

Mr Quirt: Just very briefly, I'd like to reinforce that it is the job of the placement coordinator to allow a prospective resident to make an informed choice. As is the case now, the only people who would be referred to your facility would be people who have said, "I'd like to go there." If in fact a man were to say now that he wished to move into your facility, you might well have an argument from a human rights perspective. In no way does Bill 101 change that. If under the new system a man were to insist to the placement coordinator that he wanted to be considered for your facility, it would be the job of the placement coordinator to inform you of that, and that debate would be joined as it would be now if a man were insistent on moving into your facility.

Mrs Dingle: In fact, Belmont House has both men and women -- many more women.

The Acting Chair: All right. Did you want to have one short statement?

Mr Oettinger: Could I make one final comment to Geoff's comment regarding the coordination, that it's the job of a PCS to coordinate: We would not disagree with the coordination. I think the issue of control is spoken to very clearly in this bill. I would refer you to section 9.5, where a person may be admitted to a charitable home if, and only if, approved by the placement coordinator. That smacks of control, not coordination. We would have no issue with the coordination part. As a matter of fact, we do so already, in reference to Ms Sullivan's question of a while ago. The coordination we take no issue with; it's the control that we have concern about.

The Acting Chair: Mr Owens, you have some questions.

Mr Owens: My question is to ministry counsel. In terms of a clarification around whether a male would be eligible for admission, I'm not quite sure that I understood the response. Are you suggesting that if a male wanted to gain admission to that facility, he would have grounds on a human rights complaint to gain admission? Is that what I understood you to say?

Ms Czukar: No. I'm saying that the Human Rights Code has a provision which allows for what we commonly call affirmative action. Those aren't the words in the code, and I don't have it here to tell you what the exact words are, but he would have an argument. How it would be settled is not known at this point because it hasn't been contested. It could equally be contested in the ethnic homes or religious homes, any ground of discrimination under the code. Someone could take a human rights complaint that he was refused admission to a home on a ground that's not allowed under the code. That hasn't been tested, so it's hard to say how that would be worked out. I'm just saying the argument that would be made by the home would be that this is an affirmative action or whatever the term is that allows preferences for certain minority groups, or in this case a majority group, on the basis of historical discrimination. That case would be played out in the courts. I wouldn't venture to guess what the outcome would be. I would think in some circumstances it could be justified, for all the arguments that were probably made here, and in other circumstances it might not be justified. We don't know the answer at this point; it hasn't been tested legally. But those would be the legal arguments on each side.

Mr Owens: Thank you for the clarification. Mary Lou, thank you for your presentation. I don't live beside you, but I probably drove by your home at some point, so you can count me as somebody who may know --

Mrs Dingle: Did you know because of the state of my bathroom?

Mr Owens: I want to tell you something: If you get to clean your bathroom twice a week, you're doing a hell of a lot better than most of us in this committee.

Mrs Dingle: I didn't say I did it.

Mr Owens: I'm interested in your comments with respect to volunteers. I think volunteers play an important role in the care of not only seniors but other individuals in long-term care facilities and those individuals still living in the community. I wonder if you could clarify for me in terms of your concerns about the erosion of the volunteer as a result of the passage of Bill 101. I'm not quite clear.

Mrs Dingle: I thought I was making it clear. It seems to me that, as managers of Idlewyld, we make decisions, for instance, about hiring our dietitian, the amount of time we think is appropriate, how often our washrooms are cleaned, that kind of thing. If suddenly we're meeting standards that are imposed by a guide, then we're not making those decisions any more; all we're doing is working to a government standard. You're taking away our management, you're taking away our prioritizing, you're taking away how we spend our dollar -- and that's, after all, what it's all about -- so it seems to me then that you are removing leadership from us, you're removing management, and you're generally making us feel as though we're not making the decisions but you are, and that, I think, is the danger. In other words, volunteers are only going to work when there's an interest and they feel there's a challenge that they can do well and have a result from. If everything is government-legislated, then I think volunteers will lose interest, at least in that area.

Again, it's very interesting, because I understand the figure being talked about is that about 80% of the care giving is done by women in the community -- by women.

The Acting Chair: Thank you all very much for coming today and trying to lighten things up a bit for us. This isn't the easiest bill in the world and you let me know we're dealing with some pretty serious matters. Maybe that's the guise we have sort of set ourselves in. We have certainly enjoyed your presentation and you presented it from obviously a very different perspective again. This whole discussion we've just been ending with is new to Bill 101. It's surprising that after, what, three and a half weeks of hearings, we still are having very new matters brought before us.

Mrs Dingle: It's wonderful work for the lawyers.

Mr Oettinger: Thank you.

Mrs Dingle: Thank you.


The Acting Chair: If I may have the CHO Network of Ontario representatives, please.

Mrs Sullivan: Madam Chairman, while the next presenter is coming to the platform, it appears that the clerk does not have a copy of the draft 2 standards. I wonder if we could ask the Ministry of Health officials if they would bring that copy for members of the committee tomorrow.

The Acting Chair: I understand that's already under advisement and the clerk is going to do that, Mrs Sullivan.

Mrs Sullivan: Thank you.

The Acting Chair: If you would like to introduce yourselves and begin.

Mr David Murray: Okay. My name's Dave Murray and I'm the secretary treasurer for the comprehensive health organization network of Ontario. This is Sue Goble and Sue is the president of the network.

We represent the members of the CHO Network, and the CHO Network is made up of six different sites which have formally been recognized by the Ministry of Health and are in different stages of development. The sites are the group health centre CHO feasibility study in Sault Ste Marie, the Rainy Lake health studies program in Fort Frances, in the Rainy River district, St Peter's seniors' CHO feasibility study in Hamilton, the Toronto Multicultural Health Partnership in Toronto, the Trenton Memorial Hospital in Trenton and the Wawa and area comprehensive health organization. These represent both rural and urban communities whose populations include those with varied cultural and ethnic needs and preferences.

The CHO Network fully supports the government's resolve to finally reform the long-term care system in Ontario.

The presentation I'm giving isn't the one that's in front of you, so you don't have to bother trying to read along.

Mr Jackson: Is it the same one from Thunder Bay?

Mr Murray: A little different than the one in Thunder Bay.

Mr Jackson: Okay. That was good too.

Mr Murray: Here's the one from Thunder Bay.

Mr Jackson: All right, I remember that one.

Mr Murray: In the broadest terms, CHOs will take responsibility for the delivery of services to a locally defined population. This population will make up their roster. Therefore, CHOs will work in partnership with physicians, acute care hospitals, chronic hospitals, in-home services, homes for the aged, nursing homes and community agencies to support the needs of the local community.

The CHO Network recognizes that the way to meet the increasing needs of the aging population is not necessarily by adding more beds, or more hospital beds more specifically. More of an effort must be made to forging links with community-based care givers. The CHO concept reflects the changing view of our health care system in focusing on health rather than illness. Health services will be provided in the least intrusive manner, using the most efficient and effective delivery possible. The CHO Network strongly believes in the need for a coordinated continuum of care in Ontario. One of the key objectives of long-term care reform must be to create closer relationships between care providers. As I had mentioned when I was in Thunder Bay, the CHO model seeks to do for all the people in our catchment area what long-term care redirection is trying to do for the elderly.

The continuum of care as put forward by the Honourable Frances Lankin on February 1: "What we are attempting to do is understand that there really is a continuum of care that is required, and while we have pieces of it in Ontario now, we do not have good linkages and we don't have the sense of the continuum, that people can enter and exit various points of the system at appropriate times to get the care that they require at that point in time."

The network totally agrees with the minister's comments. There is a compelling need for a well-coordinated approach, community by community, to help improve upon that continuum of care for people. The CHO system is designed to simplify and make more cost-effective the administration and funding of health care. By design, the CHO system demonstrates cost containment, restructures and reallocates dollars and resources with reduced emphasis on institutional care, enhances community and consumer participation and represents decentralization and a devolving health system delivery. CHOs are in keeping with the ministry's direction of health care reform.

The former minister had previously made a commitment to the continuum of care embodied in the CHO system. Under the proposed legislation, the ability of a CHO to provide or purchase services in a continuum will be greatly undermined. In short, Bill 101 puts one segment of the continuum under a completely different set of rules. Major changes must be made to Bill 101 to ensure that the philosophical approach used to govern long-term care does not present a barrier to providing that continuum of care now and in the future.

The CHO Network agrees with the minister's five stated policy objectives for Bill 101. The network is, however, very concerned with the approach the government has adopted to achieve these objectives. I'll ask Sue to talk about the key problems and recommendations of the CHO Network.

Mrs Susan Goble: Briefly, we've identified five areas of concern. They're in detail in the brief that we've given you today, but I'd like to summarize them. The first one is the shift to a contractual model from an insurance model, which we see as a problem; the increased expectations regarding levels of care without the necessary resources to go along with it; the placement coordinator role, and we've just listened to two previous presentations that certainly highlight that; fourth, the inspection role and the potential adversarial situation that this might lead to; fifth, the need for the long-term care facilities to determine their own role.

As a network, our major concern is that the legislation appears to set up restrictive sets of rules and regulations to deal with long-term care redirection which are not in keeping with efficient and coordinated care.

We'd like to provide the following recommendations. Under governance, the CHO Network strongly recommends that the government adopt the same philosophical approach to the governance of long-term care facilities as it has to the rest of the institutional sector in the health care system.

At present, some chronic hospitals and nursing homes in communities have set up community advisory boards made up of consumers, families, interested citizens and providers. CHOs, comprehensive health organizations, will have a similar governance structure, which we believe will not only improve the quality of decision-making but will foster increased responsibility by members for their own care. The CHO Network believes that the new long-term care institutions should maintain similar governance structures to those that are currently in place in acute and chronic hospitals and homes for the aged. Only this approach supports the concept of a continuum of care for the consumer.

Under peer review and accreditation, the CHO Network recommends that compliance management, peer review, accreditation and continuous improvement programs be the approach used to ensure accountability in long-term care facilities.

Equity in funding: It is time to distribute the funds equitably between nursing homes and homes for the aged. However, flexibility must be given to those facilities to enable them to utilize their resources as effectively as possible.

Placement coordinator: Not all levels of care can be offered in one facility. Therefore, it is important to people that those who assist in the placement need to recognize the unique needs of the individual and ensure that the placement is appropriate. The range of services in facilities is extensive, from social types of situations all the way through to specialized facilities, such as chronic care hospitals, which have created a multidisciplinary approach to care. Today, many facilities have increased their specialization and have created this multidiscipline approach to meet the changing health and social service needs of the consumer.

The placement coordinator must recognize that a wide range of highly specialized programs, both inpatient and outpatient, have been established in chronic hospitals, and these do not currently exist in either acute care, nursing homes or homes for the aged.

Placement coordinators must further be able to consider an individual's needs with respect to ethnicity, language, geography and religion when placement choices are to be offered. In the CHO system, to ensure that the widest possible spectrum of services are covered, the CHO must provide a full range of vertically integrated services to its members and as such will be able to match the consumer need with the appropriate inpatient or outpatient service.

In summary, there are many challenges facing our health system. The CHO system presents both opportunities for its sponsors and the rest of the local health care community to address today's challenges on the community's own terms. In addition, CHOs provide opportunities for health care providers to become part of that continuum of care.

There are certain common elements between the CHO and the proposed plan to redirect long-term care and support services. Both emphasize service coordination for consumers and effective use of financial and human resources. The CHO program and the long-term care division have developed a policy statement defining how a CHO may be used to deliver long-term care services. The initial focus will be on a coordination and delivery of in-home services.

In developing a reformed long-term care system there must be a properly structured, well-coordinated, integrated system of community and facility services which can improve the range of choice and enhance the quality of life for the elderly and people of all ages with disabilities so that they can live with dignity and have as much independence as is possible.

The CHO model is the most comprehensive model currently being explored, combining all the elements in the health care system under one governance structure. CHO communities have spent thousands of hours addressing the effectiveness, efficiency and efficacy of this model for their people. This has been done in good faith with the government. Now, given the dollars spent, use of resources and the commitment of both the government and several communities to the model, it's time to take another serious look at the CHO model.

In conclusion, we believe that the legislation, as drafted, would dramatically alter the current system and in our view would seriously impair our ability to manage the overall system effectively. In our opinion, the key to a workable legislation is one that ensures sufficient flexibility in order to reflect local factors and realities. Major changes must be made to Bill 101 to ensure that the philosophical approach used to govern long-term care facilities does not present a major barrier to providing that continuum of care for the health care consumer today and tomorrow.


The Acting Chair: Thank you very much, Mrs Goble. Mr Jackson, I think you're to begin.

Mr Jackson: Thank you for your presentation. We had an opportunity to raise some specific questions about the CHO development in northern Ontario, and for those of us who had not had prior exposure to it, it was quite informative.

I guess at this point, then, my question would be, to what extent are you getting feedback from the designated groups to consult with the infrastructure for Bill 101 and how you might become a comfortable fit into that process? Do you understand what I'm asking you?

Mr Murray: Not really.

Mr Jackson: All right. Under the legislation they will be developing a series of -- the buzzwords change from the Liberals to the socialists, so I'm having trouble --

The Acting Chair: Multiservice --

Mr Jackson: Thank you -- multiservice organizations.

The Acting Chair: Multiservice agencies.

Mr Jackson: Multiservice agencies. MSAs?

The Acting Chair: I think that's what they're using. Is that not the correct --

Mr Jackson: Is that the one we're using this week? Very good, we have consensus here.

Apparently, some groups have already been approached, such as DHCs, to develop how these models could be implemented. My question is, to what extent are your agencies, through your network, being involved in that process of consultation? It's one thing for you to come and present to us, but our understanding is this process is already begun, in a fashion, at a community level. So you should talk to us, but how are you linked into the groups that are already coming together to advise this government about implementation of this legislation?

Mr Murray: For long-term care, I think that changes community by community, depending on where the CHO models are being developed. I know in our particular community, which is the Rainy River district, the long-term care office for the region, which is in Thunder Bay, looks to utilize the CHO in the area as its coordinating agency, and that's something which we have been discussing with them for close to two years now.

Mr Jackson: I'm sorry to interrupt. We're familiar with that because you gave a very clear -- you responded to this question for Rainy River. I guess my question was more to your network of Trenton, Hamilton, Wawa, the other organizations to which you refer in your brief. To what extent are they being invited to the table? Clearly, we're getting a good sense of working up in Thunder Bay, but I just wanted to get a snapshot of what's happening in the other jurisdictions.

Mrs Goble: I think that specific question has not been collectively addressed by the membership, so I feel a little uneasy in speaking for a group of six people on a specific answer, but I guess in the sense that in no community where a CHO is being explored is there not dialogue and communication ongoing that does not include not only the defined population that you're looking at but also the providers, the district health council etc. So I feel comfortable in saying there is dialogue. In terms of it being a specific type of approach, I think both of us are hesitating because we would have to --

Mr Jackson: It may not be as specific and as encouraging as it is in Thunder Bay, for example. You just don't know.

Mrs Goble: It may not have been posed in the way that you've posed the question.

The Acting Chair: Mr Wessenger, do you have a question?

Mr Wessenger: Yes. I'd like to thank you for your presentation and I'd just like you to elaborate somewhat on your comments on your governance, because you indicate that currently hospitals and homes for the aged are governed by boards of directors. Ultimately, they're responsible to the government and the community for overall fiscal integrity and managing the organization. Then you say you'd like to have this system of accountability applied to all long-term care institutions, and I'm just wondering how. Does that mean you would change the structure, for instance, of municipal homes for the aged, for one example, and second, what about the whole question of privately owned nursing homes? How would they fit into that?

Mrs Goble: In the CHO model, there is one governing body for the particular comprehensive health organization, and depending on its arrangement with its providers, some of those providers may well have a seat on the governing board of the CHO, but it is not our intent to disrupt the actual operation of any particular component within the CHO model. Whether they're a municipal home, an acute care hospital, a home for the aged, a nursing home or 25 of all the above, they would still have their operation. It's the agreement that they would come into the CHO where they would then either have a seat on the board or have representation through a collective seat on the board.

Mr Wessenger: Maybe I'll just specifically make one recommendation about community advisory boards, or make a comment. Are you recommending that all institutions have community advisory boards?

Mrs Goble: We certainly see where that has been a sound way to have feedback from local communities and the actual consumers using facilities or organization services or outpatient services. We certainly see that this consumer input at each different local level has meant there is more influence in terms of the needs being responded to and the services being matched to the local needs.

Mr Wessenger: One further question: Do you think really that the CHO model is the best model for incorporating long-term care? Is that what you're saying?

Mrs Goble: The CHO model is the most comprehensive model. Any other model that is out there at the present time does not include all the elements. The CHO model does. It incorporates everything from the physicians, the acute care side, the nursing homes, the homes for the aged and the levels of care in the community. That's what it's all about. It is the comprehensive model. I think we would not be sitting here today if we did not believe it was the most comprehensive model.

Mr Murray: If I could just expand on that for one brief moment, the process has been going on for about five years now. When we started, the CHO model was an alternative that we were investigating, the idea of changing the way we delivered health care. Everybody was looking at it. It was an option, although everybody was quite happy with the status quo. The status quo is no longer acceptable. It's become imperative that we change the system.

I think at the time the long-term care reform-redirection was started several years ago, it looked to try to solve a problem with a specific part of the population. That same problem exists for the entire continuum of the population and the CHO model tries to address it in a more global sense. I guess the way we see it, what is being done with long-term care could just as easily have been done for the whole system and it would've been called a CHO.

The Acting Chair: Mrs Sullivan, you will complete the questioning.

Mrs Sullivan: My questions were quite similar really to those presented by the parliamentary assistant. My conclusion is that your recommendation is basically that the CHO should become a multiservice agency wherever possible. If that is not possible, is there not a conflict then between the work of the CHO in terms of purchasing services either in the community or in a facility and the work of the placement coordinator? How do you see that being resolved?

Mr Murray: I think the potential for a conflict is a great one. I think this is a situation where if a CHO is in place, it does have the funding authority flowed to it through a number of health agencies. The whole reason for being of a CHO is local accountability, local decision-making, with a majority consumer-driven board. To me, it should have the say. That's my feeling. But there is the potential. That's why you need to work together. That's something the CHO, in our development stage, is getting quite good at. There's not a lot of providers who are coming to us with open arms. We seem to be a threat to the status quo. So we work with people instead of working against them.

Mrs Goble: If I may elaborate on Dave's response, I think too, in terms of the placement coordination situation, in the CHO model, given that you would have, for your members, all the components in place to support their needs, you would address and probably get around the issue of having to necessarily go before placement coordination. But having said that, that doesn't mean that you would not work within the community, because it might mean that within your CHO organization you could not support your member, and therefore you would have to use and work with placement coordination, depending how that was going to fall out in the future.

The Acting Chair: Thank you, Mr Murray and Mrs Goble, for coming and presenting again. I think you were making your point.

I would suggest then that the standing committee on social development adjourn until 10 am tomorrow morning in committee room 1.

The committee adjourned at 1730.