Monday 14 November 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


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

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

*Acting Chair / Présidente suppléant: Caplan, Elinor (Oriole L)

*Carter, Jenny (Peterborough ND)

Cunningham, Dianne (London North/-Nord PC)

*Gigantes, Evelyn, (Ottawa Centre ND)

Jamison, Norm (Norfolk 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)

Rizzo, Tony (Oakwood ND)

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

*In attendance / présents

Substitutions present / Membres remplaçants présents:

Caplan, Elinor (Oriole L) for Mr Beer

Crozier, Bruce (Essex South/-Sud L) for Mr McGuinty

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

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

Wessenger, Paul (Simcoe Centre ND) for Mr Jamison

Also taking part / Autres participants et participantes:

Wessenger, Paul, parliamentary assistant to Minister of Health

Clerk / Greffier: Arnott, Doug

Staff / Personnel: Gottheil, Joanne, legislative counsel

The committee met at 1533 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 Acting Chair (Mrs Elinor Caplan): We're about to begin today's committee hearings on Bill 173. We're at the present time in the midst of debate on section 13 of the bill. Just for those who are here today, I'm Elinor Caplan and I'm the substitute Chair of the committee. The procedure that the committee has agreed to and has been working under is one whereby I will recognize any member of any of the caucuses who wishes to speak to the legislation, and ask that members, if they wish a supplementary or anything further, will just signify so that I can ensure that they are on the list.

Mr Tony Martin (Sault Ste Marie): This bill that we have in front of us today and have been dealing with for the last number of months, a piece of work or parts thereof that actually has been in front of the Ontario Legislature for approximately the last 10 years, is a very important move forward and an attempt by government to respond to an ever-increasing demand for services in the area of long-term care for our seniors. It comes out of a very sincere commitment and belief and thought that, as government, we need to be responding to the reality that each one of us sees, as we go back to our ridings, to serve those who are most in need. It is a bill that is based on our wanting to make sure that those who are most in need actually get the service they need and deserve.

This bill is not about ideology and it's not about not-for-profit versus for-profit. It's about delivering services to seniors in an efficient, cost-effective, coordinated or integrated fashion. Yes, it's difficult. There are parts of it that are going to be problematic for a lot of groups out in our communities that have, over the last few years, worked very hard at developing a number of services that have come to be relied on by particularly seniors in our communities. What we're proposing here will make the delivery of those services different, will change the names of some of the organizations in some cases or will put the services under an administrative structure that will not perhaps, in organization, look the same or feel the same or sound the same. However, in my mind it is important that we do this.

We're going to be putting significantly more money into the system and we want most of it to go to the actual delivery of services.

We have some choices in front of us, and actually, as we get to the end of this exercise, the choices become relatively simple and clear. We can choose to grow the existing delivery agent system to do the job or we can take this opportunity at this point in history to start fresh with one agent and one administrative structure.

We've been criticized for various pieces of this legislation where it speaks of this particular reality. One that we will come to in the not-too-distant future here is the question of the 80-20 distribution of purchase of service. We're sticking to this and feeling very strongly about it because we do not believe that a truly coordinated, integrated system will happen otherwise.

I said last week, as I spoke to this piece of legislation, that as a government we are beginning, however grudgingly in some sectors, to get recognition for having been able to make some tough decisions in our mandate which recognize the realities with which we have to live. In my experience, this is one of those really tough decisions.

This is a decision to move on an initiative, a piece of legislation that's been before us here, and people before us, in a way that recognizes that we will never again in Ontario have the kind of money to spend that we had in the 1980s in the growing of new agencies. It is a recognition that we can no longer provide a Cadillac version of services to people in one area of the province while on the other hand providing, if I might, with respect to those who perhaps own a Volkswagen, a Volkswagen model of service to people in other sections of the province. That's no longer acceptable, it's not fair and it's not just.

Scarce resources and yet a real need in some areas to redirect the money that we have is what's come into play in the decisions we're making around the growing needs that we see in the area and our responsibility as government to try and, in a responsible and accountable manner, meet those.


In my own community of Sault Ste Marie we had two hospitals and a lot of talk over the last 10, 15 years in that community around the bringing together of those services so that we might have a more cost-efficient, effective and coordinated delivery system of services to the people of my city. There was a buildup of opinion over a number of years that we should in fact move to a point where the two hospitals were operating as one.

We've achieved that in the last two years. It wasn't easy. In fact, it was very difficult. However, the reason it happened was the leadership of the two hospitals and the leadership at the community level around the question of how we deliver health care to our community, and a commitment by our own local government to a study, to hiring some consultants to come in and work with us to put a new plan on the table that would see us delivering services so that both hospitals were working as one.

We now have achieved that, and because of that we are able to deliver hospital care to the people of Sault Ste Marie for approximately $2 million less a year.

So there are cost savings; there are cost efficiencies in bringing organizations together, particularly if it's done right. I suggest to you that one of the keys to the successful integration of the two hospitals in our community was the commitment that was there by the leadership of those hospitals to actually get it done, and a commitment to the bottom line, which was the delivery of services to people as opposed to a commitment to continuing to prop up organizations that for all the right reasons over the years had developed, but now no longer were appropriate to the need of the day.

I raise for our consideration again here, as I've done a couple of times before, the piece of activity that happened around the development of regional governments in our province. It was thought, correctly at that time, that we would be able to deliver services to larger areas in a more cost-effective, coordinated, integrated fashion if we had regional governments, and they were set up. The plan at that time was that when the regional governments began to kick in and pick up the pieces and became operational, the smaller government entities would disappear. But that didn't happen, and the government of that day didn't have the intestinal fortitude, I would suggest, to make that happen, so that today we would have a number of regional governments delivering services across our province. Instead, what we have are regional governments and smaller governments competing for the delivery of services and for the tax dollar, and lots and lots of cost inefficiencies.

What I hear some of the folks, particularly across the way, suggesting is that we repeat that history, that we repeat that obvious, in my mind, error of the past.

So here we are today. We have a chance to do something significant. We have a chance to start something new. We have a chance to be courageous in front of a challenge that confronts us all now that has confronted us all for, as I said, about 10 years now. We have a chance at this point in time to do it right and, I suggest, with the piece of legislation we have in front of us and some of the amendments that we are bringing forward, to reflect that we listened to the folks who have come before this committee over the last few months.

Without gutting this bill, without taking away the essence of this bill, we think we have put in front of you something that will serve us well and that all of us in this House will be proud to say we were part of as it becomes more and more important for us personally and indeed for our children down the way.

Mr Cameron Jackson (Burlington South): I guess it's safe to say that this is a critical section of this bill for seniors in Ontario. We've always felt it was such and it was identified very, very early in the process of public hearings. In fact, prior to that, we will recall there were some substantive changes when the bill finally was tabled for first reading and we had moved from restrictions on commercial activities and then we'd moved from that in this same area of the bill and now had removed any reference to the corporate infrastructure or auspice, and we'd now sort of blanketed the entire sector with this 80-20 percentile rule as to what services could be purchased and which services had to be directly supplied by the preferred agency, which is the MSA. Whether we want to call it anything other than the civil service or the bureaucracy, it will amount to that.

We have all sorts of agencies that act as government agencies that have non-elected volunteer boards. The agency receives moneys from the provincial government. So if it walks like a bureaucratic agency and it talks like a bureaucratic agency, then it pretty well is a bureaucratic agency, and that's what the MSA will be.

So the 80-20 rule and why the Conservatives served notice early in the process that we would want to remove the reference to this is that we believe partially in some of the rhetoric of the current government. When the government says, "We want a more efficient system," we think it genuinely believes that. When they say that they would like a more cost-effective system, we think they're right about that too.

When we come to the 80-20 rule we're quite confused why the government can't understand that existing agencies can come together and provide services in a cost-effective way and provide choice. Choice, quite frankly, comes with a lot of protection for the consumer, because in choice you have the empowering ability to appeal your case directly to the supplier of the service to have elements of that service plan changed. In many cases you can actually even have it provided by another agency.


The 80-20 rule attacks the concept of choice, which is an empowering activity for someone who wishes to receive services. The front-line workers who are currently working in the agencies of record, such as VON and Red Cross and a whole host of organizations that have been before this committee, these persons providing service, have a certain independence. They serve predominantly the master, who is their patient. They are not beholden to a government agency to the extent that the government agency funds them and transfer the moneys to them, but generally, the relationship that they have with their employer is one in which they're measured by their compassion and their abilities to perform the service and themselves to become natural advocates for the patient, or for the receiver of the service or the client. We can use any of those words, I guess.

We on this side of the room are very much concerned that by fixating the 80-20 rule you are not just transferring a whole series of employees who will go into an employment lottery at the end of all this, and those who were unionized will probably get a job and those were not unionized won't get a job. Those who were in supervisory positions with extensive training and field experience will be set aside for employment purposes and people with very little experience and with very little seniority but who just happen to have landed in an agency three years ago that was unionized are now all of a sudden not only going to see the shakeup of their organization but they're going to get first crack at those new positions.

We should reflect upon the words of the Red Cross, which presented to this committee back in August. It's worthy, I think, to indicate just for the record about section 13 and what probably one of the largest suppliers of services had to say. I just want to briefly quote from their presentation:

"This section stipulates that an MSA may not spend more than 20% of its budget to pursue community services. This requirement is not to be administered globally but applies to each budget line for each of the categories of services" as outlined in part II, section 2: 20% of the budget for community support service, 20% of the budget for homemaking services etc. "This is unlike the present system whereby home care programs broker most of the services they provide, purchasing them from autonomous service provider agencies."

"The Red Cross recognizes that the government is committed to moving away from the brokerage system. In our opinion, the problem with the current delivery system is not brokerage, but a lack of coordination and poor access. We feel that in many situations brokerage can be an efficient system for service delivery.

"Presently, many services are provided effectively and efficiently by a number of established agencies. These agencies have long histories of service to their communities. They are often supported and governed by volunteers who are part of the community. Stable relationships have been developed between provider agencies, care givers and the individuals they serve. Rather than replacing the existing system, efforts should be made to improve coordination and enhance the efficiencies." It goes on to suggest a couple of examples of that.

What the Red Cross is trying to appeal to this committee is to say, allow the volunteer boards -- of which you cannot argue that this group of service providers have a monopoly over the membership of the volunteer boards; they are a minority on this board. They can't control the thinking of the board. They can't direct the board.

But either this Minister of Health or this government doesn't trust the very volunteers to whom they have entrusted the responsibility for the delivery of services. They mustn't really trust them very much because what they're saying is: "Look, you have to be guided by a formula. We don't care. We don't want you to get the most efficient and the best use of tax dollars. We don't want you to make sure that access has a very high rating, that those are major considerations so that you can lose a little money in this corner of your programs so that you can provide accessibility to costlier programs that may be required in remote areas within an MSA."

This government's not interested in that. They're basically saying that this one 80-20 formula contains within it all the necessary solutions to improving access and service in long-term care, and that's fundamentally wrong.

It's fundamentally wrong because of exactly what Mr Martin just said. Mr Martin was basically saying, "What's not occurring in one part of the province isn't necessarily what is occurring in another part of the province" would work in his backyard in northern Ontario. We agree with that, and rather than simply saying, "We're going to impose one set of complete, rigid rules," no matter how well the government justifies them, "our rigid set of rules is going to work in Espanola just as well as it's going to work in Kingston, Ontario" -- we're in the 1990s here, people. The whole concept of governance and service delivery is being shifted and the shift is true local decision-making. That is simply all we've tried to achieve here, to allow for that flexibility. You're entitled to impose your ideology where you say, "We don't want anybody who has a private home care business operating." But you're not doing this here. You actually remove that.

I think what disturbs me is that you're sort of saying -- if in fact private home care is the evil which your government feels it's necessary to have eliminated or stamped out of health delivery in Ontario, then why are you extending that mark against them, why are you extending that to include all these other agencies? Saint Elizabeth has the most Christian charter you'd ever want to look at. Is it because it's a Christian charter that there's something inherently wrong with it?

We can't understand why the 80-20 rule is targeted now towards all of these agencies. It would have made more sense for you to be consistent, to just say, "We want to stamp out the private sector," but leave the VON, which is the direction you were going in, and that was the 10% rule.

It's interesting. I quoted Sid Ryan in the House today, and that was one of the first things he said: "We want this 80-20 reduced to 90-10," and he wasn't happy that the 10% was just targeting the private sector. He wanted to attack all the agencies and he went on to indicate his preference for unionized workers and his lack of support for -- in fact his outward disdain for -- the growing numbers of volunteers, which is again another contradiction for the government.

The point is that Sid Ryan indicated that it was a sad day for this province because we were using volunteers more in the health delivery system. Well, I've got news for you. This is the direction we're going to have to go in as a society if we want to survive today. Twelve per cent of all of our citizens are above the age of 65. When the baby-boomers are 65 years of age, we'll be 33% of the population.

Interjection: Oh, come on.

Mr Jackson: Thirty-three per cent of the population. Now, if we think we're going to deliver all these home care services and community-based services, because we know we've cut off institutional care to upper limits, then we're dreaming in Technicolor if we're not going to expand, to celebrate and promote the volunteer sector.

Again, earlier in the House today I made reference that a lot of the government members have accused the opposition members for their concerns that they had heard about the Quebec system and why volunteers were being driven away, and Mr Quirt at the time said that he had seen some evidence but not really very much evidence. He begrudgingly indicated that there was some evidence but the degree to which it was very powerful evidence he wasn't sure.

I read into the record today a quote from the Quebec government task force report on health promotion, Objective: A Health Concept in Quebec. I want to quote right from the report. It stated that the government has often been reproached for killing the volunteer movement by systematically paying people in the community to do the work they formerly did without pay. The report stated that charities previously providing services in Quebec have progressively disappeared and the overall wage costs for services increased.


What we're talking about here is the comparison. We are behind Quebec in terms of this reform. In Quebec they have what are called local community service centres -- CLSCs they are called in Quebec. In Ontario we have MSAs. A very pro-labour Liberal government in Quebec over a period of almost a decade, and prior to them the separatist Péquiste government in Quebec, developed the model along the lines, but driving the engine of reform was how they were going to manipulate the labour pool of services and how they were going to redefine the delivery system through the agencies. And when all the cutting and slashing was finished, most of the blood on the floor was from groups like the Red Cross and VON and Saint Elizabeth's and various other agencies that were providing large support services.

To quantify the dollar loss was easier to do in Quebec, I'm told, than the numbers of volunteers, because you had multiple volunteers. You'd have somebody who would do Meals on Wheels and then take someone to a doctor's appointment and then volunteer at an Alzheimer centre for respite. So that was always very difficult to monitor. But what was easy to quantify was the huge numbers of dollars that these agencies were putting into the cost of delivering health care in the province of Quebec. That's where they expressed serious reservations about revenue loss. So who makes it up? The government. The taxpayer makes it up. Nobody else; the taxpayer. And because we have only one taxpayer, they're the ones who are going to fit additional costs that quite frankly are unnecessary because the government has walked away from the commitment to do this in the most efficient, effective, cost-efficient, accessible way possible.

Because they're not, they have a formula, so they can simply turn to the minister of the day and say: "Look, you've only given us X number of dollars. We can only spend 20% with this agency that can deliver the service for $6.50 an hour, but because we have to buy 80% of our service from within our agency, our agency costs are $8.50 an hour."

You can look at that two ways. You can say the $2 difference is just the cost of government. You can look at the $2 difference and say, "Well, if we could have more than just a 20% purchase of the Red Cross, then we could get our costs down. We could save money."

What a terribly foreign concept for politicians in the 1990s: We could save money. Or better yet, the one that I like the most of all is, how many more seniors could we service for that $2 an hour? How many people could we take off a waiting list? What new activation programs could we get into over in this part? Because in our given community in northern Ontario we have a unique problem and we really can't be suffered with an 80-20 rule and we can't be suffered with a global budget that says we can't look at developing some new programs because we have a disproportionate number of native Canadians with their unique needs in our region and we just can't find the money.

When we say that we feel this is one of the most important sections, we do because we see beyond just the bill. We see its implications for the actual application of this legislation, what it will be like four years down the road when everybody's plans have to be etched in stone and there's no turning back.

I wish I could go on further about concerns I have about the volunteer sector, a new figure which is now emerging based on some statistical information about the costs of the volunteer sector, who, quite frankly, if they can go down the street and volunteer for the Red Cross like they always have, and the MSA purchases services from the Red Cross, then that volunteer has no reason to leave.

There's no question any longer that that volunteer is not going to show up. They will still show up and do their driving Monday, Wednesday and Friday, like they have done for the last five years. But if under the 80-20 rule, Red Cross doesn't get to have any of its services purchased, they have to say: "Call the MSA. They're in this government building. Go ahead and make application, because they may or may not want you to volunteer."

We're concerned that this has been quantified to equal an amount of about $9 million at the VON, the amount of the services these volunteers are providing; $18 million at the Red Cross; and the Human Services Alliance is approximately $10 million. That's $37 million. Again, if we think of our $2 argument, $2-an-hour difference, we have to ask ourselves, can taxpayers really afford $37 million more not to help one single additional citizen, or for $37 million, how many more seniors could we provide services to and take people off extensive waiting lists in this province? That's what's at stake with this 80-20 rule in clause 13 and why we feel so very strongly.

On just one little final note, it should be put back into perspective. We are talking about a sector of women workers. No matter how you call this, we are talking about women workers. I know the government's been criticized about their Jobs Ontario plan, and they say how successful it is. Well, it may have been successful in getting people to do certain things, but 90-some per cent of the people they've helped have been men. I'm still waiting to hear what this government is going to do positive for women, but certainly this legislation is going to displace a lot of them, and if they're not unionized there's no guarantee they're going to get their jobs back, whether they resurface in a government position.

Today in the Toronto Sun is a wonderful article about a book entitled Canada's Best Employers for Women. It goes on to talk about all sorts of contemporary circumstances that are helpful for women with respect to employment.

The book acknowledges that the health care sector, especially in long-term, is a target area where it's disproportionately high in women workers. It also compliments the VON as one of the very best employers in this province. I think it's rather tragic, given the circumstances we find ourselves in with the economy, that women workers should be discriminated in such a fashion by this government.

These are all the things that are wrong with an 80-20 rule that's probably, according to this government, going to work well in Kingston, just as well as it's going to work in Espanola, and we can't agree with that.

Mr Jim Wilson (Simcoe West): On a point of order, Madam Chair: I think it's very important to the debate on this clause that we see the government's rumoured amendments that are to be tabled, or were supposed to be tabled I think by now, with respect to the labour provisions. So I just ask the parliamentary assistant when those new amendments are coming forward, because I think they're important to the 80-20 rule discussion we're having.

The Acting Chair: Well, it's not a point of order but it is a legitimate question to the parliamentary assistant.

Mr Paul Wessenger (Simcoe Centre): I understand that copies are being made now and they'll be shortly filed.

Mr Jackson: On a further point of order, Madam Chair: Is it fair to ask if any amendments deal with displacement of workers, which is the point we've been raising? If so, it may be appropriate to have a motion to stand down this section.

The Acting Chair: I'm not going to rule on whether it's fair or not to ask the question, but I will ask the parliamentary assistant to give you his best answer.

Mr Wessenger: There are amendments I believe already filed, and I don't believe the additional amendments in any way substantially change the thrust, the general principles of what is already filed in the existing amendments. So the general thrust of the amendments will be basic to preserve existing rights.


The Acting Chair: The second part of your question to me was a request to stand down section 13. Is that a formal request?

Mr Jackson: Yes. My options are to call a recess until we get the amendments, which I'm loath to do, given the other complication with this evening, which is our right to get out and vote municipally, but I'm at a loss to determine why we can't have these amendments.


Mr Jim Wilson: It's important. How are we supposed to debate this section, which virtually changes the --

The Acting Chair: I'm going to ask for order. A legitimate question has been asked.


Mr Jim Wilson: I want to know what's going to happen to these --

The Acting Chair: The answer has been given. You may not like the answer. You now have options available under the rules of procedure of this committee as to how you'd like to proceed. Mr Jackson, you have the floor. Have you finished your comments?

Mr Jackson: I'll pass; I have completed my comments on this section.

Mrs Yvonne O'Neill (Ottawa-Rideau): I arrived this afternoon to hear Mr Martin talking about Bill 173 from his perspective. I heard him say things like, "We will be proceeding with this and we are really going to push this section." Then the thought ends. That is what happens on this issue every time we bring it up. There is no real reason for the 80-20. He brings up as his last point that, "We've listened to the people," and he also brings forward that this is a cost-effective measure. I had no difficulty in coming to the meeting today with a dozen briefs that counteract those three statements.

I want to begin by one from the older adult centres. The statement was made to us that it's not apparent to the Older Adult Centres' Association of Ontario what the justification for this actual ratio is. It's unclear as to why the restriction was made at 20% rather than the more acceptable 40% or 50%. That question has been asked over and over, both by our caucus and by members of many organizations all through the hearings, and indeed before the hearings.

We also know that there is an atmosphere of divisiveness being created in this province by this bill, and I regret that immensely. The division is coming between people like the Red Cross, the Catholic Women's League of Canada, the Council on Aging, the Ontario Psychogeriatric Association, the Saint Elizabeth Visiting Nurses' Association, Victorian Order of Nurses, Villa Charities.

All of these people, in their mission statements and indeed in their actions in some cases for upwards of a century, have been acting on behalf of seniors. Now we see that there are certain seniors who are not agreeing and we have divisiveness even among the seniors' groups. Today, we have indeed some seniors coming to the province saying that we are delaying the bill and that they would like to see us do differently.

I think that there is confusion created in those communities. I regret the divisiveness because the groups I mentioned have been acting on behalf of seniors and have been indeed caring in a compassionate, efficient manner for seniors through all their existence.

I wanted to bring to you from Ottawa the Council on Aging's remarks on this particular clause:

"Bill 173 provides a restriction that not more than 20% of the amount budgeted for the four MSA service areas be used for the purchase of services from other service providers outside the MSA. This will result in less flexibility in the design of the MSA in...Ottawa-Carleton. With the recent inclusion of recreational and social services within the MSA as well as the high level of commercial involvement in the provision of homemaking services in our region, this 20% target may be very difficult to achieve" -- I would say, a very kind statement.

"The council is concerned that adherence to this provision may result in considerable disruption in service to the senior consumer." That is a very highly representative group in the area that I represent.

The costs that are given are certainly questionable, whether it be in the consultants' report or the costs that it seems impossible for the government to provide. We haven't had one cost-benefit analysis on this bill. We've asked for it; we've never had it.

This is from the regional municipality of Sudbury. I'm going to suggest that from all over the province we are getting deep concerns about section 13.

"As long as an efficient service is being provided, the provider is irrelevant. Local communities should be allowed to determine their own system. Contracting out some services may prove to be more economical, as well as more efficient. Thus, we suggest that the arbitrary capping be eliminated and that...subsection 13(2) be repealed." How much clearer could that be?

This is even a more poignant one from the Lambton Alliance, the Lambton Seniors Association: "It is a known fact that for-profit agencies can often provide a given service at the same quality level as a not-for-profit agency at substantially less total cost and still show a profit. For instance, we know of one service provided locally by a for-profit agency in direct competition with a well-known not-for-profit group which has a total cost" -- the for-profit at $9.70 per hour and in the latter case of not-for-profit, $37.50 per hour.

That's just one example from one part of the province. What we see here is not only an attack, however, on the for-profit, but we see an attack on the not-for-profit. There is only going to be one choice in a community. I was very interested today in the House to hear the minister, and I certainly want to pursue this, suggesting that if a person doesn't like one MSA, they may go to another MSA.

I stop my remarks at this point to ask the parliamentary assistant if he can enlighten us with what the minister was saying in the House. I've not heard that. Would he, from his insights and his work in the Ministry of Health, be able to tell us what she was talking about today?

Mr Wessenger: I'm not aware of the minister's remarks so it would be difficult to comment on them without seeing them in context.

Mrs O'Neill: It was in answer to a question in the House today placed on this very matter. I would place that question, because if there are alternatives among MSAs, for one thing, I understood that in most communities there will be a very limited number of MSAs and certainly in smaller communities but one. I would appreciate knowing what she had in mind.

I go back in my remarks to the costs involved.

The senior citizens centre in Windsor brought the following concerns to us: "Any limitation on the purchase of service should be applied globally and not categorized. Not to do so will fragment the delivery of service and will require undue" -- this is a point that I don't think has been brought forward -- "monstrous recordkeeping and mammoth administrative bureaucracies. People's needs and the appropriate responses to those needs do not fit into neat categories day by day or month by month. The whole person must be treated. Coordinated, not categorized, services are required. The intensity of services and their priority can and do vary and fluctuate frequently."

That is the problem with this section of the bill. We're tied into this forever, 80-20. There's no opportunity, once the four-year transition period is over, to ever change this. Even if a board of volunteers in a community who are there on a day-to-day basis make another decision, they are tied to this.

As the retired persons who presented in the media studio this morning said: "We don't know if this going to work, but we've got to destroy everything. Then if it doesn't work, what have we got to go back to?" That's the way the people in the communities are beginning to see this bill.


The Community Support Coalition of Ottawa-Carleton expresses its concerns, and I think it does it very well:

"The Community Support Coalition of Ottawa-Carleton recommends the removal of the 20% limit on purchase of service by the multiservice agencies in section 13(2). Community support services in Ottawa-Carleton are well developed. Coalition members pioneered some of our community support services in Ottawa-Carleton nearly 40 years ago, and our network has expanded so that all of the region is now served.

"Agencies were created in response to expressed community need. A great deal of effort has been expended in planning and coordination by the Council on Aging of Ottawa-Carleton," which I quoted earlier, "and between the agencies themselves, to ensure lack of duplication as they emerged. Clear geographic and service boundaries have been established; services are provided in French and English where appropriate and some partnerships between service providers and multicultural groups have already been developed," and certainly are continuing to be developed in the long-term-care planning process of the DHC.

"There exists currently in Ottawa-Carleton a well-coordinated network of services that puts consumer services first. We are the foundation of the future long-term care system in Ottawa-Carleton and we urge the government to build on that foundation.

"However, it is clear to us that the implementation of section 13(2) would require existing agencies to be absorbed into a larger body and cause severe disruption in service provision. Simplified access, coordination and service delivery can be achieved without this measure. It is unnecessary in an area as well-developed as Ottawa-Carleton."

People resent being told how they have to do things when they know their own communities. Right here in York, the Community Agencies in Partnership I think volunteered to be a pilot MSA, but of course we're not going to have any pilots. We're just doing it this way because we feel we've got to push ahead. Mr Martin said that. They're not taking no for an answer. They're going to do it this way.

"Community Agencies in Partnership believes that a limit of 20% on purchased services should not be prescribed in legislation. It is our position that this limit should be eliminated so that each existing community can determine the mix of service providers and agencies that best meets its individual characteristics and future service needs."

Isn't that rather simple? Isn't it very useful to know that some people know their communities and know the most efficient way and the most effective way to provide services there? Hopefully these are going to be the people who will be involved in governance and are indeed involved in governance at the present time.

Now, as I said before, there seems to be this great desire to build a gulf between the providers and the consumers, a gulf that I don't think has ever been there in Ontario. I really do believe, and as I've said before, I speak from personal experience, that the providers in this province can hold their heads high, and the consumers are the ones who reinforce that on almost a daily basis; very few complaints about home care in this province other than the access, which we have heard and which we know how to remedy.

The Ontario Home Health Care Providers have said to us, "The impact on businesses founded and developed by Ontario entrepreneurs will be disastrous"; Ontario entrepreneurs, people who provide jobs. "As a result of this bill, they stand to lose their businesses."

"Bill 173 doesn't reform the...system," they say, "it destroys it," and certainly what I have been seeing from many of these other organizations says the same thing. The private companies in this province employ 20,000 nurses, home support workers, occupational and speech therapists, physiotherapists and administrative staff.

This group, the health care providers, have told us, "Models like the government's proposed MSAs have been tried and abandoned in other countries, most notably Great Britain and Sweden." Indeed, Manitoba, which cut out the private sector, now wants to introduce some of that. Why can't we learn from those experiences? Those experiences have been brought to us throughout these hearings.

The bottom line here is that there will be people put out of work by this piece of legislation. I still fail to see that we are going to have a job-creation experience here. If we do, it will be at the expense of volunteers.

The Saint Elizabeth visiting nurses have provided exemplary care and have reached out to other groups and have an integrated service within this particular community and indeed beyond. "The 20% ceiling eliminates consumer choice," and indeed it does. Those who have chosen Saint Elizabeth Visiting Nurses' Association over the years have done so for very special reasons, as have they chosen other organizations and other providers for very special reasons. Why does the 20% have to sit and thus eliminate choice? I don't think that the elimination of choice is a very politically correct move in 1994.

The St Joseph's General Hospital in Thunder Bay, where I think we began our hearings outside of this city, brought to us a very comprehensive brief. One of the highlights of that brief was:

"The rule on the purchase of only 20% of services from outside the MSA will eliminate the use of many excellent support programs," and every community is now beginning to understand that. The groups that they have depended on over the years, whether it be the Red Cross or whether it be the VON, are now in jeopardy. Will they or will they not fit this 20% formula? Certainly they won't all fit.

I think the Haldimand-Norfolk Transitional Steering Committee presented us with a very worthwhile recommendation on this particular section of the bill:

"That the government eliminate the 20% figure and give each MSA community the flexibility to determine its level of outsourcing of services. Guidelines to determine the level of outsourcing should include the cost of the service, the quality of the service and the waiting lists for services delivered by an MSA."

Now, wouldn't that be a novel thought in reference to Bill 173? That we would actually provide services through the MSA with criteria such as cost, with criteria such as quality, with criteria such as waiting lists? We still don't have the answers on waiting lists. We don't know how long people will have to wait. We know the only guarantee of Bill 173 is that they will be put on a waiting list. How long is reasonable?

We know now where there is competition, where there is cooperation, where there are the beginnings and indeed in many cases solid integration of services, the waiting lists are really rather short in this province and I think we should be proud of that. We have not had complaints from people about waiting lists. As I emphasize, we've had complaints about access. You don't have to destroy a system to gain access to it, and that unfortunately is what Bill 173 is doing.

I find this entire group of briefs, only a dozen of which I brought with me -- I'm sure I could have found four dozen of these easily because these came to hand in 15 minutes of brief scanning.

To say that what is being done in Bill 173 is what was heard either in this city or in the various communities that we went to is just not true. I have read verbatim from the briefs that were presented to this committee, and I'm sure that if we were to go out into the communities now, now that people are beginning to know what this bill is about, we would get even more explicit briefs, even more explicit recommendations and people would be coming in larger numbers to tell us how they feel.

So I end with the statement of the coalition of consumer and provider groups that now numbers almost 25, and they are, as I've said to you, the Villa Charities, the Victorian Order of Nurses, the Canadian Red Cross, the Catholic Women's League of Canada, the Council on Aging, the Ontario Association of Residents' Councils. These are all grass-roots organizations and they have told us they are grass roots when they came to us. They are from all across the province. These are not Metro centred; they are indeed province-wide.

The coalition is urging the members of the standing committee on social development to amend section 13 of the bill which would permit local boards -- people who live in the communities, people who have ownership, people who have real concerns, people who have real understanding, people who know the strengths of their communities -- to determine the structure of the multiservice agencies and to let communities decide the mix of services between the MSA and other care providers.


These are logical, reasonable requests. We in the Liberal caucus cannot understand why this particular mandated, autocratic section has to stay in the bill. We have not yet had a reason. Even, as I say, when Mr Martin had his opportunity today to say they were going to push ahead with this particular section, and on many other occasions members of the government have had opportunities to suggest why this is necessary -- can't get it. It's attacked on every existing service in this province today, whether it's profit or not-for-profit. "We're going to do it a different way. We don't really know why. We have no cost-benefit analysis but we're going to do it this way because Bill 173 has come out of the chopper this way and we're going ahead no matter what anyone says to us."

This to me is unsatisfactory. I think it's irresponsible and I think I'm being kind at the moment.

We cannot support this. We will not be supporting it. If anything, the groundswell against this particular section and indeed the groundswell against this bill is growing. I hope the government is understanding that growth.

The Acting Chair: Just for those people who are here and watching and for some of the members who came in after I had already stated where we were: While we are debating section 13, at this moment we're debating a motion by Mrs Sullivan to replace section 13 with an alternative. That's the motion before us and when everyone has had a chance to speak on Mrs Sullivan's motion there will be an opportunity to vote on that motion. Did you have anything further you wanted to say, Mrs O'Neill?

Mrs O'Neill: Just to go back to the motion placed by Mrs Sullivan, what we have seen here is the request to have communities have the model that they feel would best suit their needs. It's very closely tied of course with the 80-20 mandatory capping. We have consideration that the MSAs are going to look after all people in need of long-term care whether that be the disabled or whether they be children's services and we have here the request that, if a service, as I read from Ottawa-Carleton, has been well built up -- and indeed in many communities it has; indeed here in Metro Toronto -- there is certainly much to build on, that be done.

What we see with this bill is a complete destruction of foundations; a complete destruction of partnerships that have been built and a rearrangement under a new bureaucratic organization that is going to be formed with a steering committee and staff choices made of an MSA, positions of great trust with very few people involved. We are certainly concerned about the -- what should I say? -- the democratic process connected with the MSA and the respect of the existing providers, the respect of the services and the respect of the consumer that may be lacking.

We have no guarantees with Bill 173 and that, I think, is a grave concern. All we have is a prescriptive document with very little that can convince us that the consumer and the services will be as they are, or indeed, improved as we've been promised. That's all for now.

The Acting Chair: I'd like to just clarify with the committee members whether or not there is agreement that speakers be permitted to speak in the order in which they put their hand up or whether we are rotating through the caucuses. We had some discussion at the beginning of the meeting. It was my understanding that it was going to be in order of when they put their hand up. There is some suggestion now that we should rotate through the caucuses.

Mrs O'Neill: We have been doing it formerly, Madam Chairman.

Mr Larry O'Connor (Durham-York): We'll continue, and what we've usually done, too, is limit it somewhat so that all the speakers who have put their hand up would have an opportunity to do that. I think Mr Wilson would probably --

The Acting Chair: I just wanted to clarify that at the request of the government whip.

Mr O'Connor: -- have very brief comments.

The Acting Chair: Mr Wilson, Ms Carter and Ms Gigantes are on the list, as well as Mr Crozier. Mr Wilson, you have the floor.

Mr Jim Wilson: On a point of order, Madam Chair: The House is not sitting any more, so why is the committee sitting?

The Acting Chair: There was agreement among the House leaders that the committee could and would be permitted to sit beyond the time that the House adjourned.

Mr Jim Wilson: I think, as long as I can get back on the list, I'll yield to Ms Carter, but not before I once again ask the parliamentary assistant: Some 40 or 50 minutes have passed since I asked for the labour amendments that are to be tabled today. I was wondering if they are now available. This building's full of modern photocopiers that would have copied them several hundred times over by now and it is crucial to this part of the bill. I'm thinking of asking for a 20-minute recess, which is our right, if we don't get these amendments.

Mr Wessenger: I understand they're expected in about five minutes.

Mr Jackson: Then we'll take a 10-minute recess.

Mr Jim Wilson: I think in the meantime, Madam Chair, perhaps you could continue with your list.

Interjection: Yes, let's continue with the list.

The Acting Chair: Ms Carter, you have the floor.

Ms Jenny Carter (Peterborough): I certainly agree with previous speakers that this part of the act is absolutely crucial. The question of whether we have an integrated model or a brokerage system is, I would say, the crucial difference between the government position and the opposition position. We're all agreed that there should be integrated access, that one phone call should be able to reach all the different services required, but it's what happens after that, whether we still have a system of separate agencies or whether we have an integrated system, that we're looking at here.

I'd like to address this first of all under two main headings, which are not entirely separate. The first is cost. A lot has been said on the other side of this room about cost. I think we all agree that the demands on these services are going to increase as time goes on. We all know that the population of senior citizens is increasing, the amount of money available to the government from taxpayers is not increasing, so we have to make sure that we spend our money in the wisest possible way.

The Price Waterhouse report that was done for the Senior Citizens' Consumer Alliance for Long-Term Care Reform, according to some people, has been discredited because we're told that individual agencies do not have high overhead administrative costs. I'd like to suggest that's not entirely the point, because it isn't just the internal costs of each agency that create the final cost of the system; part of that cost is the interaction between different layers, different parts, different administrations, so that a means of decreasing the cost is to integrate the system and to decrease that need for complex communication.


I'd like to read some paragraphs from the submission made by Jane Leitch, chairperson of the Senior Citizens' Consumer Alliance for Long-Term Care Reform. She says: "However, one of the greatest obstacles to multiservice agency creation is that many existing provider agencies remain sceptical that MSAs will be more cost-effective than the current system, since their own administrative costs are quite low. What these agencies fail to recognize is that the cumulative impact of a multitude of agencies, each with its own administrative expense, represents a tremendous cost to the system as a whole.

"In reviewing the expenditure on the current community-based long-term-care system, Price Waterhouse concluded that, conservatively, administration and overhead account for 30% -- almost $200 million -- of the expenditures within our current community-based long-term-care system, but within a fully evolved multiservice agency model it is conservatively estimated that expenditures on administration and overhead will fall to 16.2%, allowing almost half of our current system's administrative budget to be redeployed into service delivery."

At this point I'd like to read a paragraph from a letter from Carol Kushner to Larry O'Connor. Under "Brokerage," it says:

"The system in which others purchase care and services on behalf of clients, brokerage, has characterized Ontario's long-term-care system for a long time. Brokerage requires far more communication time and adds a layer of complexity to an already complex system.

This has been ably demonstrated in a study done in Calgary in the mid-1980s by Bonham and Carter. Dr Bonham was then the city's medical officer of health and he was able to test a brokerage model and a consolidated model in two segments of the city.

He found clear evidence that brokerage took up more time, tended to be associated with longer use of the program and cost a whopping 48% more per client. In explaining the advantages of a consolidated model, where the community nurse was doing both the assessment of need for care and the provision of care, he used to joke, `It doesn't take nearly as much time to consult with yourself,'" and this is what we're looking at here, much better integration.

To return to Jane Leitch, she says: "When case management is separated from service delivery, as in our current system, there were 36% more visits, each visit cost 21% more and clients remained on the caseload for longer periods of time. Taken together, it was calculated that the total cost of the brokered model was 48% higher per client."

Not only is this inefficient financially, but it does impact on the wellbeing of the clients, because we have had for many years a demand for reform of this system, and I think the key element in this demand for reform has been the fragmented nature of the system.

I have heard from individuals in my own community who have said, for example, somebody lived in housing that was meant for disabled people. She was disabled, she was in a wheelchair, but there was a package of care that she had to receive in order to have any care at all. The result was that she received more care than she needed, obviously at a cost to the taxpayer and with a nuisance value to herself. This person has finally achieved the care she wants, no more and no less, after eight years of having to manoeuvre with the system and battle with it, obviously at cost to the taxpayer and wear and tear to herself.

I know of another example of somebody who wanted a little help with the housework but was forced to accept personal care that she didn't need as part of the package, and so it goes on.

When we look at integration, we're looking at greater financial efficiency, but we're also looking at something which is much more flexible and much more responsive to the needs of the consumer.

I would point out that this is not a criticism of the efficiency of individual service providers -- we all know that individual agencies have done a wonderful job. The point is that the cumulative effect of having a multitude of single service providers operating separate and apart from the independent case management infrastructure creates a tremendous administrative burden for taxpayers and inconvenience and lack of properly adjusted service to the clients.

Another question that has been raised in this context is the question of volunteerism. We're being told that volunteers will desert the system and that this is another reason why costs will rise instead of falling. I would like to dispute some of the so-called evidence that has been brought for this.

There have been comparisons with Quebec and I would like to point out that there is no exact parallel with the experience in Quebec. First of all, although we have been accused of establishing a bureaucracy, the MSAs, as proposed in the act, are extremely democratic and community-based and involve volunteer, locally elected boards, so that this already involves volunteers, not bureaucrats, in the basic structures we are creating here. In Quebec, the boards that were set up as a result of their legislation gave more places to professional groups, even on boards of directors; in other words, they went in the opposite direction to us. The boards of directors were not community people; they were professional groups.

Also, there has been some suggestion that we would kill the volunteer movement by paying people in the community to do work they formerly did without pay. This is absolutely not part of the legislation that we are putting forward. The government of Ontario has no intention whatever of paying multiservice agency board members or volunteers; Bill 173 is quite clear on that. We are not trying to expand the field of paying jobs into the field now occupied by volunteers; that is definitely not the case. I believe, and it is also been expressed by other people, that where you have a community-based integrated system, it is going to be more, not less, accessible to volunteers than the present system we have.

To say that volunteers only do what they do because there is a certain label on a certain agency is to insult volunteers. I think they do what they do because they see a need in their community and they want to go out and serve that need.

I would also like to address the question of choice. It's been suggested that somehow under the system advocated in the bill we are going to lose choice. I'd just like to point out that there never has been any choice. There has been a variety of organizations such as Red Cross, VON and so on. The one that a consumer finally ended up with was something that depended on the mechanisms functioning in their own particular area.

Some areas are served only by the Red Cross. I believe some of those are some of the more inaccessible rural areas. In other areas, there is a board of health. I think this is the case in my own area, which accesses the services of the different agencies but would not do so on the basis of individual choice. I know certainly in one area whether you get Red Cross or VON or whatever depends on the day of the week on which your request for help happens to go out. I believe this is the case with other services. I am not aware that somebody accessing our long-term care services in this province would normally have any choice of who would provide that service.

I would also like to point out that this 80-20 rule, which as I have said is key to this legislation, is not aimed specifically at for-profit organizations; that 20% includes for-profit providers and other providers. To say it is an attempt to get for-profit agencies out of the system is not accurate. I do agree that by integrating the services into the multiservice agency we then put them on a not-for-profit basis, but it is my feeling that when something is being run with taxpayers' money on a shoestring and we are trying to get the very best value, we should not be planning for a margin of profit, we should be planning for the money to go into those front-line services.


While I'm talking about money, there also seems to be an implication flying around that somehow money has been taken out of the system, that people are going to lose jobs, that there are going to be fewer services. That could not be less true. I know of at least one past client of the Red Cross who has presented to a committee and has actually written a letter to my local newspaper saying that there will be no further services, that we're destroying the system.

I don't know who has spoken to her, I don't know what that person has said, but I do know that we have put vast amounts of extra money into this system, that areas which were not properly serviced previously are now going to be serviced, that in fact most consumers who were already accessing services will notice no difference, that they will probably continue to get the same care provider. We are in fact creating 5,000 extra front-line jobs, so that talk of people losing their jobs is again alarmist, because jobs will not be lost, jobs will be gained; they may come under a different heading.

But another point I would like to emphasize, and I think this has been very underemphasized in general, is that the act provides a transition period of four years and it is only at the end of that period of time that all the requirements of the act have to be met, so to people who fear that suddenly, overnight, the agencies that are delivering services are going to be overturned and the staff are going to be scattered, this is not happening. We're not asking for massive disintegration; we're asking for the existing agencies to cooperate more and more closely over a considerable period of time so that at the end of that time they will in fact have merged. I don't think that is the same thing as abolishing agencies.

Admittedly, if we are to achieve the economies that we expect to achieve by the time that merger is complete, there will not be the same number of boards, there will probably not be the same number of administrators there are in the field at the present; there will, however, be more front-line workers, not less. As has been said, there are labour amendments coming in and we're certainly concerned to make sure that the transition from one employer to another is going to be fair and orderly. I do not see vast sums going out in severance payments; I don't think that is what is going to happen.

I would also like to point out that we are continually being given lists of organizations that are opposing this legislation. They are, I believe, almost entirely provider organizations. The people this legislation is focused on, the people it is trying to assist, are the consumers, and I think that for anybody to either scare consumers by making them feel that they will not be looked after or to scare employees by making them feel that they will lose their jobs is something that is not worthy of anybody who really is concerned with the best outcome for the people of this province.

In conclusion, I would like to read the last paragraph of the Jane Leitch report from the Senior Citizens' Consumer Alliance for as per aj__ssLong-Term Care Reform, which, as I have said before, does represent over a million people. She says:

"We're therefore looking to our politicians and government decision-makers to do what is so clearly in the public interest. We're fully aware that doing the right thing is not always easy. The status quo is often an attractive alternative to change. But we're convinced that without a fundamental restructuring, we could lose access to the kind of long-term-care system that reflects the values of our society.

The success of long-term-care reform and multiservice agency creation is critical to the wellbeing of elderly consumers and our families. We do not want to see this reform delayed any longer and we're not prepared to sit quietly and allow providers and politicians to make short-term political compromises which will ultimately undermine the system as a whole.

We've all been talking about reform for years; now we want to see some action." I will also conclude at that point.

The Acting Chair: I believe that we have agreement. There has been a request that we vote on this motion by Ms Sullivan at this time. As there is another amendment to section 13, and since there seems to be agreement that we vote on this section now, the remaining speakers on the list -- Mr Wilson, Ms Gigantes and Mr Crozier -- I suggest be the first speakers when the committee next sits, if that's agreeable. The agreement is that we vote on this motion at this time and then Mr Jackson will have the floor.

Mrs O'Neill: Recorded vote.

The Acting Chair: A request for a recorded vote. Do you need to have the amendment read or does everyone know where we are? I just want to make sure. We're on section 13 of the bill, and this is a Liberal amendment that's been placed by Ms Sullivan.

All those in favour of Ms Sullivan's amendment, please raise your hand.


Crozier, Jackson, O'Neill (Ottawa-Rideau), Wilson (Simcoe West).

The Acting Chair: Those who are opposed to the amendment?


Carter, Gigantes, Malkowski, Martin, O'Connor, Wessenger.

The Acting Chair: The amendment to section 13 has lost.

Mr Jackson: Earlier, when I quoted from the book Canada's Best Employers for Women, I indicated that it was the VON. In fact, to correct the record, if I may, it is the Saint Elizabeth organization, which was established in 1908. I appreciate the opportunity to correct the record. Both deserve to be in the book, frankly.

Given that most of us around this table would like to vote before 8 o'clock in our municipalities, I'd like to move adjournment so we could participate in the municipal election this evening.

The Acting Chair: A motion to adjourn is not debatable. I'm going to call the question. All those in favour of adjournment at this time? Any opposed? The motion to adjourn is carried.

For those who are interested in the proceedings of this committee, the committee sits next at 3:30 tomorrow afternoon.

The committee adjourned at 1656.