Tuesday 26 October 1993

Expenditure Control Plan Statute Law Amendment Act, 1993, Bill 50, Mrs Grier / Loi de 1993 modifiant des lois en ce qui concerne le Plan de contrôle des dépenses, projet de loi 50, Mme Grier S-433

Ontario Association of Optometrists

Dr Mira Acs, president

Service Employees International Union

Judi Christou, assistant to international vice-president, Canada

Marcelle Goldenberg, director of research, Local 204

Sudbury and District Medical Society

Dr Jack Hollingsworth, president

Stephen Connell


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

*Vice-Chair / Vice-Président: Eddy, Ron (Brant-Haldimand L)

*Carter, Jenny (Peterborough ND)

Cunningham, Dianne (London North/-Nord PC)

*Hope, Randy R. (Chatham-Kent ND)

Martin, Tony (Sault Ste Marie ND)

McGuinty, Dalton (Ottawa South/-Sud L)

O'Connor, Larry (Durham-York ND)

*O'Neill, Yvonne (Ottawa-Rideau L)

*Owens, Stephen (Scarborough Centre ND)

Rizzo, Tony (Oakwood ND)

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

*In attendance / présents

Substitutions present / Membres remplaçants présents:

Sullivan, Barbara (Halton Centre L) for Mr McGuinty

Wessenger, Paul (Simcoe Centre ND) for Mr O'Connor

Wilson, Gary (Kingston and The Islands/Kingston et Les Iles ND) for Mr Martin

Also taking part / Autres participants et participantes:

Frankford, Robert (Scarborough East/-Est ND)

Laurier, Catherine, policy adviser, labour-management policy branch, Ministry of Labour

Ministry of Health:

Wessenger, Paul, parliamentary assistant to the minister

Williams, Frank, deputy director, legal services

Clerk / Greffier: Arnott, Doug

Staff / Personnel: Gardner, Dr Bob, assistant director, Legislative Research Service

The committee met at 1534 in committee room 1.


Consideration of Bill 50, An Act to implement the Government's expenditure control plan and, in that connection, to amend the Health Insurance Act and the Hospital Labour Disputes Arbitration Act / Loi visant à mettre en oeuvre le Plan de contrôle des dépenses du gouvernement et modifiant la Loi sur l'assurance-santé et la Loi sur l'arbitrage des conflits de travail dans les hôpitaux.

The Vice-Chair (Mr Ron Eddy): Good afternoon, ladies and gentlemen. The standing committee on social development is now in session on Bill 50, An Act to implement the Government's expenditure control plan and, in that connection, to amend the Health Insurance Act and the Hospital Labour Disputes Arbitration Act. Welcome.


The Vice-Chair: Our first delegation is present. Would you please introduce yourself and proceed with your presentation.

Dr Mira Acs: Greetings. Let me start by introducing myself, my profession and the organization which I represent. I am Dr Mira Acs, the president of the Ontario Association of Optometrists. Here with me today is Barbara Wattie Fuller, the director of policy and government relations for the OAO.

Let me just take a moment to describe our association and my profession. The OAO is a voluntary membership association, representing more than 90% of the approximately 900 active licensed optometrists in Ontario. Optometry is an independent, self-regulating, primary health care profession, governed by the Health Disciplines Act and soon to be governed by the Regulated Health Professions Act.

Provincial legislation, including the Health Disciplines Act, the Health Insurance Act and the Health Care Accessibility Act, provides the framework for professional responsibilities and a high degree of accountability. Optometrists are required by regulation to provide care in accordance with the standards of practice published by the college. These published standards have been in place for 20 years and have been upheld by the courts and the Health Services Appeal Board.

Optometrists, who are university educated and clinically trained to examine, diagnose, treat and prevent conditions of the eye and visual system, provide a comprehensive and detailed diagnostic examination of the eye and the visual system, including, on average, 20 individual diagnostic procedures. This service is entirely covered by OHIP payments to optometrists.

Practising in over 80% of Ontario communities with a population of 1,500 or more, optometrists provide more than 70% of all primary eye and vision care services in Ontario. In more than 75% of communities where they practice, they are the only source of vision care. In the fiscal year 1991-92, optometrists provided 2.3 million OHIP-insured eye examination services.

As to current affairs, let me just say that we have found the last seven months to be ones of tremendous upheaval in government relations. From April 5, with Premier Rae's announcement of the social contract, to the present, the resources of the OAO and the attention of its members have been directed to attempting to understand the always complicated, seldom clear statements on the insurability of optometric services. Concurrent to discussions centred on reducing expenditures by 5% under the social contract, on April 23 the expenditure control plan was announced, in which the one-line item referring to optometry and ophthalmology was that only one eye examination per person per year would be allowed.

This was seemingly straightforward. However, an incidental reference in a document explaining ECP to physicians stated that billing criteria for optometrists would be tightened. The OAO immediately bombarded the Ministry of Health for clarification, and on May 13 we received written notification that the complete examination, or the V-401 code, would be restricted to one per person per year, and the follow-up examination, or the V-402 code, would be deinsured. We were further advised that the expenditure control plan measures would be negotiated with the then executive director of OHIP, Dr Robert MacMillan, and would be in addition to our social contract cutbacks.

In addition to attendance at what were seemingly endless social contract meetings, the OAO held meetings with OHIP to try to get further clarification of the intent of these measures. We made it clear that the expenditure control measure that would deinsure our follow-up code was completely unacceptable. We spoke to many of you about these concerns.

On August 25, following our signing a local agreement under the social contract, which dropped and froze optometric expenditures at the 1991-92 levels, we were told by Dr MacMillan that our services would remain the same, that the social contract encompassed or replaced ECP as far as optometry was concerned. Needless to say, accurate, up-to-the-minute reporting to our members has been a challenge.

Really, that brings me to why I am here today. We have a few comments and one recommendation to make. But with your indulgence, we would appreciate use of this time to seek clarification from the ministry representatives on one or two points. My comments on the bill relate to amendments provided by the clerk and are therefore in no particular order as they relate to the bill itself.

With respect to the health cards section, subsection 2(2.1) of the bill amending section 11.1 of the Health Insurance Act, we see that under subsection (2), taking possession of a card, the amendment to "prescribed person" from "physician." We assume that the intent is to include optometrists as prescribed persons. We would appreciate clarification of this as well as what "voluntarily" means in an operational context.


Further amendments to sections 43.1 and 43.2 of the Health Insurance Act re duty to report again refer to prescribed persons. We may be misunderstanding the most recently received amendments, but it seems that the duty to report now rests on determinations of residency. For the sake of our members' ability to comply should this affect them, a clarification of what will be required of them would be appreciated.

With respect to third-party services, this entire section is a new aspect of Bill 50 and we welcome it. One of the challenges in recent months for optometrists has been trying to determine when a service is a third-party service and then explaining that to the patient who is reluctant to pay for it. It simply can't be made clear enough. We are particularly pleased to see further amplification of what constitutes a requirement or request for a service.

This brings me to our recommendation to amend under subsection 36.3(5), determining whether excessive. We respectfully request adding reference to the OAO-suggested schedule of fees or, alternatively, striking the reference to the OMA's guidelines on fees and inserting a reference to the "pertinent profession's" schedule of fees.

In conclusion, we would like to thank this committee for the opportunity to be here and to have our views heard. We are unable to comment in any further detail because we have had these newer amendments in our possession for less than a week. The flavour and the character, if you will, of Bill 50 has changed considerably from when we first looked at it.

The two sections we have spoken to today dealing with health cards and third-party services will have a definite impact on our members and the services they provide. What that impact will be is difficult to assess at this stage because further clarification must come from you and the Ministry of Health as to the intent of these measures, how the measures will be implemented and ultimately monitored.

Today we would appreciate any further clarification you can give us, and for the future we would like to say that we are willing and eager to participate in this process. We ask that you consult with us on issues that affect the delivery of eye and vision care services in this province and we in return offer our sincere desire to help serve the people of this province.

The Vice-Chair: Thank you for your presentation. Are there questions?

Mr Stephen Owens (Scarborough Centre): Dr Acs, thank you very much for your presentation. You were quite right in terms of sending representatives out to MPPs' offices with respect to your concern. I received a visit myself from a very well-versed group of my constituents.

In terms of the issue with respect to health cards, could you tell me a little more about that? I'm not sure I quite get it in terms of your concern and the amendment you would like to see.

Dr Acs: The first concern is the change from "physician" to "prescribed person." Is that going to include all health care providers who bill OHIP? Is that the intention? Is it going to include dentists, optometrists and chiropractors in addition to the physicians? That was our first concern.

The second concern was a more general concern in terms of what it means in terms of voluntarily surrendering a health card, that then it would be the onus on the practitioner to keep and return to the ministry. Those were the two concerns regarding that, unless Barbara has a different concern there.

Mr Owens: Then a question to the parliamentary assistant, Chair: In terms of the withdrawal of the billing code V-402 and its having been deinsured, can you tell me why that code was delisted, what the rationale was, and is there any thought to putting it back on the fee for service?

Dr Acs: It wasn't delisted. That was the intention under the ECP, but it really was something that was removed.

Mr Jim Wilson (Simcoe West): It was a threat.

Dr Acs: As Mr Wilson said, it was a threat.

Mr Paul Wessenger (Simcoe Centre): I'd just like to confirm that the presenter is correct that it was not deinsured.

Mrs Barbara Sullivan (Halton Centre): I have a number of questions. I appreciate that you've come today, given very short notice and an almost aberrational process with respect to distribution of potential amendments to this bill.

I'm interested, first of all, in the process you described that the optometrists went through as the original bill was placed on the table. I think it shows an almost unconscionable lack of consultation with health care professionals; indeed, that people's health care services across the province would have been affected given the status of delivery your profession provides.

I share your concern about who prescribed persons are. We have asked for the information from the parliamentary assistant and it was indicated to us that the list of prescribed persons, not only for taking possession of a card but for having a duty to report, would be brought forward to the committee. I had hoped we would have that information before committee started today.

Additionally, we were to have a report on which third-party services were affected and what the legal requirements are now with respect to institutions that require certain kinds of health assessments and so on, whether they be food handlers or boards of education and so on, and it appears we do not have that information.

Chair, could you clarify whether that information is available now?

The Vice-Chair: Mr Wessenger, would you care to respond to this?

Mr Wessenger: I don't believe we have any list of prescribed persons at this time. If I could clarify, I think it's fair to say that the intent of the legislation is to expand it to health practitioners across the board, but I think it's also fair to say that there would need to be some consultation done with the various groups, and it might be quite possible that the matter would be phased in with respect to particular health practitioners. In other words, we might work it with one group to start with before we extended it to a second one. The intention is to bring it into all, yes, but the timing could be a phased-in situation.

Mrs Sullivan: But I think this points out the exact problem. When the Ontario Medical Association and the College of Physicians and Surgeons of Ontario were here last week, the suggestion was clearly made that it wouldn't necessarily be the professional who had to take possession of the card, that it may well be a secretary, an assistant, another person who provides some service associated with the professional responsibility, or in another venue it could be an unregulated health care practitioner. Nobody knows who has what will be these legislated responsibilities brought forward by regulation. You can understand that everyone is anxious to have that information. Frankly, if we get it and you have more questions, I think you should ask for another appointment with the committee.

The next question I wanted to ask is, given the drafting of the proposed amendment, how would you, as an association, advise the members of your association to identify whether a person was a resident of Ontario or not? What signals would you look for?

Dr Acs: At this point I must say that I have no clear answer for you because I really don't know. I haven't given it much thought in terms of the operational contact you would have with patients in your office. I really don't know what kind of information we could give our members. At this point, I don't think we could give them any information, frankly, because I don't think we know. I don't think we could.


Mrs Sullivan: You're in the same position as other professionals who have appeared before us so far.

I have one more question. Just a second and let me get my mind together here. Under the expenditure control plan, the Ministry of Health had prepared a list of services to be delisted. That was the list that was talked about with respect to removing the code and lowering the fees for the other code. As a result of the OMA agreement, it appears that there is a new process in place. The Ministry of Health will put 10 services on a list, the medical association will put 10 services on a list, they will sit across the table and they will bargain about what comes out of OHIP. There will be no reference to other professions or to patients. What do you think of that process?

Dr Acs: I think it's a terrible process. If, as happened before, as recently as in the last four months, along with measures that are put there to implement restrictions on OHIP billing by physicians, it's also, "By the way, we're going to tighten billing criteria by optometrists," and we are affected by something that is decided upon by two groups where we're not present, where we're not consulted, then I think it's a very unfair process. If members around this table felt they were bombarded by members of my profession before, watch out, folks. We're coming back again in full force. It's unconscionable. We will not stand for it.

Mr Wessenger: If I may clarify with respect to that, there is nothing in Bill 50, by the way, that relates to delisting of services. There was in the original bill, but that has been removed. The process that has been discussed, which of course is not related to this bill -- but the delisting process is related only to the delisting of physician services. That process of the panel is not in any way related to the delisting of services for optometrists or other health practitioners.

Mrs Sullivan: I want to make it very clear that there is no guarantee that that is what the process is going to be or what is envisioned. Bill 50 is what is before this committee, despite the fact that the government has placed before us some conflicting and bizarre amendments and some amendments that we think are useful.

But we still have, in terms of this committee, to deal with the original bill plus the package of amendments that has come forward and a process that is continuing at this very moment behind closed doors. No one has access to either list, the doctors' list or the ministry's list. I've asked for it in the House. It's not been provided, and who knows what's being discussed.

Mr Jim Wilson: Thank you, Dr Acs, for your very fine presentation. To follow on what Mrs Sullivan is getting at, so that the public is aware, obviously the study in this committee of Bill 50 is the only opportunity that we as legislators have to examine the government-OMA agreement and the delistings contained therein, so for the parliamentary assistant to try and separate the issues is stretching reality.

Because you didn't get your question answered by the parliamentary assistant, and perhaps as a note to the PA, when presenters ask specific questions of you, perhaps it would be easier if, before going the rounds in the questions, you could answer them.

There was a specific question with respect to subsection 36.3(5) and third-party billing. In determining whether excessive amounts have been charged, there's only reference to the OMA. It's a good point brought up by Dr Acs that if "prescribed persons" in the rest of the act is to deal with all of the other regulated health professions that are currently billing OHIP, would you not need a change or some flexibility with respect to the wording in section 5?

Mr Wessenger: I will refer this to legal counsel to deal with the question of whether the bill relates to -- I don't have my brief here. I'll ask legal counsel to clarify that.

Mr Frank Williams: I'm sorry; I think I was out of the room when the question was asked. Perhaps you could go through it again. I'm not sure what section. Could you repeat the section?

Dr Acs: I was referring to subsection 36.3(5), dealing with "determining whether excessive." We respectfully request adding reference to the OAO's suggested schedule of fees or, alternatively, striking the reference to the OMA's guideline on fees and inserting a reference to the pertinent profession's schedule of fees.

Mr Jim Wilson: The witness has correctly pointed out that the current wording restricts that section to simply a referral to the OMA. If all other professions are to be included, I think a very good point's been made.

Mr Wessenger: We'll certainly take it under consideration.

The Vice-Chair: Any other questions? None? Thank you very much for your presentation, Dr Acs.


The Vice-Chair: The next presentation will be by the Service Employees International Union. Come forward, please, and introduce yourself. You can proceed with your presentation; I believe we have copies.

Ms Judi Christou: Mr Chair, honourable members, my name is Judi Christou. I'm assistant to the president of Local 204 for Service Employees International Union. With me is Marcelle Goldenberg, who is the director of research.

We welcome this opportunity to present our views to the standing committee on social development concerning Bill 50. For those of you who aren't familiar with our organization, we represent approximately 45,000 workers across the province. The majority of our members are health care workers working in service and nursing positions. All of these employees are covered by the Social Contract Act and the sectoral framework agreement for the broader health sector and the Hospital Labour Disputes Arbitration Act.

We appear before you today because we are greatly concerned about section 1 of the act. We interpret this legislation as giving the government the right to suspend our collective agreements or even a grievance made under the Social Contract Act. Originally, we understood that Bill 50 was a fail-safe mechanism that was to apply to the province's doctors, as they were excluded from the Social Contract Act. Indeed, the letter accompanying the bill from the Minister of Health supports that view.

Subsequently, the Ontario Medical Association reached an agreement with the government which specifically excludes them from section 1. It would be safe to assume, therefore, that this section applies to all other health care workers except doctors. But we too came to a social contract agreement with the government in accordance with the Social Contract Act, so we would like to know if section 1 applies to us, and if so, why?

The proposed amendment to the bill does little to clarify the situation. For example, how do you define "agreement"? Are you referring to collective agreements or agreements made pursuant to the Social Contract Act? This legislation simply speaks of an obligation to pay money and to engage in related negotiations. Indeed, this could be interpreted by some as applying to all items in a collective agreement, making it totally unenforceable.

Similarly, some health care employers could claim that the health sector framework agreement is not an agreement, because they didn't sign it and it had to be designated. If they were found to be correct, the amendment would not apply and all health care workers covered by this agreement would again fall under section 1. We have been assured by some government officials that this section does not apply to us, but we respectfully submit that the legislation is not clear enough and leaves itself open to interpretation.

This union therefore suggests that this legislation is unacceptable in its present form and that section 1 should be completely withdrawn. In the alternative, we would request that a further amendment be added which specifically says that the health sectoral agreement excludes health care workers from section 1.

The other section we would like to address is section 3, which requires that arbitrators and nominees under the Hospital Labour Disputes Arbitration Act be paid for by the respective parties instead of by the government, which is now the practice.

I'd like briefly to give you some background to this issue. In 1963, SEIU had a strike at Trenton Memorial Hospital, as hospital workers were then governed by the Labour Relations Act. The report of the Bennett commission, which was established in response to this dispute, recommended that compulsory arbitration be invoked at the discretion of the Lieutenant Governor in Council and that strikes and lockouts be prohibited only where patient care was seriously threatened or one party was bargaining in bad faith.

Instead of acting on these moderate proposals, the government completely abolished the right to strike and imposed compulsory arbitration on unions and employers in the sector, the theory being that these employees were essential and that the cost of a strike, either in human or monetary terms, far outweighed the benefits of maintaining free collective bargaining. If the ultimate goal of interest arbitration is to benefit the public good through no disruption of service, then we maintain that it is appropriate the government should pay the cost.


Another reason we object to paying for the process is because the system simply doesn't work very well. There have been few amendments to the act since it was introduced some 28 years ago in spite of constant requests through the years by union and employer groups. The Hospital Inquiry Commission of 1974, for example, recommended sweeping changes to the act. In 1980 a labour-management committee in the hospital industry was formed specifically to deal with the inadequacies of the HLDAA. The group was able to agree on a number of proposed changes to the act, and although these changes were presented to various ministers of Labour over the next 10 years, no amendments have been made.

We've listed some examples of suggested amendments that the unions and employers were able to agree to at that time, but again these tend to change depending on the circumstances and the climate of the day.

We question, though, why the only amendment we are facing today is that we should pay for the process, and not that the whole process should be re-examined.

One of the arguments put forward by the government for this change is that cost-sharing for interest arbitration is quite common in the public sector. We acknowledge that this is the case, but in most of these instances, the parties have more control and choice in the process. For example, teachers have the right to strike, but if the parties opt for interest arbitration, they share the cost, similarly with community college employees and, soon, employees who fall under CECBA.

In terms of control of the process, neither the unions nor the employers have any control over who's appointed as an interest arbitrator under HLDAA. This is in direct contrast to the rights arbitration process, where the arbitrators are screened by a tripartite committee. Therefore, we submit we should not have to pay for a process that has been imposed on us and that gives us no choice of dispute resolution technique or control over who is to hear our cases.

Finally, employers are the ones who benefit monetarily from the process itself, because unless a contract is settled prior to the expiry date, the settlement is never made fully retroactive. And one of the complaints of the system that is often made concerns the delays; the employer therefore collects the interest on the moneys owing as well as having the advantage of not having to pay benefits for the full term of the agreement. To ask them to pay the cost of this process is probably a small fraction of the money they save.

In addition, the Ontario Hospital Association in particular receives public funding and one of its primary functions is to represent hospitals in labour relations. In contrast, unions receive no such funding, surviving on the dues of their members which are based on wages which are for ever being rolled back or frozen by government dictate. In the interests of equity, we feel it is appropriate that the government continue to pay for this process.

Respectfully submitted by Service Employees International Union.

The Vice-Chair: Thank you for your presentation. You have some questions. Does the parliamentary assistant wish to respond at this time?

Mr Wessenger: Yes. I believe there was one question asked by the group, and I'll ask legal counsel to respond; that is, the question of section 1 and whether it would apply to collective agreements.

Mr Williams: I'll reiterate the comments I made outside this committee that it was never our intention that agreements reached either through a sectoral framework or otherwise would be overridden by section 1, especially now with the amendments that we're planning to bring in. I'll bring up the matter with legislative counsel, and we'll discuss whether or not in fact it goes far enough. We're prepared to look into amending it, if necessary.

Mr Owens: Judy, thank you very much for your presentation. As a former hospital worker, albeit a CUPE local president, I'm quite familiar with some of the points you make, especially with respect to not having the right to strike and binding arbitration. Can you tell the committee how many locals you have that are involved in central bargaining with the Ontario Hospital Association?

Ms Marcelle Goldenberg: We have at least seven locals, covering almost 60 hospitals, involved in central bargaining in the hospitals.

Mr Owens: About how many employees would that be?

Ms Goldenberg: That covers approximately 28,000 members.

Mr Owens: Would you characterize the central bargaining process as one that moves along quickly, that is a pleasure to take part in, that is cost-effective for the taxpayers?

Ms Goldenberg: No.

Mr Owens: How would you characterize that bargaining process?

Ms Goldenberg: Extremely painful and timeconsuming, non-productive. We're typically engaged in bargaining with the Ontario Hospital Association on behalf of our members, and there's absolutely no incentive for meaningful bargaining to take place. The recourse is usually to interest arbitration, and I believe that because of that structure we have not concluded a voluntary settlement, for example, in our central bargaining for over 10 years and we've resorted to interest arbitration each time.

Mr Owens: What's the average length of time that a set of contract negotiations, notwithstanding that you still do local issues, would take place for your workers?

Ms Goldenberg: Typically, it will take us any time from about eight months to a year to get to interest arbitration, to have a hearing, and after that we have absolutely no control, once the case has been heard, over how long it would take for an arbitrator to render a decision. And it could go anywhere from three months to a year, as well, before --

Mr Owens: And after the arbitrator has rendered a decision, of course your employer implements the agreement immediately with respect to wage increases and vacation entitlements?

Ms Goldenberg: No, there's a time period they have for implementing the retroactive clauses. Typically, we only are able to get issues like wages retroactive, but not any benefit improvements or any other clauses. Job security clauses are not retroactive, so we're limited to just wages.

Mr Owens: Have you calculated how much more this is going to cost your workers in terms of your duty to pay under this piece of legislation?

Ms Goldenberg: Not only do we have the central bargaining process to undertake but we also have individual bargaining. Some hospitals refuse to participate in central bargaining, and therefore we may have others. We typically would have about 150 interest arbitrations a year for SEIU alone. No, we haven't calculated what the cost would be.

Mr Owens: And of course the employer never disciplines any of your workers and you never have to go to grievance arbitration either, I would imagine.

Ms Goldenberg: We have many more cases of rights arbitrations than we would care to have, but --

Mr Owens: What would be the average hourly wage your workers would receive, and in terms of the malefemale breakdown of your bargaining units?

Ms Goldenberg: Our bargaining units typically in the health care sector are about 85% women. The average hourly rate is estimated, over our nursing homes and our hospital sector, to be approximately $14 an hour at the high end, probably, between $13 and $14.

The Vice-Chair: Are you finished?

Mr Owens: I have many more questions, but I'll yield.

The Vice-Chair: Mr J. Wilson.

Mr Jim Wilson: Thank you, Mr R. Eddy. I want to thank the presenters for raising a very good point about section 1 which hasn't been raised earlier in our discussions. Could I ask for a clarification from legal counsel on precisely what the government's intent there is? It seems to me you have written this act in such a way as to give the government some rather sweeping powers. I suspect somewhat of a hidden agenda and I want to hear, for the record, precisely what the intent of the section is.

Mr Wessenger: Which section?

Mr Jim Wilson: Section 1, dealing with obligations and designation.

Mr Wessenger: I think it's quite clear that it's to cover the agreement with the OMA and the other agreements, such as the one we heard with the optometrists today, with the health practitioners.

Mr Jim Wilson: Then why doesn't it say that in relatively plain legal language? It seems to me it covers everyone in the health care field.

Mrs Sullivan: That's right. It says "health sector."

Mr Jim Wilson: It uses very broad language in every sentence.

Mr Wessenger: The only suggestion I can make is that, as you may well know, legislation is drafted by legislative counsel and they do it in what they think is the best way to achieve the purposes. If there's an ambiguity here, I think it's been clear that we'll ask legislative counsel to look at the problem with respect to any such ambiguity and see if we can clarify it.


Mr Jim Wilson: With respect, your answer's as ambiguous as the wording in the act. Could you provide us with a list of those groups directly affected by this section of the act?

Mr Wessenger: I think we could probably ask. Do we have someone here who can indicate the number? I think the information was given before by Dr LeBlanc, but I wonder if anyone can give an indication of the agreements that are now subject to this section.

Mr Williams: In essence, other than groups we haven't reached agreement with, any agreements that were reached prior to June 14 where we've reached subsequent agreements, they no longer would be covered. The section was intended to cover groups like the OMA and other practitioners we've entered into contracts with at various times.

To start listing them in the statute is not normally the way -- when I was a legislative counsel, that isn't the way we drafted legislation. It was intended to be a broad general section, and the purpose of the amendments is to make it clear that with any agreements we've entered into after June 14, we will honour those agreements. That's the intention of the amendment, to make sure that we in fact honour those agreements.

Mr Jim Wilson: Will we see some amendments come forward to help clarify this section?

Mr Wessenger: I think what we've indicated is that if there is a legal ambiguity, and that'll be determined by legal counsel, whether there's an ambiguity, and if there's a need, then I would assume the changes would be made, if that's the case.

Mrs Yvonne O'Neill (Ottawa-Rideau): Mr Chairman, may I ask a supplementary on that one? This is getting very confusing. Are you suggesting that you're going to provide us with a list of those agreements you've reached beyond June 14 so we'd know what isn't covered here?

Mr Williams: The only commitment that I've suggested is that we will look into the situation of groups that have been designated by the Minister of Finance under various sectoral agreements to ensure that the wording we have covers those types of situations. We intended that the type of agreement that the presenter has mentioned would be covered by the amendments to the bill.

That's the commitment I gave, that I would speak to legislative counsel to ensure that the wording we have is sufficient. If it is not, we'll amend it accordingly.

Mrs O'Neill: So these are the agreements that were reached then between June 14 and the presentation of Bill 50?

Mr Wessenger: I might indicate that there could be agreements entered into in the future which will be covered by this bill.

Mr Williams: Yes, that's correct.

Mr Wessenger: This covers any agreement entered into by any, as I understand it, health practitioner who would be under the provisions of OHIP payments.

Mr Randy R. Hope (Chatham-Kent): You talked about the bargaining aspect and the number of workers you represent. How many collective agreements does that represent? Also, what is your rating aspect? How many agreements do you get in place without going to binding arbitration or to arbitration? I need to know your score sheet.

Ms Goldenberg: We would probably have in the health sector over 1,000 individual agreements. We do have central bargaining for our hospital group, which will take care of up to 60 of our hospitals; we have a total of about 95 hospitals, so there are 35. In an individual hospital, we may have an office and clerical group, a service group and a registered technologists group as well, so it's very fragmented in terms of the number of bargaining units and, subsequently, collective agreements per facility. Then we have approximately 200 nursing homes, homes for the aged and charitable homes for the aged.

Mr Hope: How many settled before the termination date of the contract and how many do you have to go to an arbitrator to get these things ruled on?

Ms Goldenberg: Very, very rarely do we have voluntary settlements in this area. Therefore, we proceed to arbitration on a large number of our cases and it may be that prior to actually getting to the interest arbitration, we may have a pattern that's established. That's never a guarantee we're able to apply to the rest of the sector.

Mr Hope: So it might be, I guess, safe to say that you ratify 10% of your agreements before termination date and 90% you have to take to arbitrator.

Ms Goldenberg: None of them before termination date.

Mr Hope: I mean getting an agreement without having to go to an arbitrator.

Ms Goldenberg: Perhaps, though it would be a high number -- I think 10%, but close.

Mrs Sullivan: I want to move back to the question with respect to section 1 and what is an agreement. I think there's a fundamental discrepancy between the original subsections 1(1), 1(2), 1(3) and the amendments put forward to 1(2.1).

The first and the original bill wording describes designated obligations of the crown in right of Ontario, ministers of the crown, the government of Ontario, employers in the health sector etc. The amendments speak about agreements. There's no definition of "agreement" in the bill.

One wonders whether those agreements are limited to those under the social contract and what occurs when there has not been an agreement and fail-safe has been imposed, such as is the case with the hospitals. Your union represents some 27,000 members who work in hospitals, by example. Is an agreement a contractual relationship or is it a collective agreement? What is in fact meant in the amendments as proposed?

Mr Wessenger: I'll ask counsel to clarify what "agreement" means. I would think that an agreement, if it isn't defined, would have to obviously be an agreement that is signed by both parties, but I'll ask counsel to confirm that.

Mr Williams: I guess maybe if I give you some background for the original section and the background for why we've amended it, that might explain a little bit of the conundrum you're having.

"Agreement," I would think, would have its normal meaning in law. "Agreement" has a meaning in law and there are all kinds of statutes that use the word "agreement" and don't define it, and it has a meaning; the case law certainly would support what the normal meaning of "agreement" is.

First of all, I think it should be explained that if you look at subsection 1(3), the override doesn't apply unless an agreement is actually designated by cabinet. Unless there is a designation, there is no override under section 1. That's the first thing.

The second thing to keep in mind is that the designation expires at the end of the social contract period, namely, April 1, 1996. The reason we amended the bill, or are proposing to amend the bill, was that there were several groups that came to us and said, "What if we enter into an agreement under the Social Contract Act" -- not necessarily under social contract -- "or in any other context that we enter into agreement with you, will we be penalized because of this section?"

The answer of course is no and the amendment is to make it clear that with any agreements we enter into with parties, we will honour those agreements. That's the purpose for the amendment. So "agreement" was intended to have its normal legal meaning and there's no hidden agenda here and there's no hidden meaning in it.

Again, I reiterate, if we discuss with legislative counsel and they're of the opinion that "agreement" would not cover the type of situation that's been brought up this afternoon, we will seek to correct that.

Mrs Sullivan: You're saying that if the agreement has been imposed by the Minister of Finance rather than signed by both parties, there will be a further amendment coming to the legislation?

Mr Williams: If that's thought to be necessary.

Mrs Sullivan: I see. Okay, well, you might want to come back too. I wanted to ask if you had prepared an estimate on what the costs to your union, to the SEIU, would be for the government not to take on the arbitration costs under the labour disputes act.

Ms Christou: No, we haven't done a costing of it. We know that we go to arbitration, as my colleague said, in almost 90% of our cases, so it would be substantial.

Mrs Sullivan: Would the ministry have that kind of estimate?

Mr Wessenger: No, I don't think there is.


Mrs Sullivan: If the ministry paid the bills in the past, could they review those bills and come forward at least with some data as to what the arbitration costs have been under the hospital labour disputes act?

Mr Wessenger: We have someone here from the Ministry of Labour. I don't know whether she can give any information in that regard or not, about the costs of arbitration.

The Vice-Chair: Please state your name and position.

Ms Catherine Laurier: Catherine Laurier, policy adviser, Ministry of Labour.

I don't have any information that shows a breakdown union by union, but there's a rough estimate that the annual cost to government for interest arbitrations that are held is in the neighbourhood of $450,000 a year.

Mrs Sullivan: Under this particular bill or under all arbitrations?

Ms Laurier: Just under the hospital bill.

Mrs Sullivan: Under the hospital labour disputes. Okay, thanks.

The Vice-Chair: Any further questions? None? Thank you very much for your presentation -- sorry, Mr Owens.

Mr Owens: I was just going to ask the parliamentary assistant and perhaps the Ministry of Labour person, if in fact the costs are going to be borne by the parties, what is the ministry prepared to do to ensure that expeditious bargaining takes place?

Mr Wessenger: I don't know whether it's a fair question to ask the representative from the Ministry of Labour.

If I might answer initially, the purpose of the section, besides saving the cost of the arbitration to the government of course, is to encourage the parties to negotiate on the basis that this will be an incentive for their negotiation. I don't know whether there's anything that somebody from the Ministry of Labour would like to add to that or not.

Ms Laurier: I can simply note that under the sectoral agreements, there have been certain commitments made or agreements made among the parties to review labour relations in the hospital sector in arbitration and that might provide an opening for unions to put forward some concrete proposals around reforming the interest arbitration system.

Mr Owens: The OHA receiving public money -- I'm just wondering if there will be one eye kept on the OHA in terms of its usage of funds. This is in my view a bit of a bizarre process, that when you have one publicly funded body bearing the cost -- I mean, it seems like money is just floating eternally and that if there is no encouragement from the ministry, things will just continue as they have in the past.

Mr Wessenger: I can certainly take that under consideration.

The Vice-Chair: Any further questions? Do you wish to make a statement?

Ms Goldenberg: On the last comment that was made, I just wish to note that under a recent freedom of information request, the information we received was that the OHA receives approximately $2.5 million for the human resources funding, specifically allocated to that department to oversee collective bargaining and other human resources matters.

Mrs Sullivan: Could I have clarification of where the money comes from to the OHA and for what purposes? I think it would be useful to have that on the table. Does it come from the Ministry of Health? Does it come from the Ministry of Labour? Does the Ministry of Labour provide any grants in this area?

Ms Laurier: Not as far as I know.

Mrs Sullivan: No. Presumably it's all Health money, and where it goes and how it's used --

Mr Wessenger: I'm certain that information could be made available. I would ask that staff take a note of it.

The Vice-Chair: Anything further? If not, thank you for your presentation. We appreciate your coming before the committee.


The Vice-Chair: The next presenter is the Sudbury and District Medical Society, Dr Hollingsworth. Please give your name and position for Hansard and proceed with your presentation.

Dr Jack Hollingsworth: My name is Dr Jack Hollingsworth. I'm president of the Sudbury and District Medical Society and I'm here representing physicians from Sudbury. I have what I hope will be a brief presentation for this committee. I don't have a written brief; I merely have handwritten notes which I don't think would be really legible for the committee unless they're brought to a pharmacist.

I would like to make an opening statement to the NDP members of this committee. I see Mr Owens over there, a familiar face.

Mr Owens: We seem to have a continuing relationship.

Dr Hollingsworth: That's right.

Mr Owens: I hope it's as pleasant for you as it is for me.

Dr Hollingsworth: I would ask that you listen very carefully to what I have to say, and perhaps when you're in caucus, some of the matters that I'm going to talk about might be discussed, because we have a really hard time seeing our local MPPs in Sudbury. When we do see them, their eyes seem to glaze over when we start mentioning some of the problems with health care that are occurring at the moment.

I would ask for your help and I would ask for any previous feelings you've had towards the doctors from Sudbury to be put aside, and perhaps that you would make these representations to the people from Sudbury and also to the Minister of Health as well perhaps.

I'd like to move on now to look at some of the amendments to this act. Subsection 2(2.1), section 11.1 of the Health Insurance Act, concerning physicians returning health cards: I was fortunate to have an opportunity to return a health card previously. I had a patient who died in October 1990 who unfortunately received a health card three years later, despite the fact that a death certificate was filled in and this person was obviously dead.

This health card entitled him to free medical care and free drugs. I forwarded this health card to Mr Wilson who did in fact return it to the Minister of Health. I think it shows how difficult central planning can be, because not only was the government not aware that he had died, but in fact it did actually give him a new card, even though everything was done appropriately.

Another example of the failure of central planning is the difficulty the government has in deciding which doctors are alive or dead and which doctors are actually practising. We've had physicians listed who are supposed to be in active practice who have in fact been dead for eight years. An example is Dr A. Greco from Timmins. We've had many doctors in this situation.

We were told by the Ministry of Health, and Mr Wessenger may be privy to this information, that we had about 124 GPs in Sudbury, and we said, "No, we've got 84." When we actually got the ministry to compare the data, it had a lot of doctors on its list who were not actually there.

I'd like to move on to subsection 2(3.1), section 19.1 of the Health Insurance Act, which relates to the minister giving exemptions for doctors to become eligible under the Health Insurance Act. Previously, the college has had the function of deciding exemptions for doctors, and in the past doctors were felt to be self-regulating. If you take this power from the college, the whole question of self-regulation is in doubt altogether. I would advise this amendment be considered very carefully.

Subsection 2(3.2), which relates to the Health Insurance Act, sections 36.1 to 36.4: Third-party services would be liable to be paid for by the third party. I think this is a good idea in general. I think we've had a lot of services being requested in the past from people, for example, who are going to work in day care or going to drive trucks, and employers want all sorts of forms filled out which are I think inappropriate. Perhaps if they have to bear the brunt of the cost, this may help. If this is the intent of this amendment, I would agree with that.

The next section is section 43.1 of the Health Insurance Act, reporting incidents to the general manager. The reporting of incidents to the general manager, the idea that doctors are going to be reporting their patients, is going to become quite difficult for doctors, I think. It's unlikely that doctors are going to be the police force that you want to make your central planning work. However, even if they do, the client or the patient can for 39 or 40 cents send a letter to the college saying that this doctor did something inappropriate, and we have a long investigation ahead of us.

This is one of the problems we practitioners face when we're out there working in the field. Even though one of the sections of your amendments, 43.3, states that there will be protection of the reporter from legal liability, we still have a problem with the college, and we can get into a lot of hot water with the college.


I'd like to move on to discuss some aspects of the act itself, particularly concerning audits. Mr Owens, you probably have some idea about audits. You've been around here a long time. I've met you before. You're probably familiar with short bolting in the mines. We've had the situation in Sudbury where we had people who were accused of short bolting. They would pull out the bolts and measure them, and if you put in too short a bolt, that was a way of getting a big bonus without doing the work. That's one way of auditing. Another idea is that people with their cars, you should check their brakes; you stop them.

Audits are a good idea, I'm sure you'll agree. However, there are times when audits can become harassment. An example is, if I went out and stopped every car on the street, I would stop all the traffic; it would be difficult for people to get around.

I would caution an extension of the audit system to more than double what it is. The previous executive director of OHIP, Dr MacMillan, had made a statement that 75% of the people who were audited under their auspices were in fact found to have a problem when they were referred to the college, to the MRC, to the review committee. I would submit that if you extend audits too far, your efficiency will drop quite a lot. I would ask that you consider audits carefully before this act is implemented.

The next point I want to discuss is the expenditure control plan. As you know, the Ontario Hospital Association did not sign the expenditure control plan and therefore in the hospitals we saw fail-safe provisions being introduced. We see a situation in Princess Margaret Hospital where they can no longer take care of their patients. They're in fact coming to Sudbury for radiotherapy, I understand, and there may well be an exemption in this situation. The question is, how many exemptions are you going to have to make because of this kind of legislation?

Another example of where the whole idea of a global budget and a centrally planned system falls down a bit is the situation of Wendy Majkut, who was a lady from Hamilton who needed a bone-marrow transplant. Her major misfortune was that her disease occurred late in the year and she had to have a transplant when the budget had run out. In fact funds were made available because of publicity. My question is, if this expenditure control plan is so great, how are you going to take care of people like her? You're always going to have exceptions.

Examples of underservicing and shortages and rationing have occurred in Sudbury recently. We've had children flown down to Toronto regularly to have their bones set. Oscar Bernier was a 13-year-old, developmentally handicapped child who came down with his leg very badly broken, had a very painful trip and had to wait 36 hours to get a compound fracture fixed. The normal delay should be less than six hours. Curtis Lapointe fell off some monkey bars in his school and waited, again overnight, to get his elbow fracture set. These are situations occurring on a daily basis in Sudbury. Every day two or three people are sent away for tendon repairs or for other services that we can't provide for them now.

I'd like to draw your attention to the effect of the expenditure control plan on services in the north. We recently had a meeting of our District 9 for the OMA, which is the northern Ontario section of the OMA. A Dr Slater, who's a family doctor, pointed out many of the changes that are happening because of your legislation and policies. This is what he states, and he's not a political person at all; he's never made any statements before. "Services continue to deteriorate and have taken a nose dive over the last two years. I've been in northern Ontario 32 years, and I've never seen such dramatic changes."

He quoted Harris, where two doctors have retired. Kapuskasing has gone from seven doctors to two. Smooth Rock Falls, three doctors gone down to one. Cochrane has lost a lot of doctors. A GP, an anaesthetist and an obstetrician have departed, leaving five doctors, no obstetrics available, GPs being forced to go back into obstetrics. Iroquois Falls is now closed, patients going to Timmins. Englehart, one doctor.

This is just a disaster all across the north. I think the doctors are very concerned about services in the north, and we continue to try and lobby the MPPs in the area, with limited effect because of their lack of availability.

An example of this is that there were two meetings recently concerning health in the north. For one, Mrs Grier went to Sudbury and met with the district health council but did not meet with any doctors that I know of who are involved in care in Sudbury. The second meeting was to do with the memorandum of agreement between the OMA and the government. That meeting was moved at the request of Mr Laughren, I was told, to Timmins, and one wonders, were we kept out in the dark on purpose?

I caution you of the effects of some of these expenditure control plan policies on certain groups. You'll see real shortages occur, for example, in anaesthetics. If you have your Bob Rae days -- you're closing 12 days a year this year and it may be 24 next year because you're still short billions in taxes -- you're going to reduce services, you're going to lengthen waiting lists and you're going to have a major problem in certain areas in the north.

General surgeons are being affected. One example is orthopaedic surgery. If a patient comes into my office tomorrow who needs a hip replacement, it will take six months to a year to get it. In Toronto, they may get it within four to six weeks.

I would point out to you in closing that the north has been underserviced in the past, and these policies ensure it will remain for ever underserviced. We have a hard billing cap now. We have a 5% clawback for utilization, which means that doctors can only do 95% of the work they did last year. It's become harder for us to recruit and retain doctors.

I would ask you a question directly, Mr Owens. I'd like you to respond to this. We have a situation in Sudbury, just one example, anaesthetists in Sudbury Memorial Hospital doing heart surgery, assisting there, trying to put the patients to sleep. They've lost one doctor; he went to Sheboygan, Michigan. They've gone from five to four. They're told they can do only 95% of the work done last year. How do they provide the service 25% more when they can't recruit another doctor there?

The same situation has occurred in Huntsville. There are no residents there this year. They had GPs doing the work of residents all summer and, again, their utilization is way up. How do we encourage doctors to come north? How do we get any parity with the south? There are eight diabetes specialists in southern Ontario. We recently got one to go to Sault Ste Marie. How do we manage to get more services in the north? I would ask you how we provide the services. That concludes my presentation, Mr Chairman.

The Vice-Chair: Thank you for your presentation to the committee. Questions now. Mr Owens, did you have questions?

Mr Owens: I'd like to thank Dr Hollingsworth for all the personal attention he has paid to me and for his presentation. I do want to say, starting my remarks, that I personally know that the local MPPs, Floyd Laughren, Sharon Murdock and Shelley Martel, are working extremely hard to address the issues that exist in northern Ontario and certainly didn't begin on September 6, 1990. So I'm not quite sure why you make comments about how you can't get meetings and lack of availability. I simply know that is not the case, that these members are out working hard.

In terms of the issue with respect to health cards, I'm curious to know from you, sir, why you returned the patient's health card to Mr Wilson instead of the minister.

Dr Hollingsworth: I didn't receive a reply to my question, Mr Chairman.

Mr Owens: I'm not the parliamentary assistant or the minister. I'll redirect the question to the parliamentary assistant with respect to services in northern Ontario.

The Vice-Chair: Thank you. Are you doing that now or did you wish to speak?

Mr Owens: I'd like to finish my questions.

The Vice-Chair: Yes. Continue, please.

Mr Owens: Then perhaps Mr Wessenger can respond to Dr Hollingsworth.

In terms of the physician supply issue in northern Ontario, and quite frankly across the province in rural areas, I'm wondering if you and your colleagues have come up with a model in terms of determining the numbers of physicians that are required and what is the best way to get the physicians where they're required.

Dr Hollingsworth: There are many different ways of getting physicians' estimates of how many doctors are needed. What's become the working norm is a figure that was never intended to be used for this purpose; it's the Royal College estimates of doctors per head of population.

Just to give you an example, it would be recommended that you have perhaps one orthopaedic surgeon for every 30,000 to 60,000 head of population. We're now left with about four for 650,000. It would be recommended to have one psychiatrist for every 8,000, and we have one for 80,000 at the moment in Sudbury. So the figures that we use for determining these ratios are not well worked out, they are not scientific, but by any guideline we're well underserviced, Mr Owens.


Mr Owens: You and a number of your colleagues are quite active in terms of your activity in the community with respect to physician supply. I'm asking what models you have developed. You've told me what doesn't work. I'm asking you what, in your view, would work?

Dr Hollingsworth: I'm not saying it doesn't work. What I'm saying is, this is the working principle that's been used by the Ministry of Health. It's been used by the Ontario Medical Association. It's been used by the Ontario Hospital Association.

Unfortunately, I have a full-time job. I've been on call the last two weekends; I'm on call again this Thursday. I had to cancel patients to come down here and make this presentation. I'm not sitting around wondering about ratios and guidelines. I'm actually trying to see patients who wait about four months to see me. So I haven't worked out any guideline. I would go with probably what people are working with, understanding it's not perfect.

The Vice-Chair: Mr Wessenger, do you wish to respond to the questions?

Mr Wessenger: I'll just add a quick comment. As Dr Hollingsworth may know, the OMA agreement commits the government and the OMA to work together with respect to the whole question of underserviced areas and with respect to contracts, and a lot of work is being conducted at the present time in coming up with the best schemes to deal with this matter and the appropriate form of contracts and approach. I think the most successful approach is a joint approach with the OMA, and I'm optimistic that they will come up with a reasonable plan.

Dr Hollingsworth: Mr Wessenger, that's very interesting. I have a motion I'd like to read to you from the members of District 9 at our last annual meeting and it states, "In the opinion of District 9 members, physician retention initiatives have not been successful in northern Ontario and new initiatives need to be sought by the Ontario Medical Association."

There were various statements made during that meeting; for example, "CMA in locum programs were virtually useless." This is relating to the new memorandum of agreement in which we have less than about $2 million or $3 million to solve all these problems in the north, which would perhaps give us all about a day off in the year and get us a booklet sent.

There are 850 doctors in the north. We're not going to get any change as long as people like you, who have this central, downtown Toronto idea, make smug statements like that, because it's just not working and it's not going to work. You're going to see more and more rationing and more and more shortages, and what you're saying is absolutely untrue. It may be backed up by the OMA, but the doctors in the north certainly don't agree with it.

Mr Wessenger: I see you haven't changed, Dr Hollingsworth.

Mr Jim Wilson: Dr Hollingsworth, I very much appreciate our ongoing dialogue. I appreciate your taking the time out of what I know is a busy practice and coming to see this committee. I think it's sad that there's such discontent and turmoil among your colleagues and the public in Sudbury.

What we've had a problem with, over my time here in Parliament, is trying to get the government to understand that it's the general negative climate created by its policies that is having a real impact on services and physicians' lives and forcing them to leave this province and to leave the north, and not in any way serving to encourage new physicians to go north.

I want to publicly thank you for all the time you take out. Some members may disagree with your style. I happen to appreciate people who are direct, to the point, and don't mess around. I think you speak from the heart when you try on numerous occasions to explain to the government what the climate is like in northern Ontario. You're right, we do have unfortunately a Toronto-centred mentality here. We have an abundance of services here and it's hard to put ourselves in your shoes. When the government won't listen to you, I find that extremely sad.

I'll give you one more shot at trying to explain to fellow human beings here what it's like to live and try and work in that climate that's been created in the Sudbury area.

Dr Hollingsworth: We have less than half, in many cases a quarter, the number of doctors you've got down south, so that when you cut back our utilization to 95% of the work we did last year people are living on 25% to 50%, less 5% again. When we lose people, we cannot increase our output. You have tied both hands behind our backs now.

We are working with equipment that's way outdated. Mr Wessenger, you probably know, because you're parliamentary assistant, that there are 12 MRI scanners in this province and we don't have one in northern Ontario, and yet we have about 9% of the population. You also probably know that we cover 80% of the land mass. You probably feel in your heart of hearts that we should have at least one in northern Ontario, but you probably won't say it today. Would you like to respond to that, Mr Wessenger?

Mr Wessenger: I'm not aware of what the plans are, so I'm not in a position to comment.

Dr Hollingsworth: Let me tell you what the plans are. We're going to get our own MRI scanner, the same way we got a cancer clinic. We're going to collect the money from the public. We'd better get funding from this government, because we've had it up to here. We're not going to take it lying down. We're not going to see the services in the north disappear.

Mr Robert Frankford (Scarborough East): To get into alternatives, have you given any consideration to population-based funding per capita, either in HSOs for primary care or even going big scale to an area CHO?

Dr Hollingsworth: I think what you're proposing is probably better than this death by slow strangulation. You're obviously thinking about the problem.

One of the problems we have is that we have less than half the doctors per head of population. Therefore, because you have a doctor-driven system -- the cutbacks are based on doctors largely; to some extent hospitals -- you can see the destruction coming. You can see that with half or a quarter of the doctors, when you cut back 5% this year and 5% next year, you're going to see catastrophes. We've not been offered a CHO system. The government has not come out and made that offer to us.

I think that at this point anything that can be done to preserve services in the north should be considered. We've certainly tried to help. We've taken part in a hospital restructuring. We've looked at hospital services very closely. We're trying to form an interlocking board. We're trying to make the system work, but we don't think it can work, given the plan. As time goes on and we self-combust, basically, there will be nothing left in a few years. By the time this government is finished, in two years' time when the mandate is over, there will be nothing left of health care services in the north. I'm convinced of that. Unless something is done very rapidly, things are going to go downhill very quickly now.

Mrs Sullivan: As usual, I find Dr Hollingsworth's remarks useful, not only in the debate on the bill that's in front of us now but because Dr Hollingsworth is always able to bring us around to particular legislation that goes beyond that.

I'm interested in a number of things. With respect to this particular bill, I wonder what the attitude of physicians from the Sudbury area and other practitioners, if you've spoken to them, is about taking responsibility for capturing, if you like, a health card, and returning that; how you would go about talking with your colleagues about how you would identify a non-resident, which is apparently now the criteria of people who work with you in your own practice or those who work in the hospital -- you would expect the government would be requiring to collect those cards -- and what advice you'd have for them.

Dr Hollingsworth: It's a bit like the travel grant situation. We fill in the travel grants and we do our best. Dr De Blacam, who's a colleague of mine, had a lady come and she wanted six travel grants filled in. She was going to Ottawa for allergy checks and she wanted all her children and her husband, and he said, "Well, can't you go in one car?" She said: "Actually, we're making a holiday of it. My husband's taking the Winnebago." This is what's happening in the system.

Now, we can't take responsibility for this, unfortunately. We are very busy doing the day-to-day work, getting up at night and seeing people who are sick, trying to process all the cases that are being sent to us. What's going to happen if we spend time policing the system is that we're going to get more behind. For the doctors in the north -- and I've talked to a lot of them about this and I'm glad you asked the question -- their attitude is that basically Bill 50 means the Minister of Health is going to micromanage the system.

This is what this bill really means, that she is going to be responsible for health care for every patient. It's not going to be the doctor's fault if she can't get service; it's going to be the Minister of Health's fault, because she's in charge of exemptions, she's in charge of every micro-aspect of the system that there is, and the doctors will just become employees. You'll have a position that I'm sure you've heard of before, Mr Owens, where the Ford factory worker sprays the cars when the lights are working, when the paintbrush is okay and when the cars are coming through, and when they're not coming through, the doctors won't be doing the work. It's the same analogy, and that's what's going to happen with Bill 50.


Mrs Sullivan: You talked about the requirements for physician resources. My view is that there are other health personnel in the north who are required as well as physicians. One of the things I have been quite concerned about with this bill is that it appears that in the absence of an appropriate health practitioner strategy that's long-term, that's properly funded, that starts before young people go into university and takes into account a broader extraprovincial, intraprovincial network, we're going to be operating by ministerial exemption.

We see that last week the Minister of Health said: "Oh, my God, it is finally being noticed that we have a shortage of radiation oncologists. We will contact Immigration and say, `Yes, come on, we can take five or 10,'" or whatever. Next week it may be anaesthetists for northern Ontario. Another week it may well be an emergency doctor for Clinton or for another village or town or small community hospital that now is not able to provide those emergency or 24-hour services.

It seems to me that is the absolute worst approach to health care planning and to management, and that it kind of fits with the ad hoc decision that was made about the photo identification card. You're part of the OMA, as a member of the OMA. I was astonished to see how little homework had been done by either the doctors or the Ministry of Health before signing an agreement to bring forward a health card that over the period of introduction will cost $50 million, may not solve a problem, and nobody knows what the problem is.

I guess what I'm saying to you is, isn't the entire problem in terms of the actuality of delivery of services that we're seeing now a problem that's been based in the disbanding of a planning process, where it was in place, an analysis of the appropriate delivery mechanisms and an evaluation of how things are really working?

Dr Hollingsworth: I couldn't agree with you more, Mrs Sullivan. What we have in this province and to some extent in Canada in general is an absolute absence of people going into certain programs: obstetrics, general surgery. In those specialties in all of Ontario and a lot of Canada, we have a greying population of doctors. The average age of obstetricians in our city is something like 60 years of age. The average general surgeon is 55 years of age. Many of the obstetricians are just waiting to close their offices and quit. There is nobody coming to replace them. Over half the slots for training in obstetrics are empty.

Ms Jenny Carter (Peterborough): Would the midwives be coming in at this time?

Dr Hollingsworth: We can perhaps get into that in a minute when I finish Mrs Sullivan's question. We can certainly talk about it if you'd like to pose that question, but maybe I could answer this lady's question first.

The other problem you alluded to was the health card problem. It seemed to me a very basic point that if you had made sure people were entitled to service in the first place, if you had made sure they came down to the office, and they had to come, bring their passport, bring their whatever -- their residency permit or their landed immigrancy -- and prove to you, as a clerk at that desk, that they were residents of Canada and entitled to this service, we would be a lot better off. I agree with you. Photos are not going to solve the problem if the original verification is bad. That's the basic problem.

Mr Jim Wilson: Very quickly, Dr Hollingsworth referred to section 43.1. Dr Hollingsworth, you made the statement about physicians now acting as police, and I agree with you that's very unfair with respect to the health card situation. There's protection from liability for physicians who may act under this section, but Dr Hollingsworth brought up a very good question with respect to the CPSO process if patients, or potential patients, were to complain.

I'm just wondering if legislative counsel or the parliamentary assistant have put their minds to that. CPSO mentioned that it'll probably backlog them even worse than they are now with respect to complaints. I'm just wondering if there isn't anything we can do in this legislation to try and weed out frivolous complaints that may go to the CPSO, given that, as has already been pointed out several times, there are no criteria by which physicians or other health care practitioners are to approach this issue in terms of determining residency. I would appreciate your comments on that.

I can see exactly Dr Hollingsworth's point, and given the experience with some of the harassment of northern Ontario physicians by the Ministry of Health and complaints process of CPSO, I think we should try and do something to stem what could be a very large tide of complaints.

Mr Wessenger: As you may know, we passed the Regulated Health Professions Act and the regulations under that act will, I assume, be proclaimed in the near future, the end of this year. I assume as part of those regulations that there will be regulations passed by the college with respect to the complaints procedure. There should be a definite item set out.

Mr Jim Wilson: But with the introduction and passage of this legislation, which we have been unfortunately unable to stop at this point, there's a new ground for complaint. You're adding another type of complaint that could go in there and you're not giving any guidance to physicians and those you're asking to police your system.

Mr Wessenger: I think if you recall, the evidence given by counsel was that the provision exempting the medical profession from liability, the thing "no proceeding" would also include a proceeding under the complaints procedure. That was the legal opinion that seemed to be relatively agreed upon: The words "no proceeding" would be broad enough to cover the complaints process. So at least a formal complaints process would certainly not be able to be taken as a result of the physician reporting.

I think also CPSO made a very good point; they made two points in their presentation, I think, that were quite interesting. The first point they made is that they felt the reporting should be mandatory. Secondly, they felt there should be a standard that was reasonable with respect to when the report should be given. They felt they would create a liability problem if there was voluntary reporting. They felt that would create more of a difficulty with respect to the CPSO than if there was mandatory reporting.

Mr Jim Wilson: But more accurately, CPSO made it clear that if there had to be reporting, they preferred mandatory. I don't think they particularly appreciated the fact that they were to be the police of this system and made that quite clear in the presentation.

Mr Wessenger: I'm just reading their report. Certainly, I was under the impression that they were in favour of mandatory reporting but that they wanted a standard they felt would avoid the frivolous complaint situation, with respect, being dealt with.

Mr Jim Wilson: Chair, could we hear from the witness with respect to this issue?

Dr Hollingsworth: I think there is a situation where you're in double jeopardy here as a doctor. You see someone who clearly has probably just come across the border from the US and is using the system, which I presume is what we're talking about, and this will be very bad in certain pockets; for example, in the Niagara Peninsula and Sault Ste Marie. Certain areas will be very bad. Certain areas like Sudbury really won't be too bad. You'll be faced on a daily basis with deciding whether or not -- I'll give you one example: somebody in our local area who is an American who owns a lodge who somebody has told me is suspected of using the system here for free. I'm giving this as an example anonymously just to illustrate a point.

Do I find out this person's name and call Mrs Grier's office or Mr Wilson's office or Barbara Sullivan's office and tell them, or what do I do about this? How far does my responsibility go? Is it only when they come into my office and use the services? There are many other situations that will occur that are very grey. If I don't report them, am I going to be blamed because I serviced them and will I have to take my fee as a loss and take the overhead as a loss? There are many things to be worked out about this legislation and the speed at which it's going through makes that impossible.

I would like to respond to the lady on my left here. She asked me a question.

The Vice-Chair: Proceed.

Dr Hollingsworth: Could I ask her to identify herself?

Ms Carter: My name is Jenny Carter, the member for Peterborough. It just occurred to me when you were talking about the number of obstetricians going down, whether that will not be to some extent compensated for by the services of midwives, who as you know are now becoming available in Ontario.


Dr Hollingsworth: This may take some time, so I'll very quickly abbreviate what I'm going to say, as short as possible for time for the committee really.

The midwifery situation in Sudbury is going to be a disaster because there will probably be nobody left to supervise these people as far as we can tell. We, at the medical society, have passed motions similar to what the Ontario Medical Association said. We're against birthing centres for reasons of cost and safety. A separate birthing centre to a hospital is going to cost you money and it's going to cost lives. If women are bleeding to death or the baby comes out very blue or black, you don't have a lot of time to transfer people by ambulance. We're against the current model of midwifery for reasons of costs mainly and safety.

In the European model, as you know, they have nurses who go on to take extra training and these nurses are very capable. They work in delivery rooms and I must say I have the greatest respect for these people. They're very, very capable and they have a very good safety record. But if something does go wrong, the obstetrician, the doctor who's in charge of the case, is called in and comes in very quickly.

You're going to have the reverse situation. Is the NDP government against home births or for home births? As far as I understand, they're for home births. Now home births went out with the ark. I mean it's great to have a home birth and a nice experience, but there are many women who'll tell you they were quite shocked when in their third and fourth pregnancies, which should have been their easiest, they had major complications.

We're not against midwifery because we're against women. We're against it because at this time we're sending our patients home clutching their sides after they had their appendix or gallbladder out after two days or three days, and we're not able to get our patients into hospital. We've got 14 people waiting in the emergency room every night to try and get into hospital, and here we have money being found to build centres of excellence and comfort.

The midwife salaries will be $50,000 to $80,000. There'll be two at each delivery, and if you work out the numbers -- they're going to do about 50 deliveries a year -- it's going to cost you $2,000 per delivery, and you're going to tell me you're going to save money because you're not going to use the hospital system? I can tell you, you just need one disaster and you're going to cost the system millions and you're not going to save money.

Ms Carter: I'm not familiar with the situation as it is projected to be in Sudbury, but my experience is that as long as you have an expert within call, that is to say, who can arrive within 10 minutes or whatever, then you don't have a problem. Now I realize in the north people live in scattered areas and they need to move physically so that they are near to the services that they just might need.

But having said that, I would have thought that the immediate hospital situation and the immediate presence of an obstetrician or whatever is not required in a very large number of cases. I speak as somebody who has had home births and with the knowledge that help would arrive, if necessary. I don't see why that would be impossible in your circumstances.

Dr Hollingsworth: Just very briefly, to respond to that, this current model is based on somewhat the Dutch model, which is a small, flat country with a high density of population. As you rightly pointed out, we've got problems in the north immediately with that. But they have flying squads for these home births. They have groups of people sitting in an ambulance or sitting in a room and an ambulance is outside.

This is what we used to do in Ireland when they had home births. An obstetrician, a doctor, an anaesthetist and a nurse rush out 15 miles, pick up the woman, give her blood etc. We don't have flying squads here; we don't have the money for them. If we're going to have the money, you've got to give us the money.

The same problem occurs with billing numbers for the midwives. How are we going to pay the doctors who see the patients the midwives want them to see? Who's going to refer these patients to the doctor? It's going to be the midwives. They're going to need a billing number and who's going to pay for that? Is it going to come out of our global budget, our 95% that's going down every year and with which we can't service the patients we've already got?

The whole thing is based on a house of cards. It's not going to work. It was a very good idea when it started out with the Liberal Party. I think it was very nice that it would have worked. There were some problems with the model, I think, when your party got hold of it. It came from the Liberal Party. I know it's not your fault. It was something you inherited. It was a very popular thing with the public. You have to try and do something with this. I'm not against your party or the policy. The point is that in this fiscal time with this particular model, you're going to have a lot of disasters and it's not going to save you money, it's going to cost you money.

Ms Carter: You see, I have reason to believe that where you have a less clinical setup when a person is giving birth, there are less likely to be complications. Now I know books that have been written on this, but the figures bear out that where you have a fairly primitive situation, where women who have some knowledge of what they're doing at least are responsible for births, actually a lot of the backup services are very rarely required, far less than they would be in a more high-tech situation, for various reasons, including psychological ones.

Also, of course, people do get cross-infections and so on when they're hospitalized, which they wouldn't get in a less medical situation. I think you are putting a rather one-sided view of this.

The Vice-Chair: Thank you. Mr Owens.

Mr Owens: Thank you, Chair. I think we're over time now. I'll yield to the Chair.

The Vice-Chair: Ms Sullivan, did you quickly have a question.

Mrs Sullivan: I have one very small question with respect to third-party billing. We have been asking for a list of third-party billings that are required now for certain institutions, agencies and so on, nursing homes, by example, boards of education, and you had indicated that you thought billing for third-party services was appropriate.

One of the things that is of some concern is with respect to the prevention aspect of third-party requests. I'm thinking particularly of boards of education. You thought that it wasn't too bad. In an attempt to move towards third-party billing or third-party payment, the government has already introduced regulations. In fact I don't think this part of the bill is necessary. It seems to me that the government has the power under current regs to do it.

But one of the areas is with respect to the Education Act and permits the Minister of Education to require certain employees, as a condition of employment, to have a tuberculin test. Do you think that's something that's worthwhile maintaining and, if so, who should pay?

Dr Hollingsworth: This is just one example of many things people ask us to do. We get endless forms put in front of our faces for people going to day care, to bring the child to a day camp, most of which we feel is futile, in particular with tuberculin. We know the incidence is very low in North America. However, it is a disease that affects immigrants, it affects people with AIDS and it may have a resurgence unless we're careful. I would think that the answer to your question would come from public health people rather than me.

But again, if the board requires it, perhaps it should pay for it. What is it they're trying to prevent and how good is the evidence that the money will be well spent? You're very good, asking these questions, because you're really trying to prioritize the dollars as to where they're going to go, and what you're asking is, is this a priority? I think it probably isn't, but you probably should talk to some of the public health people in that jurisdiction. We have to keep prioritizing and that's the way we have to go. I think you're right.

Mrs Sullivan: Thank you.

Dr Hollingsworth: Thank you very much.

The Vice-Chair: Thank you very much for your presentation and responses, Dr Hollingsworth.


The Vice-Chair: Dr Stephen Connell will make the presentation. I understand you're very short of time so I'm sorry to --

Dr Stephen Connell: Yes. I'd like to leave at about 5:20.

The Vice-Chair: All right. We'll make note of that and perhaps you would give your name and position, please.

Dr Connell: Stephen Connell. I'm a psychiatrist. I'm here today for two reasons. Firstly, I believe in the democratic process of deputing to our elected representatives. Secondly, I believe that the government listened to Ontarians when it resisted the pressure of the health bureaucracy to delist intensive psychotherapy last year, and I believe that it will listen to Ontarians again this time around.

Both opposition parties, the medical profession and health consumers have spoken out against the elements of this bill that have bureaucrats prescribe psychiatric treatment. Despite what the former Deputy Minister of Health told the public when these proposals to cut psychotherapy services were announced, this is a proposal to again attempt to strike out against those psychiatric patients who need intensive psychotherapy. This is the bureaucracy's second attempt to delist a psychiatric service that affects hundreds of patients.


Both Health critics eloquently presented the public's concerns when these proposals came out on July 26 and 27, and I have circulated the Hansard which summarizes their excellent speeches to the House. I really feel they had a very good grasp of the issue.

As Barbara Sullivan stated, "What about the patient? If a patient needs a medical treatment that the government has arbitrarily deemed to be not medically necessary, according to its own arbitrary standards or calculations based on cost, where will the patient be?" She continues, "The universality criterion is under attack here, but the accessibility criterion is also under attack."

Mr Wilson, in respect to psychoanalysis, stated: "I have tons of paperwork on this, tons. I want to commend many, many people in this province who took the initiative for the first time in their lives to come forward and to take on the NDP government and to point out the public need for psychoanalysis.

"Psychoanalysis, in many of the studies I have read over the past few weeks, can be a life or death issue.... We're not just talking about cardiac surgery or lung surgery or all kinds of services that I think everyone in Ontario would agree are medically necessary; we're also talking about mental health services. Psychoanalysis is a prime example of that."

It saddens me that the government has been put in a position where it has been unable to address any of the issues raised by the Health critics in the House with respect to restricting psychotherapy services. I believe, with respect to this proposal, that they've been led down the garden path by a small core of ideologues in the Health ministry who believe that those who are treated by psychotherapy are not seriously ill.

In 1992, these ideologues attempted to delist psychoanalytic treatment because they said it was cosmetic. They expected to save $1 million at that point, and that's the second document I've circulated which I've obtained. Suddenly it went up to about $26 million. We've got juggling around of figures here with really no substantiation of -- what's going on? There's an important vote, is there? You're watching the TV.

The Vice-Chair: We have time.

Dr Connell: Okay. According to information that has been obtained under the Freedom of Information and Protection of Privacy Act, it appears that these bureaucrats naïvely expected that there wouldn't be any fuss about this. Instead, a massive wave of protest occurred and hundreds wrote in to the Minister of Health, Mr Decter, and the OMA. All the heads of psychiatry in Ontario challenged the prejudiced view coming out of the bureaucracy, and I enclose those letters from every head of psychiatry in Ontario for the record of this committee.

The minister at that time happened to my MPP. I believe she listened carefully to the public and responded by reassuring those who contacted her that their treatment would not be delisted. She attempted to begin a dialogue between psychoanalysts and bureaucrats working on mental health reform. I commend her on having done this and I think this is the right approach in dealing with issues like this. However, this dialogue was not pursued by the bureaucrats beyond one meeting, and I attended the first meeting.

The matter was referred to an appropriate body, the joint management committee, and it concluded that psychoanalysis should remain in OHIP. The matter should have rested there. What a debacle then when the bureaucracy tried to end-run this fair and open process by re-presenting the proposal in the guise of expenditure control with grossly inflated figures beyond the $1 million they originally said they would save; it suddenly went up to $26 million.

What is worse is that the previous Minister of Health, my MPP, the person who had managed this issue on behalf of the government, knew nothing about it, she told me, when it reappeared on the expenditure control list. She told me personally, "That a bureaucracy would attempt to exercise its prejudice in the heat of a frenzy of expenditure control measures without informing those in government who had already made decisions, who had already performed the role on behalf of the people governing this province, to me is reprehensible."

Similarly, the current Minister of Health does not seem to have been informed about this issue and was apparently not informed of the previous tremendous public outcry that had occurred the first time the delisting was attempted. The government has been embarrassed, I think, by the bureaucracy and made to appear as if it doesn't know what's going on.

One of the key things that impressed me about the Premier's initial approach to government was his attempt to involve the public in decision-making. He attempted to create a government of the people. Recently I watched the town hall forum on television with respect to the federal elections, and what struck me was the universal sentiment that comes across, one way or another, that people want transparent government. The public wants accountability and wants to participate in government decisions.

With respect to the issue of restricting psychotherapy, none of the issues that I've asked about personally or that I know others have asked about in the House have been answered. Suddenly, no one seems to know who is responsible. Suddenly, the savings stated, annualized $42.4 million and $26.5 million projected, cannot be explained by anyone. Suddenly, information is not provided to the opposition even though it's asked for under formal parliamentary rules.

The information that has been provided is paltry and is clearly being doctored to present and to perpetrate a prejudiced view. For example, information has been provided to the Health ministry about intensive psychotherapy and psychoanalysis by the public, but it has not been assimilated into the overall opinion and conclusions it presents material about.

I personally put in a freedom of information request to try and get to the bottom of this. This is because my MPP and the Minister of Health had been unable to answer any of my questions, amazingly despite my MPP's previous position as having been the Minister of Health. She says she doesn't know what's going on with respect to this motion and she tells me it's being dealt with by the OMA and the government. But we see in this bill still, in subsection (7) of point 2, the ability of the government to unilaterally limit services such as psychotherapy outside of decisions reached by the joint management committee.

How can this process be a fair one? How can the public be involved in a way that's effective and that keeps prejudiced ideologues within the Ministry of Health in check? Ideologues may be well-meaning, but they aren't physicians; they don't have clinical training and they don't treat patients. They must not be able to end-run the JMC by throwing in these measures in the guise of expenditure control, particularly when extensive public consultation and participation took place around this issue and concluded that the bureaucrats were wrong and that delisting should not take place.

There must be a way that a bureaucracy is kept in check and that the public whose taxes pay these bureaucrats can obtain genuine accountability and transparency with respect to their actions. Furthermore, the government must be protected from actions by the bureaucracy that only serve to embarrass what I believe has been a genuine attempt on behalf of the NDP government, and indeed most politicians, to fairly represent the wishes of their constituents.

I should add, however, that I was alarmed to read in the Hansard documents of the night following the ones I provided that several senior government MPPs have been prescribing measures on the basis of their own experience to constituents who are already being treated by psychotherapy. One senior government member is cited as having suggested that a constituent try drugs rather than the psychotherapy, and another suggested that because she had had two-times-a-week psychotherapy, therefore all people in the province of Ontario should not need anything more funded by OHIP.

In conclusion, I ask only that the members of the committee be aware of certain aspects of the expenditure control bill that I believe reflect bad government and bad process. Overall, I am very much in favour of the government's attempt at reducing the expanding budget deficit within this province. It must be done, however, in a way that protects the public from overzealous ideologues who in this case, I believe, are misguided and out of control. Thank you for your time.

Mr Wessenger: Dr Connell, thank you for your presentation. I must apologize, because I had thought it had been communicated to individuals that psychotherapy was not going to be restricted. I certainly have written quite a number of letters to various of my constituents advising them of such, and I'm sorry that somehow you were not advised of that situation. I appreciate you coming and I'm glad to be able to indicate to you that it's not intended at all.

Dr Connell: Thank you, Mr Wessenger. I've been told that since the first attempt, when it was called "cosmetic," and I was told by my member of Parliament and I've been told over and over again that it's safe, that it's not going to be delisted. What really disturbed me is that with the expenditure control bill, suddenly we see it emerge again, and my MPP says that she knew nothing about it. I feel there's still a risk that these ideologues will strike out again, and I have a stack of freedom of information material that really demonstrates how out of touch on this issue they are and how zealous they are to have it delisted.

I notice that in the amendments, section 7 has not been deleted. You've deleted sections 4, 5 and 6, but in the amendments I was provided with, section 7 still provides the opportunity for the government to reduce amounts of services. Is that the case?

Mr Wessenger: No, section 7 of the bill is gone, I'm advised.

Dr Connell: I'm very pleased to hear that.

Mr Williams: I think there's a confusion because unfortunately the numbering of the bill and the numbering of the subsections in the act itself are sequential, but subsections 4, 5 and 6 of the bill are gone. Included in subsection 6 of the bill was the reference to subsection 45(7) of the act. That's where the confusion lies. The only thing that's basically left in the bill is the section dealing with the Hospital Labour Disputes Arbitration Act and the sections dealing with the medical review and the practice review and section 1.

Dr Connell: That was not at all clear. Thank you.

The Vice-Chair: Thank you for the clarification.


Mr Jim Wilson: Dr Connell, I still think we're not out of the woods at all with respect to this issue. I think the government has been somewhat dishonest in its approach; that is, it's removed these sections because they looked bad in the original Bill 50, but the powers, of course, are still there with the status quo with respect to deinsuring services.

I'm going to take one more stab at it, as Mrs Sullivan has in the past; we both have. Can we see the list, Mr Wessenger, with respect to the items that the government is proposing to delist and with respect to the OMA's list of services to be deinsured? If that were put out to the public now, we would save a lot of people like Dr Connell a great deal of time and anxiety if, as you say, it is true that psychoanalysis is not on either of those lists.

Mr Wessenger: I don't have that information available to me.

Mr Jim Wilson: Then how can you make a categorical statement that psychoanalysis is not in jeopardy?

Mr Wessenger: It's been made very clear through the process that it's not in jeopardy.

Mr Jim Wilson: It's not clear to me, and I'm the critic. I don't think it's clear to the Liberal Party. Obviously, Dr Connell has given evidence that it's not clear to his MPP, the former Minister of Health. I don't know to whom it is clear, other than you.

Mr Wessenger: Section 7 originally permitted restrictions on the limits on a treatment, and that section has been removed.

Mr Jim Wilson: You took that out of this bill, but you still have those powers in existing legislation, and you're going to do it behind closed doors with the OMA.

Mr Wessenger: I don't think that's fair to say, but I would suggest it's fair to say that anything could be, in future at any time, if any government decided to take a particular area and make a political decision. I'm not saying we're going to do that; I'm just saying that's the way, under the existing legislation.

Mr Jim Wilson: I agree, so I think it was somewhat cosmetic and a political exercise to remove those provisions out of this bill so that we wouldn't have a lineup of people, including Dr Connell's patients, coming to this committee. You've taken it out of the bill, you've put word out to everyone via letters etc, "Don't worry about the delisting psychoanalysis; it's not in the bill any more," and you told us earlier today that those issues are now separate from this legislation. Yet as legislators we have no other avenue to tackle this delisting or potential delisting because we have no other avenue to discuss the OMA-government agreement.

Mr Wessenger: Mr Wilson, that's just like --

Mr Jim Wilson: So if you're prepared to categorically say --

The Vice-Chair: Please, one speaker at a time.

Mr Jim Wilson: Mr Wessenger, I need more than just your word on record that psychoanalysis won't be delisted. I want to see a document from the Ministry of Health indicating that.

Mr Wessenger: When the public announcement is made with respect to the matter of which items are on the list, you'll be entitled to see that. However, I point out that the deletion of the section from the original bill does take away the power to deal with, for instance, the limiting to 100 hours. With that section gone, the government no longer has the power to put on those limits.

Mr Jim Wilson: I disagree.

Mrs Sullivan: The more we deal with even the amendments to Bill 50, the most outrageous bill that's been before the House in a long time, the more I think that this bill should be off the table. The third-party billing stuff can be dealt with, as it already has been, through the regulatory process. The labour disputes act and the other bills should be dealt with in a separate piece of legislation that deals with the arbitration process and the Medical Review Committee.

With respect to powers of the ministry -- and as we're dealing with Bill 50 in committee we have to deal with the original bill and not just with the amendments -- I can't tell you how outraged I am with respect to the proposals that have been made and how psychiatric patients have been treated over a period of time.

In the beginning, there was a proposal that emanated directly from the Minister of Health -- not from the profession, not from people who are providing service to patients, but from the Ministry of Health -- which made a judgement about the cost of the service and nothing else, nothing about the benefits, nothing about the patient outcomes. They didn't look at those things. Then Frances Lankin, then-Minister of Health, finally, as a result of pressures from Dr Connell, patients and other professionals, removes that from the Ministry of Health proposals.

Lo and behold, it's back on again. Can you imagine the tension and stress that those people have gone through over that period of time? It's back on again; intensive pressure, people breaking down in offices. We had a witness who was going to appear before the committee today who could not stand the stress of appearing here. This is outrageous.

We now have a list being prepared, behind closed doors, of services to be removed. I have had a private conversation with an individual from one of the parties who indicated to me that neither one of the parties would dare to have psychoanalysis, psychotherapy, on their lists, and that is the only reason it's not on their list. It has nothing to do with medical benefit, it has nothing to do with outcomes measurement, it has nothing to do with patient services. It has to do with the fact that there was a public outcry raised about taking the procedure off the OHIP list.

That is no way to plan health care services. It is no way to ensure that our patients have adequate treatment when they need it, how they need it, without barriers that are created by some bureaucrat or a minister intervening in decisions about what should be appropriate health care. The Minister of Health should not be making those judgements and there should be no Ministry of Health list.

I don't have any questions, Dr Connell. I'm sorry to blow up, but I'm really annoyed about this.

Mr Wessenger: I'm just going to make one correction with respect to the comments of Ms Sullivan. The reality is that third-party liability can only be imposed by legislation. You can't, by regulation, impose liability on a third party, so that is quite an incorrect statement.

Mr Frankford: Do you want to just clarify? We're talking purely about psychoanalysis or psychotherapy. I don't know if it's my fault, but I find it a bit confusing in some of the documentation I'm reading.

Dr Connell: I think the bureaucrats are confused as to what it is, because one thing that they harken back to is this idea of Freudian classical psychoanalysis where you see a patient many times a day, many days a week, indefinitely.

That's the biggest bit of BS I've ever seen. That is a gross attempt to malign and misrepresent what it is we're doing in the front lines treating people. We treat people on the basis of training and on the basis of well-defined criteria for treatment. You later on have the proposal that it's going to be restricting all psychotherapy to twice a week, but we don't know the rationale for this.

You're mixing up apples and oranges when you make these two different proposals. If you track through the freedom of information material, it begins with this statement that sounds terrible: "How could a doctor see a person many times a day? It must be abuse of the system." Then it somehow gets refined, but with the same prejudice, to become two times a week, that everyone can be seen no more than two times a week.

We're really talking about a proposal to restrict psychotherapy to treating someone only 100 times a year or two times a week, whether it's psychoanalytic treatment, behaviour therapy, cognitive therapy or whatever therapy it is. That patient can be seen no more than 100 times a year because some bureaucrat in Kingston has this notion that classical Freudian psychoanalysis, which went out in the 1930s, should not be practised in Canada.

Mr Frankford: I'm not sure you really have totally clarified for me.

Dr Connell: The proposal was for intensive psychotherapy beyond two times a week.

Mr Frankford: I think it says psychoanalysis per se would be delisted in the same way that, if one is going to delist, one might delist one particular operation. Is that correct or not?

Dr Connell: That's how it began. The first document I provided was in 1992, and it said that psychoanalysis was a cosmetic procedure: A, B, C, D; there were skin tucks and ear lobe repairs and on the bottom was psychoanalysis; this was a list of cosmetic procedures. Fortunately, Frances Lankin saw through that, and we had a big discussion, lots of meetings; it was dealt with. Then it came back again as psychotherapy no more than two times a week in 1993 with this bill, in a different form.

Mr Frankford: Just for my information, is it your understanding that that was aimed at GP psychotherapy?

Dr Connell: Oh, no, I don't think it was at all attacking GP psychotherapy, because as you track the documents through you see exactly the same phrases that were used with the initial cosmetic procedure delisting attempt back in 1992, when there was a huge outcry and it all calmed down. Then we had a new Minister of Health, we had the expenditure control bill, and it came out with the same language and -- you can track the process -- the same discussions, because they had discussions in the JMC on marginally insured services, but with the expenditure control proposal to reduce it to two times a week. They were trying to do it in a different way, but they were attacking the same group of patients; that is, patients who are seen more than two times a week by a psychiatrist. I haven't heard anything about the government's proposals. I didn't see anything in the material specifically about GP psychotherapy. I haven't seen any mention of that specifically.

The Vice-Chair: Dr Connell, thank you. I must interrupt; we're running short of time. There are two other items we need to deal with, and I know you're under pressure for time. Thank you for your presentation and your responses.

The committee will note that there was another presenter listed, Ms Carole Rodrigue, who is unable to make the presentation at this time but has left a tape for the committee's viewing. I would expect you would want to see that -- I hope you do -- and we'll arrange that at another time at the next meeting.

The clerk has one item to present to you -- oh, for the subcommittee. All right, if there is nothing before the committee at this time -- Ms Sullivan?

Mrs Sullivan: I do have some concern that perhaps other presenters who will be asking to present before the committee may be patients who have been receiving psychotherapy or other psychoanalytic services and who may not want to present in public. I wonder if the subcommittee could consider that as a part of our public hearing process.

The Vice-Chair: That indeed will be considered by the committee; we've requested to do so. Nothing further? The meeting is adjourned. Thank you.

The committee adjourned at 1732.