Monday 15 August 1994

Long-Term Care Act, 1994, Bill 173, Mrs Grier / Loi de 1994 sur les soins de longue durée, projet de loi 173, Mme Grier

Ministry of Health

Hon Ruth Grier, minister

Paul Wessenger, parliamentary assistant to the minister

Geoff Quirt, acting executive director, long-term care division

Gail Czukar, legal counsel, long-term care legislation

Registered Nurses' Association of Ontario

Kathleen MacMillan, president

Johanne Mousseau, member

Margaret Watson, executive director

Jacqueline Choinière, nursing practice and policy coordinator

Ontario Medical Association

Dr Michael Gordon, chair, advisory group on long-term care

Dr Barbara Clive, member, advisory group on long-term care

York Region Home Care Program

Carol Dockrell, director

Brenda Andrachuk, program manager

Association of Treatment Centres of Ontario

Joanne Renahan, chair, long-term care committee

Diana Thomson, member, long-term care committee

Catholic Health Association of Ontario

Ron Marr, president

Sister Bonnie MacLellan, member, long-term care task force

Sister Alice McEvoy, board member and chair, long-term care task force

Saint Elizabeth Visiting Nurses' Association of Ontario

Shirlee Sharkey, president and chief executive officer

Joel Rochon, board chair

Human Services Alliance; Catholic Charities of the Archdiocese of Toronto

Brian Dunn, president, Catholic Charities

Michael Fullan, executive director, Catholic Charities


*Chair / Président: Beer, Charles (York-Mackenzie 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:

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

Malkowski, Gary (York East/-Est ND) for Mr Hope

Sullivan, Barbara (Halton Centre L) for Mr Eddy

Wessenger, Paul (Simcoe Centre ND) for Mr Owens

Clerk / Greffier: Arnott, Doug

Staff / Personnel:

Boucher, Joanne, research officer, Legislative Research Service

Gardner, Dr Bob, assistant director, Legislative Research Service

The committee met at 1005 in room 151.


Consideration of Bill 173, An Act respecting Long-Term Care / Projet de loi 173, Loi concernant les soins de longue durée.

The Chair (Mr Charles Beer): Good morning, ladies and gentlemen. We are beginning today our hearings on Bill 173, An Act respecting Long-Term Care.

We have the Minister of Health with us this morning, but before I turn to her we have just a couple of orders of business. Mr Wessenger, I wonder if you'd be good enough to start us off.

Mr Paul Wessenger (Simcoe Centre): Yes, Mr Chair. I'd like to move that the report of the subcommittee held on Monday, July 11, 1994, be approved.

The Chair: All right. Members have received that report, which basically sets out the schedule of the hearings. All those in favour of the subcommittee report? Opposed? Carried. Thank you very much.

There will be a brief meeting of the subcommittee at the conclusion of our hearings this morning, just on a couple of matters affecting the rest of the schedule.


The Chair: With that then, as I noted, the Minister of Health is with us. Minister, welcome to the committee, and I'll turn the proceedings over to you at this time.

Hon Ruth Grier (Minister of Health): Thank you very much, Mr Chair. I'm delighted to be here and to say to all of the committee members I hope they had a restful and tranquil summer so far and are here in a benign and generous mood to deal with what's going to be, I think, a very interesting set of hearings and certainly some very important legislation.

The Chair: I should say the committee is always generous, not necessarily benign.

Hon Mrs Grier: I think that this is going to be exciting new legislation that will deal, of course, with long-term care and support services in the community.

As it was pointed out during the second reading debates on this bill, other Ontario governments have been discussing for many years how to organize and deliver better long-term care services.

This government has acted. We carried out the most extensive consultation ever, in which 70,000 people across Ontario were asked what they wanted and what they needed in facility care and in community-based services.

We listened to what we heard and we passed, with the help of this committee, Bill 101, which made major changes in the long-term facility sector. That bill provided a uniform funding arrangement for nursing homes and homes for the aged. It also put in place a fair and consistent resident fee policy, thus ending what had been long-standing inequities throughout the system.

Bill 101 also made it possible to establish a province-wide placement coordination service system to ensure easier and more equitable access to facility care.

Now, in Bill 173, we have introduced long-awaited legislation supporting community services. Committee members will recall that Bill 173 received the support of all parties in the House during second reading, and the vote was unanimous.

Mr Cameron Jackson (Burlington South): On a point of order, Mr Chair: It would be fair for the minister to stylize all three parties, but it was not unanimous. I was clearly on record as voting against the bill. I spoke for a good half-hour in the House about the reasons why I couldn't support it. It's fair to say that there was a majority of Tories and almost all the Liberals supporting the bill, but I clearly did not support that legislation.

Hon Mrs Grier: Mr Chairman, I do apologize. I did not mean to spark a partisan note at this point, and certainly my understanding had been that there had not been a recorded vote and that it therefore passed without dissent. I do not, as I say, wish to make an issue of that and perhaps I can really withdraw that comment.

Mr Jackson: It was my understanding that the minister had heard the debate and would have been familiar with my comments.

The Chair: I think your comments are noted and the minister has changed her comments and will continue.

Hon Mrs Grier: Consumers and their families, service providers, the volunteer sector and people who work in long-term care have been telling us for some time that changes are needed.

What they've said is needed are a number of things: simplified and better coordinated access; increased care and service in the community rather than in institutions; greater flexibility in responding to individual needs; a consumer-focused system that puts customer service first; consistent rules and accountability; and, finally, local planning, governance and management of services.

In Bill 173 we have responded to these needs and built the legislation on the strengths of our current long-term care services. This bill creates a foundation for a more effective community-based, consumer-focused system.

Bill 173 will enable us to achieve one-stop access. That means that communities will be able to develop local multiservice agencies that will offer one-stop access to long-term care and support services. These multiservice agencies will give consumers an easily recognized local point of access to the information and services they need to meet their independent living and health care needs. MSAs, as they've been called, will be governed locally by volunteer boards that reflect the diversity of their communities.

The second thing Bill 173 does is provide improved community services. The bill creates the foundation we need to improve the community-based service network. Such a system will provide more care and support and higher levels of service to people in their own homes and in their own communities. To ensure greater equity of service across the province, the act requires that every MSA offer a specific range of services.

The third aspect is a consumer-focused system. Our objective is to have a system that puts the consumer first and focuses on customer service, and the way to ensure that services reflect what consumers want and need is to give them, the consumers, opportunities to participate in decisions about their own care and the planning and management of services.

To this end, the bill includes provisions that will ensure that consumers consent to services, participate in their own plan of service and have access to their service plan and their personal records and that consumers will participate on the boards of MSAs and through DHCs are involved in the planning process.

The fourth principle is consistent accountability. To improve accountability, Bill 173 introduces a consistent set of rules and expectations that correspond with the functions and roles of service providers under the act. This builds upon the best practices currently in place in existing programs and on the sound experience from the decentralized community-based service systems of the Ministry of Community and Social Services.

Finally, local, volunteer and community-controlled planning is the fifth goal. We want to ensure that that is the kind of involvement and planning that leads to the development of the new system and manages it in the future.

In recent years DHCs have been asked to assume more responsibility for planning and for advising the minister on a broader range of health issues. DHCs, of course, are composed of volunteers and represent the districts in which they plan. In the fall of 1992, district health councils were also asked to lead the planning of long-term care services.

This means that DHCs can design the system that fits their community. There is no cookie-cutter at Queen's Park cutting out plans for long-term care. Each community will develop long-term care programs that suit its particular needs.

DHCs need legislative support for this expanded role, and the bill includes an amendment to the Ministry of Health Act which strengthens and clarifies the district health council's mandate to achieve strong, community-directed local planning. This amendment creates specific authority for the minister to establish district health councils. Members may be surprised to find that that authority does not exist in legislation despite the fact that the Ottawa district health council, I think, celebrated its 20th or 25th year of operation just last year.

The amendment specifies the functions of a district health council. It provides a means for ensuring that the membership of a district health council and its committees reflects the diversity of the community served and includes both health and social service perspectives in relation to long-term care and support services.

Finally, the amendments provide a mechanism, through regulations, for ensuring that service providers submit plans and other information to the minister and the local district health council and that the public has access to those plans when they are submitted.

Ontario has a long and proud tradition of volunteer involvement in its health and social services. People in their communities recognize the need to come together to help others. Community agencies developed with volunteers playing a large part in their growth and in the provision of services. So, over the years, specialized volunteer agencies sprang up to fill specific needs as our society grew and became ever more complex.

The result has been a patchwork of services. In many areas there are gaps in the system, and in some cases services overlap. The obvious solution is to bring these services together in a logical and coherent system and that's what we're doing with Bill 173, in providing a framework for community-based, multiservice agencies.

Of course, this melding of services into an effective system cannot take place overnight. Each community will have to handle it differently to reflect its own specific needs, history and experience.

That's why Bill 173 provides a good deal of flexibility in moving towards multiservice agencies. It recognizes the differences in time, resources and abilities needed to accomplish this goal. It provides flexibility for communities, the government and the people who work in these agencies to adjust to the changes. It offers volunteers and workers time and space to make the necessary changes to a new and better way of serving those in the community who need long-term care services.

The values and traditions caring volunteers have demonstrated for many years in this province are at the heart of our changes to long-term care. Together we are building on the strengths and expertise of those traditions.

We believe that the provisions in Bill 173 will go a long way to expand and improve Ontario's long-term care system. But it's important to remember that this is part of extensive progress towards changes in long-term care. We've already accomplished a great deal through the passage of Bill 101 and improvements in existing programs.

We currently spend $2.1 billion on long-term care every year and we will increase that by about $200 million by April of 1997.

In community-based care the growth has been dramatic. We were spending $550 million on community long-term care services in 1990-91. Currently we are spending over $880 million and by 1996-97 we plan to spend over $1 billion in this sector.

Let me briefly outline in addition some of the changes and expansions that have already taken place in our long-term care system.

We are building links between hospitals and community-based services through 20 new quick response teams. We have invested $5.4 million in this program. It's a program that is directed at people who come to hospital emergency departments but who don't require hospitalization. Quick response teams refer such people to the appropriate community-based services, thereby reducing unnecessary hospital admissions. Quick response is a good example of partnership between communities and hospitals and the teams will be operating in 70 hospitals across the province this year.

We are providing $4.4 million to fund a pilot project that will help people with disabilities hire and train their own attendant workers. This will support independent living for between 80 and 100 people with disabilities and enable them to exercise much more control over their lives. Right now attendant services are supplied by agencies, sometimes without much consumer control.

The integrated homemaker program is one of the key elements in helping older people remain in their own homes. This program is now available right across Ontario. This year we've established 18 new sites to provide integrated homemaker programs, thanks to $133 million in annual funding from my ministry, plus another $6 million over two years for training and recruiting workers for that program.


While these changes help to improve community-based services, long-term institutional care has not been neglected. For example, we've already achieved one-stop access for those needing care in a nursing home or home for the aged through our placement coordination services. As of July 1, 1994, this service is now available all across Ontario. Placement coordination will become an important part of multiservice agencies when these begin operating across the province.

As for long-term care facilities themselves, we are investing this year more than $65 million to expand and upgrade 13 homes for the aged, such as Cummer Lodge here in Metro and the Fairview Mennonite Home in Cambridge.

Development of multiservice agencies is well under way in many communities under the leadership of the district health councils. Already I've received from the Metropolitan Toronto District Health Council its plan for how MSAs should be configured to meet the diverse needs of Metropolitan Toronto. I look forward to receiving plans from other district health councils later this year.

In addition, many communities are seeking district health council support to allow them to put multiservice agencies in place as soon as possible. I support this idea of early leaders where communities are ready and where district health councils believe that the early leader that's proposed is in conformity with the plans that are emerging through the district health council.

It was recently pointed out to me that acute care is often about procedures but long-term care is about relationships. I'm very proud of Bill 173 and the relationships it is building on, as well as the new relationships that will develop to provide the best care for our communities.

Thank you again, members of the committee and Mr Chair, for the opportunity to appear before you. I trust that the schedule of hearings you're about to embark upon is very productive. There is enormous interest in these reforms across the province, and I know that you will not lack people who wish to come forward and make comments to you. I certainly will look with interest at your comments as a result of that.

I know that you're going to have a technical briefing when I've finished. I just wanted to indicate that with you and following the committee hearings will be Gail Czukar, who is the legal counsel for the Ministry of Health; Geoffrey Quirt, who I think has appeared before this committee, as has Gail, on many occasions, acting executive director of the long-term care division; and Joanne Gottheil, legislative counsel who drafted Bill 173.

The Chair: Thank you very much, Minister. As you have noted, the next part is the technical briefing by ministry staff. The minister is able to be with us until 11 o'clock, roughly, so that if there are questions as we go along with the technical briefing, I would certainly welcome those as we go along. But I just note for members that the minister will have to go at 11, so if there are some specific questions that members would like to put to her, you could keep that in mind. The clock there I think is about correct, so we have about 35 minutes.

I then call on the ministry staff, if they would be good enough to come forward. While you are known, I think, to most of us around the committee, given that we are also in living colour, perhaps you would be good enough to identify yourselves for everyone else who is watching.

Mr Geoff Quirt: Thank you, Mr Beer. I'm Geoff Quirt and I'm the acting executive director of the long-term care division. With me is Gail Czukar, who is counsel for the Ministry of Health on the long-term care bill.

The minister has spoke to you about how proud she is of our new bill. We share that feeling. She has also talked to you about the objectives of the bill, what we hope to accomplish with it. What I'd like to do in my brief remarks is to follow up on the minister's reference to those objectives and provide you with some concrete examples of what will be different and improved for consumers and volunteers in the long-term care system as a result of this bill passing.

I recognize the time constraints and I want to leave time for the minister to respond to some of your questions prior to her departure at 11.

The minister talked about one-stop access and the provision for the first time of one place, one contact number where consumers can gain access to the full range of long-term care services in Ontario. This, we think, is perhaps the most important objective that we'll achieve through the passage of this legislation.

Let me give you some examples of how things will be different for consumers as a result of the passage of this bill and the achievement of one-stop access to long-term care services.

As you know, in Ontario currently an elderly person and their family may receive services from three or four or sometimes five community service agencies, each doing an important job in meeting a very important need of that consumer and family. Our system's structure, however, makes it very difficult for those organizations to cooperate and deliver services in a coordinated manner. In Ontario we've had a system to date that gives the responsibility for deciding how much service some person is eligible for to one group of agencies and the responsibility for actually delivering that service to another group.

For example, if someone needs homemaking or nursing services, 38 home care programs across Ontario decide how much someone's eligible for, but when it comes to actually delivering that service, delivering the nursing service or the homemaking service, they could call upon a range of other agencies, the VON and the Red Cross and other agencies, for example, to actually deliver that service. In addition, there are over 1,000 community service agencies that deliver support services like Meals on Wheels and transportation.

In a nutshell, those efforts to coordinate services will be greatly improved through the integration of those two functions. In other words, the multiservice agency brings together the responsibility for deciding who's eligible for how much under what circumstances with the responsibility for actually delivering those services. So those decisions are made under one roof in one organization.

What does that mean for the consumer? Rather than having a home care employee visit and do an assessment and then have the VON nurse come and visit and do a similar assessment and having a representative from the Red Cross come and ask similar questions, it means that one agency, or one group of people, can take collective responsibility for saying, "Yes, Mrs Smith, you need nursing services, and we think a homemaker would be helpful to you as well, and a meal program. I've got responsibility to say I'll be back tomorrow to help you change your dressing and my colleague in the next office will come to help you with your homemaking needs and I'm sure that one of our volunteer coordinators will ensure a meal comes tomorrow as well." So we bring that responsibility together to let thousands of workers in the long-term care system, who are doing an excellent job now, do even a better and more coordinated job for people in the future through one-stop access.

The minister spoke about an improved community-based service system and talked about how services would be better for clients and consumers. Let me give you some concrete examples of how that will change.

In Ontario we've relied on eligibility criteria that are consistent and service limits that are consistent across the province. In other words, we've said that, as a provincial rule, homemaking can be limited only to 60 hours for people, regardless of their individual circumstances. Because we've had so many organizations and agencies relating to us, each has had its own set of eligibility criteria and its own rules about how much service can be delivered. By bringing the responsibility for service delivery together in multiservice agencies, it lets us be much more responsive to the actual service needs of consumers. Let me give you a couple of examples of how we'll be doing that.

One important example is to ensure that key services, mandatory services, will be available in each community, and the bill requires that multiservice agencies deliver a full range of long-term care services. So it won't matter any longer whether you happen to live in north Frontenac or in downtown Toronto. The law will require that the multiservice agency in your area will have a range of appropriate services to meet your needs.

How did we pick those services? We listened to 70,000 consumers and hundreds of service provider organizations who suggested to us what the most important services should be to meet the long-term care needs of the majority of our clients. So that's the first consumer-oriented service improvement the bill makes possible.


Secondly, the bill allows for a great deal more flexibility in how services can be delivered to consumers. Let me explain a couple of ways in which multiservice agencies can be more flexible than our current system is now.

I mentioned earlier that our home care program is limited by provincial policy to providing a maximum level of service across the board to individuals. This doesn't allow our workers on the front line to differentiate between the needs of individual clients and families to the extent that they should.

As a result of providing an improved range of eligibility for services the MSA delivers, our front-line workers are going to be able to decide that in this particular case, with this client or this family, a much higher level of support is important and necessary to keep someone from having to, for example, have their long-term care needs met in a facility.

It allows us to service-target; it allows us to say, in a fair way across the province, that in these sets of circumstances someone is eligible for a great deal more in-home support than they would have got under the previous system. Because all the players are involved in the delivery of that service plan, we avoid the problem that one agency considers the case a priority while the other agency doesn't. It allows us to have the decision-makers about what range of programs and services collaborate under the same accountability system to decide what's fair for a particular client and consumer.

What would be different for volunteers as a result of improvements in the community-based service system? This a very important topic, and I'm sure the presenters will talk at length about the importance of volunteers in their long-term care system. I don't think anywhere in Canada you would find a more cost-effective range of programs than the home support programs currently at work in Ontario, where provincial funding really goes to coordinate volunteer effort, the thousands of volunteers who make a great deal of impact on the ability of consumers, elderly people and people with disabilities, to stay at home and live independently.

What will be different as a result of our service improvements for volunteers? One thing we want to be sure to do is that each multiservice agency is equipped to do even a better job than the current system does in recruiting, attracting volunteers and training them so that they feel comfortable discharging the responsibilities they have, supporting the volunteers not only by reimbursing their expenses but through training activities and so on, and recognizing the volunteers for the tremendous effort they provide and the tremendous impact they have on our service system.

Contrary to the opinions of some, we see multiservice agencies as the vehicle through which to equip communities to attract even more volunteers in the long-term care system, train them better and, secondly, to allow them to become more flexible players in the long-term care system.

If you and I were to volunteer now in many communities, if we volunteered for one agency, we'd be volunteering to drive our car around and deliver meals. If we decided to volunteer for another agency, we may be called upon to make a visit to an elderly person who's shut in, who doesn't have much contact, and to just go and make sure he or she's all right and chat and provide a friendly visit.

If we thought it would be reasonable to not only deliver some meals but perhaps drive somebody to the hospital while we're out on our route, we'd have to get in touch with a third agency sometimes and say, "Look, I'd like to volunteer for your transportation service." Volunteers would have to relate to three agencies if they were interested in doing that for their neighbours in their community.

With the advent of the multiservice agency, volunteers can become a more effective and more flexible part of a team of workers who meet in a more flexible way the long-term care needs of consumers.

We feel that the community-based service system will be improved not only from the point of view of consumers, who will have a more flexible service response at their disposal, but also from the point of view of volunteers, who will become fuller players, a more flexible, important resource in the community-based service system.

The minister talked as well about --

Mrs Barbara Sullivan (Halton Centre): On a point of order, Mr Chairman: We had thought that the minister would likely be here for the entire morning session. Since we have a fairly general overview of the philosophical intent of the bill from the ministry officials now, I wonder if we could proceed, and interrupt the ministry officials at this time, to address questions and comments to the minister particularly and then continue with the technical briefing after the minister's departure.

The Chair: If that is agreeable to the committee. I know the minister does have to go at 11. That would leave us some 25 minutes if there are questions, and then we could go back and continue with the technical briefing. Is that okay?

I have then Ms Sullivan, Mr Jackson, Mr Malkowski, who have indicated a desire to ask questions or speak, so perhaps we'll do that, and Ms O'Neill, if there's time, and I'll try to include others as we go along. We'll begin with Ms Sullivan and come back later.

Mrs Sullivan: Thank you, Mr Chairman. There are a number of issues that I want to place to the minister and ask for her comments on with respect to this particular bill on long-term care reform in general.

The first, of course, is with respect to the dollars which are constantly quoted as being the government's commitment to long-term care reform over a multi-year period. The $647.6 million is frequently quoted. We have asked on numerous occasions for an enumeration of how that money is being spent, what is projected, where it's being spent. We certainly know that there has been inaccurate forecasting in some of the funds that are included in that package of $647 million. The most obvious is the $150 million which was expected to be raised in facility fees from residents of long-term care facilities. That clearly did not come through. That's very obvious from the ministry's estimates.

One of the things that is of deep concern to us and to many people who are very involved in long-term care reform is the accuracy of the data and the financial projections on which this reform is based. That is key and important for a number of reasons, not the least of which is that we hear promise after promise of a better future ahead in long-term care reform. Frankly, we believe that people should have their feet on the ground rather than their heads in the air about what actually will happen, what will be promised and in fact what it is possible to deliver.

We know there has been no feasibility study of the costing of any MSA in any region. We would like to see more of a pragmatic approach to the design, including the financial design, of a multiservice agency in each community or in a number of communities. That hasn't been done. We'd like to know why that hasn't been done.

With respect to the bill itself, once again the director has spoken, as has the minister, at some length on the emphasis of linking together the assessment and delivery functions and indicating that that linking is a necessity to assure appropriate care. We are concerned that the kinds of assessment that are contemplated under this bill don't include the treatment assessments which are so vital for ensuring that people have the appropriate care that they require over the long term. Unless it's the minister's proposal to include medical care as part of the MSA, ie, doctors on staff or something similar, in fact the entire long-term care spectrum and analysis of the patient needs will not be taken into account.

The minister talks about treatment aspects, medical aspects, being procedures, and long-term care being relationships. In our view, that's facile verbiage. Long-term care is far more than simply social and other kinds of relationships. It includes very much a part of care delivery. In fact nursing care is a part of long-term care, and we'd like to have the minister's comments with respect to the assessment function and where the treatment aspects are taken into account in that.

The other thing we find hard to understand is why the minister is so committed to the linking of assessment and delivery. It seems to us that that linking isn't necessary if there is an accountability function at the assessment level for follow-up with the person who's involved. We would like to hear the minister's comments with respect to that.


Certainly the minister appears to contemplate that kind of approach in that there is an exemption in this act, for four years after the designation of an MSA, for an assessment plus service delivery from elsewhere in the community. We would like to know how that four years was chosen, why it was selected and whether the minister would consider eliminating the four years so communities can in fact choose what meets their needs.

Neither the minister nor ministry officials have satisfied our concerns with respect to volunteer activity, and I'm fascinated with the scenario that was painted by ministry officials about how volunteers select their philanthropic volunteer activity.

There are two issues here. One is with respect to those agencies which are mission-oriented, and I speak particularly about religious agencies, whose volunteers want to work with a particular and in a particular religious environment; and similarly, those volunteers who work in a cultural environment that is frequently based on ethnicity, but there may be other cultural surrounds to that.

We feel that the volunteer sector in terms of the activity base will be, if not decimated, certainly reduced, and that has been the circumstance in other provinces, notably Quebec, when similar models were put into place.

The issue that has not been addressed, however, is the volunteer activity associated with fund-raising. A significant amount of social agencies that are providing long-term care is supported by fund-raising activity in the community at the volunteer level, a different kind of volunteerism than exists in actual care delivery. We'd like to know, first, what assessment has been made of the funding that comes out of the volunteer fund-raising process, and how the minister suggests that could be replaced.

There are a number of other areas we would like to ask the minister about. I'm not going to take more time now because time is so limited. Some of those include the minister's views with respect to labour rights of those people who are already involved in the volunteer agencies and their transfer to the new MSA, the issues with respect to the appeal process, and the liability issues that are associated with what will become statutory requirements for employees now, rather than volunteers, to deal with issues such as banking and finance.

There are lots of other issues. I'm sorry that the minister can't stay longer, because we would like to hear direct from the minister's mouth responses to some of these issues.

The Chair: I wonder if in the interests of time it might be worthwhile to move to the Conservatives --

Mr Jackson: And of equity.

The Chair: -- and equity, and then, Minister, if that's all right, to Mr Malkowski, and then you could respond, just to make sure we get the questions on the record. In all of those interests, I turn to Mr Jackson.

Mr Jackson: Thank you very much, Mr Chairman. I'd like to welcome the minister for her brief appearance before these important hearings, but I have to focus some of my questions on what the real facts are about the situation affecting long-term care in Ontario today that bring us to this very moment in our hearings.

I certainly have a lot of concerns about the fact that long-term care was started in the late 1980s and then it was sort of put on the back burner and then revived, but I don't think it's useful to get into a long history except for the area -- my one question from the past administration has to do with the costing. Ms Sullivan raised that.

It is my understanding from ministry sources that there were feasibility studies done on the costing of the MSAs, that in fact when Ron Van Horne was the first minister for seniors there were four pilots done in Ontario. I briefly had occasion to look at part of a report done in the very late 1980s. One of the communities that caught my attention was in the Cambridge-Paris area of southwestern Ontario. That report exposed hundreds of millions of dollars of necessary seed moneys to pull together this vision of an MSA which both the minister and Mr Quirt stylized in almost romantic terms.

That causes me some concern, because they were the same kind of concerns that were expressed about the financial realities around institutional care amendments and the same kind of romantic notions that were portrayed about life after Bill 101.

I certainly have several unanswered questions I've raised both in the Legislature and in correspondence to the minister and Mr Quirt, but I really do believe this committee deserves the right to have a look at those reports. Albeit they were developed by the previous government, there were pilot moneys, taxpayer dollars, invested in a variety of communities in Ontario to develop one-stop access for seniors' services, and the reports came back with horrendous dollar figures attached to them.

I'd like that information because the minister, by her own admission, has indicated in the House -- not today, though -- that the whole schedule for the implementation of long-term care reform is badly behind schedule, that in fact the hurdle which has been most difficult is the one that is before us: the MSAs and how they're to be constructed, their implementation.

On the one hand we have the reduction of the institutional beds, the choking of a large number of beds and access to services in the chronic care field, without the resultant -- this romantic vision of how our long-term care plan with MSAs will be in place. In fact the minister was very careful, or she ran out of time -- but she was unable to give us specific time frames with respect to the MSAs, only that with these early leaders, she was very encouraged by the report.

I'm sure the minister would be willing to share with this committee an example of this wonderful cooperation and understanding about how an MSA should be constructed, and would share with the committee the Toronto model which is before her, even if that were done in a private briefing to this committee, but I think it should be a public document since public boards and volunteers have constructed it.

Hon Mrs Grier: Mr Chair, it is. I think it was released by the DHC some weeks ago.

Mr Jackson: Perfect. That is a concrete one. What we're also looking at are the other early leaders, where the minister announced in the House that there would be potential pilots in place early. We'd like to know how far that has developed. I suspect Mr Quirt would be able to respond to our questions before noon today on that.

The minister expressed that she felt that within this bill it was again a consumer-focused system she was putting in place, that the decisions by the consumer would be more important and more focused, and her biggest example was the consent to treatment, which I thought was already the law in this province, but that's fine.

I thought the cornerstone of consumer choice was access to service, yet within this legislation part XII again has that terrible, terrible clause in it which I disliked so much in Bill 101, that is, the removal of a benefit from the Health Insurance Act, which gives the state -- the minister referred to the financial times we live in, but this power transferred to the state is basically to say, "We're lifting some of the previous protections under the Canada Health Act as it's implemented in Ontario." It's hard for me to really accept that the state, coming before a committee as the minister just did, saying: "Look. Trust me on this. This is going to be a more consumer-driven piece of legislation" -- but if you look carefully in the act, we're removing the universally accessible component.


When I listened patiently to Mr Quirt's presentation, he stylized this section of this legislation in, quite frankly, romantic terms: more this, more that. He used the word "more" and never once used the word "less." When you go from a system which is somewhat more universal in application, which is the system you describe, sort of a basic standard, and then suggest to the citizens of this province, especially our senior citizens, "This is a really good thing for you people because now we're going to have the ability to differentiate" -- and the examples Mr Quirt used were really positive ones, like, "Boy, we could really move in on a family and say, `Hey, you need more service,'" but it's fair to say that this bill also says, "You now should get less service." It also, according to this section, goes so far as to say, "You get no service at all."

In my view, that's a fairly serious consequence of this legislation. It is the same consequence, in legal terms, written as legislation, which existed in Bill 101 when we removed chronic care from the schedule of benefits under the Canada Health Act as interpreted in Ontario with our companion legislation, the Health Insurance Act.

When a person is offered three nursing homes in Ontario and it's completely unacceptable to them either for religious or cultural or for distance reasons, that's it, you're out of luck, no service, or the state says right in the first round, "You can appeal, but you're really just not eligible to be in a home." We're now going to take that new vision of long-term care and we're going to transfer that under the details of how MSAs make substantive decisions about people's lives as it relates to care and support in a home setting. It's consistent, Minister, but it's inconsistent with my conscionable beliefs about how long-term care should be structured in this province.

The concept of "universally accessible" is something which should not be cast adrift, as it is in this legislation, without a fuller and clearer understanding, which brings me to this issue of the 70,000 people who were consulted. It is fair to say that 70,000 people were consulted, give or take a few 10,000. You know how politicians are with numbers: We're all very generous with them.

But I recall the meeting I went to. I was one of those 70,000 who showed up. I just tend to think I was 30 or 40 years early, that's all. But when, asked about the issue of care being not for profit, the question was, "You don't want people to make a profit from long-term care?" everybody said, "No, we don't want that to happen." Therefore that statistic was recorded. But I rose at our public meeting and said: "Just a moment. Do you wish to have a choice? Do you wish to have in place a system like we have today, where profit is governed, rules are governed, but you have access so that you can have certain care at night or on weekends and so on?" Of course the response was completely opposite to the one being taken.

I think we'd best be very careful when we suggest that these 70,000 people in Ontario said, "This bill is a wonderful piece of work," when in fact many of the questions raised at those public hearings do not in any way, shape or form reflect the vision that's set out in legislative terms here.

The Chair: Mr Jackson --

Mr Jackson: I understand, Mr Chairman. Just let me summarize, then. I think we should, during the course of these hearings, get some very clear or straight answers about:

-- The funding arrangements.

-- We should get some straight and clear answers from staff with respect to the fallout from Bill 101. I'm told that millions of dollars of provincial money that was supposed to be going to home care is being redirected now over to institutional care, because under Bill 101 people's fees went up by some $160 million and people just can't pay and therefore the province is picking up the slack. I would hope we would get some real numbers on that.

-- The issue of the MSAs and their structure.

-- The assessment and delivery link components of how that affects the Health Insurance Act.

-- The removal of this benefit, which is implicit in this legislation, and clearly will change access, in my view, for seniors for many, many years to come.

My colleague Mr Wilson and I look forward to the public hearings over the course of the weeks, but we feel there are more unanswered questions than those that are satisfied in the minister's brief but, as I say, somewhat romantic presentation this morning.

The Chair: Mr Malkowski and then, Minister, you can respond.

Mr Gary Malkowski (York East): Thank you, Mr Chair, and thank you, Madam Minister, for a very comprehensive opening. I know my own constituents in East York, with East York Community Care, have been very excited and are very happy to see this legislation coming into being and are looking forward to the improvements in service that are going to take place because of it.

In my own constituency, I have met many constituents who have disabled children. This legislation applies to seniors and disabled people who are adults, but what about the gap in services in terms of people with disabled children, and how can they fit into this type of legislation?

I also want to ask about the role of the district health council. Is there a requirement that there be members of the disabled community represented on the district health council, specifically in terms of the planning stages, making sure that the MSAs are accessible? When I talk about accessibility, I also mean in terms of making sure that the information can get out there, that communication is accessible. I don't see any requirement in terms of the district health councils actually including disabled people in the planning process, and I'd like to know whether there is a requirement that that take place.

My final point would be really more of a suggestion. In terms of seniors, 50% of all seniors have a hearing loss. My suggestion is to make sure that the MSAs are accessible, that information in terms of being able to communicate with this population is provided in an accessible fashion, that there be a guarantee of a specific level of support service. I think we need to have an expansion of that.

Probably the most appropriate place is through the public hearings. We'll be hearing comments from consumers on these issues, I'm sure, but I would like to hear your comments specifically on those three areas.

The Chair: Minister, there are a good number of questions on the plate, if you could try to respond to them. I'm sure staff have also taken note, and some of them we may have to come back to.

Hon Mrs Grier: I certainly will attempt to at least briefly touch on those that have been raised, but let me say that not only the staff but certainly my colleagues have been involved in the preparation of this legislation and the debate about long-term care for the last four years. Both my parliamentary assistants and the parliamentary assistants to other ministers who have been involved in our discussions as a government in what this legislation should contain are very familiar with all of the details, and I know they will be able to respond to questions and comment as you go through the hearing process.

Let me also say that as I listened to my colleagues in opposition and their concerns, I worried that they were implying that the status quo was somehow acceptable. I say to them that given the changes in demographics, the aging of the population, all of the factors we have heard about in every discussion we've ever had about health care, the fact that we have 1,200 agencies out there providing long-term care, some of them in first-rate fashion but some of them quite isolated from each other, and in anticipation of the bulge in population that will increase the senior population over the next 20 years, it is essential that we finally, after, as Mr Jackson said, more than a decade of discussion, get to the point of not just expanding, improving, but almost creating a long-term care system. We are not beginning that with this legislation. We are putting in place the legislation that facilitates the continuation of the work that has been begun.


Mrs Sullivan asked for details of the funding. I think in our estimates discussion and in the follow-up a lot of that was provided, but let me repeat the figures I mentioned in my comments in a percentage form, because they are dramatic.

Since 1990-91 this government, faced with all of its fiscal constraints, has increased expenditures for home care by 53.5%; has increased expenditures for integrated homemaker programs by 65%; has increased expenditures in funding for home support services by 37.4%; and has increased expenditures in programs providing attendant care by 35.9%. That is the increase in expenditures that has already occurred, and the $647 million in additional spending that was announced when the program began is largely out there. There is the addition of almost $200 million that will occur over the next two years on long-term care; I think $160 million of that on the community support services. Our commitment to not only creating the system but to funding the system is there for everyone to see and for everyone who needs long-term care to benefit from across this province.

When we get into the specifics of what an MSA will cost, I can't at this point produce any specifics around that. I know that some work has been done and I suspect that staff can share that as you get into the hearings.

Mr Jackson mentioned work that was done by one of your colleagues, Mr Van Horne, the minister responsible for seniors' issues. I remind you that that was based on a very different model. That was the previous government's approach, which was to put in place ministry-led service coordination agencies; it was the top-down approach, that was rejected almost universally during the consultations that we began in 1991 and which we have replaced by the growth and evolution of the existing volunteer-led agencies into better-coordinated and integrated, still volunteer-led, agencies. If any costing was done of models based on the top-down service coordination approach, I'm not sure they would be still relevant, and they're not ones I'm familiar with, though I'm certainly prepared to ask if those exist.

The other major change, and Mrs Sullivan referred to it, was the fact that the previous government's approach had been a continuation of the brokerage model. That's the fundamental debate that I think we get into with those who question our approach to long-term care and who suggest that the integration of assessment and provision of services is not required and that all we need is a better coordination of agencies that then continue to contract out and be brokers for the provision of service. We don't believe that is the way upon which we want to build an integrated system for the future.

But acknowledging the difficulties and the concerns people have in the coming together of these agencies in communities was why we moved to a transition period. Mrs Sullivan said, "Why four years?" It was our assessment, from discussions with EHCs around the province and with agencies across the province, of the maximum amount of time that would be required in order for workers, boards, volunteers to come together in a more integrated way. But while we heard from those discussions that people were a little alarmed at the prospect of there one day being 1,200 diverse agencies and the next day 400 or 500 integrated agencies so we acceded to the request or the suggestion that there be a transitional period, certainly it is my sense that well before the end of four years, many of those will come together.

The question around assessment and who does it: the same professionals who do it now. Now assessments are done by hospital discharge planning staff, by home care programs, by placement coordination service programs, by adult day program staff and by community support agencies. The kinds of people who are performing those assessments will continue to perform them, but they will perform them on behalf of the multiservice agency so that, having done the assessment, they can no longer be put in the position of saying: "Well, I've assessed you. You don't fit the needs of my particular agency and the services we provide, but here's a number to call where another assessment can be done by another agency that I think provides the kind of service you need." We will now have one assessment and a direction from that to the kinds of needs that are identified through that assessment.

Mrs Sullivan: I wonder if we could have a further clarification of this assessment role. Clearly, the people who are the new assessors will be employees of a multiservice agency. They will not be hospital discharge planners. In fact, the hospital discharge planners have quite a different role.

When the minister says the same people who will be doing the assessments are those who are doing it now, in fact that's not quite right. I'd like further clarification of what she sees as the role, the qualifications of an assessor who is going to be not from an existing agency but a new employee of a new multiservice agency.

Hon Mrs Grier: The social worker who's now working for a small volunteer agency and doing assessments I hope will be exactly the same social worker who'll be working under the aegis of the multiservice agency and doing the same assessment. The standardization of criteria and the definition of what service is required depending upon what assessment is something that is being discussed in detail by the ministry and people who've been doing assessments for 20, 30 years.

But I can assure the member that the education qualifications of a social worker working now for the Red Cross are not going to be any different from the education and qualifications of a social worker or a physiotherapist or a nurse working for a multiservice agency.

Mrs Sullivan: But I'm still not getting the picture. If there are treatment requirements, including nursing requirements and so on, surely the minister isn't suggesting that the social worker will make those assessments?

Hon Mrs Grier: No, nor do they now.

Mrs Sullivan: Then how does she see --

Hon Mrs Grier: I used "social worker." I could well have said nurse-practitioner, psychiatrist, whoever was doing it.

Mrs Sullivan: The assessor is the person who comes into contact with the patient.

Hon Mrs Grier: I think we could bog down on this for some period.

The Chair: I think the minister will respond that this may be an issue that we need to continue to explore.

Mrs Sullivan: It's the way people get into the system. It's a very important question. The minister should be quite clear.

Hon Mrs Grier: It is certainly very important and I'm sure it's one that, as you hear from various presenters, will be discussed in more detail. I'd be more than happy to have a specific briefing on that aspect of it as you get into your technical briefings, if that would assist the member in understanding what happens now and how that can be performed in a more coordinated way as a result of the changes we're suggesting.

But I did want to touch on a couple of the other points. One was again from Mrs Sullivan, her sense somehow that volunteers who came from a particular cultural or religious or set of values to their volunteer work would be unable to continue to perform as volunteers with the same values. I guess I don't understand what she's thinking, and that may also come out, but certainly as a volunteer, as I've been for many years in my life, I decide what kind of agency is most compatible with the kinds of objectives and satisfactions I want to achieve as a volunteer, and if that agency doesn't provide me with that sense of satisfaction, there are lots of other roles in which I can fulfil my volunteer responsibilities.

If merely delivering Meals on Wheels becomes not satisfying enough -- and having delivered Meals on Wheels, I know how frustrating it is when the person wants you to stay and chat and you really don't have time -- you may say, "I'd much rather be a friendly visitor so I can go and spend time with that particular client."

But I bring to that as a volunteer whatever cultural, mission or religious beliefs I hold, and certainly no agency is going to say to you as a volunteer, "You must visit that person and not that person." That is worked out, as it always is, with agencies, and I don't see any of that changing. It's the concept that suddenly by bringing together agencies under one roof everything changes that I think is unsettling to some people who may feed into that belief or assessment of what's going to happen and that we need to be very clear about.


From my own experience 20 years ago in putting together a multiservice agency to provide health care services, I found that the number of volunteers who came forward to both fund-raise and to volunteer expanded as a result of the variety of opportunities that were provided by bringing 10 or 12 agencies under one roof and the critical mass that was created by doing that. I have every confidence -- and it is not romance -- that the same will happen to a great extent as multiservice agencies are created.

With respect to the insured services, I wanted to point out to Mr Jackson that those insured services are provided where they are available. They're not now available, with consistency and equity, across the province, and that has been the decision of whatever government, as to whatever funding has been put into the provision of the services, and they're provided only under the Canada Health Act in one province of Canada: New Brunswick. This legislation lays out a long list of requirements to be provided through multiservice agencies that I think will be an incredible improvement in the volume and quality of service provided over the current legislation.

The Chair: Excuse me, Madam Minister. Mr Wilson, you just had a question on that?

Mr Jim Wilson (Simcoe West): I just wanted to raise a point about the minister's premise about reform to date. If she'd like to finish her comments, I'll just raise that point while we have the opportunity.

Hon Mrs Grier: With respect to the specific issues that Mr Malkowski raised, I have to say to him that the integration of disabled children into the long-term care system is not something that is happening as a result of this legislation. Responsibilities for children still primarily lie with Community and Social Services, and those agencies working with multiservice agencies and benefiting from them is something that I think will evolve over time but is not part of this particular thrust.

The question of representation for the disabled is something about which I have been particularly pleased to note, as I've met with district health councils and their long-term care planning committees, the number of people with disabilities who are today involved in the planning and in the discussions and preparation for the development of multiservice agencies.

The act and the amendments with respect to DHCs specifically provide for the minister to make the nominations to DHCs, as they always have, and to ask the DHCs, as they make nominations for members of their boards, to look at the diversities and all the people in their community, and specifically in the designation of a multiservice agency to reflect the diversity in the community.

I see this as moving us some distance towards full recognition and integration into planning and into the management of the system of people with a diverse range of needs across this province.

Your point about the acknowledgement of the prevalence of hearing loss in seniors and the need for multiservice agencies to be sensitive to that is one well taken. While it is not something explicit in our policies and programs or in the legislation, at this point, it's certainly something I will take back to the ministry.

Let me say, with respect to the member for East York, that when others ask for examples of communities that are coming together to do the planning in preparation for these changes, East York is a first-rate example. With the support of the member, I know the agencies there, which already had integrated homemaker and were the only community in Metro to have integrated homemaker before the expansion this year, are well poised and discussing between themselves and the DHC the potential to be an early leader and to demonstrate what a multiservice agency can do and the enhancement of services it will provide.

I thank the members for their questions. I know I've only touched on the surface of them, but I certainly will be following with interest the ongoing discussions. Both ministry staff and my colleagues on the committee will I'm sure be able to address these questions in further detail as time goes on.

The Chair: Thank you, Minister. Mr Wilson, one last question and then we'll move on.

Mr Jim Wilson: I've paid a great deal of attention to what the minister said in the past few minutes. I just want to inform the minister that I slipped out to attend the Catholic Health Association of Ontario's press conference just down the hall.

Minister, you've made a great deal of hay out of the fact that large sums of money have been transferred to the community-based sector and to long-term care. I think your government takes a great deal of pride -- I would say unjustified, but you claim pride -- in the reform of the long-term care system's that's occurred under Bill 101 and that's about to occur under Bill 173.

I just want to quote for you Sister Alice McEvoy, who's the executive director of Marianhill Centre and chair of the Catholic Health Association of Ontario task force on long-term care, because I think Sister McEvoy very succinctly summarizes where a lot of these concerns are coming from. That is that there's a great deal of distrust out there about this reform process. Here are a couple of paragraphs from her remarks at the press conference:

"When it introduced this legislation" -- referring to Bill 173 -- "the government promised that it would produce greater access and better service to consumers. These are the same promises it made during the debate on the reform of institutional long-term care last year," referring to Bill 101.

"Let's review the results of that reform: fewer beds, less funding, less staffing and a 47% increase in the cost to consumers. The government promised more money to the program and to provide services to match local needs. The only new money came from the pockets of our residents and services were provided up to a dollar level, having little to do with an individual's needs.

"In light of this experience, we find it difficult to accept bland assurances that this bill will fulfil the government's promises."

These are very strong words from Sister McEvoy. Her concerns are reflected by almost every group that we've been talking to in the past several weeks, not only about Bill 173 but about the so-called reform that's occurred to date.

The Catholic Health Association, Minister, goes on to very clearly talk about loss of consumer choice in, again, very explicit language and charges your government with wanting to "eliminate all the charitable community non-profit agencies, and replace them with large, impersonal regional bureaucracies." They also point out the cost of MSAs and come up with an estimate that the 20 or so proposed MSAs for Metro Toronto alone will add an additional $7 million worth of bureaucracy just to provide nursing services.

I wonder if you have any comments, Minister, because these are very strong charges coming from an extremely reputable association in our province.

Hon Mrs Grier: They are, and I certainly regret that that perception exists. I think the amount of additional funding that has been provided speaks for itself. I'm certainly prepared to lay out in detail what I've already laid out in estimates about the additional spending that has occurred on long-term care, both on the institutional side and, as I've enumerated here today, on the community-based side.

I think the placement coordination has in fact increased access to services and has done it in a way that is sensitive. I have certainly heard, and there have been many letters to me and anecdotal reports and certainly stories, about people who benefit from placement coordination, as opposed to being on eight waiting lists for a home for the aged or a nursing home, who are enabled, through placement coordination, to have a placement that both meets their needs and if, in an emergency, they have to go to a home that does not meet their needs, because that's where a bed is available urgently -- the fact that placement coordination services maintain the file and assume responsibility to make a shift to a culturally appropriate nursing home is an innovation that does not exist where placement coordination does not exist.

I will certainly look with interest and be happy to speak to the Catholic Health Association, as I have on a number of occasions, about its concerns, but I hope that, through the course of these hearings, some of the misconceptions that are out there and that have perhaps been fostered inadvertently by some of the questions or concerns that others have raised can be addressed and the real picture of the enormous, long-overdue expansion of long-term care in this province that is taking place under our government and that this bill confirms and directs will truly become obvious to all, because I think that's what will happen.


Mr Chair, I'm afraid I'm going to have to leave after that.

The Chair: I'm afraid the minister has stayed 20 minutes beyond when she had indicated she would leave. Thank you, Minister, for coming before the committee. I'm sure that these questions and others will be brought to your attention and we'll be returning to them.

Hon Mrs Grier: I suspect the same questions will be raised many times. Thank you for your hearing.

The Chair: Thank you. We have about 40 minutes until noon. Mr Quirt, approximately how much more time did you want in terms of other points to raise, or did members simply want to get into more questions? Did you have a number of other points when we altered the schedule?

Mr Quirt: I could complete my presentation probably in about five minutes, but I'm at the pleasure of the committee.

The Chair: If it's agreeable to the committee members, could we do that? Then we'll go back to any questions or comments from members, if that's all right.

Mr Jackson: Could I ask why the materials that are in the binder are very much reflecting the sorts of comments that Mr Quirt's been giving us? I'm just wondering if we could get into some questions, because I sense a lot of similarity in the presentation from the minister and Mr Quirt.

Mr Jackson: Are we scheduling any additional time with Mr Quirt before the committee or will we be able to continue much in the fashion we did with 101 where, from time to time, Mr Quirt was asked to come forward to clarify points?

The Chair: I think we will do that, but we also have some flexibility. I want to discuss that with the subcommittee later, in terms of some other time. With that then, perhaps I could revert to the question list that I have.

Mrs Yvonne O'Neill (Ottawa-Rideau): I object to that. I think that Mr Quirt is giving us examples. These are examples that he has given in the community. We haven't heard them. For five minutes, I think it's worth getting the acting director's presentation.

The Chair: Okay. Then if I look at heads, we'll return to Mr Quirt. If you would complete your comments, then I'll revert to the question list that I have.

Mr Quirt: Thank you, Mr Chairman. I'll try to do so as quickly as I can.

I spoke before about some tangible improvements in the system made possible by this bill for consumers and volunteers, and I talked about the provisions of one-stop access. I talked about the improvement in the range of programs and services consumers can expect to receive from multiservice agencies in the reformed system.

I wanted to very briefly talk about two other objectives of the bill and give you some similar concrete examples of how consumers and volunteers will play a more active role in the accountability relationship that multiservice agencies will have to consumers, their community and to government, and also talk about how consumers and volunteers will play a more tangible role in the planning and management of the community-based long-term care system.

The minister talked about improved and consistent accountability. I'll deal very briefly with the accountability that will exist between multiservice agencies in the province. We feel that -- and certainly provider agencies have complained in the past about a myriad of expectations and rules and regulations that apply variably to community service agencies.

We are working now with representatives from provider and consumer organizations to develop a program manual for multiservice agencies that will reflect the best possible and clearest accountability relationship between those community-based not-for-profit organizations and the province, which funds them.

We feel we've made some great progress in that regard on the long-term care facility side, and I think if you were to ask either representatives from the Ontario Nursing Home Association or the Ontario Association of Non-Profit Homes and Services for Seniors, they would feel that they have contributed significantly to the new long-term care facility program manual and feel it's a much fairer representation of good practice and facilities than the government's previous policies were.

We hope that we'll be able to say the same when we complete our work with the numerous provider and consumer groups and develop the program manual for multiservice agencies.

With respect to accountability to the consumer, I think it's important to point out that consumers will have a place and a role in the actual governance of multiservice agencies. You'll see that the bill requires the minister to take into account whether in fact the board of a multiservice agency is representative of those people receiving services from the multiservice agency.

Certainly many of our stakeholders have suggested to us that the minister's policy should be to expect perhaps a third of the members of the board of directors of a multiservice agency to be people familiar with the experience of being served and delivered long-term care services in that community.

In addition, for the first time, the system will be more accountable to consumers through provisions of the bill that require agencies and consumers and the community at large to recognize certain rights that consumers have. This will be the first time that a bill of rights will apply to the delivery of long-term care community services. You'll note that a bill of rights now applies to care in all types of long-term care facilities.

In addition to that, the bill requires that consumers are actively involved in the development of their individual service plan. The bill requires that consumers, their representatives, families, have input into designing that package of services that best meets the needs of consumers. We feel in both these ways consumers have a much stronger role in the accountability relationship that exists between those agencies funded by the province and consumers, their community and the government.

With respect to planning, the minister has already pointed out that long-term care subcommittees across the province do have consumers of service at the table planning the new long-term care service system. Her requirement was that fully one third of the people on district health council long-term care planning committees were consumers.

In the future, volunteers will continue to be involved in planning those services. While district health councils are provided with support staff, the vast majority of the work done by district health councils is done by volunteers in their community, representing various sectors but coming together to plan and advise the minister on the appropriate range of health care and long-term care services in their community.

Volunteers will continue to fulfil that role, and as is the case now, volunteers will continue to have the major role in the governance of not-for-profit, community-based long-term care programs, multiservice agencies that will not only be governed by volunteer boards of interested folk and consumers but will be accountable to a membership of the not-for-profit organization in each community.

In summary, then, we feel that the objectives of a consumer-focused system and the objective of local community-controlled planning will be achieved through the tangible improvement of the involvement of both consumers and volunteers in that area.

The Chair: Thanks very much, and we'll start with Ms O'Neill.

Mrs Yvonne O'Neill (Ottawa-Rideau): Yes, Mr Quirt. I just have a couple of things to begin with.

I had the same difficulty as one of the other members has brought forward already of the unrealistic expectations when you're talking about service targeting.

You're talking about lifting the 60-hour limit. Could you say a little bit more about that, because I really don't think we can talk about more and have less to put to it. I really do feel that some of the figures that have been thrown around this morning are not understood by the general public. They certainly see that in some outlying communities, as you've suggested, there is much more in the way of placement coordination, there's much more in the way of integrated homemaking, but the actual services in the home are not what some people expect.

I would like to have you tell us exactly how that decision would be made. I think it ties in with what Ms Sullivan said earlier regarding the assessment. It sounds great, but how is that step going to be made from the way things are done now to the way things are going to be done in the scenarios you have painted?

Mr Quirt: You're quite right, Ms O'Neill, that there is a finite amount of money available to spend on long-term care services in the community and in facilities, and we have not claimed that everybody's service demands will be met at the 100% level to their satisfaction. It would be misleading to suggest that.

What we have claimed is that we're making a substantial investment in both facility and the community service side, and we will provide for members of the committee a schedule of expenditures that will show how exactly $206 million was added to the budgets of our existing long-term care facilities over the long-term care reform budget, and we will show how roughly half of $440 million is already at work in communities across Ontario in providing more services through home care, through home support agencies, through supportive housing programs and so on.


As the minister mentioned, we're not finished yet in that expansion. We hope that over the next two fiscal years ending in 1996-97 the balance of that $440 million, or an additional $200 million roughly, will be added to budgets. Those specifics we can provide on a program-by-program basis.

But your point is well taken, that even with that significant investment the demands that we're facing are significant as well. We need to do our best to manage those resources in such a way that most people get the best service that we can afford under those limited circumstances. There's a great deal more money, but there is a limit to how much money there is. That's why we feel that allowing our front-line service delivery organizations to not only make the decision about who's eligible for how much but to have at their disposal a wide range of service responses within their own organization equips them to be more effective managers of that money.

There's no question that sometimes those organizations, multiservice agencies -- like the home care program does now or like community support service programs do now -- are going to have to say, "No, I'm sorry, you're not eligible." But for a larger percentage of the clients they'll be able to say, "Yes, you are, and we have a fair way to determine how eligible you are and how much service we can provide."

What I'd be happy to do, Ms O'Neill, is to provide you with the draft of the multiservice agency program manual that talks about service limits in terms of dollars expended on a particular client and their family, as opposed to the across-the-board cap of 40 to 60 hours that we've been working with currently, and if there are any specific questions about eligibility and who would fall into what category, we'd be happy to answer them.

To give you one concrete example, we intend that each multiservice agency would have the capacity for some clients to authorize and deliver a level of service that would be equivalent to what some people with physical disabilities get now through the attendant care outreach program, that right now is quite separate. In some communities that attendant care outreach capability will become part of the range of services the multiservice agency provides; in others we've offered consumers the right to opt out and say: "No thanks. We're not convinced your multiservice agency is sensitive enough to our needs. We'd like to continue to be funded separately." And we've said, "That's fine."

I hope I've covered the questions you've raised, and if there are ones I've missed, I apologize. I'll catch them later.

Mrs O'Neill: Thank you for helping to clarify that situation. I think the manual should be helpful. I think your remark that you stated, that people are going to have input into their personal care, also raises expectations. I think, if anything, we should be realistic and honest and upfront about the limitations that we can provide in the community.

Mr Quirt: I think your point's well taken.

The Chair: Ms O'Neill, can I just ask, just because Mr Quirt has mentioned that he could make available the draft manual: Is that something that each caucus could have, or how big is it?

Mr Quirt: Well, it's a fairly thick manual at this point in time, but I see no reason why within a few days we couldn't have it copied for each member of the committee.

The Chair: Okay, fine.

Mrs O'Neill: I just have one other question. It has to do with the statement of the minister, which is a technical statement that she made, so I'm going to ask you. She said that 80 to 100 people are going to be, at present, involved in the direct funding for the disabled. I was quite surprised with that number. I thought it would be much higher, having been involved in the Bill 101 hearings. Is that the limitation of the pilot project, or why are those numbers so low?

Mr Quirt: It is a limitation of the pilot project, clearly, and we have taken a rather unique approach to this, in effect designing this pilot project at the table with representatives of groups of people with physical disabilities. Off the top of my head, I don't recall the particulars of arrival at that number of 80 to 100. I think it's fair to say that the disabled consumers who are helping us plan this are comfortable with that number as a pilot. Certainly, if they were before the committee, they would say that's only a pilot, and we hope that this program's expanded once it has proven its worth.

But I can provide the details of not only how that decision was arrived at, but the eligibility process that's currently under way involving organizations that represent people with disabilities in selecting appropriate pilot cases, if you like, or pilot individuals who will have the right to receive money directly from the government to hire and train and employ their own attendants. We're relying on the community of people with disabilities to help us with that selection process in, I think, five or six locations across the province.

Mrs O'Neill: Finally, the time line on that pilot.

Mr Quirt: We hope that we will be writing cheques to people this fall so that they can start to recruit them, employ their own attendants this fall.

Mrs O'Neill: But what is the limitation on the length of the pilot?

Mr Quirt: I believe the pilot, at this point in time, is scheduled for a two-year period. It will cost us a little over $4 million a year. Both those figures are subject to my confirmation. If I've misled the committee I'll give you the exact details.

Mr Larry O'Connor (Durham-York): Mr Quirt, you suggested that one third of the representatives will be consumers. I believe that the consumer representative on the multiservice agency is going to be crucial to continuing some of the participation that we've seen in the past, the volunteer network that is out there and in the community. But when I take a look at part VI of the bill, I guess you could say 11(2)(a) is a good definition of what a consumer would be. It's quite flexible and it doesn't point to numbers at all. You suggested one-third makeup. Because it doesn't say one third in the bill, I wondered how you'd arrived at that and if you could maybe share with the committee where that figure came from.

Mr Quirt: That's a very good question. In response to that I'd point out that the bill is somewhat flexible in that regard. We were reluctant to draft the bill in such a way that it said, "In every circumstance, in every part of Ontario, there shall be one-third consumers on the board of the multiservice agency."

As has been pointed out with some of the members of the committee already, there is a great variation in the speed at which local communities are coming to consensus about their multiservice agencies, and it may well be that in some parts of the province the minister would have to approve or designate as a multiservice agency a service provider organization that would have difficulty at first, perhaps, in meeting that one-third consumer expectation.

For example, the minister's position is that public health units or municipalities are not our first choice for multiservice agencies because they don't, in their current format, provide for that degree of consumer input at the governance level. If, for example, a community was to come forward and suggest that a hospital board or some other local organization was really best equipped in that community and the district health council had looked at all other options and suggested to the minister, "Gee, we'd like to do it the way you suggested but it isn't exactly possible right away in our community," the bill gives the latitude for the minister to accommodate that unique circumstance.

But she's been very clear, as have we through our policy documents and through statements, that a significant and meaningful consumer representation on the board of the MSA is what is called for.

Mr O'Connor: Accountability -- another point. You mentioned just now local health units. I'm sure that it will be pointed out to us through the committee hearing process that local health units could provide the service; in fact, as far as representation is concerned, they report to an elected municipal council. Why couldn't they then continue to serve us and be the MSA? Perhaps you can share some of your thoughts there.

Mr Quirt: I'd be happy to. Mr O'Connor has pointed out in his remarks about the perspective of public health units and municipalities, a fairly consistent theme in that public health units across Ontario in many communities are saying, "Well, heck, we've been the operators or managers of the home care program to date and how can you be more accountable to your community than having to get elected by it?" That's a valid perspective.

On the other side of the equation, through our consultations and through the submissions of important consumer organizations and provider organizations, notably the Senior Citizens' Consumer Alliance for Long-Term Care Reform and the Ontario Community Support Association -- both groups spoke very eloquently in their submissions about the importance of real consumer representation on the board of a grass-roots, community-based organization, accountable to a membership in a broad sense as opposed to accountable strictly through the political process. Based on that advice from consumers and providers, the government has adopted a definition of, if you like, accountability to the community that's a little broader. It allows for direct consumer involvement, it allows for interested folk to be members of the not-for-profit organization that operates the multiservice agency to elect each year the board of governors or the committee of management of that multiservice agency and to truly deliver on the commitment of consumer involvement.

While that's a valid perspective that has been raised, I think in weighing the different points of view we certainly heard more often about the importance of broad-based consumer involvement in the governance of MSAs.


Mrs Sullivan: There are a couple of things that I want to raise. First of all, I'm interested in Mr Quirt's discussion of the policy manual on the long-term care facilities because while his suggestion is that the homes for the aged and nursing homes see this manual as being an extremely positive and forward-looking step, I am not hearing those same kinds of responses.

In fact, what I'm hearing is that the Ministry of Health is micro-managing, making decisions and putting forward specifications including, for instance, the brand of mouthwash that has to be stocked in a long-term care facility, when in fact many of those decisions are more appropriately made at the level and at the place where they have to be implemented. That's one of the concerns that I see with respect to a program manual. I will definitely want to see not just a portion of the MSA manual but the entire manual so that we can review that while the process is proceeding.

Another issue: You speak about the involvement of the consumer in the planning and delivery and so on of care. I suggest to you that we have to remember that the consumer is the public at large in the way you're using that term. If you are speaking about the consumer as being a participant in the system itself, you will see that in fact clients aren't involved in the planning, other than in terms of their own personal file, of the system as a whole.

I would like you to comment, before you run away in about 15 minutes at the end of this particular session, with respect to the 20% provision in the act. The policy statement made by the minister earlier indicated that 10% of services could be purchased from private sector organizations and agencies. The bill indicates that 20% of services can be purchased outside of the agency, presumably not only from the private sector but if, by example, there was a service required by a client that is not included in the mandatory basket or in the services that the MSA is able to offer, that could be purchased outside.

One of the interesting interviews that I had in recent months was with representatives of the Ottawa-Carleton area who indicated that their costs in fact would rise by over $1 million because of the requirement of the 10% rule with respect to purchase of private sector services. In fact, what we're seeing here, if the 20% includes both private sector services that are available and other agency services, may well be an incremental cost that hasn't been fully factored.

I'd like you to comment on that: What the 20% rule means, what other services will likely be provided, who can provide them and what happens if those services are required above the 20% level to meet the reasonable and assessed requirements of clients and yet the agency has in fact met its 20% cap.

First of all, I should say that I hear your comments on the direct-funding pilot with some amusement because each time we've seen you before a committee, we are told that the funds are going to flow imminently and I think this is at least three or four years now that the pilot has supposedly been under way. I guess we'll believe you this time, but it's been an awful long time coming. You'll recall that pilot was ready to go when the last government left office.

Perhaps you can respond to those issues.

The other issue I want you to respond to at this time is with respect to the statutory requirement for employees of the MSA to deal with banking and other financial transactions of the client. I think there are particular legal problems in association with that and certainly enormous liability problems that many agencies have already faced and have been and are deeply concerned about.

The Chair: Sorry, if I could just interrupt, Mr Quirt, after you've responded to Ms Sullivan, then turn to Mr Wilson in your response, and that should bring us to the end of this morning. I would note, just because it came up, that you will be with the committee, so there will be other questions and we'll work out an appropriate way for you to be able to respond at other times to questions as we go along.

Mr Quirt: Thank you, Mr Chairman. I'll try to respond as quickly as I can to Ms Sullivan's points, and I remind the committee that my colleague Gail Czukar is prepared to provide a detailed briefing on the specific wording of the legislation and how it arrived in its present form. I feel the committee would benefit from her remarks in that regard. I'll also ask Gail to speak to the last issue raised by Ms Sullivan, the statutory requirement with respect to banking and clients and so on raised by Ms Sullivan.

If I may quickly go through the three or four things you raised, I agree with you that it's important that a policy manual reflect the different points of view of service providers and others. I think you've quite rightly pointed out that particularly from the homes for the aged perspective, some providers find our program manual and our new set of provincial expectations too specific and have accused us of micromanaging, and have for the first time really been subject to a consistent set of expectations with respect to what the province would like to see delivered in long-term care facilities.

On the other hand, the nursing home program would see the current program manual as building on the compliance program manual previously developed with nursing homes, with their input. Certainly, when we pull our program manual committee together, which not only has representatives from the nursing home association and the homes for the aged association but people from Concerned Friends, from labour organizations, from the Ontario Association of Residents' Councils and from the Advocacy Centre for the Elderly, there is often a difference of opinion in how specific the province should be and the degree to which the province is responsible for safeguarding the interests of residents in those facilities. I think it's fair to say that sometimes the provider perspective and the consumer perspective differ in that regard. That's why we want to balance all those perspectives and hope that our standing committee to improve the manual will do that.

Secondly, I would agree that the multiservice agency should be accountable to the public at large as well as to the consumer. We hope that a balance of perhaps one third consumer representatives and two thirds from other interested folk in each community will provide that variety of perspectives and hopefully lead to good governance that's really reflective of community wishes.

You asked specifically about the 20% rule and the former 10% rule. You will recall that during the early developmental stages and expansion of the long-term care system, as we invested a couple of hundred million dollars in the community, we did have an expectation that over time, home care programs would alter their purchasing practices so that they would achieve a 10% maximum purchase of commercial services overall.

We listened to our planning partners, not only district health councils but agency representatives as well, and recognized there had to be a closer link between the achievement of our multiservice agency program objectives and the achievement of the government's objective of not-for-profit service delivery. As a result, we've replaced that 10% expectation with the provision that you see in the bill, which is an expectation that multiservice agencies will buy, in each of the categories of service, a maximum of 20% of service from outside agencies.


We felt that we had to stipulate a percentage of service that MSAs would deliver themselves in order to achieve the benefit of the integration of case management and eligibility determination on the one hand, and service delivery on the other. If the bill wasn't specific in saying the majority of services has to be delivered by the MSA, we may never move away from the brokerage model, and it's precisely the move away from the brokerage model that consumers are asking us to make and that the Ontario Community Support Association, representing 400 volunteer-based organizations and more, is suggesting we make.

The 20% would apply as follows: For example, in the area of homemaking, the multiservice agency would be expected, in its complete and full version, to purchase only 20% of its homemaking services from outside agencies. That would allow for the continued purchase of some services from the commercial sector, particularly in those cases where a particular client had developed an affinity or a long-standing relationship with a particular worker who didn't become part of the MSA and was still involved with a commercial agency. The 20% purchase limit would also allow for just the situation that you pointed out, Ms Sullivan, where you pointed out that sometimes with a very specialized service, it wouldn't be appropriate or economical to have a highly specialized professional in the employ of the multiservice agency. It could be that, for example, a psychiatric assessment or a psychological assessment might be purchased, and that 20% would allow for that, or particular services of professionals.

The four-year exemption period is designed to allow some flexibility in achieving that, and for example, the 20% rule is one of those rules that the minister can grant an exemption about. So if, for example, in a particular community a not-for-profit homemaking or a nursing organization needed time to plan its transition into the MSA, in effect 70% or 80% of the nursing service might continue to be purchased for the first year, and then that would go down the second and the third, and it will allow for a more orderly transition to the integration of eligibility determination and service delivery.

I'm sorry if I've taken too long and too much of the committee's time on those answers.

Mrs Sullivan: No, that's fine. Just on that, that ministerial exemption is only in place for four years, for an absolute maximum of four years.

Mr Quirt: For up to four years, that's correct.

Mrs Sullivan: If at the end of the four-year period there is a client population of the MSA which requires services that the agency is not able to provide from within and that agency has already reached the maximum of 20% of purchased services, the client will therefore go without because there is no exemption and no opportunity for exemption after that point.

Mr Quirt: I would suggest to you that the minister, in granting the exemption for the four-year period, would be asking for a plan for how the organization, the MSA, would over that period achieve the mandate prescribed by legislation to deliver those full range of services, recognizing that the agency has at its disposal the capacity to buy 20% of the services in each category and, secondly, recognizing that any purchase that's made from another MSA that may have that specialized service you're talking about doesn't count towards that 20%.

For example, if a particular multiservice agency among the 15 or 20 recommended for Toronto had a specific capacity to deliver services in a very culturally or linguistically appropriate fashion, it may well be that somebody in Durham region might say, "Heck, for this family of Italian origin, I think we may in this case decide to purchase services from the MSA that's our neighbour that is particularly good at that." That doesn't limit their ability to spend 20% in other circumstances.

I'll ask now that the last question, Mr Beer, if you don't mind, be addressed by my colleague Gail with respect to the statutory requirement.

Mr Jackson: Mr Chairman, I would like to put this request for information for the record, since both legal counsel and Mr Quirt will be touring the province with us on this bill. If I could serve notice of these additional questions, that might be helpful. Could I get a list of the current MSAs which are filed with the ministry or the minister and the locations of those MSAs? When we're in a given community, it would be helpful to committee to know, when we're listening to deputations, what the nature of the formal consultative process has produced in that given community.

The minister mentioned 13 homes for the aged with upgrades. Could we get a list of those and their location and where the moneys were coming from, because I suspect that is very much like peeling an onion where we're going to find the funding if Jobs Ontario has gone into a given facility, and what is its impact on the number of beds because in some of these, I know, as a prerequisite of an upgrade they had to reduce the number of beds. I think that's very helpful to the committee. If we're in a community during the course of these hearings where they've actually lost institutional beds, we'd like to know that.

The third question has to do with the matters with respect to the amount of moneys which the government is free-floating to homes for the aged and nursing homes as a consequence of the scheduled residential fee restructuring which occurred July 1, was it, of 1993.

My last conversation with Mr Quirt was that the province is subsidizing the loss of revenue from residents who are unable to pay the rate or where the facility cannot offer them less expensive accommodation. I would like to know what cost is currently coming out of this budget, and in estimate terms, what panel you may have budgeted from that you're borrowing from in order to make those commitments. I know that was not a budgeted item but that they're coming from some other budget, and we'd like to be able to determine if it's come out of somewhere within long-term care or if the minister has some $70 million float fund that she can work with on this one.

I'm sorry, just for the record, do we have the regulations now in place for Bill 101? I'd like to know if that's a yes or a no.

Mr Quirt: That's a yes.

Mr Jackson: Could we get a copy of those regulations --

Mr Quirt: Yes.

Mr Jackson: -- with respect to 101, because we have yet to see those, those of us from the committee who participated in 101.

The final question: Are there any services or procedures that are being anticipated in the new manual as a result of Bill 173 that are missing from what we are currently, or have been working with, up to this point? Any procedures, any services, any levels of service or level of procedure which have been removed? I'm talking about if certain support services are now -- because unless that's monitored, they can just sort of slip away, because it's all done in a regulatory fashion. It's not anywhere in this legislation. What is the final status of any regulations with respect to the current bill before us? Who is drafting those and when might we have an opportunity to have a look at those?

Mrs O'Neill: Mr Beer, may I ask, are the regulations complete now? I know in this particular bill they've been released in sections. The Gazette's been bringing them forward in different groupings. Are we going to get a complete set now? Is that process complete?

Mr Quirt: The regulations for Bill 101? There may well be regulation-making powers in Bill 101 that we haven't exercised yet, but yes, there have been a number of regulations that have been made and passed.

You'll note that some of the sections of Bill 101, the majority of them, were proclaimed July 1, 1993, and some remaining sections were proclaimed July 1, 1994. What we can provide the committee with is a list of the things that were proclaimed July 1, 1993, what was proclaimed in 1994 and when each regulation came into effect.

Mrs O'Neill: That would be helpful.

Mr Quirt: There may well be some regulation-making power that might be exercised in future, so I wouldn't say that they were all done at this point.

I'd be happy to provide the material Mr Jackson requested, with a couple of modifications, if I might inform the committee about it.

The only formal submission that the minister has received yet on the creation of multiservice agencies has been from the Metropolitan Toronto District Health Council. As the minister mentioned earlier, we'd be happy to provide you with that material and the minister's response to the district health council in that regard.

I can think more about ways in which we could apprise the committee of the status of particular planning in each community as we travel there. I wouldn't want to steal the thunder of the district health councils which may well be coming to apprise the committee of just that, and certainly many presenters will provide that update, but we will try our best to respond to particular questions in that regard.

We'll be happy to provide the home for the aged information specifically. We'll provide exactly how much of the resident revenue we expected to receive or predicted we'd receive that has been made up from provincial funding for the previous year.

I can respond now to say that there is no service now provided by the home care or the VON or any other agency that we anticipate deleting. We are exploring the addition of some services through both our quick response team programs and our hospital-in-the-home pilots. So we're looking at ways in which it might be increased. I'm not aware of any decrease proposed.


The Chair: If we could then just have the response to Mrs Sullivan's last question, and then I want some time for Mr Wilson, who will be the last questioner this morning.

Ms Gail Czukar: Just before I address that, I guess I regret that I haven't had an opportunity to make a presentation on the bill itself. The minister had asked that the technical briefing include a briefing on the bill, and I know that in Bill 101, during the hearings, we encountered some misconceptions on the part of both presenters and committee members about what the bill actually said and how it accomplished certain goals. So I'd just like to say that I'm, of course, at your disposal with respect to that briefing and prepared to make it.

The Chair: If I might comment on that, I noted earlier on that point, the subcommittee will be meeting and I think that will be one of the things we'll talk about. I think it's clear in the discussion this morning, and as we found with Bill 101, that at different times in the committee's hearings it was useful to just sort of stop and try, with ministry staff -- yourselves and others -- to go back over a number of points. We'll have a look at that one and try to make sure that we have a means of doing that.

Ms Czukar: Okay. With respect to what Mrs Sullivan has referred to as the statutory requirement to deal with banking or financial transactions, I'm going to have to ask her where she sees it. I don't see it. We didn't intend to put that in there. The only place I can see it is the requirement -- it's not a requirement; it's part of the definition of "homemaking services" -- that one of the services that could be made available and is available to people now is assistance with paying bills. Is that where you see it, or is there some other place in which you see a requirement that MSA staff deal with banking and financial transactions?

Mrs Sullivan: I believe that's the section it's included in, and banking is specifically delineated as one of the responsibilities of community services. Here it is in section 2, subsection (5).

Ms Czukar: Right. Okay, that's where it is, in the homemaking: "banking" and "paying bills." The requirement there is that that kind of service be made available as part of homemaking services. It's my understanding that those are the sorts of things that homemakers now do and assist people with. This is simply, as with most of these items in the definitions in the bill, delineating what the services are that are to be provided and assisted with. If there are problems with those being done now --

Mrs Sullivan: There are.

Ms Czukar: -- we'd certainly be prepared to hear about them.

Mr Jim Wilson: I'll try to be quick. Concerning the 20% rule -- 20% of approved budget -- and the requirement that approved agencies meet this rule, as delineated in section 13, I just want to ask Mr Quirt, because I'm very worried about consumers in this case.

One of the services or section of services that comes under the 20% rule is obviously professional services. That includes nursing. What if a consumer, an elderly person, for example, needs nursing on a priority basis, urgently, yet that agency has capped out already at its 20% ceiling? How does one control this?

For example, is it going to be like the bloody drug program that your ministry tries to run, where the prior approval process takes six, eight weeks; four, five, six months? I've got letters in my office that haven't even been answered in six months, let alone the drugs approved. How are you going to monitor this 20% rule -- that's the first thing -- and ensure that consumers get the services they need right away? I'm ruling out, here, Mr Quirt, that you can easily purchase from the agency next door, because it's hit its 20% rule, to take the worst-case scenario.

Secondly, I'm extremely upset, and I guess this is more of a policy question that probably hits the political realm, that we see the 20% enshrined in legislation. It makes it very difficult -- this government is not going to survive many more months -- for any future cabinet to introduce some flexibility in this section. We would have to go back to Parliament, whereas in Bill 101 we were able to have cabinet deal with the 10% rule because it was simply a policy statement by the government itself. I want to know what the background was in coming up with a legislated 20% rule, which I think will hurt consumers in this province.

Mr Quirt: If I might respond to your first question, in the event that a multiservice agency had a so-called run on nursing services, if a number of clients appeared who hadn't been planned for, who required extra nursing service, it was our intention to allow that 20% purchase to deal with those types of fluctuations in demand. In other words, from the 20%, the MSA would say: "Well, gee, we hire and employ 20 nurses. I guess we'll contract for three or four additional clients, because it looks as if that's kind of a blip, that we won't have an ongoing need to serve those extra clients."

My response would be that if that became a trend, that this amount of nursing service became the normal volume for the MSA, they would simply hire another nurse or offer the job -- you know, advertise it or offer the job to one of their other agency partners' staff in the community.

How would we monitor it? Each year we hope to enter into a service agreement with each multiservice agency that would document what the province's commitment was fundingwise in terms of the eligibility of that particular community for funding, and the multiservice agency would document the level of service outcome that the people of Ontario could expect in return for that money. In that service agreement, there would be a negotiation process that would agree on how many nurses should be employed in the first place, depending on how much demand there was the previous year, and hopefully with some latitude in that to allow for additional purchases in perhaps peak periods, Christmastime or whenever the community service system is called upon at a higher level than normal, to accommodate those shifts.

But it would take some planning ahead of time and you've got a point: If somebody is at their 20% rule limit and somebody needs to be served, then the agency is either going to have to ask us to go over for that particular month and make it up later or they would ask us for quick approval to hire another nurse or would have that approval already in the service agreement.

Mr Jim Wilson: There's nothing quick about approvals in the Ministry of Health, is my point.

Mr Quirt: I can't speak to your experience on the drug program, and I'd be happy --

Mr Jim Wilson: Or anything else.

Mr Quirt: -- to refer any particular problem you have there to the right official, but I can say that most of our community service agencies that we deal with do find a reasonably quick answer to many of their policy or operational questions, given the fact that our division is equipped with decision-makers in 14 communities across Ontario, as opposed to every question coming to Queen's Park for an answer. I suspect that when you hear from --

Mr Jim Wilson: But this is a statutory ceiling.

Mrs Sullivan: Statutory: They don't have any power.

Mr Jim Wilson: Your person in the field, unless it can meet these exemptions, which are also statutory, doesn't have that flexibility. The MSA police in the field can't decide whether to issue the ticket on the side of the road or ignore the violation; this is a statutory requirement, unless you're suggesting you're going to be in breach of Parliament. Then we can get into all kinds of niceties about that.

Mr Quirt: I'm not suggesting that our staff would propose to multiservice agencies that they don't follow the law. I am suggesting that they'd be involved in discussions throughout the year in a service planning process that would agree on a contract from year to year, and that my staff would be expected to say: "Hey, wait a minute, what happens? You should employ another nurse, because if you hit a high period six months from now, you might be too close to your 20% limit. Why not hire a couple of nurses and bring it down to 3% that you purchase so you've got some latitude?"

It would be that kind of discussion and negotiation that I'd expect the public would want their public officials to engage in to ensure that the bill could be followed and that service, as a result of the bill, would not be jeopardized. I can't argue with the theoretical situation you have described. If some agency is about to break the law on the service delivery side of it, then obviously we'd be working with the agency to figure out why they got themselves in that position.

The Chair: I'm going to have to cut us off at this point.

Mr Jim Wilson: Could I have an answer to the second question? I'm sorry for prolonging this.

The Chair: I would ask the parliamentary assistant to respond to that.

Mr Jim Wilson: Yes, it's probably better in his realm. We thought it would be interesting.

The Chair: It's just that it's after 12. We do have a set of weeks ahead of us and we will be able to return to some of these questions. I just feel that after this we need to move on.

Mr Jim Wilson: Could I just thank Mr Quirt for answering the question, which was no doubt difficult.

The Chair: You may, and just before Mr Wessenger answers the second question, can I note again that I need to see the subcommittee briefly at the conclusion of this meeting.

Mr Wessenger: I'll be very brief, since we have gone over the time. I'll just reiterate what the minister said when she indicated that it was a policy decision to ensure that we had a service delivery model for the MSA where you had the assessment and the delivery of service primarily with the MSA, and pulling the 20% as a figure that was felt would achieve that end.

Mr Jim Wilson: Given that it was 10% and now it's 20%, it seems to be a fairly arbitrary figure, and rather than putting it in a regulatory-making section, you're putting the figure 20% in this legislation. On what basis do you come up with that figure, Mr Wessenger?

Mr Wessenger: I can't give you an answer of how the particular 20% was arrived at, but I could indicate that certainly it's the intention to have a legislative model that can't be converted to a brokerage model. I think that's basically the intent behind the legislation, to ensure that it preserves the model of the integration of the service delivery and the assessment and not that it could be converted to a brokerage model type of service delivery without change in the legislation.

The Chair: With that, then, we will complete our morning's hearings. I know that we will be --

Mrs Sullivan: On a point of order, Mr Chair: Could I put another question on for the ministry officials? I think that as a result of this last question and other questions that have come up, it's very clear that we have deep concerns about funding, and the response to the last question has even added to my unease with respect to the funding.

First of all, I think it would benefit the entire committee if we learned what the ministry contemplates in terms of how MSA budgets will be determined. I am given enormous pause by the suggestion that the budgets will be negotiated with the personnel in the 14 regional offices. It is very important that we know what needs-based planning is going to go into the budget preparation, if in fact this becomes an across-the-table negotiation, if the MSA has determined a level of need for services in a community, is attempting to meet the statutory requirements as well and if one of the 14 regional people or somebody in downtown Toronto MOH offices says, "Yes, you have to provide this, this and this; this is required under the law," but you don't have the money to do it and the budget request that you've provided doesn't cover those needs. I think we need a full briefing, and frankly I think consumers do too, because consumers are being led down the garden path on this.

The Chair: We'll add that question. As I said before, I think we will need, throughout these hearings, to just create some time where we can come back to some of these questions.

With that, then, the morning's proceedings come to an end. We'll begin again at 2 o'clock sharp here in this room. Thank you. We stand adjourned.

The committee recessed from 1214 to 1408.


The Chair: Good afternoon, ladies and gentlemen. The standing committee on social development is back in session and we are reviewing Bill 173, An Act respecting Long-Term Care.

We will begin our afternoon submissions by hearing from the Registered Nurses' Association of Ontario, if the representatives from the RNAO would please come forward. Members should have a copy of their submission. We welcome you all to the committee, if you would be good enough just to introduce yourselves for Hansard, for the committee members, for the great television audience that is out there. We look forward to your submission, and at the end of it I'm sure there'll be some questions.

Ms Kathleen MacMillan: Good afternoon. I'm Kathleen MacMillan. I'm the president of the registered nurses' association.

Ms Johanne Mousseau: I'm Johanne Mousseau. I am a member of the Registered Nurses' Association of Ontario.

Ms Margaret Watson: I'm Margaret Watson. I'm the executive director of the registered nurses' association.

Ms Jacqueline Choinière: I'm Jacqueline Choinière. I'm the nursing practice and policy coordinator.

The Chair: Welcome.

Ms MacMillan: The Registered Nurses' Association of Ontario is pleased to have the opportunity to speak to the standing committee about this most important legislation. The registered nurses' association is a professional association representing approximately 13,000 registered nurses who work in a variety of community and institutional settings. Many of these are in long-term care.

The framework for our response is the government's long-term care objectives: objectives which we strongly endorse and that we, as registered nurses, are committed to realizing.

Objective 1: the issue of one-stop access. The move to simplify access by Ontario citizens to long-term care services is an important objective. Current services are often fragmented, confusing for clients and their families, and too often result in unnecessary delays in attaining needed care. The principle of one-stop access through MSAs can be a step towards ameliorating this confusion.

As registered nurses, we realize that the client's initial contact, by phone or in person, is but one half of the access equation. The events that follow first contact are equally important in ensuring appropriate access. Appropriate assessment and screening must be available to the client in need. This initial assessment becomes even more critical in a streamlined system; it may be a client's only contact for weeks. Although assessment tools are valuable, there are many situations in which the tool alone is inadequate without a skilled assessor who has the knowledge base to critically appraise each client situation.

I'm going to give you an example here. The daughter of an elderly woman who is able only to visit her 84-year-old mother irregularly because she lives out of town might notice that her mother isn't keeping up with her personal hygiene, housework or food shopping. In this situation she would be placing a call to the local MSA for assistance, and a standard assessment might be carried out and a decision made to send in a homemaker two days each week for a total of six hours. The homemaker can do the shopping, the housework and assist the lady with her bath.

On her next visit, the daughter would probably notice that things look better. Mother doesn't have as much energy as she used to have and she sleeps more and her appetite is poor, but, according to the usual myths, the daughter figures it's because she's 84. The homemaker can go ahead and notify the pharmacy when the medication supply of digoxin and Lasix runs low, and the lady is not due for another medical assessment for two months.

What the daughter doesn't know is that her mother has been self-medicating for constipation by taking Ex-Lax on a daily basis. Her potassium is seriously depleted, she is digitalis toxic, she has an irregular heart rate and is a high risk for a cardiac arrest. Her underlying problem is poor bowel management, which is easily corrected with diet and certain over-the-counter medications. What will probably happen is a major cardiac event and an emergency hospital admission, followed by fairly intensive medical care. She'll probably likely experience further deterioration and also become a placement problem.

What should happen is an initial nursing assessment, an assessment that includes a full functional health inquiry and risk assessment. The nurse can then alert the homemaker regarding warning signs and symptoms, and the homemaker also has a nurse contact within the MSA whom she can consult if the client's status changes. In addition, there could be regular client review meetings within the MSA between the relevant care providers and professionals.

We therefore recommend that registered nurses, who are educationally prepared to play multiple roles in the system, be utilized in the long-term care setting as assessors, care providers, coordinators, educators and resource planners.

The changes in the long-term care system outlined in this legislation constitute a radical shift in the coordination and delivery of long-term care services. Described in this legislation is a transformation from a traditional, hierarchical, complicated system to a more democratic, accessible and simplified system. Although in principle these are welcome changes, there is a need to provide adequate education about these changes to clients and to potential clients. The public must be adequately informed about which services are available, where these services are available, who performs the various services and how these changes have been incorporated.

In addition, health care providers will also require comprehensive and ongoing education about these system changes so that they can let clients know about their existence.

We therefore recommend the development of educational plans for public and long-term care providers in order to ease the system transition and avoid interruption in needed care.

Objective 2: improved community-based service system. In order to achieve and maintain improved community services within an increasingly complex and diverse system, we believe it is essential that services be coordinated by health professionals with expertise in health promotion, illness prevention, managing the full range of care options and evaluation. Long-term care is built on a strong foundation of nursing research and practice, from which nurses and other providers draw their knowledge. We are concerned about the deprofessionalization of services: services delivered by non-regulated workers, such as personal support workers and homemakers, without the leadership of nurses in the community. The services that these support workers provide can be safely delivered when the client is well informed about his or her health condition, can direct the care and only needs the provider to meet the directed needs.

The frail or the cognitively impaired elderly person, for example, is a much different consumer of services. Their physical health is more fragile, less predictable and more complex. They may be unable to advocate on their own behalf and may well require professional nursing services, if only as a resource to other direct care providers.

Even care as apparently straightforward as personal hygiene is an integral component of comprehensive nursing care as a vehicle to assessment. If we are to truly realize holistic care, then we must not subdivide the care of individuals into separate, isolated tasks. A devaluation of both client and care provider is the result.

We therefore recommend that the same principles underlying the integration of health and social services be applied to ensure the healthy coordination and integration of providers in long-term care settings.

The skill and expertise of the registered nurse promotes earlier identification of client problems, complications or treatment side-effects. This in turn is likely to result in more timely treatment alterations and a better informed, more satisfied and healthier client. In addition, the health care system may be spared the cost of emergent or urgent treatment intervention because earlier symptoms or needs were not identified. The less costly provider may not in certain circumstances be less expensive in either human or financial terms.

We therefore recommend the inclusion of a well-defined system for assessing clients which health administrators and managers will utilize when identifying the right provider for the right service.

Objective 3: a consumer-focused system. As registered nurses, we support both the letter and the spirit of the bill of rights for consumers receiving community services. However, we believe that the rights do not fully address the need for clients to be fully informed about their health condition and the implications of specific care on that condition. It has been our experience that when care is reduced to a series of tasks, essential information is not exchanged and the client fails to receive comprehensive care.

I'll give you another example from clinical practice. An 18-year-old male with Duchenne's muscular dystrophy is living at home with his mother and a much younger sibling and is now ventilator-dependent at night because of sleep apnea. His mother is responsible for his care at night, which includes getting up with him at least once and also generally listening for the ventilator or other problems. She also works full-time outside of the home during the day and has frequently become exhausted and had to arrange for respite care for her son.

His illness is chronic and long-term but will eventually be fatal due to cardiac failure. Until turning 18, he had access to a full range of professional services, including a visiting registered nurse, a school RN and a respiratory therapist. Suddenly, at 18, he is considered able to direct his care with the aid of a personal support worker, a change which he views as enhancing his autonomy.

This situation demands more, however, than the services of a personal support worker to provide physical and emotional care and assistance with the activities of daily living. The complex family situation, the needs of the care giver mother and the sibling, plus the effects on their health, all need to be considered. This young man is medically very fragile and he needs regular assessments and early problem recognition to prevent complications.

Who decides on the most appropriate provider? The personal support worker needs a clear reporting mechanism and adequate instruction and supervision. The situation is not just a single person who cannot meet his own daily needs, but a constellation of complex issues needing professional health services. Fragmentation of care will have disastrous results for the client, the family and the system.

We therefore recommend that the bill of rights be strengthened so that the right of clients to full and comprehensive explanations of their conditions and the implications of specific treatments is underlined.

The impetus for long-term care reform has been largely driven by the well elderly and the well disabled in the community. As registered nurses, we have long advocated for the right of clients to fully participate in decisions about their care. Those needing long-term care services have not been well served under the present delivery models, which denied them control over the nature and the selection and delivery of support services.

However, missing from the planned reforms is attention to the largely silent voice of the sick in the community. The documents on long-term care do not reflect the needs of vulnerable populations such as the frail elderly, the cognitively impaired or their families. The words "nurse" or "doctor" rarely appear in any of the long-term care reports, reflecting the focus on those who are able to direct and access services relatively independently.


While persons have relatively unfettered access to physician services, access to nurses in our health system is highly problematic unless the client can afford to pay direct on a fee-for-service basis. Access to insured nursing services is dependent on admission to a hospital, a nursing home or a long-term care facility; referral on discharge from such a facility; or a medical referral in the community. This is an unnecessary, complex and expensive method of accessing nursing services. It requires the potential client to enter the system by the most expensive route and often the least appropriate route before finally seeing the correct provider for the problem.

Again I would like to invite you to think about an actual example. An otherwise healthy 90-year-old woman living in the community with her daughter experiences a sudden onset of acute illness with nausea and vomiting. Her daughter calls the family physician, who doesn't make house calls and refers her to a doctors' house call agency where the woman is able to get a doctor to visit.

He diagnoses acute constipation and prescribes a suppository, which the daughter is asked to purchase and administer. The cost is $50 to OHIP and no cost to the client, but there's an incomplete outcome. Because of lack of experience, the daughter doesn't know how to give a suppository, but fortunately has access to a neighbour who is a nurse. The nurse is willing to provide one hour of nursing services which include a complete assessment, administration of the suppository, comfort and hygiene measures and teaching to prevent another episode, plus an assessment of the outcome. The cost is $30 in time to the nurse, no cost to the client.

It is also relevant to our presentation that nurses have been subsidizing the health care system by providing free services in their communities, where needed, for decades. If the nurse had not been available, where would the daughter have turned for help? Even if the daughter had known to call a visiting nurses' agency directly, she would have had to pay for the service out of pocket.

Sometimes people need a nurse, not a doctor, but they cannot access one. If this daughter had subsequently taken her mother to a hospital emergency department, she would have seen another doctor, undergone a full range of medical tests, laboratory tests, possibly abdominal X-rays, been diagnosed finally with constipation and ultimately she would have been referred to a nurse in the emergency department for treatment. This, I would estimate, might have cost $600 to the health care system.

We therefore recommend that long-term clients have direct access to professional nursing services when this expertise is required.

Objective 4: improved and consistent accountability. We strongly support the need to ensure that the composition of the MSA board reflects the community that it serves. However, in order to enhance accountability, we believe that this issue deserves stronger assurances within the legislation. Culture, gender, age, language and differences in ability fundamentally influence every aspect of care assessment delivery and evaluation. We would also recommend the addition of economic status to this list of critical variables.

Health and social service providers possess expertise that is critical to decision-making at the MSA level. Registered nurses have demonstrated the strength in community programs and are knowledgeable and effective in creating linkages between individuals and also between the individual and the required service. Nurses have a long history of being especially effective in development and implementation of programs designed to meet the needs of the economically disadvantaged, those most likely to experience both acute and chronic ill health.

The legislation is unclear about how the MSA board will actually be selected. Furthermore, what role will the community at large play in selecting the service delivery models? How can we assure that community members are effectively involved in this process? Will town meetings or other types of community forums be held?

We therefore recommend the inclusion of stronger assurances that the community at large will be actively involved in the selection of service delivery models and the MSA board members and that the board itself will include a truly representative sample of community members and the critical element of practitioner expertise.

We recommend that full and inclusive public consultations be conducted to decide on the full range of MSA services and service delivery models. We also encourage the ministry to ensure that the participation of those not traditionally included in consultations is actively sought. There is always a possibility, when services are decentralized, that inequities in service availability could result. We therefore urge the ministry to mandate a true quality assurance of services by upholding a common and province-wide standard of excellence.

We therefore recommend the assurance of high-quality services for Ontario citizens through the existence of effective standards, and we also recommend that improved and consistent accountability be enhanced through effective community consultation.

Finally, objective 5: local planning of services, We support the strengthening of the mandate of district health councils within this legislation. We are very supportive of this affirmation of local participation and planning. However, we are concerned that the DHCs, like the MSA boards, are truly reflective of the community they serve. Accordingly, we would recommend the inclusion of stronger assurances that DHCs will actually reflect their communities. We would also recommend additional assurances that DHCs will particularly seek out those in the community who have not traditionally participated.

Registered nurses have traditionally played a coordinating role among other health care providers within all health care settings, and this coordinating position finds its rationale in the fact that nurses are the only health care professionals who span the entire care continuum. As such, we consider nursing expertise to be critical in the decision-making activities around community services.

We would also recommend that the ministry ensure that DHCs have access to appropriate resources, both financial and human, in order to fulfil this very critical mandate. Valid health care planning requires ongoing information gathering and dissemination, activities requiring adequate resources.

Therefore, we recommend the inclusion of assurances that DHCs will accurately reflect their communities, with particular emphasis on those community members less likely to participate, and drawing on the special expertise of nurses from the community. We also recommend that the minister provide DHCs with adequate resources to effectively fulfil their mandate.

Some summary comments: People tend to think that the line between health and illness is clear and easily recognized. In actuality, the distinction is very blurred, more like a continuum. When persons have concurrent chronic and acute conditions, it is often very difficult to distinguish what is happening. The elderly in particular do not always exhibit the commonly recognized signs and symptoms of illness such as pain or elevated temperature. It requires professional knowledge, judgement and skill to determine the underlying problem and to decide what needs to be done.

While the needs of the well disabled and the well elderly have not been adequately met under our current system, neither have the needs of the ill in the community. We must be careful not to reform the system in a piecemeal fashion so that reforms for one type of consumer will actually exacerbate existing problems for another.

We must also evaluate the impact of the perceived least expensive approach to service delivery. The least costly provider may not always be the most cost-effective.

We urge the committee to carefully consider the issues and recommendations identified in this submission by registered nurses in the province in order to ensure that the worthy objectives of long-term care reform are fully realized.

The Chair: Thank you very much for your submission. We have some time for questions, and I'll try to work in one from each caucus. We'll go with Mr Wilson, Mr Malkowski and Ms Sullivan.

Mr Jim Wilson: Thank you very much for appearing before the committee today and being the first at bat, as it were. It should prove to be very interesting committee hearings if the briefing this morning was any indication.

If you're limiting me to one question, I'll forget about all of your recommendations for a second other than the assessment. I know in the past, in this room even, we've talked about the capabilities and talents of nurses to carry out a full range of assessment. It came up in particular during the Regulated Health Professions Act, and again under Bill 101.

The government has set up the MSA program design assessment approach working group. Are you familiar with that group? Because I note that on the inclusion of participants in the group the Ontario Nurses' Association is there, VON is there, but I don't see a listing for the Registered Nurses' Association of Ontario.

I'm just wondering if perhaps you should be on the group, or is that sufficient representation from nurses already? Secondly, is not that group looking at exactly that: who and where the assessment should be done and to what extent? Let us know, because I'm not on the group.


Ms Mousseau: The group is addressing that issue. I think there's a greater concentration on the assessment tool at the moment. The point we're trying to make is that certainly the assessment tool is a very important part of the equation, but it also requires the judgement of an individual to apply that tool. I don't think just anyone can screen someone by applying a tool when an individual calls, say, the MSA. Yes, those details do need to be worked out, and I would imagine that would be one avenue. But right now it seems that they're concentrating on the assessment form, the actual tool that will be used to assess.

Mr Jim Wilson: Do nurses have sufficient input in that process that's developing the tool?

Ms Mousseau: There is some nursing representation, yes.

Mr Jim Wilson: This is your chance to let us know if you need more nursing representation.

Ms MacMillan: I think we'd always like to see more nursing representation. We won't turn down any nursing representation. We certainly are in continuous discussion with our colleagues at the Ontario Nurses' Association, so we're quite well informed usually about what it's doing. We have opportunities to have input through our connections with them, but it certainly wouldn't hurt to have some of the expertise of members of the registered nurses' association sitting on that committee.

Mr Jim Wilson: Give me a better feel for specifically what type of model you would look for. Obviously, assessment is critical to accessing the system and to make sure you're appropriately placed in the system. It's the first step after the phone call, I would think. What would be ideal?

Ms MacMillan: We personally think that nurses are the ideal people to do those assessments because of the comprehensiveness of our practice and because of our experience and knowledge and skill in this whole area of assessing and referring people to appropriate providers. It has been part of our practice for a long period of time.

Mr Jim Wilson: In terms of structure, though, my understanding of the legislation, so far anyway, is that the assessors appear to be working directly for the MSA. I don't know whether they're coming out of existing agencies or what. You have registered nurses now working at Red Cross and VON and various agencies. It's a chance to tell us whether you think we should keep current structure or pull those people out of those agencies and have them work directly for the MSA. What are your thoughts on that?

Ms MacMillan: I work for a visiting nurses' association in the city of Toronto, and one of my difficulties as a practitioner is that the current model of insured health services, in any way, is really organized around a medical model of what is required in the way of services. Frequently a client requires nursing care but does not require the list of tasks that are identified as insured services.

When you ask, what would we like in the way of structure, I guess we'd like some kind of reassessment of how nursing services are paid for, and we would also like to have a way where the nurse can work for the client and not necessarily work for the agency. That would probably be the way we would like to see it.

I'm a little worried as a practitioner about introducing another bureaucratic level. I'm very concerned. You see, currently what happens when someone's being referred to nursing services is that they have to be referred either by an agency or a physician, so there's that. If it's in a hospital setting, there's a home care coordinator who goes over the assessment. Then it goes out to the nursing agency and there's another assessment, and often clients have four or five assessments before they're actually the recipients of nursing care.

What I am concerned about personally in my practice is that we're going to have another layer here and that instead of having four or five assessments, we're going to have six. Then when you're in the practice setting and you identify a need for a client, who am I going to have to call? What hoops am I going to have to jump through in order to get that need met?

When you're talking about structure, I would say that's probably the thing nurses are most concerned about. Is this another bureaucratic layer or is this really going to be simplifying people's access to nursing services? Right now, I'm telling you, people have to jump through hoops to get a nurse.

The Chair: Thank you. I'm afraid we're going to have to move on.

Mr Malkowski: Thank you for your presentation. Your information was very helpful, and it's valuable to have the health care professional's role involved in the long-term care.

One point I'd like to talk about is the fragmentation of care you mentioned, that would have disastrous results. What fragmentation do you see now and do you think the MSAs will resolve this?

Ms Mousseau: First of all, fragmentation occurs because you have different ways of accessing, at the moment, the health care system, whereas with one-stop access you would have one phone call to make. However, with triaging, once you've actually made that phone call, if whoever is doing the triaging at the other end is not equipped either with the appropriate tools or with the clinical decision-making abilities to determine what resources or services are required for that person, you will begin fragmenting care at that point. It's very important that the person receiving the call from the client in fact has all the tools needed in order to make the best decision for that client. That's the first point where there might be fragmentation of care.

I'm wondering if you're referring to the actual scenario we used in the presentation.

Mr Malkowski: I can give you an example. MSA is going to have a basket of services, and perhaps we could talk about the things that you may see missing. As a front-line worker, what administrative overlap could you see, for example, when you're talking about the multiassessments with home care, with VON and with other providers? Do you think the MSAs will be helpful and do you see the RNAs having any role here in terms of exploring what gaps you see out there?

Ms MacMillan: The concept of one-stop shopping does have the potential to reduce some of this fragmentation, depending on how good the assessment is up front, and that's reiterating who's doing the assessment and what kind of tool they're using to do that assessment.

In the example we put in our presentation, the person who doesn't have a comprehensive picture of that home situation might think it's perfectly okay to put somebody in who can help this young man meet his activities of daily living and look after his ventilator, if you're really looking at what tasks need to be done here. But the nurse who might assess that would look at the whole picture, of the family, of the mother's needs and of the sibling who's trying to deal with having a terminally ill brother, and realize that this is a very complicated situation that really does require professional services.

While it's true that this young man, when he turns 18, should have autonomy, and we're not denying that, if he also thinks that all he really needs is a pair of hands to do some tasks for him, he's not considering all the other factors in this situation. It takes a professional viewpoint to be able to do that.

What you can wind up with is that you've got somebody who does tasks, and then you'd have to call in somebody else to do another task and somebody else to do another task and there is nobody with the big picture of what's going on. One of the hallmarks of nursing practice is this holistic big picture, it's the whole family, it's the whole lifespan, it's the whole health-illness continuum, and that's really the basis of our practice. Does that answer your question?

Mr Malkowski: Yes, it does. Thank you.

The Chair: We're going to have to move on. Ms Sullivan, final question.


Mrs Sullivan: This morning in her remarks, the Minister of Health said that she felt that treatment was about procedures and long-term care reform was about relationships. I think most of us on the committee were a little taken aback with that view, in that it seems to us that long-term care is more than simply relationships and in fact is delivering care in an appropriate way to a person who is not well and who does need services that are being provided at the taxpayers' cost or payment, as a result of a need.

Your emphasis on how one gets into the system, ie, the assessment process, it seems to me is quite key. The minister also indicated that she felt that a social worker, by example, could in fact do the assessments just as a person who's involved in providing professional care could.

I wonder if you could expand more on the kinds of tools that should be used, and the appropriateness of treatment needs having a certain priority in determining what care should be provided, whether it's community supports or whether it's health care. I think those are really key issues.

My own view is that long-term care isn't relationships. This isn't a social ball game we're in.

Ms MacMillan: I would be pleased to respond. I think part of the minister's framework for responding there goes back to what we were initially saying, that the main drivers of long-term care reform have been the well elderly and the well disabled. There has been a wellness focus on this, and they have been very effective in making their needs known to the people who have been looking at the long-term reform bill. What we're saying is that there isn't this Rubicon between people who are well and people who are ill; we also have a whole pool of chronically ill people out there.

Probably what we're doing is trying to clarify that it's not as simple as it might seem to start with. This is why, for example, when you're talking about assessments, there would be a need for a nurse to do that assessment, because nurses are knowledgeable not only about the support and rehabilitation concept of delivery of health care services, which social workers would certainly be involved with, but we're also in that whole issue of health promotion, illness prevention, care and cure, which we're also integral providers of.

There certainly would be treatments involved with some of the clients who would be accessing these services at the MSAs. Again, if we were just to assess the treatment people need, we're going to fragment services. You can teach anybody to do a treatment: In the situation I described, that mother has been taught to look after a ventilator-dependent son, and with nursing support and teaching, she has learned to be quite adept at doing that, but she does not have the knowledge a nurse would have in terms of assessing complications and problems, or even the knowledge a respiratory therapist would have about the actual machinery.

It's just not as easy or as clear as it might seem when you look at it at first blush.

Mrs Sullivan: I suppose some might understand that the diagnosis is as important as the actual delivery.

Ms MacMillan: Yes. The assessment and diagnosis of what services are required here is probably at least equally important to, and maybe even more important than, the delivery of the services.

Mrs Sullivan: I would like to turn to another area we didn't have responses to this morning, although it was put on the table. There have been promises implicity made that those people who are displaced with hospital restructuring would move into the community-based sector to provide care needs under the new employment structure of the multiservice agency. Have you entered into any discussions with the long-term care division and are you anticipating that any of your members who've been displaced by hospital restructuring will be guaranteed jobs with MSAs? Because you will have other members who are already working for community-based agencies, have you discussed with them the kind of conundrum that will be faced with respect to their own employment?

Ms MacMillan: We have not specifically discussed this with the agencies, but we're certainly discussing this within the profession. In fact, with the reduction in the number of hospital beds there has been no accrued benefit to the communities. Moneys are not being transferred to community services and indeed the jobs that nurses have lost are not being replaced.

The nurses who work in the community setting have a very different focus of practice from that of the nurse who works in acute care. In fact, nurses who work in the community are usually degree-prepared and have had additional preparation in community health and developing programs and that kind of thing, and nurses who work in hospitals are often prepared at the community college level to work with sick people, so you can't easily move one from one area to another.

And I agree with you. We've already got people working in the community. I'm not sure there will be vacancies immediately there. But what we are saying is that we do have currently in this province, we think, about 5,000 unemployed registered nurses. That's an awful lot of health care expertise that's not being utilized and that the public has very little access to.

It seems to me, as we're talking about who should be providers of care, that it's rather foolish to have spent a lot of money educating professional nurses and now we're talking about educating a whole bunch of non-professional workers to fill in. It does look like it will be less expensive, but we're saying it may actually be more costly in the long run not to have the access by the consumer to professional nursing services in some way.

The Chair: I'm afraid I'm going to have to close it off. I regret, but we have a very full afternoon and we've run beyond our time. On behalf of the committee I thank all of you for coming here this afternoon and for your submission.


The Chair: I call upon the representatives of the Ontario Medical Association. I also welcome you to the committee. If you would be good enough to introduce yourselves, please go ahead with your submission. We have a copy in front of us.

Dr Michael Gordon: Members of the committee, I would like to thank you for the opportunity to speak to you on issues of concern regarding Bill 173. I am Dr Michael Gordon, a geriatrician from Toronto and the chair of the Ontario Medical Association advisory group on long-term care. I would like to introduce you to Dr Barbara Clive, a geriatrician from Peel and a member of the OMA advisory group on long-term care, and Carol Jacobson, the OMA health policy staff support for the advisory group.

The OMA represents more than 20,000 physicians and has as its mission to serve the medical profession and the people of Ontario in the pursuit of good health and excellence in health care. Examining proposed legislation such as this is one of the ways we fulfil our mission.

You have before you the OMA response to Bill 173, An Act respecting Long-Term Care. The document includes an executive summary, which you can quickly review for the OMA's issues of concern. Today we will be highlighting some key issues of concern. Also, for your information we have given you a copy of the OMA response to the government's four Partnerships documents.

The Ontario Medical Association supports the government's objectives of enhancing health care and social services and supports the concept of community-based long-term care and support services for elderly persons, adults with physical disabilities, and persons who require services at home. The OMA is concerned that the legislative framework created by Bill 173 will not be able to effectively meet its stated objectives.

Throughout the planning and development of the long-term care reform initiative, the physician's role within the very important continuum of care has not been addressed except to state what the physician will not be doing. With the changing system and the evolving roles of the individuals within the system, it is important that the consumer knows who is doing what and who is responsible for what. If not, this may have unintended negative consequences on the health status and long-standing relationships which have been developed between the patient, the family and the physician. The physician does have a significant role to play, and the medical community would like very much to be part of the very important process and work with the many providers so that the needs of the patients are fully and adequately met.

The role of the physician, including primary care physicians and the full spectrum of specialists, is multifaceted in ensuring the provision of seamless care to the recipients of long-term care services. I'm going to put a little aside in here: I think we should change "seamless" to "well-tailored." From a family of tailors and seamstresses, I do not know what a seamless garment is, but I certainly know what a well-tailored garment is.


Physicians also act as a clinical resource to service providers. Many individuals who will require and be provided with community-based long-term care will have complex medical needs which are significantly greater than is being acknowledged in the long-term care planning process. It's been noted already by some of the speakers that although many of the individuals may be relatively healthy elderly, we are going to be looking at an increasingly ill group of individuals with many complex medical problems.

An individual's health status changes constantly and in some instances can change quite rapidly. Medical input is necessary to establish an individual's true health care needs. For example, the symptoms of those receiving palliative care who may be on different medications including narcotics must be carefully monitored so that changes in status which require attention can be appropriately identified. The same degree of need may occur in an elder with multiple medical problems, including cognitive impairment. We feel it is important that medical input regarding the patient's physical, psychosocial and cognitive status be an essential component of the MSA's assessment. This will certainly be important so that individuals do not receive services for potentially treatable or even reversible conditions which, if properly identified and dealt with, might eliminate the need for the service or modify it.

The OMA recommends that physicians involved in the various health care sectors be integrated into the decision-making process for the care of the patient moving through the acute and long-term care systems in order to facilitate not only continuity of care but also continuity of communication and support for the patient and their family. It is especially important that local physicians be involved with the DHCs in the local planning of the needs of its communities to ensure the appropriate integration of the role of the physician into the long-term care system.

The legislation addresses in detail the many aspects related to the multiservice agencies which the government considers a fundamental building block of a reformed long-term care system. The dramatic shift of how we provide service and care as a result of the establishment of MSAs will impact the different long-term care health and social service sectors in the acute care system, long-term care facilities, chronic care hospitals, and special programs such as regional geriatric programs. All will have to interact with the MSA in their area.

The shortcomings of the current system, it is said, are that long-term care and support services are duplicated, fragmented or not available at all. The OMA therefore strongly recommends that where there are multiple MSAs within a catchment area, these MSAs must be closely linked in order to prevent not only duplication of services but to avoid gaps and fragmentation in service delivery.

We understand, for example, that in Metro Toronto the DHC is planning for 15 MSAs with 15 separate boards and an association of Metro MSAs for common administrative, evaluation and communication functions. It is hoped that this does not become a bureaucratic and an administrative nightmare and that clients do not fall between cracks in this new system. For this reason, linkages must include a common database, the ability for individuals to move from one MSA to another within geographic regions, and closer interaction and working relationships of the MSA boards.

In fact, there must be coordination, integration and linkages between all the health and social service sectors, including those sectors involved in the government's initiatives of mental health reform, the chronic care role study, consent, advocacy, substitute decision-making and the changes occurring in the acute care system and restructuring initiatives.

The OMA carefully monitors the health care process in Ontario. We participate in policymaking and consultation wherever and whenever it is appropriate and responsible to do so. From our vantage point, doctors in Ontario are increasingly concerned at what appears to be a fragmented and uncoordinated approach on the part of government in dealing with health care and the reform process. We have reached the point where we have grave concerns about the number and the magnitude of the changes being made to the system without a concomitant understanding of both the short-term and long-term impact on the public and our patients.

We subscribe to health care reform that does what it is supposed to do: enhance the quality of care, improve access and increase efficiencies. Implementing that kind of reform without a fundamental grasp of how all the pieces, both old and new, must fit together is doomed to cause disruption and untoward consequences on those who look to us for care and support.

Dr Clive will continue with the presentation.

Dr Barbara Clive: I would like to address an important area of concern to the OMA: that of consumer consent. This is an issue which, if not dealt with appropriately, may marginalize certain patients.

There are patients who, due to their condition, will respond by saying no when initially asked the direct question, "Do you wish to be assessed for eligibility for services under the MSA?" For example, an elderly widow living alone might readily accept needed services offered by a friendly nurse, but now may not even have that nursing visit until assessed for eligibility.

It is important and necessary to develop a trusting relationship with these individuals. This may take time. Once this relationship has been established, the individual may agree to an assessment or to the receipt of services, even though a direct question using unfamiliar phrases would continue to elicit a negative reply. Also, experience shows that these people will often be reluctant to sign consent forms.

We strongly recommend that the MSA intake and screening system be established with the necessary flexibility to pursue consent in a user-friendly and creative manner with those individuals who, when initially contacted, may refuse assessment or services. It may be that a telephone call will not suffice, and several visits to the individual's home may be necessary.

Culture and language may also be issues that need to be taken into consideration in this matter. The manner in which people are approached varies within different ethnocultural groups. To leave these people out of the system due to their inability to consent according to the law would create definite gaps in the system and would be a disservice to these individuals and their families.

Two of the purposes of this legislation are (1) to ensure a wide range of community services are available to people in their own homes or other community settings, and (2) to recognize the importance of a person's needs and preferences in all aspects of the management and delivery of community services.

We are very concerned that the government has unrealistically raised the expectations of individuals who will be accessing community-based long-term care services. People have been told they can expect a wide range of services that will meet their needs.

We strongly recommend that the issue of needs versus wants be carefully explored when determining the necessity of the community services. This must be adequately reflected in the criteria for the determination of eligibility, assessment, and the service plan which is developed with each client.

For example, a patient, two years following a stroke, may want physiotherapy in the hope that it will return his arm strength to normal. Medically, it is clear that further therapy will not change his arm function. In the past, a physician's referral would have assisted in ensuring that services were provided where most needed. This is no longer required.

This issue may have a significant impact in two areas.

First, it will be critical that sufficient funds are allocated to each community to allow for the delivery of the legislated mandatory services and for those authorized optional services which the DHC has determined are necessary to meet local needs.

Second, the government with this legislation and in its many policy documents is telling the people of Ontario that they will have all sorts of choices and that their preferences will be met. On the other hand, government is telling community service providers that health care dollars are limited, that there is a finite pool of money available.

As Dr Gordon has stated, there will be many individuals with complex medical conditions who will require myriad health and social services to be able to remain in the community. Can the needs of these individuals be met while meeting the expectations of all clients served through this legislation? If so, that is commendable. If not, let's work it out before we build a system that won't provide, if for nothing else than to avoid an unwieldy volume of appeals.


In conclusion, I will reiterate that we want long-term care reform to work but that we want it to work well. Reform for its own sake will certainly fail. The system is at a very delicate point, with no fiscal relief in sight and an aging, increasingly needy population which continues to be promised unlimited access to all the services they want. There is need for improvement, for change, for keeping up with the times. Advocating wellness and supporting wellness programs is admirable and represents a long- overdue shift, but enhancing wellness at the expense of ensuring excellent, accessible and timely community-based care for the sick -- and there will be people who will get sick -- is not acceptable. We are concerned this may take place under this draft legislation.

Reform must be undertaken in such a way that it will allow the entire system, the entire continuum of care, to be stable and effective during and after the process of reform. Reform must rely on the expertise of the people who are currently making the system work. We urge the committee members to seriously listen to all the presenters you hear from in the coming weeks. We are individuals and organizations who have invested as much time and thought and energy as you in considering how to achieve the best long-term care program for our patients, clients, families and ourselves.

The Chair: Thank you. We'll move to questions.

Mrs Sullivan: Myriad questions come from this presentation, and I know I don't have all the time in the world. Your presentation, following that of the RNAO, which emphasized so much the assessment phase, is an interesting juxtaposition. I think you have taken the RNAO's issues a step further, in talking about the actual diagnostic issues that particularly are evident for the long-term care patient and aren't limited simply to physical problems. There may be psychological and psychiatric problems or mental health issues that have to be addressed as well as the physical issues.

Certainly the points you make with respect to the medical assessments and ongoing monitoring we attempted to put to the minister this morning, to a certain extent, in asking her whether she contemplated medical staff in each MSA as salaried professionals or whatever, and she declined to answer or at least skipped over that. We'll come back to that, because I think it will be interesting to know if that medical component is in fact considered to be a part of the MSAs.

I heartily agree that there are enormously raised expectations, and I wonder if you have been involved in any way in participating in discussions with respect to the criteria for determination of eligibility for long-term care services. Has the OMA been involved in those discussions?

Dr Gordon: Yes, we are involved. We've had some meetings with ministry officials looking at the development of assessment tools, prototypes, systems. We made an initial presentation requesting that we be involved and that was received in a positive manner, and I think this is important.

I wanted to step back to your comments. It was by chance that we followed the previous presentation of the nursing association. There's a false, sort of arbitrary line between assessment and therapeutic intervention. They go back and forth. You're doing them sort of concurrently.

Our concern, in terms of what happens to people -- and we're talking about people who have many medical problems. The fact that they can manage in the community with appropriate services is wonderful, but that doesn't mean they don't have real, complex medical -- or let's use the word "clinical" and get out of the so-called "medical" -- clinical needs that require ongoing assessment, diagnostic, at least labelling or putting it in some kind of framework, and therapeutic interventions which may change in multiple levels.

Which professional is involved with which level is not really the question. It's the fact that you have the professionals who understand what is going on and what the needs may be and what the symptom changes may represent, and this is really quite complex. Anybody who's done clinical care of the elderly -- again, I'm using "clinical" rather than "medical" or "nursing," whatever -- knows that the changes can be profound and that it takes a great deal of expertise and knowledge in order to deal with them.

On the other part, in terms of the assessment, one of the concerns that we have is that there may be a request for service based on a symptom complex that may in fact be due to a medical condition that, if recognized, is changeable and then the request for services becomes a moot point.

The best example is the person, for example, who has trouble walking. You say, "Well, you have trouble walking; let's send in the walking team." There's the person who fixes up the wall and puts on the grabs only to find that in fact the walking problem is due to an identifiable medical problem for which, if there is treatment, the walking team becomes irrelevant. Parkinson's disease is a very good example. We see a lot of undiagnosed Parkinson's disease that gets referred for a lot of reasons because they don't look like the typical case.

We're concerned that we may lose the importance of the clinical evaluation, and that's really a major concern. Who and how it's done is another issue. As for physicians being involved in the MSA, we didn't create the model of the system.

If the long-term care community-based system is supposed to be in lieu of, instead of, the facility-based system, because that's what we're saying -- all facilities have a medical adviser, a physician who's responsible for standards, for the way that the people receive their services -- I think if we were designing the system, we would probably include a physician at that level, or clearly in a role to make sure that the medical care provided within the community achieves standards and expectations, but how it's structured is not for us to organize. We would probably support it.

Mrs Sullivan: I've got a wee one. Many people, although not all, who are seeking long-term care, will have an established relationship with a family physician. How do you see that family physician tying into the MSA as proposed?

Dr Clive: Perhaps I'll answer that, practising as a community physician in Mississauga.

We would like to see the family physician be part of an integral communication loop that involves the patients, and the goal is to make sure they're getting the best care available; continuity of care. The present design of the system, which tends to exclude the physician even right at the very beginning, at the initial referral process, doesn't fit into that model. As you mentioned, these patients often have a very long-term, ongoing relationship with their doctor, and we would certainly like to encourage, in the way the system is designed, some mechanism for communication with the physician.

At the present time, whenever someone is placed on the home care program, they have an attending physician identified. I think this is key when we are dealing with complex cases in the community whose medical needs may change on a day-to-day basis. The staff caring for those persons and assisting them in their homes need to have someone they can call who knows these persons well and who can assist with sorting out the various medical or non-medical concerns that may come up. So we see that it is key to have the family physician as an integral part of the communications circle around that client.

Mr Jim Wilson: Thank you for your presentation. Just around this very point, I wonder if you can suggest something a little more specific, perhaps, on how we put a remedy into this legislation.

For example, a couple of weeks ago, a lady in my riding called me at 9:30 on a Sunday morning -- sorry, it was actually her son who called me. The lady was in pretty bad shape and the son couldn't get really enough home care or community-based services and he could no longer really look after her in her home -- and I'm making a very short story out of this. He said, "Jim, what do I do?" I said, "Well, take her over to emergency and just tell them you cannot look after her at home any more," because that's the quick solution to get into the system now.

Eventually, throughout the day the family physician and the placement coordinator -- or she used to be the placement coordinator; they've basically fired her now and she's just doing it on a volunteer basis -- talked her into, "You're going to have to go to the local home for the aged." It all worked out okay after a couple of days in the hospital.

But there was the family, who couldn't confront the decision even though they'd known for a couple of months that perhaps she should be going into a long-term care facility, that this was going to come. There was the physician, who was her friend, finally breaking the news to her and saying, "Your son just can't look after you at home any more."


And you're right. How does the physician work into this? Because you point out in section 22 that any approved agency can't do an assessment and there's no automatic link to the physician. You raise a very good point. I mean, in my scenario what would happen? The act went through as is. I can't believe this would happen, but the physician would basically have no say in this and somebody would phone the MSA and the MSA would go over to the emergency room. But the lady's obstinate and doesn't want to go to a nursing home. She doesn't want to be assessed because she knows, "Well, that means I've got to go to a nursing home." Do you know what I mean? You must deal with it all the time.

Dr Clive: I know what you mean; I deal with it all the time.

Mr Jim Wilson: I only deal with it the odd Sunday.

Dr Clive: I want to tell you it's a miracle that she found a place to stay in a few days. Where is it she is?

Mr Jackson: Well, this is on TV.

Mr Jim Wilson: Phone your MPP.

Dr Clive: Right, phone your MPP. You'll get a nursing home bed in no time.

Mr Jim Wilson: They'll bring in an MSA and we'll be out of the picture too.

Dr Clive: I think there are several issues that this case demonstrates. Number 1 is the assessment of competency of the individual and her ability or right to refuse treatment or placement, and certainly that issue -- the family physician plays a key role in helping to assess the competency of that individual. Perhaps she was not competent and yet refused and no one was asked to make that assessment and so the family kept following her word when they were unable to meet her needs and placed her at risk, and the whole family at risk probably from an emotional sense.

The second is, what is it that precipitated whatever happened on Sunday morning? My experience is, when I've been following patients who are in the community who perhaps are even on a waiting list, a long waiting list, for placement, they are doing fine until a medical event occurs, something that changes their medical status. Again, there is a place for the doctor or an experienced nurse to come in and identify the change of status to the physician and say: "There's a problem here. Something has changed. What is it? What can we do?"

Sometimes going to the emergency department -- I shouldn't say this -- may be the right thing to do because at least there you can get some tests done and you can find out if there is a new, reversible problem. If there is, and that's something that can be treated, perhaps that person can be stabilized in the community again to await placement. Perhaps that event has been catastrophic, such as a stroke, a new, irreversible medical problem that will now mean they cannot be managed at home.

The other time that things happen is, perhaps the crisis was not in the patient or client but in the family, the acute illness of a care giver. Presently, in many emergency departments, we have quick response teams and these sorts of emergencies come up where we can facilitate placement or institute community services to support that person at home in the absence of the care giver. But so often in that situation there is a key role for the doctor because there are several problems that could have occurred and the physician is important in that.

Mr Jim Wilson: Well, there are many areas in rural Ontario where we don't have quick response teams either or many of the other things that are talked about at these committee hearings.

Dr Clive: Yes, and a lot of the things that are in this legislation, I think, create problems because of lack of service. Then we have to say what is appropriate in terms of waiting lists for various services that are not available in rural communities. I live in Halton and I service north of Peel where we don't have a lot of the services that are supposed to be in these beautiful new structures called the MSAs.

Mr O'Connor: Actually, following right along with the quick response teams, how do we then -- in the case of an assessment here, where there is a quick response team available, you can then make some of those assessments, evaluations, and get the appropriate care provided. How do you suggest we inform the physicians or partner, or whatever, to get the physicians to know that there are other services available that they may not know about?

A common problem that would be found throughout the province is that the referral patterns of physicians don't necessarily match the referral patterns of some of the medical treatment facilities. We all look back at our own home ridings; it makes it a little bit easier. But if somebody from Orillia or somebody goes to the hospital in Orillia from Beaverton and they get sent back home, they're sent back down into Durham region again. How do they know where to look for services? Sometimes from Durham they get sent over to York County Hospital, where we do have some services, you know, quick responsewise. Make sure that the physicians know that there are services that could be available. They don't always know what's available. I think this is where we can actually help by going through this process. An MSA is going to actually help the doctor make a better referral.

Dr Gordon: I think with some of the discussions we've had with the ministry we've tried to emphasize the importance of the link, loop, communication system between the primary care physicians, the responsible physicians, and whoever the MSA participants are. Certainly, whether the system -- through education or however you make sure people know where they refer -- will enhance services, I don't think any of us disagree with the contention that having an easily identifiable organization or grouping to deal with services is good. I think we all have no question with that.

The other question is, I don't think any of us want to be gatekeepers any more. That's an issue that we've long been happy to relegate to anybody else. But we want to make sure that in the loop of care we are active participants, because many parts of that loop -- if you want to call it a chain, there are many links in it. Without our input, we may end up doing the wrong things for people who really have a lot of complex medical problems; we know that there are those who don't and have very simple needs. Whether it's shopping or something, cleaning the driveway in the winter because they have a simple physical disability, that's an easy group to look after.

But we are already seeing people discharged early from hospital who are not having access to long-term care facilities who 10 years ago there wouldn't have been a question that they would require a long-term care facility. We're trying to patch together a way of keeping them in the community. For many people that's fine, but their health care problems don't disappear, and if they're not managed well, then we will end up not providing appropriate services and when they get to the long-term care facility it will be in much worse shape than they were.

Mr O'Connor: I think the problem we've had is it has been patched together, over a long period of time, and what we're now trying to look at is pulling things together and making them more comprehensive.

Dr Clive: I agree with the concept of the one-stop shopping. So, for the physician, if we can get that phone number into the physician's head, whether it's 451-HELP or something like that, then that will be wonderful. At the moment, if I have somebody in my office who has several problems and needs services, I have to phone five different numbers. So the idea of consolidating this I think is wonderful.

I do sit on our DHC long-term care advisory committee trying to develop an MSA, and I am worried that once that phone call is made there are going to be 10 days of paperwork before that client ever gets services. Right now I know who exactly to call to get a nurse in there this afternoon. I may then have to call somebody else to get a homemaker and somebody else to get a physiotherapist, but that's another story. But when I hear that the initial draft of the assessment form or referral form is 26 pages long, I think, "Is this really going to improve service?"

The Chair: Thank you. I know there are many more questions. We could pursue this for some time, but I regret that I must call it to a close as we still have many other presenters this afternoon. But thank you again for coming.

Dr Gordon: Thank you for having us.

Mrs Sullivan: Mr Chair, I note that in the Ontario Medical Association brief there are some quite specific recommendations that are detailed in relationship to the bill. I wonder if we will have an opportunity to look at these at some point. Some of the things that were included, by example, are evaluative mechanisms for paraprofessionals and other instances, such as the banking and finance issue that I raised this morning. I think that, because they are more specific and less generic than the discussion that we've had, it would be worthwhile to look at these quite particularly.


The Chair: Thank you.


The Chair: Welcome to the committee. If you'd be good enough just to introduce yourselves for those who live outside of York region and then please go ahead.

Ms Carol Dockrell: Thank you, Mr Beer. It's comforting to see a couple of familiar faces from York region on this committee. My name is Carol Dockrell. I'm the director of the York Region Home Care Program, and with me is Brenda Andrachuk, a program manager, to assist with any of the questions. I'll be doing the presentation.

I'm representing 127 staff and contracted rehabilitation service workers of the program today. I would like to stress that I'm not speaking for the administering agency, the York region municipal government. They will be doing a presentation later on in the hearings, so I did want to make that point very clear.

The staff that I'm representing include 46 case managers, sometimes known as coordinators, depending on the program; 28 clerical support staff; 44 rehabilitation therapy staff and contracted workers; and nine administrative staff. I would like to say -- and I deviate the odd time from my written presentation here -- that I feel quite comfortable to speak for these 127 people because we did quite a lengthy in-house process over April and May within our program to have a task force representing all of these groups go into the detail of our paper and to distribute it to everyone. So everyone had an opportunity to have their say, give their feedback, and I believe this truly does represent -- it's not simply myself or my colleague.

As I begin my presentation, I would like to underscore a significant point. Although we are indeed workers in the system, health and community services, we also believe strongly that we are consumers. Many of us are dealing with or have dealt with aging parents, terminally ill family members and friends, critically ill children, and personal health and social issues. We are, of course, also taxpayers, and we believe we have the experience and the knowledge to assess the cost implications of an ideal as well as a realistic approach.

I have personally held my position for almost 17 years. I think I am one of the more senior or long-term people. I've watched a lot of changes in the system. I truly do believe that my staff colleagues, both here in York region -- in York region, rather; I'm not in York region -- as well as our local partner agencies are responding to this proposed future wearing not only our worker hats, but indeed our consumer and taxpayer hats.

In the package I'm leaving with you, you will find three documents, and I'm really only very briefly commenting on some of the issues in there.

The first one is the staff recommendations for a multiservice agency in York region. It's very specific to our thinking in relation to where we work and live.

The second is entitled Factors to Consider in the Planning of an MSA: specifically, acute short-term care; secondly, age-related issues; and thirdly, palliative care. I am going to speak more to those in a moment.

Finally, we have the preliminary results of a survey that we recently conducted in April and May of clients receiving services at our program, and I will speak to that, but there's more detail in the documents for your reference. I would appreciate your attention to this detail. Time does not allow me to extensively review it, but it is very relevant, I believe, to the reform of the system, and although it's specific to York region, I think there's a lot of applicability across the province.

So in the time available to me now, I will highlight certain key points which I did review with my senior staff last week to assure their relevance today.

"Acute Short-Term Care" is my first point. These aren't necessarily in order of priority, but this is one that I'm constantly raising in my circles and I wish to stress it today. Throughout the lengthy process leading up to this bill, including all of the actions of the previous government, I believe there has been a glaring lack of acknowledgement of the impact of acute care. In our home care program in York region, in the fiscal year just ended in March, 65% of those individuals we served in that year were served through the acute care program and the 35% remaining were served through our chronic and our integrated homemaker programs. I did not factor in the school program for this particular analysis. I would like to point out as well that in our particular program we serve all of the palliative care clients through our chronic program simply because it saves transferring and a lot of administrative work. I certainly believe that all or most palliative care clients could easily be defined as acute, and that's an interesting issue that often raises the distinction between acute and chronic.

We believe the administrative implications for acute care in planning for a multiservice agency funded within a limited global budget are enormous. I have made only three points here; if I had time, I could go on.

In our program, approximately 75% of all of our acute care admissions to the program are direct discharges from hospitals, and I expect that is relatively typical provincially. In most current geographical home care locations there are several local hospitals, and many home care programs deal with hospitals outside their boundaries, a significant factor in large urban areas, and most particularly within the greater Toronto area. I have to say York region -- I'm sure Peel and Durham would say the same if they were here -- are strongly impacted by the 30, give or take, Metro hospitals.

In today's health care environment of shortened length of hospital stay -- and we've seen a dramatic change in the last few years -- quick response initiatives -- I heard you speaking about that earlier -- to serve clients presenting in the emergency departments, communication needs to be efficient, effective and rapid. The integration of acute care community services within a multiservice agency has significant administrative implications.

My second point is somewhat tying into that. In a competing fiscal environment -- which, from my read of the situation, it appears it will be -- how will the board and the administration determine priorities to respond to hospital pressures as well as social service pressures?

Thirdly, the more MSAs established throughout the province -- and I've heard numbers ranging from 100 to 150 as potential -- each with their local "flexibility," the more potential there is for communication problems. Most of the current 38 home care programs will attest to the challenge we face today in interprogram and interagency referral and communication.

Ontario has a very mobile population. As stated earlier, they often receive their medical care in a hospital outside of the area where they actually live. Imagine the challenges for physicians -- and I was quite interested listening to the part of the previous presentation to hear that -- and hospital staff in determining the process to contact and to interpret the flexible approach of one of 100 to 150 MSAs.

My next point is just some brief comments around the "Union and Non-Union Staff Issues" that will inevitably result from this proposed direction. In our opinion, the magnitude of the resulting issues emerging from establishing the MSA model proposed in the bill are staggering. We understand there are seven different unions affected within home care programs in this province, and two of those are currently within the structure of York region. The integration of agency staff from other non-union areas into a union environment has enormous implications.

We seriously question the cost-benefit of merging current administrative structures of home care programs and contracted agency services. We have never seen any evidence to analyse the potential costs of both transitional costs and the new system weighed against the benefits of the future outcomes. Our experience suggests to us that it would not be cost-effective to change in the radical way that is being proposed.

That leads nicely into the next point, which I've titled "Corporate Merger Versus Contracted Service Delivery." We believe that proposed direct service delivery by a staff of 80% minimum, which is, I understand, the intent of the bill, is not an appropriate direction. We support a contracted service delivery approach with quality and cost-effectiveness as the key criteria.

As noted in my last point, the costs and implications of such a merger are quite enormous. We believe that the principles of reform can be addressed without such a merger. We'd ask that you please refer to our client survey report, when time permits, contained in the package. For clients who've been able to access the system -- I'm only speaking, I admit it, for the home care part of the system -- there is a very high degree of satisfaction in our region; 53% of 244 people who responded to our survey -- we sent out 500, so it was almost a 50% response -- rated the program as excellent. Another 27% said very good and no respondents rated it as poor.

In our minds, this raises serious doubts about the need for the drastic change proposed to the system. In fact, we are concerned about the risk of creating a less effective system in the end.

During this lengthy process of consultation and proposed reform, it is "business as usual" for home care programs and the agencies that are potentially affected by the proposed merger. Certainly in York region it is not business as usual, in my opinion, since we are experiencing dramatic case load growth as a result of hospital changes and other factors and much greater complexity in the kinds of services, care and support we are providing.

The expectations to participate in numerous, often repetitive meetings are placing undue burdens on staff already stressed by demands. An often-quoted comment is that the merger will save significant administrative costs. I have seen no analysis to support this supposition. As a long-term administrator in the current system of contracting services, I seriously question the validity of this.


The next point we'd like to comment on is the not-for-profit policy. We do not support this policy. We believe that consumers and the system are best served by a mixed approach of not-for-profit and for-profit agencies. Currently, all agencies receive the same fee regardless of their administrative character, and our experience does not suggest that quality is greater from the not-for-profit sector. We have difficulty, therefore, understanding the rationale. Furthermore, we believe that costs would be greater to the taxpayer, ourselves included, with the 80% staff approach.

We fully support the principles of improved service, better communication and easier access for consumers, but we do believe these could be accomplished equally well, if not better, through a contracted services system.

The next point is related to services to children. We are concerned with the emphasis on seniors throughout the evolution of the reform process. While we fully support and we acknowledge the need for unique service delivery to this population, we believe that the paediatric population has unique needs as well. As Brenda and I were chatting in the car, it's our observation that the public speaking for the paediatric population isn't nearly as well organized and obviously not perhaps as strong in numbers, so we're concerned that this group may not be heard and our fear is that their needs will not be addressed adequately because of the long-standing emphasis on other groups.

Palliative care: We believe that palliative care to terminally ill persons at home, when desired by the client and family care givers, is one of the most effective and supportive roles the program currently provides, along with many other partner agencies in the community. It is a very cost-effective alternative to hospitalization, which would be required in a substantial number of situations. More importantly, however, it provides a special and unique quality of life to those undergoing the experience, clients and care givers alike, and the rewards in terms of the surviving care givers and family are immeasurable.

However, the growing nature and increasing medical complexity, such as intravenous therapy at home, are significantly impacting on costs for nursing, homemaker support, supplies and other costs in the community setting. Planning for the future must recognize this shift from hospital to home and will have to rationalize the costs. If budgets are capped, a serious dilemma for the administering board and administration will undoubtedly be faced.

If I could speak now just briefly to age-related issues, our point is simply not to forget that the proposed MSA model will be serving all ages. There is a widespread assumption that the majority of clients are seniors, and this is not accurate. It's certainly not in York region; it may well be more so in other areas. We again would ask you to refer to our attached reports for the details. Often, clients in the under-age-65 adult years -- many, I think, here would fall in that category -- are high consumers of service, particularly in palliative care situations and other situations of long-term care, since there is often a working spouse or partner.

Volunteer issues: We know that this is a controversial and often-stated objection to the proposed reform. Our home care program does not have direct experience recruiting and working with volunteers, so we do not feel qualified to provide a firm opinion. However, I did want to say we lean in the direction of having concern about the ability to attract, retain and recognize volunteers in a large bureaucratic organization.

We have watched the highly successful use of volunteers in our home support for seniors agency in York region, known as CHATS, Community Home Assistance to Seniors, and we are sceptical that the dedication and spirit would be comparable. We are referring more to volunteer client services in the home setting in the community, as opposed to volunteer board member services, which we think would likely be more easily achieved in a community-based board.

Governance: I wasn't going to say anything. As I said earlier, our region will be speaking. I believe it's appropriate for us to simply say we do a staff-endorsed consumer participation in any governance model. We are currently employees of the regional government in York region, and as such you can likely appreciate our difficulty in being any more specific about a governance model.

We appreciate the opportunity to have our views heard and considered. In summary, while we acknowledge the need for improvement to the system, particularly in terms of consumer access and effectiveness of communication, we believe that radical restructuring is not necessary. A more modest approach to improving and building on current strengths is our preferred approach.

I thank you for your time and I certainly am pleased to answer any questions.

The Chair: Thank you. We thank you as well for the attachments that you brought with your brief and we will look at those closely. We'll begin questioning with Mr O'Connor.

Mr O'Connor: Thank you. I appreciate the opportunity to welcome you down to Queen's Park on behalf of Mr Beer and myself.

Ms Dockrell: Both of us long-time residents of Ontario have never been here. This is an unexpected bonus.

Mr O'Connor: We're not that hard to come before, actually, and we've had representatives from York region come before us and we always treat them quite nicely, as we do anyone else. I hope we don't scare anyone who may come forward. In listening to your presentation, I want to kind of point out that we see the home care program that's there now, which has, I think it was, a $2-million increase year over year just this past year and the integrated homemaker program that's under way and what not, we see all of this as coming together to be part of what will evolve as the MSAs.

Maybe you could help me and some of the committee members. I think we're going down a direction that'll help us progress in providing services into the community a little bit better than has been in the past, and I think if we took a look back at the historical importance of a lot of the services that are out there today, they evolved over a long period of time, and it was because of a need within the community.

You'd pointed to some problems that you see in the involvement of an MSA locally, and I just wondered how you see this as being a problem. There's going to be a core basket of services that'll need to be provided. Would not the services you provide still be part of that? Do you see that being eliminated somehow?

Ms Dockrell: No.

Mr O'Connor: What seems to be the problem there?

Ms Dockrell: Primarily, the potential administrative structure we see as being no proven or demonstrated benefit to changing the current structure, which is essentially my point around contracted versus merger. Certainly, having dealt with other large organizations -- and I believe this again confirms the point being made previously -- in attempting in reality to weave your way through a large bureaucratic structure causes us some concern. I guess our point is, for our clients currently, having asked them, "Are you happy with what you're receiving?" and they are, we're asked: "Then why are we changing? What is the benefit to change?"

Mr O'Connor: I guess the difficulty here is that there's a limit in some of the services you provide. I know that with all the agencies that came together and put in a request to the ministry for palliative care dollars -- and with that we saw things like the Georgina Hospice come about, which is going to provide services to people at home in a palliative care setting that is something different than what you offer now.

To me, if a client, a consumer who is going to need some services now has the ability to go and make one phone call that's going to give them access to all the services that CHATS provides -- in fact, the Georgina Hospice and CHATS have worked together in some of that -- all those types of services actually just with one phone call, I think that would be better for servicing not only the needs you fulfil now but some of the needs you don't fulfil; then, if the service you are providing should be accessed, maybe a different way of accessing it.

Ms Dockrell: I didn't comment in my presentation, but we fully support improving the access particularly for those who aren't in the system. We believe once they're in the system, as far as the home care program part of the system, that they're brought into the system quite efficiently and effectively. We fully support improving the access for the consumer who doesn't know how to get into the system. In fact, in York region we're currently proposing and have had meetings over the last three months with our partnership agencies to do a demonstration trial project on a 1-800 access number in York region. We believe, however, that can be accomplished without the changes proposed in the bill, within the strengths of the current system, and we intend to hopefully demonstrate that before the end of March.


Mr O'Connor: Have you made a presentation to the DHC in York region?

The Chair: We've going to have to move on, Mr O'Connor. I'm sorry. We're tight this afternoon for time.

Mrs Sullivan: My comments are with respect to proposals that York home care has made with respect to what's almost a managed competition model, whereby the MSA would be the point of access, the one number that people would call, whether they be the professional who's referring a patient or a person for services or whether it's the individuals themselves who are calling for information. I think your concept is that the MSA would then contract for services on the basis of quality, cost, the innovative approach and the evaluation of the services that are provided.

One of the things that is of major concern -- and I hear Mr O'Connor speaking about the Georgina Hospice -- is that most community-based agencies which are now providing services provide more services than those which are funded by the government. Once those services are reduced by 80%, ie, once those services will now be provided by one new government bureaucracy, the services that are left that those agencies provide will in fact become too expensive in administrative terms and other means and therefore those services will be lost.

I'm wondering if you could describe what you see from the home care perspective of the effect of the loss of services above and beyond those which are government services in the York community and if you want to comment more on the managed competition which would provide the triage services initially and then referral out.

Ms Dockrell: It's rather difficult to comment in the sense that it's hard to know just what potentially stands to be lost. I understand your point and I share your concern about that, but I have difficulty conceptualizing in my mind or making clear in my mind just what stands to be lost, presumably some of the services currently, as you say, not funded.

I know from personal experience, having worked as a visiting nurse many years earlier in my career, there's no question that nurses, I believe, who currently work within the visiting nurse agency structures have an incredible dedication and spirit. I personally think that kind of thing's going to be somewhat lost.

I personally, as a nurse with my background, have concern about that sort of -- it'll be a 9-to-5 sort of approach, very much different than the spirit that currently exists within these agencies that have a long-standing tradition and history and somehow instinctively instil that kind of attitude within the staff who work there.

As far as the other specifics are concerned, though I do have some difficulty commenting on them, I share your concern.

Mrs Sullivan: Could you talk about the managed competition proposal then?

Ms Dockrell: Do you want to comment, Brenda?

Ms Brenda Andrachuk: I just wanted to say that part of our point was that all of these services are already available. All of the services that you're proposing that will go into the basket are available: as Larry pointed out, the Georgina Hospice, and within the home care program we can access that right now. It seems like we're trying to rebuild a system that's already in effect. We just have to tidy up some things and get some things put in place that make it more accessible for the everyday consumer. Because that's what we're trying to do, make it a better system for consumers who don't understand the system but know they need some kind of help.

Ms Dockrell: I'd like to just comment on that as well. I don't have any data, but in preparing to implement a 1-800 number in York region -- and we did use one when we implemented our integrated homemaker program, so we've had some experience in getting the word out -- we actually had a very good response with very limited -- we just used cheap little flyers to get the word out. So we're going to continue on with that process.

But in preparing for this, we've been doing a survey of individuals currently calling into home care programs, VON, homemaker agencies, placement coordination services etc, and it's interesting. I wish I had the results, but I saw the first about a week and a half ago.

One of the questions we were asking these consumers was, "How many calls have you made before you -- " because once they got to one of these agencies they're going to be into the system right away because of the network. We're being surprised -- I think there's perhaps an illusion, and maybe it's unique to York region so I wouldn't want to say this applies provincially -- that the consumer isn't making that many calls in actual fact.

I would personally love to have seen a more scientific study done on that with consumers as opposed to perhaps the emotional feeling that people bring to a consultation, which I know reflected that consumers were expressing a great deal of concern about that. But that may not be the findings that we're seeing, which is interesting.

You wanted me to comment on managed competition, I guess, back to the original point. I think I was reflecting the strong feelings of the staff and rehab workers in our program that we have had very positive experience in all the years we've worked within what we believe is already a managed competition system. We see many, many pros, but we see a great deal of cons in moving away from that system into a system where all workers are on staff.

We believe there'll be some disincentives to productivity; some disincentives to competitiveness, which will lead potentially to increased costs; many, many issues around unions, union implications for a large organization, and just the sheer time involved for all the communication to be accomplished in that process of working with unions and the collective agreements.

Mr Jim Wilson: I just want to, on behalf of our caucus, thank you. Your presentation gets five stars with respect to every section. It reflects very much what we've been saying for at least the last four or five years with respect to some of the reform that is going on in our health care system and in long-term care. I think you've been very, very honest.

When we started into this process it was going to be fairly simple: one-stop shopping, a 1-800 line. There were going to be some provincial standards. It wasn't going to be this complicated malaise that we have now in Bill 173, and I think you're right, there is another agenda at play here and it has a lot to do with unionization and ties into the labour laws that were passed last year. It's get everybody under one umbrella and do what they can while they're still in office, and you're the second one so far today -- the Ontario Hospital Association hinted at it in its press conference, in reading between the lines, and you've indicated it fairly clearly on page 4.

You later didn't want to comment on governance, but this is appointed regional government in long-term care; that is essentially the way I look at it in terms of the amalgamation. A lot of these agencies that come to us and ask, "What's going to happen to us with the MSA?" "Well, you won't be around in a few years." It's that simple.

Something has to give, or the government truly is building a big bureaucracy on top of a lot of existing administrative structures now. They say they're not but they won't tell you exactly what the new picture looks like. So something's got to give. Boards have got to go, administrators have got to go, staffs have got to go, and everybody's coming under one roof. I think that's pretty clear to me over the past few months and will become, I think, clearer to everyone throughout these hearings.

I do want to ask you one thing, though, because it's something that my party's been harping about for quite a long time, and that is your comments about the not-for-profit sector. You are in the not-for-profit sector yourself, being in the municipal sector, yet you're one of the few not-for-profit groups who come forward and say that this arbitrary 80-20 mix just doesn't seem to make much sense and that you're currently contracting out services, I assume, based on what you say here, "quality and cost-effectiveness."

Can you give us any feel, because you only get a minute, as to what the new policy might do in human terms? Will you have less flexibility, or is it a red herring, as the government always tells us?


Ms Dockrell: I believe there'll be less flexibility. We've observed over the years tremendous flexible and rapid response from both the not-for-profit contracted service agencies -- and I'm really speaking most specifically here probably about the nursing and the homemaker agencies, which are the ones where we require quite rapid response very quickly, and becoming more so all the time. Our experiences have been very, very positive with both sectors. I've just lost my train of thought. I do believe there will be less productivity in the proposed system.

Another area that concerns me is the whole area of standards. Organizations such as Red Cross, such as Saint Elizabeth Visiting Nurses, such as the Victorian Order of Nurses, have a long, long, long history of developing, refining and adapting standards, very often in collaboration with home care programs once they entered into a purchase-of-service relationship, and I think those are excellent standards. I don't know what happens to them if these agencies no longer play a significant role.

I know they can still play a potential of a 20% role, but presumably multiservice agencies will have to reinvent the wheel in terms of these standards, and you're talking quite complex care standards. Particularly as we've moved into more high-tech-type treatments and approaches in the community, I believe that would be an enormous, time-consuming activity that each MSA would have to undertake to provide the professional and supportive services of nursing, homemaking and rehabilitation services as well. No one has any idea of the time involved and the cost to do that.

Mr Jim Wilson: It strikes me, if I may just say, for instance, take Simcoe county, next to you. I think we're about 97% non-profit agencies delivering a variety of services, yet they're accountable to the public through their boards, and their argument to me all the time is, you know, who loses in all this is the consumer.

Right now you can go into the Red Cross and absolutely scream at them and you can go to their volunteer board members that you meet at the IGA store, and things get fixed pretty quickly if you make a complaint; and there are very few complaints, I might add. But now everyone's going to work for the government. Everyone's going to work for the MSA.

In all the reading you've done, who is the MSA accountable to?

Ms Dockrell: That is an area of concern. Again, I know this will be an area our administering agency will speak to. They share that concern of accountability.

Mr Jim Wilson: But they're appointed by cabinet.

Ms Dockrell: Presumably the board will be appointed members, as opposed to publicly and democratically elected. So there is a concern around that very issue.

The Chair: Thank you both very much for coming today. I'm sorry. I know there are more questions that could be asked, but we do have a full afternoon. So again, our thanks.


The Chair: I then call upon the representatives from the Association of Treatment Centres of Ontario. Welcome to the committee. If you would be good enough to introduce yourselves, we have a copy of your presentation. Please go ahead.

Ms Joanne Renahan: We are pleased to have the opportunity to make this presentation to the standing committee on social development regarding Bill 173, An Act respecting Long-Term Care.

My name is Joanne Renahan. I'm the executive director of Lansdowne Children's Centre in Brantford, but I'm here as chairman of the Association of Treatment Centres of Ontario's long-term care committee. With me is Ross Lawless, chairman of the association's board of directors, and Diana Thomson, member of the association's long-term care committee.

The Association of Treatment Centres of Ontario represents the collective voice of 20 children's treatment centres. The centres are community-based agencies funded by a number of government ministries as well as by municipalities and private sources. They are multiservice, providing a broad range of programs for children and their families. A detailed listing of the services is provided in appendix A.

The association is committed to providing leadership on a regional and provincial basis in planning, developing and providing services to enhance the quality of life for children and young adults with disabilities.

With that in mind, the association has been monitoring and seeking active participation in the proposed redirection in long-term care and support services in Ontario since the beginning of public consultations in 1991. As a representative of children's services, many questioned why we were so concerned about an adult system. However, we knew that the impact would be significant due to the school health support services program currently being administered under the home care programs. To clarify, let me briefly provide some background.

In 1984, in response to Bill 82, regulation 452, section 44(a) under the Health Insurance Act established the mandate under which home care programs would provide services in the school setting to students enrolled in special education programs. This is now commonly known as the school health support services program. This action was taken without any consultation with our association or membership, in spite of the fact that many of our members had been providing the major aspect of this service for decades. In fact the majority of our members continue to actually deliver this service by contract with the home care programs.

Our concerns about compromise to our service model, service fragmentation and duplication of legislated mandate were thoroughly reviewed with various ministry staff. There was an independent substantiation of these concerns via a study conducted by Price Waterhouse in 1989. The relevant text is attached as appendix B, but basically the conclusion was reached that school health support should be transferred to children's treatment centres.

Why no action? The main problem was there was no mechanism available for flowing school health support funding directly to treatment centres without a legislative change. The association reluctantly accepted the situation because of ministry assurances that we would see a resolution when the long-term care legislation was introduced. You can understand our surprise when we read that the intent of the long-term care legislation is to entrench the status quo rather than implement the Price Waterhouse recommendation. That is why, for the first time in the association's history, we feel compelled to appear in front of a legislative committee to advocate for children with special needs.

As is often the case with human service issues, a detailed outline of every implication can be overwhelming, so for the sake of brevity we've given priority to three concerns: status of children, fragmentation of the service system and discrimination.

With regard to the status of children, our position is simply that children are not and should never be viewed as little adults. As a society we acknowledge this in many ways, but every now and then, for whatever reason, perhaps due to an honest belief that in a particular case they are not that different, their unique service needs are not acknowledged.

We suggest that the systems established for their education, child care and acute health care have been established because they are different. There are few, if any, who would question the need for paediatricians, hospital wards, head start or recreational programs etc that specialize in servicing children's needs. Trying to make a child fit into an adult long-term care agency is analogous to asking him or her to make do with an adult wheelchair.

As an association, we applaud the work done by the Premier's Health Council, outlined in its recent report Yours, Mine and Ours, which speaks to the importance of planning for children on the basis of developmental transition needs. As service providers, our members have long promoted and practised the developmental service model to address the constantly changing needs of children. This model requires a team approach by people who understand children, are specially trained in paediatric services and have the opportunity to develop and reinforce their skills in a paediatric environment. Our concern is that this legislation is going to entrench some services for children in an adult agency. It is imperative that this not take place. Decisions about children's services should be made on the basis of their needs and not on the basis of expedience.

Our next major concern is with regard to the fragmentation of the children's service system. If I may be allowed to use an analogy, it appears to us that in recognition that the family home needs some renovation, we are tearing the house down and building two town houses. This fragmentation has potential implications both on established services and on the current planning and reform that is occurring in the children's service system.


With regard to established children's services, the potential growth of a parallel system within the multiservice agency is apparent. A specific example is a recent consultation paper on the school health support services program initiated by the Ministry of Health's in-home services branch.

While this paper notes that resources are scarce, it offers for consideration the expansion into a number of new areas for this program, such as summer services, transfer of services into the home, transportation, equipment provision, social work and behavioural consultation. We would suggest this need to consider the expansion of the school health support program recognizes that the needs of the child and family go beyond the school. It does not, however, recognize that these services are already in place or under development in the children's service system.

We cannot support the notion that the resolution of current service fragmentation is best addressed by establishing a parallel system when the opportunity for developing a fully flexible, coordinated service system for children already exists. Not to take advantage of this opportunity is particularly alarming when research by the Ministry of Health-funded neurodevelopmental clinical research unit reveals that organized programs of service such as are provided at children's treatment centres do a better job, according to parents, than do scattered pieces of service received across the community. We therefore earnestly request that plans to establish a parallel system be abandoned.

Another direct service implication is in relation to a number of established children's programs presently funded by the Ministry of Community and Social Services. Specific examples are respite care and the highly successful special services at home program. In discussion with our children's service system partners, we find we are not alone in identifying that the mandates of both these programs fit components of the MSA's mandated services. It is our concern that this type of duplication has not been considered in the drafting of the long-term care legislation.

We grant that parallel systems are not intentionally planned, but they do happen when, as we believe is happening here, a small service component of one system is transferred to another or a service reform occurs in isolation of other parts of the system. It is critical that the sector planning and reform presently occurring in the children's service system be recognized.

Key reviews and reforms are occurring in the following areas of children's services: child care, special services at home, education, children's services policy framework and speech and language services for children. Our members are striving to participate actively in all these initiatives. However, what is required is a provincial commitment to support the coordination of these many planning initiatives. This commitment is essential for the development of a truly integrated customer-focused children's service system. Our fear is that the inclusion of any children's services in the proposed MSA is going to heighten service fragmentation and isolation.

Our third concern is that this reform not only supports the discrimination the school health support services program introduced into the system, but it's going to reinforce an old discrimination that the association thought it had conquered.

The discrimination introduced by the school health support services program is age discrimination. Unlike their school-age counterparts, preschoolers with special needs have limited access to therapy options and are denied access to nursing and dietetic services in child care settings. It has been suggested by some that in child care the responsibility rests with the Ministry of Community and Social Services. If this is so, why has it been clarified that this responsibility does not rest with the Ministry of Education for school-age children?

The association's position is that all of these services are unquestionably health services and, as such, are the responsibility of the Ministry of Health. It would be considered ridiculous to suggest that the Ministry of Community and Social Services should pay for preschoolers to see their doctor.

It is our position that health services should be equally accessible to all. We would further suggest that this particular discrimination is of even greater concern, given the government's commitment to prevention and early intervention in childhood. This inequity must be addressed as part of a children's service system reform.

The second area of discrimination is with regard to the exclusion of people with developmental disabilities from this reform. It is acknowledged that their needs are to be addressed at a later date. Why are their needs not being addressed right now? As an association that has struggled to move away from diagnostic labels and eligibility criteria for service and has striven to focus on functional need, we cannot remain silent on the potential ramifications. To be clear, our position is simply, if a child needs physiotherapy, he/she needs physiotherapy and is therefore eligible.

Many children have multiple disabilities that necessitate coordination of services funded by different ministries. This is a system that can be managed, but with different ministries offering the same service on an exclusionary basis it becomes unmanageable. This only leads to game playing about which label to use today to secure funding and services for clients. We must not allow the long-term care reform to take us back to the days when interpretations were put on what came first, the physical disability or the developmental disability, and if the latter was determined to be dominant, service could be denied. We require your reassurance that this regression will not occur.

Our experience, when combined with these concerns for the status of children, fragmentation of the children's service system and discrimination, leads to one conclusion: Children's services must not be included in the proposed multiservice agencies.

We are requesting instead that the 1992 strategic priority given by the province to children's health, especially the goals to (1) "establish a more coordinated system of services, which focuses on children, youth and family," and (2) "develop effective, efficient and economical ways of improving and maintaining the health and wellbeing of children and youth," be aggressively pursued. It is recognized that in this time of so many competing needs this is not a small challenge, but given that our children are our future, it is a challenge that must be met.

As an interim measure to ensure that there is no break in service to any clients, we offer the recommendations contained in our position paper submitted in February of this year and attached to this brief as appendix H.

We also offer our full support to work with you to find the best solution for address of all our children's needs.

We thank you for your consideration of our submission.

The Chair: Thank you very much for your submission and for the various attachments that you've put there. We'll move right to questioning.

Mr Malkowski: Thank you for your presentation. It was very helpful for members to hear some of the points that you raised in your presentation. On one line or one comment that you made, that children's services should not be included under the long-term care MSAs, I asked a question of the minister this morning and she said that the legislation applies to seniors and to adults with disabilities, and does not include children. That was something she was very clear on this morning.

But another point I'd like to ask you: Currently, access to home care services requires a medical assessment and clients must meet very tight eligibility criteria. How do you think the one-stop access through the MSAs could help children and their parents? The criteria may become more flexible to allow adults with disabilities who need the home care. Perhaps you could just comment on those two points.


The Chair: Just before responding, the parliamentary assistant wanted to make a clarification which might help in terms of the question.

Mr Wessenger: Yes, I'd just like to make clarification with respect to the whole question of the role of children under the MSA. I think it's quite clear what the position is. The MSA will continue to be responsible for the services which are presently provided to children under the home care program. I think that's probably all I should say to indicate there is no anticipated change in jurisdiction. In other words, there's going to be no giving up of any jurisdiction that's presently there contemplated under the legislation, although I might just add that certainly it's anticipated that in the interim, until we arrive at that time when we have a -- I agree with you that we need to move towards a comprehensive system with children's services and I believe the ministries are working on that. In the interim, I understand it's anticipated that likely, for instance, services will be purchased by MSAs from children's treatment centres.

Ms Renahan: Can I respond now? If I understand the first point, and we've had the clarification that children are within the system, I would only expand on that in the case that it reinforces the point of why we're here. We've continuously forgotten that children are being impacted, and as I've had it explained to me several times, it's often because they are a minority and they are certainly going to be a minority in this situation, so they become forgotten.

I can also add to that in that we can hope by the time we leave there will be a change and they won't be included, so maybe the first statement would have been correct.

But the second question, if I understand it correctly, is how families can be helped through an MSA model, or just particularly with regard to children?

Mr Malkowski: For both.

Ms Renahan: For both? From the association's perspective, if I understand the question correctly, the children are entering due to the long-term home care services that are going to be included through the children's treatment centres by and large wherever they exist, of which there are 20 of us across the province. It is in many ways already one-stop shopping and we just refer to the home care program to pick up the school health support and continue to provide the other components of the service to the children and families. So we don't see how that is going to improve for our particular clientele as a one-stop shopping perspective.

There is the other component of the acute care needs that are being met through home care, and we are presently not involved in that area of service, but in line with our support of single-access multiservice type of agency, we are quite prepared to consider and have communicated that in the past, to be prepared to take on, though with some apprehension, full responsibility for children.

Mr Malkowski: Okay, just to follow up, I'd like to ask a question with the policy people. I'd like to ask the policy people, what is the current system now, and then after MSA legislation is set up, what will be the benefits with the system? Will their criteria be more flexible, or what will be the changes on that?

Mr Wessenger: I will ask Mr Quirt, if that's all right.

Mr Quirt: I'm Geoff Quirt and I'm the executive director of the long-term care division. I'd be happy to try to answer that question.

Currently, children's treatment centres receive funding from a number of different sources, as it's been pointed out. With respect to the home care program, the home care program has two responsibilities for delivering health services to children: one responsibility where they are responsible for purchasing or delivering health services so that students can attend school, and as has been pointed out, sometimes children and their families are the home care program's clients with respect to the provision of professional services or homemaking supports when the children are at home as well.

The home care program's required to provide that school program all across the province, and in locations where children's treatment centres exist it's often the practice, and I think for about 50% of the expenditures on children, for the home care program to buy the services delivered to children at school from children's treatment centres.

This is one form of funding that children's treatment centres get. We also core-fund children's treatment centres from our division and we also know that those who are affiliated with hospitals receive funding from the institutional division of health as well.

I think the point's been made by our presenters, a point well taken, that under the auspices of the Ministry of Community and Social Services there is a review to look at how services for children can be best integrated across various disciplines. We are involved in those discussions with Community and Social Services, but we certainly don't want to see, as the result of the advent of multiservice agencies, children fall through the gap. So the intention is that multiservice agencies would assume responsibility for delivering the same range of services to children that the home care program does now; in other words, serving them at home and at school.

It's fully expected that when delivering on that mandate, multiservice agencies may choose to purchase some of the specialised expertise that has traditionally been purchased by the home care program from children's treatment centres. As has been pointed out, it's conceivable that down the road, through the collaboration of the Ministry of Community and Social Services, Health, Education and others, there may be a better system that evolves for meeting children's services needs.

We want to be part of those discussions, and the mandate of multiservice agencies may change as a result of those discussions, but in the meantime, we want to make sure that the services that the home care program provides for kids now will be there through multiservice agencies.

Mrs O'Neill: I want to thank you for coming. I find this a very helpful brief. I want to ask you a couple of questions about your first page. You say you've been seeking active participation. Does that mean you haven't achieved the active participation you were seeking?

Ms Diana Thomson: I think we are really quite satisfied with the invitations to the various working groups that are currently in place, but we feel it's very important that the word get out, about more, bring to more people's attention the special and particular needs of children because they are a really rather small group in the context of this whole long-term care reform.

Mrs O'Neill: I don't know whether you've had a chance to see the most recent report of this committee. We've just completed a study on children at risk which I think was quite helpful. If you don't have the report, I'd certainly be happy to send it to you.

Ms Thomson: Thank you.

Mrs O'Neill: It would be of great interest to you, I'm sure. I found your appendices very helpful, from the Price Waterhouse one to the definitions of respite and special services at home. I think, as you say, many people don't know these programs. I'm also quite happy that you've put in your February 1994 submission.

I could say many things, but I am particularly happy that you touched on the developmentally disabled. I think there's a great possibility here to take many steps backward rather than forward, and not many people are talking about it, although the people who are in the field are talking. I'm glad you put children on the agenda of the committee on the first day, and I thank you for doing that.

Mr Jackson: I'd like to echo Ms O'Neill's comments because I support them with respect to getting them forward on the agenda. I can't help but think that one form of discrimination that you didn't list, but it's an equally -- it's the school health support services program that, depending on which school you go to, you're discriminated against.

I remember that when I pursued this matter on behalf of one of my constituents who was attending a Dutch Christian school, the government of the day, which isn't this government, indicated that it was an education program and therefore the government had the right to discriminate against a child who was attending a school that wasn't one of the two recognized school systems. Now I'm hearing everybody say, "Oh, this is a health program." It's very painful to hear that, from all sorts of people, in the last half-hour.


But that discrimination still exists today in this province, and I'm fearful that those handicapped children will be further discriminated against in this setting, because I doubt seriously if the components of a purchase-of-service agreement allow for school boards to contribute, that in fact the policy of the day will continue, that MSAs will not be allowed to breach that provincial guideline and that we'll still discriminate against the child, regardless of their handicap, but on their religious beliefs, frankly, is what it ends up being, in almost all cases.

Would you like to comment a bit on that? I know you've probably come up against those cases, since you deliver a component of children with health needs attending school.

Ms Renahan: It's a good example of what we're trying to communicate, in the sense that what has been included in the MSA is very limited, it has a lot of limitations put on it and it's very focused on who it will deal with and when and how. What we're trying to advocate is that we exist to provide a much broader-based service or other children's services. It doesn't have to just be a treatment centre, but a children's system, because we do service the children with different religions in their schools. So in a sense the Ministry of Health is supporting, but it comes from a different program.

We also go into the homes. We also have children who are contracted with home care. We would send a therapist who is our staff into the school to deliver physio, but the child will come on an outpatient basis for occupational therapy to our facility, and it's going to be split even further.

Also, we're hearing the families say it can only be delivered from 9 to 3:15. Now, try to refer to that. These family needs go beyond school hours. We're also saying -- and we're prepared, with support and dollars that could be transferred with it -- we should be open in the evenings. We should be open on the weekends. That's when our families need the service, and they should be coming in to us. That's what a lot of them would like. So there's a lot of limitations that one example highlights about that whole program.

Mr Jackson: Could I ask Mr Quirt to consider reporting back to the committee? The other application that concerns me, for example, is a child with a physical disability requiring speech-language pathology, which is, quite frankly, a big mess in this province at the moment, with three different ministries fighting over who should or should not be delivering it, but these children are caught in that.

Are we to have faith in the system that the MSAs will leapfrog that and that they can then cut through that and say, "Okay, that child's assessed needs" -- and I wish I had more time to discuss who is assessing children if they're an employee of the MSA, when 94% of their case load are geriatrics. But having said that, are we to believe that the MSA's going to cut through this or jump above it and say, "Here's a child with a physical disability who's a pre-schooler," because the school board's no longer doing those programs, the hospital has cut off the program and Comsoc won't fund it, are we to now believe that there'll an envelope of moneys under the MSA to ensure that these children's services will be made available because they fit the definition? That's a very hopeful sign if that's in fact what will be achieved, because the government's been unable to resolve this in the last four years and service delivery's getting worse, not better.

That's a loaded question, and there's no secret about it, but there's a clear example involving thousands of children, and if that in fact is how we're going to deal with this, then great, give us more details; if it's not, then let's determine if these certain kids with disabilities are going to be discriminated against even further because some are going to get on one side of the line for funding and others aren't. I'd like some answers to that, and Mr Quirt maybe needs some time to consider the question and the presentation.

The Chair: I think as well it's an issue around how children fall or do not fall under this particular bill, which committee members are going to want to look at a little carefully. I will take that question under advisement. May I thank you all for coming before the committee today and for raising a number of issues.

Mr Malkowski: I'd like to make a request, Mr Chair, from the person -- perhaps Comsoc could provide a briefing note related to the home care programs and how they are to relate to the MSAs.

The Chair: Thank you. Perhaps we can work that out with ministry staff and ensure that that is done.


The Chair: I call our next witness, the Catholic Health Association of Ontario. I see some familiar faces that come before this committee. If you'd just introduce yourselves for Hansard, then please go ahead. We have a copy of your submission in front of us.

Mr Ron Marr: Good Afternoon. My name is Ron Marr and I'm president of the Catholic Health Association of Ontario. With me today on is Sister Alice McEvoy, who is a member of the CHAO board of directors, the chair of our association's long-term care task force and executive director of Marianhill in Pembroke. Sister Bonnie MacLellan is executive director of St Joseph's Heritage in Thunder Bay and also a member of our long-term care task force.

Our membership is diverse, but it has a common heritage and embraces a philosophy that recognizes that those in need of health and other human services also need the dignity of having their needs met on the basis of respect for their personal, cultural, faith, social and linguistic preferences. Our members, our employees, our volunteers and our care providers share a common sense of mission and a commitment to purpose that, among other things, fosters initiative and encourages innovation without all of the constraints which often inhibit public sector providers of service.

The Catholic Health Association of Ontario supports the basic principles that are embodied in this bill: equity of services, increased access to services, and reform of the long-term care health system. We and our members have conveyed this message over the past few years as part of the government's review of long-term care. However, we cannot support Bill 173 because it is not, in our view, an appropriate reflection of the positions advanced at that time and will not achieve the objectives of long-term care reform.

The government is promising that this legislation will produce greater access and better services to consumers, the same promises which were made in advance of reform of the long-term care institutional sector. We must learn from the recent experience of what has transpired since reform has taken place in the institutional sector. What we now see is that the results of that reform are fewer beds, less funding and less staffing, and an increase in direct cost to the consumer of 47%. In light of this experience, it is difficult for us to accept bland assurances that this legislation will either increase the availability or improve the quality of community-based, long-term care in this province.

There are a number of issues which we would like to address this afternoon: (1) the destruction of community-based agencies; (2) the span of control of government bureaucracy through multiservice agencies; (3) the loss of mission, community support and volunteerism in the delivery of long-term care after Bill 173.

Prior to speaking to these specific concerns, I would like to address what we believe is a basic policy deficiency with this bill.

A key premise of this bill is the assignment to a single agency, the MSA, of the planning, funding and delivery of all community-based, long-term care services. The bill also entrenches the role of district health councils in the planning, funding and ultimately the delivery of services. It was our understanding, from the public consultations, that the major objective of the reform process was to improve the access, efficiency, effectiveness and ultimately the quality of long-term care. To the best of our knowledge, there is no research to demonstrate that the linking of planning, funding and service delivery will have this effect. Indeed, research has demonstrated just the opposite.

Research in Europe on similar monopolies demonstrated that this approach has been tried and abandoned. In a January 1994 paper, the Thames Valley District Health Council, one of the government's own official planning bodies, concluded: "Monopolies invite inefficiency and insensitivity to users. The provision of direct service by the MSA, could result in a loss of quality in the services delivered and a loss of incentive to maintain or improve the quality of service." They went on to state further: "We would like" to see "some assurance that this model (MSA) will work and that it isn't a model that other countries are moving away from. Publicly funded with contracted-out private service delivery appears to work best."

Turning now to our more specific concerns with Bill 173, I would like to ask Sister Bonnie to begin our presentation on how this bill will result in the destruction of community-based agencies.


Sister Bonnie MacLellan: The Catholic Health Association of Ontario has a long history of providing institutional and community health services for the people of Ontario. Most of our facilities and services were initiated to fill the service delivery gaps in the delivery of health and social services in the community. If Bill 173 proceeds unchallenged, the tradition of denominational and cultural group sponsorship of long-term care services, both in the community and perhaps eventually in institutions, will end. In the process, we will lose one of the foundations of our cherished Canadian health care system and we will lose an established mechanism for providing value-based safe, efficient, effective, holistic and compassionate care.

The major concern raised by both consumers and providers of long-term care was ease of access to a myriad of community health services. With the introduction of Bill 173, the government has determined that the solution to the problem of access rests solely in the arena of planning and management, ensuring that all planning and management is not only coordinated but accomplished by a central bureaucratic structure, the multiservice agency.

This bill goes beyond supporting MSAs in the planning and management of long-term care and community services. Bill 173 assumes those who plan and coordinate services will also employ professional, paraprofessional and support staff to provide these services. This is clearly an implementation and expropriation bill that will disband local community health and social service agencies, which have a long history of meeting the needs of the people in the community, and replace them with large, impersonal, regional bureaucracies. Charitable, non-profit providers are being told by this government: "Thank you very much for all that you have done for the people of Ontario for over 200 years or so. We're glad you could provide these services when we needed them. Now we think we, the government, can take over and be as efficient and as effective as you have been in the past. Your presence is no longer required."

Most people in this province, hearing this claim, would be appalled. With all due respect, there are few if any who would associate the adjectives "efficient" and "effective" with anything associated with government. While the spirit may be willing, the flesh is indeed weak. Show me those public services controlled solely by government that are more sensitive to consumer needs than to political and fiscal agendas. I'm from Thunder Bay, far away from Queen's Park. While I have a lot of faith in some areas, this is one in which I'm siding with Thomas. I challenge you to prove to me that the dismantling of the entire long-term care and community health care system will indeed improve the delivery of compassionate care to people in communities.

Mr Marr: I'd like now to ask Sister Alice McEvoy to address our second concern, which is the span of control of government bureaucracies through the establishment of the multiservice agencies.

Sister Alice McEvoy: Bill 173 is being promoted on the basis that it deals with the issues of access, coordination and integration of essential community services. Using these goals as a smokescreen, the government is attempting to position this bill as a consumer-driven initiative. We would argue that most consumers, real consumers, are not aware that criteria will be put in place which will actually limit their access.

There may be one-stop shopping, but consumers are not aware that choices will have to be made between the provision of health services and social services as they will all come from the same spending envelope. An individual's needs may have little to do with the level of care provided.

Consumers are also not aware that this bill will serve to constrain the development of new and innovative initiatives within our community, such as we've done in Pembroke with the community Alzheimer system.

Under the current system, the public has a choice in the services they receive and from whom. Under the new system, MSAs will absorb existing community services, including those that are now delivered by charitable agencies such as the Red Cross, the Victorian Order of Nurses, and the St Elizabeth Visiting Nurses, and take away that ability to choose. We do not believe that our communities and health care consumers will be better served by the elimination of the freedom of choice.

Under this legislation, the MSA will become a very powerful and centralized agency rigidly controlled by the provincial government. Through MSAs, social service providers will be competing for health care dollars. Acute health care needs in the community are constantly increasing due to shorter hospital stays. These needs can drain available resources away from other services, both health and related social services. The result may be fewer overall services for the MSA clients. Choices will have to be made which may have little to do with the individual's need and more to do with balancing costs.

The introduction of MSAs as proposed will also inhibit the innovation and development of new services. In the absence of competition, multiservice agencies will become monopolies, organizations known for their tendency to get bigger and more expensive, just as they are known for their inability to innovate and excel.

The consolidation and absorption of all community-based service organizations into an MSA will reduce the efficiency and effectiveness of those services now offered by charitable organizations, without bringing these services closer to the community. One of our major ties to the community is through our volunteer boards. Under this legislation, they will be replaced by large regional provincial bureaucracies directed by a handful of government appointees.

Charitable community non-profit agencies do not generate profits through their endeavours, nor do they have government's seemingly unlimited capacity to incur debt. By any standard, the administrative overall cost of charitable agencies is low. Funding in the future and, perhaps more importantly, the effectiveness of that funding will become an issue.

As community agencies are merged into the provincial bureaucracy of the MSA structure, each agency's staff will be absorbed. With this will come the pressures of unionization. Salary and benefit costs will inevitably escalate. Many community-based workers with a significant long-term commitment to this type of care could well find themselves out of work once the MSA is established.

Transitional funding is being promised along with this legislation. No doubt the government will point to these expenditures as an example of its commitment to long-term care. However, these funds will in large part be consumed by labour adjustment, retraining and administrative costs in order to set up these new bureaucracies. None of these precious long-term care dollars will have been used to provide new beds or new funding for additional home care services.

We believe you can easily address the objectives of one-stop access and the coordination and integration of services without eliminating community-based charitable organizations. Instead, the government has chosen to establish itself as the sole provider of long-term care, thereby trying to ensure the equity and availability of services, if not the excellence of those services.

Through this legislation, quality, creativity and innovation in long-term care will be stifled in exchange for rigid control and whatever limitations the government may feel compelled to impose. We do not believe that the interests of consumers will be better served by the inflexible delivery mechanism that will be imposed by this legislation.


Mr Marr: For our last point, Sister Bonnie will speak to the issue of the loss of mission, community support and voluntarism in the delivery of long-term care after Bill 173.

Sister MacLellan: In its discussion papers that preceded this legislation, the government attempted to address the issues of vision, mission and commitment that drive charitable community-based organizations such as those which make up the membership of the Catholic Health Association of Ontario.

In its document Partnerships in Long-Term Care, you assure consumers that they can ensure "some services do not lose their individual identities as they become part of the larger MSA organization, especially if this individuality is important to consumers." The document goes on to suggest that "the use of identifiers such as a service name, logo or service location," once amalgamated under the MSA, can retain their individuality. Nothing could be further from the truth.

I suppose I should be grateful that through this statement the government recognizes the role that values and tradition play in charitable human service agencies. What the government seems not to understand is that the passionate commitment of our staff and volunteers to the philosophy and values of these health care organizations are not the product of service names and logos or service locations. They are the product of our heritage. They are the product of having the hearts of our employees, our boards of directors and our volunteers captured by the vision of providing value-based and -driven holistic care, meeting physical, social, emotional and spiritual needs. These fundamental elements form the foundation of the services of the Catholic Health Association of Ontario and are not transferrable to the MSA. How do you transplant the heart of an organization into a bureaucracy? It cannot be done.

In terms of the commitment of our volunteers and those who support our fund-raising efforts, a significant proportion of our operating costs is offset by the efforts of the communities that support us. The government assumes that this volunteer support will continue to accrue to the benefit of the MSA bureaucracy. It is highly unlikely that this will be the case. Long-standing support for a community-based organization is generally just that: support for that specific community-based organization, its philosophy, its values, its mission and the founder's heritage. It is not the support for the general service itself. If we look at other rigidly controlled government services, it is difficult to understand how the government can claim that the existing level of voluntary commitment can be maintained.

Our members have been on the front line of human service delivery in this province for more than a century. Inspired by our historic roots and traditions, our member institutions have been leaders in designing, expanding and improving programs and services. Catholic health and human service providers respect the dignity of those we serve by recognizing their desire for services that are based on personal, faith, cultural, social and linguistic preferences. We only ask that our legislators now do the same.

Mr Marr: Just a final few comments, Mr Chairman. In conclusion, the Catholic Health Association of Ontario does not believe that the interests of consumers nor the interests of the public at large are better served through the elimination of the freedom of choice that results from this legislation. We believe that the proposals put forward by the government in this legislation are lacking in many basic elements which are vital to a properly functioning long-term care system. A lack of general public awareness exists regarding the effects of this legislation, and this has led to an overall lack of informed input and consultation. Only those who are plugged into the system have really been involved in this issue, not the people who actually need the care.

We do not believe that this province will be better served by the destruction of community-based volunteer boards in favour of a large bureaucracy directed by a handful of government appointees. We must be cognizant of other jurisdictions which have proceeded in this manner and have not been successful.

The enlarged health care bureaucracy created through this legislation will not attract the volunteers and the private donations that now augment the services provided by charitable community agencies. Without these funds and people we would be unable to provide the level of services we currently do. What will this mean for the level of available services in the future?

Finally, this bill does not guarantee that either the efficiency or quality of long-term care in this province will be enhanced as a result of its implementation. As we acknowledged earlier, changes are required; however, we should be sure the changes will bring about improvements to the system before they are implemented. We believe that the important goals of the reform of long-term care are in danger of being lost unless this legislation is modified significantly. Thank you very much.

The Chair: Thank you very much for your submission. I'm going to have to play the heavy as Chair and just note that we have a problem with time. I can allow one person from each caucus to ask questions. We could probably be here quite a bit longer, but I'm afraid we have a problem. I have the parliamentary assistant, Ms Sullivan and Mr Wilson.

Mr Wessenger: I was interested in some of the statements made. First of all, it should be indicated that there's a misconception about the planning being part of the MSA function. That's not accurate. The planning is part of the district health council function and not part of the MSA function.

Second, in view of the fact that MSAs are going to be non-profit corporations, in view of the fact that their membership will be open to all members of the community, in view of the fact that they will have people elected, I assume, like any other non-profit corporation, to the board, with the election undoubtedly to meet certain criteria of consumer and provider requirements, and in view of the fact that in many ways this type of structure will be somewhat similar to what we have in many hospitals -- and if we look at the success that the hospitals have with respect to fund-raising, with respect to volunteers, we see they have a great deal of success -- therefore I'd like to ask you on what basis, in view of the fact that we're in effect having a community equivalent to a hospital, with a charitable status, a non-profit status, local input, why you feel this is going to be a large government bureaucracy.

Mr Marr: I think I'll answer that one. I'd like to start out by clarifying one point for Mr Wessenger -- and I think we've been in this debate in the past -- that there are significant differences between hospital corporations and the MSA. Hospitals are charitable, not-for-profit corporations, you're correct, but that's what exists today with individual agencies such as Saint Elizabeth Visiting Nurses, VON, Red Cross etc.

What's being proposed in this legislation is very different. It's one agency. There will be one game in town, where all agencies will lose their identity and will become one government-run and government-controlled bureaucracy. It's very different from hospitals that have unique and individual missions and enter into purchase-of-service agreements with the government.

Mr Wessenger: No. I can understand your concern about your own organization's individual existence, but it would seem that in many cases -- for instance, in many communities you have one hospital. Other communities have more than one hospital, but the trend has been towards, as we see what's happening in the Windsor area, the hospitals getting together and forming one type of joint management process. It seems there's very much an equivalent between the institutional sector and the community sector.

There's certainly a major difference in the model that's proposed here from the Quebec model. You're quite right, the Quebec model is a government-run -- well, maybe not. It's a different type of model. It's certainly not based on the non-profit, charitable model, which is of course the basis of the MSA. The MSA, being a charitable, non-profit corporation, would be able to elicit donations and seek donations and would be seeking volunteers, the same way a hospital does. I have this difficulty in understanding the perception of the MSA as -- it doesn't fit the centralized model. It's certainly not centralized from a provincial basis, anyway. It's really a community-based model: one organization, I agree, but a community-based one.


Mr Marr: Our concern is not so much with the objectives of the MSA. Everybody appearing before this committee today has probably said the same thing in terms of reform of long-term care. Where we're having some difficulty with this is in the methods to achieve the objectives. We do not believe that disbanding existing expertise and putting everybody under one umbrella is going to achieve the objectives that are being stated for long-term care, any more than in the hospital sector merging two hospitals is going to result in efficiencies that everyone thinks are there.

I see Mr Martin from Sault Ste Marie here, for example. There's an experience in Sault Ste Marie where two hospitals have managed extraordinarily well to come together and achieve many of the government objectives and everybody else's objectives in terms of hospital care without merging the two hospitals, with maintaining two distinct identities and being true to the heritage of both facilities and offering the highest quality of care.

The merger of institutions or agencies does not always result in the objectives that are being suggested for long-term care reform. That's the basis of our concern.

Mrs Sullivan: I too am concerned with the disappearance of the mission-based facilities and agencies that we see as a direct result of the new multiservice agency concept. I wonder if you could speak in a quite directed way with respect to the canon law base of the Catholic health care organizations' missions and mission statements and what effect the canon law requirements would have ultimately if the MSA is formed and the Catholic agencies' existing missions are not met through the MSA. What would be the position of the Catholic health care organizations? Could you participate, or are we indeed looking at simply a new employer and all the Catholic agencies are gone by the board?

Mr Marr: I think this goes beyond a Catholic issue and an issue of canon law. What we're talking about --

Mrs Sullivan: I understand that, because we will have other agencies that are Salvation Army agencies or Anglican agencies or Jewish agencies that are affected by this particular situation. But in hospital discussions, one of the things there has to have been extreme care about is to ensure that the canon law requirements are met in terms of joint management or participation in any kind of joint venture. That's what I'm getting at here. I'll have other questions for the other religious organizations with respect to their missions and how that will be maintained and ultimately integrated.

Mr Marr: The basic principles of canon law, when applied to a health institution or facility, generally imply that in order to maintain the mission and values of that community-based or institutional-based service, the only way you can guarantee that is through direct governance of that institution or community-based service. Once you remove the governance, the ability to govern that institution, which will happen under this legislation to every community-based agency, not just Catholic community-based agencies, that mission is lost, it is then a new institution. In terms of Catholic providers, we could not continue with that, and I don't think any -- you may call it the VON or you may call it Saint Elizabeth's, but it isn't. It's an MSA program.

Mr Jim Wilson: When I studied canon law, I wish I had paid more attention to governance matters. It seems to me it would be a question of conscience indeed for not only employees of Catholic institutions but previous governors of Catholic institutions also. I mean, if they're going to take the crucifixes down from the walls and water down the program totally and take the ethos out, I can't see why any of the denominations would want to be involved in it.

Second, the parliamentary assistant's comments were extremely misleading. I don't think we're reading the same bill, Mr Wessenger, because you are gutting these institutions. As I said earlier, either you're bringing in a big bureaucracy to put on top of existing agencies -- you tell us you're not doing that, so second, you're bringing in a bureaucracy and these other agencies will have to give; I mean, they'll be dissolved. You can't have it both ways. Your bill's certainly designed to bring in a bureaucracy. I just can't picture anyone fund-raising for an MSA.

Mr Jackson: I already pay taxes. Why would I give to an MSA?

Mr Jim Wilson: The Premier just isn't that popular, nor can I picture people volunteering for the government, goodness knows. Look at our own bloody polling on these issues. People are trying to get away from government, and look to sectors such as the Catholic Health for the delivery of services.

It's an astounding presentation you've made and it follows on the press conference you had. You've used extremely strong words: "expropriation," the "elimination" of denominational services such as yours in governance. I know you've had a lot of months in working with the government or at least talking with the government -- maybe it was one-sided. I want to know, given that we understand from our briefings that you were consulted along the way, and other denominations were, now that Bill 173 appears in its present form before us, what's your opinion of the process?

Second, I just want to read for you an excerpt. I think the minister, doing damage control from your press conference today, has issued a press release. It's kind of happy, but there's a line in it, a quote from the minister saying, "The values and traditions that caring volunteers have demonstrated for many years in this province are at the heart of changes in long-term care." She's directly challenging the statements you've made, both in the press conference and here. I think there was some scepticism of members of the press gallery too, and I suspect you got the point across rather powerfully when they persistently asked, "Give us an example of how this will gut your institutions and how it will discourage volunteers."

I want to talk about the process at this point, because I don't ever want to see it happen again in this province -- I've had enough of it -- and second, with respect to volunteers once again.

Mr Marr: I'll try and answer what I think you're asking. We have been involved for the last two or three years in discussions around reform of long-term care and we have participated actively, and I hope that various constituencies have heard what our member institutions and community agencies have been saying. Why we're coming out now: We are not saying anything different today from what we have said for the last two and a half years, in terms of, if you go forward with MSAs this is what you're doing to community-based agencies.

My concern, quite frankly, is ultimately to institutional care as well. If you get the community agencies under the umbrella of the MSA, two years down the road maybe it's time for the homes for the aged to be brought under the MSA umbrella; maybe two years later it's time for all hospitals to come under the MSA umbrella. We don't know.

We've been saying this for two and a half years. Why we're coming out strong now is because the legislation has now been tabled. The messages we've been giving and that other agencies and groups have been giving for the last two and a half years are not reflected in this legislation. We've had since, what, June 3 or June 6 or something since this legislation was tabled, to prepare this response. There's nothing new in here; we've been saying this for two and a half years.

Mr Jim Wilson: The minister doesn't believe that your volunteers will be affected. Do you want to try one more time?

The Chair: This is the last question, please.


Mr Jim Wilson: Well, she challenges them. It's absolutely astounding.

Ms Jenny Carter (Peterborough): Seventy thousand people were consulted, and we're being told that there was no consultation?


Mr Jackson: Did you go to one of those meetings?

The Chair: Order, please.


The Chair: Order. Please allow the witness to respond, and I'm afraid this will have to be the last response.

Mr Marr: I think the question was the impact on volunteers and on service agencies. There are two agencies following us after this presentation that I think can talk to you much more specifically about these particular issues than we can at this time. Maybe you can ask the same question of Saint Elizabeth Visiting Nurses' Association of Ontario and Catholic Charities of the Archdiocese of Toronto.

The Chair: Thank you. I'll just jump in quickly before exuberant members get going. Thank you very much for your submission and for coming before the committee today.


The Chair: I call on the representatives from the Saint Elizabeth Visiting Nurses' Association of Ontario. I just note to committee members that we are running about half an hour late. I apologize that we can't have everyone's questions, but we will try to cover as much ground as we can with the next two presentations.

Ms Shirlee Sharkey: Mr Chairman, members of the committee, I am pleased to be appearing before you today to present the views of Saint Elizabeth visiting nurses' association regarding the government's legislation to establish multiservice agencies. My name is Shirlee Sharkey and I'm the president and CEO of Saint Elizabeth, and with me are Joel Rochon, the chair of our board, and John Burns, a board member.

Saint Elizabeth has provided quality home nursing services to the residents of Ontario for over 85 years. We employ over 800 staff. This year we served over 13,500 residents and made over 600,000 visits to the regions of Peel, Durham and Metropolitan Toronto. We have provided teaching for over 500 nursing and medical students this year alone.

Our values come from origins in the Catholic community, but we provide professional care to Catholics and non-Catholics alike and specialize in working with a variety of ethnic cultures. Over 66% of our clients are senior citizens. Our mission is very simple: We are committed to providing integrated nursing and related health care which meets the physical, emotional and spiritual needs of both clients and their families in their homes and communities. We have an independent volunteer board of 18 members which governs our operations.

We are responsive to and reflective of the communities we serve. Saint Elizabeth is an organization which provides innovative services and programs such as gerontology, psychogeriatrics and an elder abuse protocol. As well, we provide palliative care, renal dialysis, paediatrics, mental health, respiratory and chemotherapies. We care for each person on an individual needs-driven basis in their own home. Emphasis is placed on illness prevention and teaching individuals and their families to assume responsibility for their own care. All of this work is done in-home by way of a locally sensitive community-based system as opposed to the proposed large MSA bureaucracy.

For the most part, our clients are referred to us from physicians through home care. This latter organization evaluates a client's eligibility, assesses need and arranges for Saint Elizabeth's. This system is not perfect, given the limited mandate of the home care program. In this respect, Saint Elizabeth agrees with the sections of the bill which aim to improve and broaden access to important long-term care services.

However, while we support the commitment to access and also to the patients' bill of rights, it is our experience in community-based health care over the last three quarters of a century which makes us so concerned about some of the proposals contained in Bill 173. We believe in the community-based approach which this government has been promoting and applaud many of your initiatives in this area. However, aspects of this legislation are of great concern to us.

The proposals contained in Bill 173 will lead to an unknown number of multiservice agencies. While the MSAs will be allowed to contract out some of their services, they will be limited to 20% of total services. The MSAs will take over current well-functioning organizations and absorb them into one agency within that geographic area. Ironically, the resulting duplication of community health services runs counter to one of the stated goals of this legislation: lower costs.

For example, if all of the nursing services currently provided are offered by individual MSAs, our calculations indicate the proposed establishment of up to 20 MSAs in Metro Toronto alone will cost taxpayers an additional $7 million in order to support just these nursing services.

The proposed changes also mean that long-standing service organizations will lose their individual focus and identity within their communities. Clients will no longer have the ability to choose a specific organization for their care. Many worthwhile organizations with established standards, efficient operations and a critical mass of highly trained and responsive health professionals will not be used to provide necessary services. Many of Saint Elizabeth's workers will lose their jobs and will have to apply for new positions in the MSA, and the volunteer element will be removed from our organization. All of these items will dramatically affect the ability of the MSAs to provide adequate and appropriate services, since it will be impossible to replicate Saint Elizabeth's specialized professional service in each MSA. We believe these changes will impact negatively not only on our clients, but on the system in general.

The changes being proposed would remove our individual nature and replace us with a faceless government-mandated agency. One of the most positive features of Saint Elizabeth's is that we are part of the community, we know the community and we are supported by the community. People know we will provide care enhanced by our respect for cultural and religious beliefs. These features provide a more responsive and caring service, the type of care we should be moving towards, not away from.

The choice of agencies to provide services will not exist if MSAs are established as currently outlined. As we understand it, the individual will be referred to one service provider, the MSA, which will provide all the required services. This obviously precludes the client's choice of accessing services from existing agencies.

We do believe that some of the provisions of Bill 173 could facilitate consumer choice, specifically those which establish a single access point for determining the availability of required services and the options which exist. This is the role that government and government-mandated organizations should play, to determine eligibility and access to the system and establish program standards. But it is here where the activities of the MSA should stop. The delivery of professional health services should continue to be the responsibility of the well-functioning organizations which currently exist. They should not be provided by government-mandated organizations which have taken away the identity of the agencies they have absorbed.

As currently outlined, MSAs will become the major community employer of health professionals. What will happen to Saint Elizabeth's non-unionized professionals? Indications exist in some government guidelines that unionized employees will have the first opportunity for available jobs. This will place Saint Elizabeth's workers and other non-unionized workers at great disadvantage. In our view, this is an unacceptable situation for hardworking, skilled and devoted employees of organizations or groups like ours.

The Minister of Health must ensure that non-union staff have protection similar to that offered to unionized staff under the Labour Relations Act, but more importantly, the Minister of Health must be concerned regarding the quality of workers. The skill, quality and commitment to community health care that exists today is not easily or cheaply replaced. Rather than absorbing independent organizations, increasing financial costs and making them part of the government MSA system, these organizations should be retained to allow the provision of the best and most cost-effective services possible.


Currently, Saint Elizabeth is supported by hundreds of volunteers, enabling us to efficiently run our operations and devote funds to providing care to clients. With MSAs, virtually all volunteer time and financial support now contributed to charitable agencies will disappear. It is highly unlikely that volunteers who support Saint Elizabeth's will continue to support a bureaucratic structure which is taking away the individuality of the organization they believed in. People choose to volunteer and support individual organizations due to their values and personal experiences. We doubt that this bond will be developed with a government-mandated MSA.

We at Saint Elizabeth's agree reforms need to be made to the long-term care system and we have been an active participant in the government's review of this matter over the last number of years. Changes are particularly needed in the area of accessibility to and knowledge of available services. However, it is possible to achieve these reforms without changing the entire system and eliminating much of the good which currently exists. We believe that it is still part of our social fabric to have volunteers continue in their role of helping others in their communities. Support for services such as those provided by Saint Elizabeth shows that many others believe this as well. This is not the time to water down home care by simplistically blending social and health services and forcing choices to be made between them as if there is no difference. This will only hurt the people we are trying to serve. This is the time to be supportive of those independent community organizations which are successful and try to replicate their activities across the province.

Rather than devoting millions of dollars towards taking over and running current agencies such as ours, why not target that money to promote the development of well-thought-out community-based organizations? Why not put a system in place which will provide real one-stop shopping and easy access to service information without having to provide the actual services? This should be the role of the MSAs: to establish criteria, ensure equity of access. These actions would be much more beneficial to the people we are trying to help, the clients and their families, than the proposals currently on the table.

While we support the principles of long-term care reform, the role of the MSA should not be to provide services. The elimination of non-profit, ethnocultural agencies that are efficient and well managed is not only wasteful but unnecessary. The replacement of these professional health care organizations with the proposed MSA structures will cost the taxpayer more and will deprive clients of high-quality care given by well-trained specialists. It will also eliminate individual choice, thus interfering with personal liberty, and as we all know, the price of liberty is eternal vigilance.

We urge this committee to exert that vigilance in considering these factors and to take the necessary steps to put in place a long-term care system which will really serve the needs of the people of Ontario.

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

Mr Malkowski: Thank you very much. Interesting presentation. I think it's important to clarify, if we could just touch on some of the facts, that MSAs are not a bureaucratic system. They are and they will be run by the community-based agencies that are out there.

I just wanted to ask a question. You are saying that choices might be limited and, "You're going to remove choice to individuals." I want to be clear that I believe it's actually going to be an increase in personal freedom and choice. I believe there will be an increase as a result of long-term care.

But let me ask you a question: Right now planning is happening across the province. Can you tell us how Saint Elizabeth could be involved to date and what they have been doing in the local district health councils?

Ms Sharkey: I'd be pleased to respond to that question. Saint Elizabeth has been actively involved in the last two and a half years with the reform of long-term care reform, at the DHC level, both on the long-term care steering committees and on the MSA design working committees.

We have voiced the same concerns today at the DHC over and over again and have clarified the specifics of the concerns with the service delivery aspect of the MSA model but have also been clear about the other aspects that we support.

We have also, at the local level, throughout all of our years, been very involved in community involvement. In Metro Toronto alone we are involved in 18 of the planning consortiums for MSAs and in Peel and Durham have been actively involved. We also have been involved in the York region, where we have currently expanded our services, and in the Kingston region.

Mr Malkowski: Just a quick supplementary. Could you tell me or give me an example then, where you talk about the limitation of choices, where you believe that choice will be eliminated, if you strongly believe an MSA would do that? I believe it actually will increase our range of options. Could you give me an illustration of how you think one's choices might be limited?

Ms Sharkey: I'd be pleased to respond to that. We have, with our program in the areas that we service, the ability for anyone in the home care programs to ask for Saint Elizabeth nurses or the Victorian Order of Nurses as a choice of service. During that opportunity, many may choose to have one or the other agency, based on preference, history and even some of the unique programs that we currently provide. My understanding with the MSA model is that Saint Elizabeth's and VON will not be around for the client to choose either one of those agencies, and that is quite clear, from our perspective.

Mr Malkowski: May I ask a follow-up of the policy people? If in fact these comments are based on reality, is that true, that the Saint Elizabeth and VON won't be under?

Mr Wessenger: I think what the member is asking is how the process works at the present time, and I think the staff could probably indicate how it works with respect to the home care being provided.

Mr Jackson: It's not a process question, it's an outcome question. Will it happen? Yes or no.

Mr Quirt: I think it's fair to say that across Ontario now MSAs are being planned through the DHC planning process, and in some communities it's conceivable that the nurses who now work for the VON or the nurses who now work for Saint Elizabeth would become part of the multiservice agency.

Mr Jackson: Employed by.

Mr Quirt: And employed by.


The Chair: Order, please.

Mr Quirt: That's a distinct possibility. It's a distinct possibility that many other --

Mrs Sullivan: On the other hand, they might not get a job.

Mr Quirt: It's quite possible that in some communities an existing Victorian Order of Nurses branch or an existing agency currently, like a home support agency, may be seen as the logical provider of the MSA services and in effect workers would be transferred to that organization as opposed to those workers going elsewhere.

There's no question that this is a disruption for those employees who are now employed by over 1,000 long-term care agencies across the province, and it is an organizational change that's difficult for many people to cope with and to move forward with. But I think the objective is to create a system that's more integrated.

Right now, we have over 1,000 agencies that deliver long-term care services in the community. We heard from consumers that this is too many agencies. We heard that it's difficult to have to deal with four or five agencies to have four or five different needs met and, quite frankly, consumers told us that they'd rather go one place and have one agency equipped to meet their needs in a more flexible and comprehensive way rather than deal with a number of organizations.

In recognition of the fact that it will be difficult for workers and organizations to make this transition, the bill allows for the designation of a multiservice agency with a period of up to four years for that type of adjustment to take place. In terms of a period of four years within which the 20% service limit may not be applied, the minister can exempt the MSA from that requirement or the minister can exempt the MSA from delivering all the mandatory services indicated.

We recognize it's a difficult transition. It has to be planned locally. I'm pleased to see that your organization is involved in the planning not only here in Metro but in other parts of the province, and we're pleased with the advice you've given us on the provincial advisory committees as well.


It is a fundamental organizational change. We believe it's one that's necessary and we believe it's one that will result in better service for consumers across the province.

Ms Sharkey: If I could just clarify on a few comments, Geoff. One, I do appreciate your concern about the difficulty of the workers, and we do also. But our concern goes far beyond that. It's the quality of care that will be compromised in the system if in fact the workers are not used in the MSAs, and the retraining costs and the educational costs, which is another issue where we've not received a response regarding unionized and non-unionized employees.

In addition, the comment about 1,000 agencies providing services, let me be perfectly clear: From the health agencies in the system, there are less than a handful of professional health agencies. In the areas that we provide care in Metropolitan Toronto, with 2.2 million people, there are a handful of community health providers; in fact, less than a handful of community health organizations. So let's be very clear when we collapse all of the agencies into one analysis of thousands of agencies.

Ms Carter: Could I have a point of clarification, please, I guess from Mr Quirt. You say, and obviously it's true for Metro, that people you serve have the choice between VON and the Saint Elizabeth nurses. I'm just wondering how general that is across the province. I understand that in most places, there would be one or another of these agencies; there would not be a choice in practice in most circumstances.

Ms Sharkey: That's in fact what we are proposing, that more community agencies be allowed to be accessible throughout the province so that the comprehensive services we now provide with Saint Eliz and VON can be offered province-wide. In fact, some of those services are extremely limited in areas where there is only one provider in the system. So that's very much what we're trying to encourage.

Ms Carter: But I understand that home care organizations would often have a contract with one of these groups only, so that, in effect, their consumers would automatically receive a nurse from that organization rather than having a choice. Could you confirm or deny that?

Mr Quirt: Certainly you're quite right that in terms of accessing publicly funded services in your own home, like a publicly funded nursing visitor, homemaker visit, there is one place you go, and one place only, to have that decision made currently, and that is to the local home care program, of which there are 38 province-wide. So in terms of choices, to go talk to someone who decides whether you're supported by the publicly funded system or not, there is one place to go; there is not a choice in that regard.

In many parts of Ontario, your second observation is also quite accurate. In rural Ontario in particular, there may well be circumstances where there is one contract for nursing service or perhaps one contract for homemaking. In many parts of Ontario, there is the choice that the home care program can exercise among a variety of providers, but in rural areas in particular there is not a large number of agencies from which a client could choose to be served. As I pointed out earlier, there's one place where you go to have it determined whether you're eligible or not in the first place.

In many parts of Ontario, you would have the one home care program to go to, to have it determined that you were eligible to receive either nursing or homemaking services. There may be one or more nursing or homemaking agencies that would serve you at the discretion of the home care program, and it's conceivable you might receive a Meals on Wheels service from another agency, a transportation service from yet another, and a friendly visit from another home support agency. I suppose you could look at that as a choice, but you certainly wouldn't have a choice of two home support agencies to choose a meal from and you would be having to deal with, on your own, those five agencies to coordinate the full range of service that you needed.

The Chair: Sorry, did you want to make a comment?

Mr Joel Rochon: Yes.

The Chair: Please do so and then, just to committee members, we must move on to Ms Sullivan and Mr Wilson.

Mr Rochon: I just want to say that when we're talking about choice here we're not talking about an insignificant group. We're talking 48% of the citizens of this province say that their religion is Catholic. I mean, half the tax base comes from these people. So if you have a cancer situation and you feel that you're dying and you want palliative care, you might want a choice of who is delivering the palliative care in your home. That being the case, maybe it's conceivable that half the MSAs should be Catholic in origin, because that represents the community.

What is the definition of community here? Is it geographic, as this organization says it is, or is it the Italian community, the Greek community, the Hungarian community, the Jewish community, the Anglican community, the Catholic community? Maybe that's another definition which would very significantly change the shape and form of this organization.

I suggest that the organization is very simplistically designed, and it's designed to say that the best way to do this is to have a bureaucratic -- and no one likes that word, I know, in this room -- organization to run it all. I think that's insensitive and, by the way, flies in the face of the objectives of this initiative in the first place, which said that it was going to be spiritually, culturally sensitive. It is not.

Mrs Sullivan: That's a very eloquent summation.

There are two points that I want to raise in my questions. The first is with respect to what Mr Quirt calls the disruption of the existing employee base. That disruption is going to be not a disruption that's calm. It will be tantamount to a revolution. There'll be severance issues -- who pays; there will be succession rights; where is the non-unionized worker in relationship to the Labour Relations Act; there'll be the question of job guarantees and promises which have been made to agencies; there'll be the question of where the funding comes from for retraining; there'll be the whole question of what happens to the, I think it was 5,000 nurses we know of who have been displaced from hospitals during restructuring who've been told that their new places are in the community agency.

Those issues I think have to be addressed and we're going to have to turn our mind to it. If you want to comment further on that during this dialogue, that would be useful.

The other issue, though, that I want to ask a particular question about is with respect to the 80% of services which the government now says will have to be provided by the new multiservice agency. If 80% of those services which are now provided by community-based agencies such as your own are provided by the new agency, that means that the services which you offer will be depleted by 80%. Some of the services that Saint Elizabeth's offers are above and beyond what are required mandatory services in this bill, and you've delineated some of them in your presentation, not the least of which are dialysis services and home chemotherapy and so on.

Will Saint Elizabeth's be able to sustain the provision of that other 20% of services if your government-funded base is taken away from you to the tune of 80%?

Ms Sharkey: Absolutely not. Some of those other additional programs are our palliative care volunteer program, which is completely funded and supported outside of government funds; also our bereavement program, where we receive additional funding from Catholic Charities and ShareLife. In addition, many of our specialty programs -- our mental health program, our home chemotherapy program -- received enhanced contributions in funds to provide the educational support through our own charitable status. It is with those additional costs and value added in the system that we feel we are able to provide a very cost-effective approach to the services that, quite frankly, no government can afford at this point.

Mr Rochon: May I have a supplemental?

The Chair: You're in the right place.


Mr Rochon: I'd just like to speak about critical mass. The reason that Saint Elizabeth is such an excellent organization with its specialties in palliative care and oncology and in-home chemo and the rest of the thing is that they're able to train specialists among their group. If you take that group of 800 and you divide it by 20 times, you lose the critical mass and the ability to develop and sustain that professional confidence. The person who suffers as a result of that lack of critical mass and ability to train is the patient, the citizen of the province you're trying to serve.

What is wrong with going into the MSA organization as a point of call, the 911 sort of number, and then having organizations like Saint Elizabeth, representing a very important constituent in the province, provide those services in an efficient, flexible way?

In business it's well known that you can either have things in-house or contract them out. In our case, we have delivered those services against government-provided standards as to cost, and you know what you're paying. What will happen to those costs in the new mode, when you don't have that contracting piece? You all have homes. Would you sooner have someone hired on an hourly rate or would you sooner have a contract rate? You want a contract rate because you can manage it.

You are responsible for managing the fiscal resources of the province. Are you doing a responsible job of that when you do away with professional services such as this and the contracting that allows you to control costs? How do you go to your voters and say, "We've done a wonderful job with this"? Or is it really just a political agenda being played out here? You have to ask yourself that.

Mr Jackson: Well, there's no question, Mr Rochon, that it is a political agenda. I think both your comments and Ron Marr's, who preceded you, have indicated with some of your comments -- I can't help but say that how you were describing what would be a wiser approach for the MSA, and Ms Sharkey had also said that as well, was in fact what we were discussing in this province for the last six years and it's exactly what our public consultations were built on. These are the images we built in the minds of the public and professionals.

It wasn't until just recently that the government just announced, all of a sudden, out of the blue, "Oh, by the way, we're going to deliver the services through the MSA." This is why I'm rather cynical about any reference to 70,000 people being consulted. I went to those public hearings -- and a whole series of issues. People wanted a 1-800 number. They didn't want to dance around the four agencies while people tried to assess them over the phone. They wanted to be able to go to your agency, but they didn't want to make four phone calls before they arrived at your doorstep for service. That's what the public said in this province, pure and simple.

Now, when you raise the issue of, is there a political agenda here, I want to propose a couple of issues for you and ask for your comments. I would have, if time had permitted me and I had shared my rotation with my colleague more and my number had come up when I sat through all of Bill 101 -- and you remember when that thing was unveiled and there was no reference to the cultural, religious, ethnic aspects of a whole infrastructure that has a history in this province for nursing homes and homes for the aged. I mean, the government literally had to be dragged to the table to get them to consider amendments that would acknowledge that these institutions exist. If you go back a step further and you look at our chronic care hospitals and what -- frankly, the Catholic-based chronic care hospitals suffered the most in the last six years in the first hit that chronic care took in this province. It was the Catholic hospitals that got hurt the most by those government decisions.

Here we're seeing a trend, but Mr Marr tipped on it and it's the first time it's come up in the public hearings, and that is, is that the grand vision, the plan, the political agenda that eventually will move all our homes for the aged and retirement homes and all of those facilities under the MSA model now that we've disfranchised the mission statements, the ethnicity, the cultural diversity of these organizations?

Frankly, half my family is Ukrainian Catholic. I'm telling you, there is absolutely no way in the world that we can dismantle the kinds of deeply felt convictions about the need for service and how that service is rendered in this province. I see the MSAs and their structure as working against that, and eventually it'll percolate back up to the homes for the aged and the nursing homes and retirement homes around this province, and that may be the real political agenda.

Then there's that whole aspect of its implications for labour negotiations and how OPSEU and other organizations will absolutely refuse for an individual to say, "Quite frankly, I'd like my services provided by a Catholic agency," or, "I would like my services provided by someone who speaks Greek, please, because my mother only speaks Greek and she deserves the right to have her needs understood." But OPSEU's not necessarily convinced that that's appropriate in Ontario today. So your comments on those, please.

Mr Rochon: First of all, I'd like to say that the way I read this thing is that this thing started out with people objecting, "We can't get at that maze of agencies simply and it's confusing for us." We've all had that experience. How do you get a handle on this thing? But that was the problem. As a matter of fact, that piece of the problem, I might add, was the part that was managed by the government through home care. That was not well known and so people went to the agencies and said, "How do I get at this?" and they said, "You go to home care or you go to your doctor," and so they kind of guided them around.

The part that screwed up, if you'll pardon that expression in this august hearing, was a governmental piece of it, the management of the governmental piece. I know everyone likes to take shots at the government, but that was the truth; so as a result of that, saying: "We've got a problem here in communication. We'll change the whole thing. We'll throw the baby out with the bathwater. We'll take the strengths and the weakness and we'll put them in a bundle and send them down the river."

I ask you, if you've got a well managed, cost-effective organization that's responsive to the needs of the community and is well respected, not only in Canada but in North America, for its excellence, why would you dismantle that in favour of an organization that's unknown, unproven and that has a heritage that is not particularly healthy in terms of management skills? I just find it very offensive to look at the destructive force this legislation puts into motion against people who have dedicated their lives, as many of the staff and the people who have worked in this organization have done, and the beneficiary of all of their work, with the support of their volunteers, has been the patient.

So the winner in this case somehow will be some kind of government agenda. The losers will be the taxpayer, because it's going to cost more, and the patient because the quality of services is going to decline. How does that make sense?

The Chair: I'm afraid with that question left there, we're going to have to move on because we still have one --

Mr Malkowski: Just on a point of clarification --

The Chair: I'm sorry, we have to move on. It's 25 to 6 and we're late and the Catholic Charities of the Archdiocese of Toronto have been here for some time. Perhaps you can work your question in at that time, Mr Malkowski. May I thank you all for coming on behalf of the Saint Elizabeth nurses' association.


The Chair: I invite the representatives from the Catholic Charities, who have been waiting patiently. I trust we've not kept you too late but I think you can sense the nature of the issues is such that we sometimes go over. Do you want to just take one second, just so people are leaving the room, and we'll get a quieter room for your presentation. If you would also just be good enough to introduce the members of your group.

Mr Brian Dunn: Thank you, Mr Chairman. We appreciate you staying over as well, and your committee. My name is Brian Dunn. I'm the president of Catholic Charities of the Archdiocese of Toronto. I've been a volunteer board member for five years and it's from that perspective that I'm speaking to you today. With me today, on my left, is Mrs Norma Barone, who is a volunteer board member and past president of the Catholic Family Services of Toronto. To my right is Michael Fullan, the executive director of Catholic Charities.

Catholic Charities provides extensive funding for our member agencies throughout York, Durham and Peel regions, Simcoe county and Metro Toronto. Our goals are to provide leadership, to advocate on behalf of those in need of service and to ensure quality service available through our member agencies to all members of the community regardless -- and I stress "regardless" -- of religious affiliation.

We are here today as representatives of the Human Services Alliance. The Human Services Alliance has grown out of a small group of Catholic-value-based organizations which first met in the spring of 1993 to discuss common concerns and potential points of alliance in response to the rapid changes in the human services system. Today more than 40 organizations are members of the alliance, and they provide services such as housing, social services, health care and other components of the care system.


The members of the alliance have a rich history and experience of reaching out to those in need: the disadvantaged and vulnerable; to those who are at risk of falling between the cracks of the existing system. Throughout our individual histories, we have continued to develop partnerships with each other in order to provide the best care possible to the community.

The Human Services Alliance has four main goals: to ensure a continuum of care for all individuals, to ensure consumer choice and local access to services, to preserve our members' service philosophy and values and to maintain our linkages within the community through our volunteer and staff commitment to its needs.

We believe that reforms to the human services system are necessary in order to better serve all members of our diverse community. The care system should be coordinated and responsive. It should be simplified so that access can be made through one phone call. However, we have concerns regarding Bill 173. Specifically, we believe Bill 173 will result in the disappearance of existing non-profit and charitable agencies, the reduction of volunteer support and donations and of individual choice.

We believe that Bill 173 as it is today will mean the end of the non-profit and charitable organizations we represent. Instead of building on the existing strengths of the human services system, in particular in terms of long-term care services, the government is proposing to tear it down and replace it with an MSA structure that will be extremely bureaucratic in nature.

With the disappearance of these agencies, community support, both in terms of donations and volunteer time, will disappear. From a historic perspective and a cultural perspective, people don't volunteer for government-based agencies. The members of the Human Services Alliance currently rely on the efforts of thousands of direct-service volunteers and over 500 volunteers at the board and committee level. These volunteers give their time because they appreciate the work we do, the agency does, and because they particularly support a special service provided by one of our member agencies. They are attracted by our individual histories and service philosophies. Ongoing volunteer association with our agencies is supported by the quality of service provided.

If this community support was converted into financial compensation, it could conservatively be estimated at a value of $10 million a year. We do not see this volunteer commitment and dedication continuing within a government-mandated structure. Volunteers donate their time because of the history and value structures of organizations, and if these lose their identity by being swept under a large government umbrella, a lot of people are going to say, "I'm not going to give my time or my money to serve the government." This would have a significant effect on those who rely on our agencies for services, as these invaluable assets would be removed from the system.

Disappearance of individual choice will be a direct consequence of the legislation. The ability to choose or seek a service will be seriously diminished with the introduction of a government-mandated structure for long-term care services. People will only be provided with the options the case worker decides to give them. If an individual is unhappy, an appeal mechanism does exist in the proposed legislation, but dollars and time would be wasted while the individual would not necessarily receive the care they wanted and needed.

We do believe that some of the provisions of Bill 173 could provide individuals with a choice, specifically those which establish a single access point for determining the availability of required services and the options which exist. But the delivery of care should continue to be the responsibility of these well established and high-quality service provider agencies which currently exist. For example, the Society of Sharing is a small, midtown Toronto agency. It's completely volunteer, providing friendly visiting to the lonely, the sick, elderly and mentally ill; over 100 volunteers. I suggest to you that that delivery of service is cost-effective. Of course there's St Elizabeth Visiting Nurses, with a history of over 86 years of service providing high-quality nursing care to the public.

We believe that the proposed long-term care service delivery model should be one of linkages and partnerships with existing agencies rather than the creation of one unwieldy bureaucratic structure. The system should be one of functional rather than structural integration. The legislation does speak of a four-year time frame to establish structural integration, but we do not believe that this consolidated model is the most appropriate goal. Further, we are concerned that no empirical data is available to substantiate the claim that structural integration will be cost-effective and responsive to individuals.

The Human Services Alliance is developing innovative examples of functional integration to service delivery. We have developed subgroups to look at care pathways for individuals with mental health needs, with palliative care needs and with needs that are specific to Alzheimer disease. All our member agencies are working together to build partnerships that will better serve the clients of our communities in York, Durham, Peel, Simcoe and Metro Toronto.

Rather than creating a new structure, we are building on the strengths of our existing human service system, which includes our neighbourhood parish network, to provide the best and most flexible care possible based on the needs and choices of our clients. What we are missing is a single access point to services.

The Human Services Alliance suggests that the provincial government has a role in assisting individuals to access services by creating a single access point. As well, the province is responsible for developing and implementing guidelines, standards of service and provisions for protecting individual rights. As service providers in the care system, the Human Services Alliance partners are committed to working collectively to meet diverse human need. As partners, we can demonstrate coordination, flexibility, responsiveness and proof of cost-effective and respectful service delivery models.

We believe that the partnerships of the Human Services Alliance ensure continuous provision of high-quality care through existing non-profit and charitable agencies and will functionally integrate our long-term care services in the system. Voluntarism and financial support can remain as components that are invaluable to us and to the system. Better, more innovative and more flexible care can be provided by us in response to the needs and individual choices of our clients. All this can be achieved by the government playing a role in providing easier access to our services through a single access point rather than restructuring the entire system at enormous cost to the taxpayer and to the service consumer.

Attached to the submission is a list of the current members of the Human Services Alliance membership.

The Chair: Thanks. Mr McGuinty.

Mr Dalton McGuinty (Ottawa South): Thank you for your presentation. In fact, I want to take the opportunity to thank the two presenters before you, as well, for not sitting back and simply rendering unto Caesar that which is Caesar's but rather coming forward and making, I think, very powerful presentations.

I'm not an expert in this field and I think have acquired somewhat of an education on the basis of the presentations made so far today. But I think when you approach any particular legislation, what you've got to ask yourself is: "What is the policy that informs us? What is the thinking that has gone into this?"

To me, it's very clear. Bill 173 is based on the assumption that when it comes to delivering the kinds of services which form the subject matter of this legislation, bigger is better, and that if we are somehow able to deliver these services through a large, grey, monolithic institution which has no distinguishing features or characteristics, somehow this will be a better service to the end users or the consumers, to clients, the people who need the services.

I disagree with that heartily. I think that one of the real tragedies, if Bill 173 goes through, will be the loss that we'll experience in the voluntarism in the province which sustains so much of the social work that goes on, not only in terms of these kinds of services but others as well, for which we simply cannot afford to pay. These volunteers are attracted by the texture of the various organizations, religious or otherwise, that have come to deliver these kinds of services in the province.

In terms of a question, the answer is obvious but I want to put it to you anyway. Notwithstanding what I've said in my criticism, the act's got the right buzzwords. It's got the right catchphrases that you want to put into legislation in 1994 in Ontario. If you look at the purposes, it says we're going "to ensure that a wide range of community services are available," we're going "to recognize the importance of a person's needs and preferences," we're going "to promote efficient management" -- just reading some of the wording from the objectives.

Then we go to the Bill of Rights and it talks about promoting autonomy or recognizing "individuality...that respects cultural, ethnic, spiritual, linguistic and regional differences." Then it goes on to say the act "shall be interpreted so as to advance the objective that the rights set out...."


Is this act, in your mind, advancing those objectives? Is it giving autonomy? Is it giving freedom of choice? Is it respecting religious and cultural differences?

Mr Dunn: We don't think so. From the point of view, again going back to just the voluntarism aspect, I'm sure all of you have volunteered at one time or another. Why did you do it? Think about why you volunteered. Basically it was because it was probably a local agency. You appreciated the work that agency did. Maybe it had a special service that you appreciated was provided to your mother or your grandmother, or you personally identified with the mission and the service philosophy. We don't think that's necessarily going to be the case here.

You have to remember, I think, that charitable agencies, most of them, started because they were based on the communities, on either a faith, a linguistic or a cultural basis for it. That's not the situation here. We're just going to start MSAs on one day. There's no historical basis, or cultural basis, for that matter, to volunteer for government-type agencies. It's naïve in the minimum. I think it's ludicrous in the extreme.

Mr McGuinty: Just a follow-up, Mr Chair: One point on that is that we as politicians ourselves recognize the importance of different institutions and traditions and cultures. When I run in my riding, I don't run as somebody who wants to be in a government; I run as a Liberal. When I raise money, I try to raise money as a Liberal, and so does everybody else around this table for their respective parties. We run on behalf of a party because it has a history attached to it, and this act doesn't recognize that.


The Chair: Order.

Mr McGuinty: This act goes against that fundamental truth which recognizes that people quite naturally have attachment to history and tradition and distinguishing characteristics.

Mr Michael Fullan: If I could just add one point about our volunteer piece of this, Brian had talked earlier about the $10-million value added if we were to translate the volunteer hours into dollars. What is not included here, and we haven't done a very good job of selling ourselves, is the tremendous volunteer capacity at the parish level. We don't hear that. That goes virtually unrecognized for the most part, quietly going about, and that's been continuing for many, many years. As I say, we haven't sold that very well at all, but it's a very active part of who we are and of our agencies and our service to the community. That would literally be thousands and thousands more hours and millions of dollars if we were to translate that.

Mr Tony Martin (Sault Ste Marie): I found the three presentations this afternoon rather interesting. You make some very compelling arguments but as well present to me some rather disturbing perspectives. I'm a Roman Catholic as well and, as one letter to the editor stated a couple of weeks ago, a self-proclaimed Roman Catholic, and, you know, certainly have been the beneficiary of and have contributed in many significant ways to some very interesting things in my community by way of service and that.

However, I don't share with you some of the cynicism that you brought today re the ability of government to deliver programs. I didn't know how many government workers lived in my community until the social contract last year. I recognize that many neighbours and friends worked for government, very hard-working, committed, dedicated individuals who do their job well, who go beyond the call of duty, on many occasions come home late, go to work early and contribute in significant ways to the fabric of this province and work very hard. For me to sit here and listen to folks be cynical about that I guess disturbs me because it speaks to a more fundamental problem re what we face as we move towards the end of this millennium and into the next century, and my four children.

The other thing that concerns me is the sense that somehow because we're Catholic we do it better or that we have a corner on the market re the issue of volunteering and raising money and all that kind of thing. I have to tell you that I used to think that. I used to live in Ireland where we thought a lot of different, very sad things about people who weren't Catholics. I've come to learn differently in my experience as a person who lives in Ontario, a multicultural, very diverse province that leads in the world in recognizing the richness of the various people who live in our communities and what they can contribute. To suggest for a minute, it seems to me, that I will only volunteer or raise money or give money if it's to some Catholic organization or spiritually rooted organization or some organization that only has local connections -- I look at this province and I look at the thousands of people who participate with government in the whole area of trying to save the environment for a myriad of different reasons, who work within my community in the jails, and in the northern treatment centre for a myriad of reasons: some of them Catholic; some of them of no faith connection whatsoever. To suggest that there's some devious, political agenda on the table here as well disturbs me personally, if not as a member of this government at least. Our agenda is simply to make sure that long-term care is delivered in this province in a way that is cost-effective and available to people from one end of the province to the other. The choice question is really one of a choice of having that care delivered.

There was reference made earlier by Mr Marr to an exercise that happened in Sault Ste Marie over the last couple of years when the two hospitals came together. That wasn't without some tremendous struggle and effort and -- continued today and into next year -- pain as we laid off very valuable employees in both those institutions so that we might take advantage of the efficiencies that could come with that. We still continue to deliver health care in Sault Ste Marie in, I think, a quality atmosphere and in a way that all of us can be proud of.

I ask you to maybe comment on some of those questions that I struggle with now as a member of this committee as I try to deal with this legislation.

Mr Dunn: If you've been in any way involved in trying to secure volunteers, you'll know it's a difficult task. With Catholic Charities we have 29 various agencies and, with the Human Services Alliance, we're up to over 40. We don't ask their religious affiliation when they come through the door to volunteer for one of our agencies. We don't do it. It's the same as when we deliver service; we don't ask what religious affiliation you are when we deliver service.

So we're not suggesting to you that this is just a Catholic thing; that the Catholics aren't going to volunteer. I suggest to you that anyone with the VON who has been volunteering with them might turn around and say, "I think maybe I'm just going to volunteer for the local hockey association." There's no history, I say to you, of people volunteering for a government-based agency that starts on day one looking for volunteers. I just don't think that's going to be the case. I think it's naïve of us to think that's going to be the case.

Ms Carter: It is still community-based, like the hospital --


The Chair: Excuse me.

Mr Dunn: All right. Let me continue with that --


The Chair: Order, please.

Mr Dunn: I'm not suggesting everybody, as soon as the legislation comes in, if it comes in, is not going to recognize a responsibility to volunteer, but it's the degree of support that you're going to get. When people start to realize that they're supporting a government-based agency, they are going to think twice about continuing their voluntarism. That's our submission.

We may be completely wrong, but you're taking a chance on losing, as we suggest, possibly upwards of $10 million worth of volunteer time.

Mr O'Connor: Are you planning on --

The Chair: Excuse me, please. One last supplementary for Mr Malkowski and then we have to conclude.

Mr Malkowski: Are you people aware of the Progressive Conservative philosophy on long-term care, and would you support their strategy to shift from community-based to institutional-based models in long-term care? Would you like to comment on that?

Mr Jackson: Point of order, Mr Chair: I'm unfamiliar with Mr Wilson and I having ever commented on that in this hearing or in the previous hearings on 101. In fairness, Mr Malkowski shouldn't play with words in such a fashion. It's quite unfair.

Mr Malkowski: To be fair, in response -- you said Bill 101. You've talked about institutional care before. I want to hear their comments on your party's platform, in point of fact.

Mr Jim Wilson: That isn't our party platform.

Mr Jackson: If Mr Malkowski wants to ask me a question about my party's position, fine. But that's a completely unfair question to these people unless they're all Conservatives and they're aware of our party's policy. This line of questioning's only going to make them Conservative.

The Chair: Order, please. Order. I think it being 6 of the clock and since memories of policies may be a bit dim, we'll conclude at this time. I want to thank you for coming before the committee and for your presentations.

Mr Dunn: Thank you, Mr Chairman.

The Chair: The committee will resume tomorrow morning at 10 o'clock. It stands adjourned.

The committee adjourned at 1800.